American Health Information Community

Electronic Health Records Workgroup Meeting #13

Thursday, February 22, 2007

Disclaimer

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

>> Judy Sparrow:

Welcome, everybody to the meeting of the Electronic Health Records Workgroup. Again, just a reminder that we operate under the auspices of the FACA, which means this meeting is being broadcast out to the public and there will be a opportunity at the end of the meeting for the public to make comment. Also, Workgroup members please remember to identify yourself before you speak and also speak clearly and distinctly and mute your telephone lines when you're not speaking, to help reduce static and noises.

With that, I think I'll turn the agenda over to Jonathan Perlin and Lillee Smith Gelinas, our co-chairs.

>> Lillee Gelinas:

Thank you so much, and welcome everyone to this conference call on February the 22nd, 2007. Jon Perlin and I are delighted to have you with us. We have a great agenda for you today, and are excited to get started.

Jon, would you like to say hello?

>> Jonathan Perlin:

Let me join you Lillee in welcoming everybody, thanking you, everyone for their participation and indeed it is a very full agenda. Again, I would simply ask that everyone keep the focus on how we translate our learning into concrete recommendations to the Secretary in order that we might meet the aspiration which is to make real the implementation of electronic health records.

Let me thank Lillee Gelinas for carrying the water today. I am, due to a scheduling mishap, in an airport at the moment. I'll probably be quiet for the rest of the call. Certainly when I get on a plane. Thank you very much, Lillee, for your expert leadership, and let me turn it back to you.

>> Lillee Gelinas:

I want to assure the committee that Jon and I do stay in close contact and that we do have a solid co-chair leadership of this group and I just want to thank Jon for that. He is incredibly easy to work with on a very tough challenge here.

Matt, could we have introduction of participants, please.

>> Matt McCoy:

Absolutely. On the phone for the call today, James Sorace, CMS. Alicia Bradford from the Office of the National Coordinator. Robert Smith from the VA. Bart Harmon from the Department of Defense. Pam Pure from McKesson. John Houston from University of Pittsburgh Medical Center. And Connie Laubenthal is here for John Tooker from the College of American Physicians. Are there other Workgroup members who are on the phone who I did not just mention?

>> Carolyn Clancy:

This is Carolyn Clancy, I'm here at ONC.

>> Matt McCoy:

Anyone else, Judy, live with you over there in the building?

>> Judy Sparrow:

That's it. Karen and I are here.

>> Matt McCoy:

Okay.

>> Lillee Gelinas:

Okay, super, thank you very much. It looks like we have a quorum and we can proceed. We would begin with review and acceptance of our minutes from our January the 11th meeting that came with numerous attachments here. Let me just be quiet for a minute and ask the committee are there any changes, corrections, or comments to the minutes?

Okay. Hearing none, I just wanted to compliment the staff on the format where the action items are very, very clear as we can refer to them. So I thank you for that. There's been tremendous work, I know, that has gone into putting together a robust group of minutes that clearly show discussion as well as action.

So hearing no recommendations for change, I'll declare consensus and we'll move on to our first agenda item, which is emerging items and updates. Dr. Karen Bell, please.

>> Karen Bell:

Thank you very much. Actually, it's going to be very short. We have a lot of work to do and it's a very robust meeting today. So I'm going to keep my comments down to a few. The most important one is in reference to the next American Health Information Community meeting, which is the 13th of March, but will be in California. Mountain View, California. We're still setting up those logistics. But just wanted to make sure that everyone here was aware of that and would stay tuned.

The relevant piece of information for today is that that is also a very packed agenda, and we have been asked to postpone our recommendations until the April or possibly even early June meeting. So we actually have time to get these to the point where we're really comfortable with them and we really feel are the best possible recommendations. We're no longer under the gun to get something done in a very, very short timeframe. So I thought that might at least give everyone a sigh of relief as we start the meeting this morning.

And the last thing I would like to call your attention to is that at the AHIC meeting of January 23rd, which again was a very packed schedule, some decisions were made to move forward with a number of use cases. The one that's most referable to this group, I believe, is that of medication management. We will be developing those internally over the course of the next several weeks, and they will be available for public comment. The other two are in the area of consumer empowerment, i.e., making information available to consumers. And then the third one is in the area of population health and that's in the, and that is focusing on quality. So those three use cases are the ones we will be working forward over the course of this coming year, i.e., what that means is moving along to HITSP, the Certification Commission, our privacy and security group, and all other interested parties.

So I think I am going to stop there and as we move on to the state of the technology, I recognize that Dr. Middleton may not be on the line just yet. Is that correct?

>> Matt McCoy:

Yeah, that's correct. I talked to him as early, or as late as this morning and I know he was planning on doing the demo and he’d just tested it, so maybe he's just a couple minutes behind here.

>> Karen Bell:

Well, what I would like to suggest is that we have been trying for several sessions to also bring in a demo of the Cleveland Clinic’s electronic health record, and it is probably one of the premier ones, not only in the country, in the world, and so they spend a lot of time traveling around the world and we keep losing their ability to present here.

So I'm just very briefly going to say that I will continue to try to align one of their possible days for presentation with this meeting, but I will also underline for you that the reason I think this is important is that this is an electronic health record, an institutional electronic health record that has some very unique features. I think most of us are aware that a lot of the large delivery systems have a patient portal, and as does the Cleveland Clinic. But the Cleveland Clinic's patient portal is not just to acquire information. It is also a mechanism whereby patients communicate with all of the providers at the Cleveland Clinic. And I also want to underline the fact that Cleveland Clinic is not one building. It is probably about 17 hospitals at this point, maybe even have moved up to 20, multiple physician’s offices throughout the area in Ohio and beyond, and is really a very extensive network.

In addition to allowing all of those clinicians access to the same record and patients access to their own information as well as communicate with their providers, the Cleveland Clinic has also, again, a very unique feature which is related to the fact that there are many patients who are referred into the clinic for one-time situations. So for instance someone from Kansas may be referred in. When that is the case, the referring physician from Kansas has access to that patient's medical record while they are there at the clinic and for one month after. So that any referring physician has access to all the information he or she needs as the patient returns home. And this attention to continuity of care is a very important feature, and one that again is fairly unique. And I also recognize that our own federal systems, the VA, the DOD, are not, are in need of these same type of services to the same degree as patients going in the private sector but it is a unique feature and one I'm looking forward to sharing with you when it comes forth. But did want to at least underscore why we think it would be important for this group to see the full range of capabilities that an EHR can offer from this point of view.

Now I understand that Blackford is now with us?

>> Blackford Middleton:

Yes, I am, sorry for being late.

>> Karen Bell:

Not a problem, but I am going to invite you to jump right in.

>> Blackford Middleton:

Okay. What I'd like to do is, let me just get the application started.

>> Matt McCoy:

And I'll jump in here and I know we've done these live demos before but for members of the public and Workgroup members, you might have to click a little button that says click here to open the new window in which Dr. Middleton is going to conduct his demo. But once you do, that you should see that window pop open and you'll be looking at his screen. And Dr. Middleton, I'm seeing your screen, so it looks like you can go ahead and open the application. One more note, while Dr. Middleton is getting set up, this demo should happen in pretty near real-time. It varies about depending upon people's connection speed, but your computer should catch up, so if it looks as though you're a little bit behind what Dr. Middleton is actually talking about, just be patient and your computer should get up to speed.

So I think Dr. Middleton, if you're ready, we're all ready as well.

>> Blackford Middleton:

Okay, I'm sorry, I was on mute, and I had begun. Can you hear me now?

>> Matt McCoy:

We can.

>> Blackford Middleton:

So I was saying I'm a primary care general internist at Brigham and Women's Hospital and corporate director for clinical informatics, research, and development at Partners HealthCare, and the IS group, my group is responsible for the product design of the Longitudinal Medical Record, or LMR that I'll be demonstrating today.

What I have done here is log on to the LMR, our Web-based EMR, and chosen a demo patient named Tom OETest. Can everyone see that?

>> Matt McCoy:

Yep, that's up on the screen.

>>

I don't see it on my screen.

>> Blackford Middleton:

So what people should be seeing soon is our summary page in our EMR called the Longitudinal Medical Record which displays of course the patient name, and a wide variety of information in summary form. And let me just go through this briefly to give an orientation to where we are.

The top of the page shows the reminders that are due, alerts or reminders that are firing for this patient. For example, he has had coronary artery disease on the problem list, and a beta blocker is not on the medication list, recommendation for considering beta blocker for this patient. Below the reminders is the to do function. Below that the problem list, medication list, allergies, advanced directives, all in that leftmost column. In the middle column, flow sheet view of data can be shown, let me expand that. So there's a recent set of flow sheet data. All of the notes from across the enterprise are summarized here, and below that then immunization records, social history, procedure record, and other sources of information as well.

In the rightmost column is an area for patient-submitted e-mail communications from our patient portal called Patient Gateway which hopefully we'll have time to take a peek at. They appear here for the receiving primary care or specialist physician to review and go over with the patient. The source, the e-mail for the patient can be listed here, or other e-mail aliases, and then a visit history, caring physicians, care providers, and healthcare maintenance reminders are shown at the bottom on the right-hand side.

So that gives a quick overview of the summary screen layout. Note the little icon here at the top. This PG for Patient Gateway with a pencil on it means that the patient is enrolled in the Patient Gateway application, which is a patient-facing portal revealing an abstract of the information, including laboratory tests and results, problem list, medications, and whatnot, to the patient for their own review.

This icon at the top indicates, one of our enterprise initiatives focusing on smoking cessation, that this patient is a smoker and considering using this tool to launch some smoking decision support. And this last icon, the page with a star on it indicates that the patient could have, could be, a smart form could be used for documenting clinical encounter and receiving decision support. So does that basic layout of the homepage make sense? I'll just continue, then.

Each of these areas can be looked at in more detail. For example, if I were to open up the problem list, I could review the existing problems as well as see comments that might apply to anyone who documented this problem. In addition, this little icon next to the diabetes mellitus problem shows there's a disease monograph, what we call a disease monograph, available for reviewing the diabetes mellitus status of this patient. So if I click on that, a new window will pop up -- can everyone see that, Matt?

>> Matt McCoy:

I can see the new window opening up for me right now.

>> Blackford Middleton:

And this shows a diabetes disease monograph, as I've said, which will summarize the data for this patient only, over time, on a variety of clinical parameters for diabetes-related care. So, for example, some charts at the top, an access link to our virtual diabetes center for additional decision support and information, other information, reminders. And notice of course that it's easy for the clinician to review. For example, under last foot exam, the last foot exam documented in this record, a dummy patient, if you will, was June 21st, 2000. So that's one of the ways we provide individual patient data review and decision support using those disease monographs, and they're created by the Laboratory for Computer Science over at Mass General by Henry Chueh and his group.

Going back to the summary page, then, this is a restricted patient because he's a demo patient. The same thing can be done for medications. For example, I can review the med list in great detail and see, for example whether or not this is an on formulary or off formulary drug based upon the red, yellow, green indicators in the second leftmost column on the med list.

It also has indication about the co-pay requirements for each or any medication that's prescribed. The next button is a little I, a yellow circle with an I on it. That shows an info button which if clicked, for example, for any medicine, or clicked anywhere they appear, takes you to our knowledge link resource which is a tightly coupled set of resources available for looking up a wide variety of information on drugs, tests, procedures, care pathways, protocols, guidelines, what have you. So you can see with one click on the info button next to Ambien, I'm taken to the medication monograph on zolpidem.

Other aspects of the chart summary, I won't go through all of them, but another important one is the healthcare maintenance. This is where one can review all of the existing healthcare maintenance alerts and reminders and others that might be firing for this patient given our knowledge base and decision support operating in the background. And of course you can update any one of these by simply clicking on it, clicking on the rectal exam, for example, and updating with a new finding, whether it was done here or elsewhere.

By the way, I should point out that the electronic medial record system here includes the full scheduling system, I can see the schedule for myself today or for any other provider by reviewing schedule. I can also change to any other date, of course, simple kind of practice management decision support, or work flow support is built in.

Going back to the chart, though, and just looking at the demo suggestions, I've reviewed the medication history and problem list, let me look now at the clinical notes environment. For Tom OETest here we can review what notes exist on the charts for him and then show three different ways or describe three or four different ways notes can be added. So if I look at the notes list, I can see all the recent encounters and documentation that has occurred for this patient and it's obviously useful to be able to filter the list in a variety of ways so I don't have to sort through potentially thousands and thousands of notes. I can look for notes that are just by me or by any provider, or look for notes that are by my practice or any practice, so here by choosing this filter I found all the notes pertaining just to my practice.

If I want to view notes in sequential fashion, I go into a notes view module which allows me to scroll through notes or even more usefully, perhaps, to search for any occurrence of any text string in any note. For example, if I was interested in the occurrence of mammogram documentation in any clinical note, by searching for mammogram, all of these notes have something to do with mammogram, it's mentioned in these notes in the left-hand list.

Now, by way of documentation, this electronic medical record allows the user to really do it their way. There is no best way or preferred way or single way. We have a wide variety of users, of course, in the Partners HealthCare environment, across Harvard Medical School, in both community and academic practice settings, in both primary care and subspecialty care, of course. So we use the usual assortment of dictation, which can, notes can be uploaded to the EMR. Unstructured free text notes, people can type directly into a notes window in the free text form. They can use templates, which I'll show you an example of. Or they can use what we call a smart form. Part of a recent AHRQ research grant that has supported our development of smart forms which try to combine decision support, documentation, and data review into one seamless workflow environment for the end user.

If we were to use a template, for example I could type up a note in a free text window here, I can do certain things like review the meds and bring them in in one fell swoop if I'm compiling a note here in a free text window. Alternatively, I can go through a more structured and templated note, for example one I use frequently in primary care is the BIMA, Brigham Internal Medical Associates urgent care template, and here for example a patient comes in with cough, I can say for example this patient has had a productive, and then continue through the rest of the documentation by actually typing into the templated note all the findings and observations. Obviously, it can include pre-canned text within template sections, or it can pull forward from prior notes text for editing and insertion into today's note.

This includes a full history and physical assessment and plan. I can add new sections to the template if I wish, from the left-hand side. If I wanted to insert the patient data, I have the same ability here, for example, to insert data from the rest of the record into the note, or from the problem list or what have you. Oops, there's no problems to pull on this one. But that's the idea of a text template or structured template note.

The last version of documentation that we have in place today, and it is in the midst of a randomized control trial, is the idea of a smart form. And what a smart form does, for example for disease-specific or even in general purpose across multiple conditions, it allows a very sophisticated set of decision support to occur in one environment, as I've already described, for the end user. So here if I invoke the smart form, you can see what's now been on the fly created for the clinician user is an environment for data review in the leftmost column, documentation in the middle column, and then guided decision support for problem-oriented management and work flow support on the right. In this environment I can also insert templates like we saw before, the very same urgent care visit note can be used to populate the middle section here for clinical documentation.

On the right-hand side I can review the problem list, I can add new problems, right here in context, if you will, I can derive additional information about problems by clicking on the info button next to the problem. Here, for example, I've invoked the knowledge link E-medicine resource for looking at an asthma monograph. I can review the procedures simply by choosing the other tab on the left-hand side. I can review the current medications and non-medications, if there are any, that are known to this patient. These data by the way are dummy patient data and may not make clinical sense, obviously. A lot of garbage flows into these demo patients over time. You can review today's vital signs as well as a chronological record of recent laboratory data and recent lab tests or last known values for relevant data. And I can review, of course, health maintenance items here on the left-hand side. And the last module is the end of visit module which does the end of visit order capture, charge capture, and routing of the patient, if you will, for order entry.

So the middle kingdom here, the documentation environment is similar to what you've already seen. We at this point also can pop up subwindows, if you will, for more structured data entry, but in general practice I haven't been using that. I've just been using the structure data templates. On the right-hand side you can see there's a wide variety of decision support occurring already in this patient. For example, it might suggest since this patient is a smoker, I start a nicotine replacement. If I'm not sure what to do in choosing nicotine replacement or prescribing bupropion, I might ask for some guidance. Here we can pop up a guidance tool. This is a static decision support graphic which shows how to start either nicotine or other smoking cessation therapy. I might want to e-mail the tobacco counselor suggesting that this patient is ready for tobacco counseling or smoking cessation if he's at the point of willingness to consider that. I can also do other simple clicks here, to, for example, print the referral form, print the smoking cessation in Spanish, print tips for smokers, and what have you. In addition, once all these things are clicked, when I get, when it gets time to actually finish the documentation, I can execute the rule set and add that conveniently, for example now it's going to ask me to print the various forms I've just clicked. I can add that documentation with a single click to the plan section of the clinical note. Let me pause there to ask if there are any questions about documentation. If there are none, I'll just continue.

Looking at laboratory data or population data, if we wanted to view historical lab data the basic work flow is that clinical labs come back to the ordering physician in what we call the results manager area for work flow management. Here, for example, there's one test result, a microbiology test result for a patient, showing their microbiology test results on urine. The results manager allows not only review and documentation of the result review but I can also write a letter, for example, to the patient, and in this case, given that it's a microbiology report and that the finding is remarkable for a E. Coli, I can write in here for example, if I can type, and very simply add that to a pre-canned letter asking the patient to call for prescription guidance given that she has had a UTI. Let me not do that in this case. I can also write ticklers to remind myself to follow up certain lab results or patients over time. I can add items to the to do list so that the reminders in any other way that I need to have, I can have them fire it in the to-do list. And I can also quickly document a patient telephone consultation or conversation here in the patient calls area.

So that's how we review the individual results coming in after a clinical encounter. All laboratory results of course are available online. We can review labs across different domains, chemistry, hematology, coagulation, what have you, and we have some color coding in here which facilitates the end user in finding the most recent labs quickly. You can see at the very bottom here, this little spinning orange icon indicates these lab test results are less than 72 years old, yellow is one week, green one month, blue six months, purple one year. So here, for example, are the chemistry panel results for this patient and I can view down into individual detail, if required, for any particular result. All the laboratory results come from any source system across the Partners environment into the clinical data repository, so labs done anywhere across 11 hospitals and dozens and dozens of outpatient care areas are available to the EMR. In addition, X-ray and EKG and other image data are also available here. This test patient actually doesn't have any chest X-rays or other X-rays, of course, or I think not an EKG either. Oh, yes, so there is an EKG, for example, to look at. So all those image data are also available online if you wish to review them.

Let's see. I've gone over the med and preventive care reminders and showing the smart forms I gave some sense of how we view chronic disease management. One other thing we do, though, to facilitate chronic disease management of populations, is enable the end user to access a wide variety of reports on their own patient care, their own practice, and do comparisons of their patient care to their practice or national benchmarks. Here, for example, you should now see the report central environment, here's where we've created a bunch of canned reports, allowing the end user to see, for example, what their asthma practice pattern is, defines those with potential asthma based on perhaps use of corticosteroid or inhaled bronchodilator as well as documented asthma on the problem list. One of the new ones we have created is a snapshot of your clinic, if you will, snapshot report, which shows for the end user their age distribution, payor distribution, top five medications used, smoking status, top five problems, patients with chronic conditions, and whatnot. So we're finding that the end user actually loves the data more and more, and as we enter into pay for performance we of course are building pay for performance reports which indicate how well the end user is doing on the pay for performance benchmarks and whatnot.

Another thing we've built are called quality dashboards. Here the quality dashboard shows for acute care condition, acute respiratory illness what this provider -- this is my data in fact -- what my prescribing patterns are for antibiotics in ARE visits, my own average against clinic average against the national average. As a doctor seeing patients in the second or third visit perhaps that might justify by overuse of antibiotics but I won’t make any clinical judgment today, I hope none of you will. It also shows, though, what broad spectrum versus narrow spectrum antibiotics I'm using compared to my clinic colleagues, it breaks down the distribution of acute respiratory visit types across the cohort and also shows the level of service for this population of patients.

A slightly more interesting dashboard is one we built for coronary artery disease. This shows some of the core measures, if you will, for coronary artery disease, hyperlipidemia management, and gives some visual cues to the end user quickly as to if their status on the individual measures for that cohort of patients is up to snuff or not. Red is bad, green is good, and yellow is sort of take note. Here, for example, you can see the value for my patients with CAD, and the actual count for this measure of who are in compliance or at benchmark. And as a primary care doc, I actually mostly do urgent care, don't have a large panel myself, so these data are somewhat spurious and only have five patients with this diagnosis in my panel. But nevertheless, you can see in more detail what each individual measure is reflecting in the cohort of patients to whom it applies across antiplatelet use, beta blocker, blood pressure management, lipids, the ACE inhibitors or ARBs, BMI for these folks, smoking status. And we're experimenting with the measure of zero defect care, where hopefully, if every measure is up to snuff for a patient, they have zero defects in their care process at least, and this allows the end user to target their follow-up or interventions on those patients that are not yet at zero defect care.

We also give the end user an ability to create ad hoc query, if you will, of the EMR database to create a patient list of any kind that they wish for management and what we're building is the ability to act then upon the entire cohort defined by an arbitrary patient list or parameterized list of patients so that the end user can send off letters to the patients via paper or perhaps even send off a letter electronically to the Patient Gateway. If I were to look at a different patient here, Tom OETest is another patient who happens to have a Patient Gateway portal established. -- I guess I'm almost coming up on time but please tell me when I need to stop. -- This patient has a Patient Gateway connection established to his record and to his provider and I wanted to write the patient a secured confidential e-mail, I simply click on that Patient Gateway icon with the pencil on it and I'm taken into the mail environment where I can write a letter to any patient that is so enabled. And here is Tom OETest. If I want to write him a letter -- oops -- you basically get a e-mail environment. I had a problem with pop-ups here before. I'm not sure if I'll be able to demonstrate writing this patient but let me try one more time. Well, for some reason the demo environment here is not allowing the pop-up to work. But that would create an e-mail environment where I could send a confidential e-mail to that patient.

In the record we have a wide array of other tools that I simply won't have time to show. But we have specialized tools for, for example, in oncology management, oncology care, managing an infusion flow sheet for outpatient infusion care for oncology patients, a BMT flow sheet, oncology staging, and access to OncPro resources. Here, for example, I'm not an oncologist and I only have a read-only access to this resource, but here, for example, the oncology flow sheet would allow an oncology therapist, nurse, or clinician to document in a protocol format, if you will, the infusion protocol, whatnot.

All of the tools that you have seen today are customizable by the end user at a level -- of course we do a great deal of customization in the design and development shop within informatics and IS. There are other reports that are made available as well. Administrative reports and administrative functionalities is available as well. Everything requires signature to document and dedicate, if you will, to the database. There are a wide variety of other results methods that I don't have time to show, and of course all online training and health resources are made available. The handbook is the knowledge-based resource that's used by knowledge link. All of these information resources are available online, and let me stop there and perhaps take some questions.

>> Karen Bell:

Blackford, this is Karen Bell. Thank you so much. That was really an outstanding demonstration of a lot of the capabilities. I have a couple of quick questions. Number one, this is a system that's been in place for I think over a dozen years. How do you add in information for patients who are new to the system that may come with a paper chart that’s about three inches thick?

>> Blackford Middleton:

Sure. This system, Karen, is actually a descendant of the prior ambulatory medical record that was in use at the Brigham, and this Web-based EMR has only been available for about six or seven years. I just wanted to clarify that for you.

When a new patient comes in, of course the registration data is taken by registration clerks and that will instantiate a chart. There is an opportunity to actually scan in documents from any other source, if you will, and have them made available via the in-patient scanning which can also be used outpatient, of course. In this case there are no scan documents on this demo record, but documents can be scanned in. That's usually not done, though, in fact. What the implementation practice is typically, is to instantiate the medication list, instantiate the problem list, and perhaps, if one is eager and aggressive, instantiates some cardinal, key critical data from the patient's past medical history such as healthcare preventive maintenance items such as mammo, pap, pelvic, cholesterol, what have you, if the user is so inclined.

>> Karen Bell:

My second quick question is related to a comment made earlier. Last meeting. About physicians concern about managing large amounts of information coming in. Now, if this is gone live for about six or seven years and most of the patients that you're seeing stay within the Partners system or within the Brigham system, is this about as complete records as you would see so that you're really looking at a very robust and very complete medical record? And you can certainly manage the size of that?

>> Blackford Middleton:

Well, it is a, certainly I'm a proud papa, Karen and it is a comprehensive and robust record, with full features and functionality. We haven't gone through the certification process yet but we're planning to do so. By way of the information load, however, to answer your question, I think this is perhaps about as bad as it can get. And in fact this record, given that it’s a demo patient, has a lot of spurious data which your average adult chronic care patient really may not have this volume. But of course things accumulate over time. And some of our records have yes, over a dozen problems and potentially 30 years worth of data.

>> Karen Bell:
Actually I have a few more questions but I don't want to dominate. So I'll sit back for a few moments here.

>> Jim Sorace:

This is Jim Sorace from CMS. I was just curious, what's been your experience and this is a big question so maybe a very brief summary, in terms of how users respond to reminders and prompts and how best to couch them so that people act appropriately on them?

>> Blackford Middleton:

Yeah, that's a great question. This is an area, you know, of long-standing academic investigation here. Lots and lots of papers are available, if you're interested. Fundamentally, we think the user is now, in this environment, expecting alerts and reminders. It doesn't mean that they don't ignore a great many of them, though, if they're very comfortable or confident about what they're doing. I think the average user here certainly does appreciate the healthcare maintenance alerts and reminders, appreciates the drug/drug interactions and drug allergy alerts. I didn't get to demo that, but those would all occur during prescription order entry and whatnot. The expectation is that this tool is a support or buttress, I think, for clinical practice, and, you know, we have the usual feeling here among our users. They don't want to practice without it.

>> Karen Bell:

I do have one other question, Blackford. And that has to do with the fact that we're well aware, and Dr. Clancy is sitting opposite me here, the study that AHRQ did last spring that demonstrated the large delivery systems using HIT truly have improved care. One of the questions I have for you, because I know that your delivery system is quite diverse, you have the academic physicians within the Brigham setting and then you also have a number of physicians in small practices throughout the Boston area. Do you see there's any difference, or have you been able to look for and detect any difference in quality improvement depending on the clinical setting, the physician setting?

>> Blackford Middleton:

We haven't done that kind of analysis that I'm aware of internally. We certainly know that the EMR is a critical factor in achieving our pay for performance objectives, and that physicians using EMR are more readily available to achieve those P for P objectives. But within system quality differences, I haven't seen those data, or I probably couldn't talk about it if I had seen them anyway. But I agree with the notion that this, we have probably achieved here, from comparison of this system to other non-EMR-enabled systems, better outcomes and better throughput.

>> Karen Bell:

Thank you.

>> Blackford Middleton:

I'm just showing a quick peek at the prescription writing module. One can search for a new med by any route, and in our system you can use a practice favorite formulation or go to a new formulation, for example, of Zocor, and here I'm getting a alert that the patient previously was on Zocor, so I can activate the inactive or continue a new order, and we spent a lot of time devising the right strength and form combinations and route and frequency combinations so that we aim to decrease the incidence of medication administration error, or medication prescribing error rather, at the time of order entry in the prescription screen.

>> Carolyn Clancy:

Blackford, this is Carolyn. Can you just talk a little about who sets policies around clinical decision support and other things? And I'm thinking of two things in particular. One is an updating function, in terms of new information becomes available and therefore a prompt or message to clinicians, you know, needs to be revised or refined. The second is the issue of opt in versus opt out. Yours is clearly an opt in kind of system. Does that ever give people pause in some areas?

>> Blackford Middleton:

Resistance is futile at one level. But, you know, I think most people now are eagerly moving toward the EMR use across our environment. You may know, our adoption now is probably, let's see, it's greater than 90 percent of primary care in the AMCs, greater than 30 percent of specialists in the academic medical centers. Not quite so good in the community yet: on the upward of 50, 60 percent in primary care and 20 or 30 percent in subspecialty practice. But given the latest best data that you're well aware of in adoption across the country, we think we're far along compared to the rest of the country.

>>

Yeah.

>> Lillee Gelinas:

Blackford, this is Lillee Gelinas. You did an outstanding presentation. Is there a sense of cost to the physician for the technology?

>> Blackford Middleton:

Sure. In the AMCs, it's supported of course by the institutional infrastructure for IS. There's no faculty cost per se, although there are real costs that are supported by the individual institutions. The charging structure in the community for docs who are not Partners physicians but wish to use the EMR is not something I'm intimately familiar with but we have I think a fairly market-competitive, if not slightly less, pricing structure that has an upfront implementation and interface development cost and then and ongoing cost for maintenance of interfaces and new knowledge and development of new decision support or tools. I don't know what those latest figures are. I think it's on the order of 2600, 3K, per doc, per user for implementation and then about 20 percent of that roughly ongoing.

>> Lillee Gelinas:

Because, you know, part of the charges of this Workgroup as we've been discussing how to be effective is around the business case for practicing physicians.

>> Blackford Middleton:

Yep.

>> Lillee Gelinas:

And the issues related to that. We just hear time and time again that there's no cushion for private physicians to invest in health IT.

>> Blackford Middleton:

Well, I agree strongly with that, and I think I have sent in to the committee perhaps in some of our early meetings, some of the stuff I'm written on this very issue of the market failure for healthcare IT, particularly in a small office environment. I'd point you back towards our American Journal of Medicine article, or the Health Affairs articles that we have done. I think fundamentally, given the razor thin or negative margins for most physicians in small office environments and even small hospitals, and the fact that our analysis suggests that 89 percent of the benefit of HIT goes to folks other than the paying physician, if you will, buying the HIT, primarily the benefit goes to the payors, that it's really unfair and thus the market failure for adoption at a variety of levels in the small office environment, for the end user physician to foot the total bill.

>> Lillee Gelinas:

What is the uptake of adoption across your system?

>> Blackford Middleton:

So I was just alluding to that. It's greater than 90 percent in the academic medical centers of primary care docs, greater than 30 percent of the specialists in those AMCs, and in the community, greater than 50 percent of primary care physicians and approximately 20 or 30 percent of the subspecialists. We're about double the national average for adoption, and nearly complete in primary care.

Carolyn, I wanted to go back a second to your question about the knowledge management and updating governance, if you will. One of the things I think I may have shown you previously but might be of interest to the committee, we recognized that the knowledge management problem is in fact one of the biggest problems in HIT implementation, adoption, effective use, and transforming care. We have created a knowledge management portal wherein we catalog all of the knowledge in the LMR, the CPOE systems, the EMR applications, even the smart pumps, all that kind of knowledge is being now cataloged and maintained in this resource we call the knowledge portal. This allows a user to go in, for example, and do a filtered-based search of all the knowledge assets in any of the systems across the entire enterprise. The foundation on which we do our governance, because not only does it allow to you keep track of what's what, authored by whom, when it was authored, and when it's due for an update, it also enables, the infrastructure also enables distributed collaborative knowledge engineering. We know it's basically impossible to get a room full of clinicians together with pharmacists and IT folks to do the rule update and maintenance, so we do it all virtually in E-rooms wherein we can do an update on the Gerios (ph), for example, geriatric prescribing knowledge base, virtually, over time and over geographic distance, without having to get everyone together. We're finding this to be very effective. That's the tool part of it.

The governance part of it is that we've created an enterprise committee, the clinical content committee, which is an enterprise empowered committee, if you will, that is responsible for saying what, where are we supposed to go and what are the directions we should follow for new knowledge or updating knowledge in the LMR resource, the EMR.

>> Carolyn Clancy:

Thank you.

>> Lillee Gelinas:

Any other questions for Blackford?

>> Karen Bell:

This is Karen Bell. I have one last quick one. Clearly you have multiple physicians using the same electronic health record and having access to a lot of historical information they didn't order themselves, which means that they can be seeing abnormal lab results that perhaps someone else didn't pick up or act on. What types of policies or procedures do you have in place to assure that A, either patients don't fall through cracks, or B, if something unusual is picked up that could be problematic, then it gets to the right clinician?

>> Blackford Middleton:

Yeah. It's an excellent question, and I don't think we have any secret sauce or magic bullets there. Every order is returned to a responsible physician as I've showed already in the results manager module, so if you ordered it, you get a result. And if it you aren't able to retrieve that result, it's your obligation to find a colleague or practice partner who will review those results for you.

We have another system that I can't show here, behind the scenes, that is the physician notification system. Any panic lab result, that is something that is far out of normal range on any laboratory value or any other result, the physician, ordering physician, or the responsible physician on call, is paged immediately with those kinds of results. And we found for example in papers that are available online, you know, that that has improved the response rate to panic laboratory values by as much as a third less time. Does that make sense?

>> Karen Bell:

Yes. Thank you very much.

>> Lillee Gelinas:

Karen, I believe it may be time to thank Blackford and move on to our next presentation.

>> Karen Bell:

Absolutely. Thank you very much, Blackford. Very nice to sort of see what's happening in the real world, and I put that in quotation marks, in addition to see the electronic health records you've seen in the federal state.

>> Matt McCoy:

Can I interrupt you just one second with a quick technical note. I'm sorry. Dr. Middleton, if you could, so we can go back to the slides, if you go back to where you started the application sharing and hit the green door with the orange arrow icon to shut it down for all of us, please.

>> Blackford Middleton:

Thank you, kindly.

>> Matt McCoy:

Thank you.

>> Lillee Gelinas:

Karen, just as I looked at what Blackford was highlighting there, the dashboards and, Carolyn, for you, I know, this zero defect care screen, I'm not so sure I've seen a lot of that in other EHRs. Since my time on AHIC I have seen a lot of EHRs and I'm not so sure I've seen that example of a dashboard that actually had status related to zero defect care.

>> Carolyn Clancy:

No, I have not seen that either, thank you for pointing that out.

>> Lillee Gelinas:

Terrific.

Okay. Legal and regulatory review. Karen, I believe there's a letter in our packet of materials.

>> Karen Bell:

That is correct. As you all recall, we had a very exciting, but too short for the timeframe, set of public testimony from a number of legal experts. Mr. Michael Kidney from Hogan & Hartson. We also heard from Mark Tatelbaum from George Washington University and from Bruce Wolff of Manatt, Phelps, & Phillips. They've provided us with a good deal of information about possible increases and decreases of liability associated with electronic health records, which is summarized in your minutes from last time, and also will be summarized as we move forward into the recommendation mode. But we did have an opportunity to ask them for a few additional questions. A number of people did have additional questions, and they did respond in writing to the Workgroup.

This letter is now part of the public record, and will be available on the Website. Our intention is not to read the entire letter, because it is actually quite long and would go beyond the five minutes. But I would like to just highlight a few elements from the letter.

One of the questions that was asked about whether or not certified EHRs that attended to and included in the functionality good ways of organizing clinical information upfront so that it would come to the attention of the physician and would not be lost, could in fact decrease liability. And so they did agree that perhaps we might be wanting to speak with the Certification Commission about ways that a certified EHR can present information so as to decrease liability.

There was also some question about clinical decision support systems. I believe that here the response really did fall in the area that physicians have a responsibility to review available records. So that if in fact turning off various modules or not using available clinical decision support would be tantamount to not reviewing available records, that could be -- that could be a problem. And I think that really underscores the fact that if we are moving towards clinical decision support, it is clinical decision support that is truly helpful and not something that is easy to ignore or suppress. And again, there's a full discussion of all three in response to that as well.

There was a further question regarding information overload, and again I think the issues here that they responded to are very similar to ones that they made earlier in that if the information is well organized, it clearly will be important to move in that direction.

The other kinds of questions resulted in responses that refer to some of the previous work that they had had, and the entire letter itself went on for about six pages. So what I would like to suggest is that we make this, this is available online, everyone review the letter and everyone review the previous information, and we will take that into account in our further discussion about possible recommendations in the medical liability area in the future. So that -- and again, if anyone has any other further questions or concerns, related to this area, then we can again get back to the team and they can continue to inform us.

Is there anyone who has any questions or concerns or have any other comments about this particular area? Before we move forward with our 2:00 testimony.

>> Lillee Gelinas:

Karen, related to our previous Workgroup meeting, it's all about there's been terrific testimony but it's the so what. What is the recommendation that's going to come out of this? And I'm struck by one of the presentations that really clarified how much information hits the physician and the caregiver as a result of EHR, just that overloaded piece. So I would really want to encourage what Karen just said, that the Workgroup members look at this in the spirit of reminding us the terrific testimony that we have had up to this point, and crafting what the recommendations would be as a result.

>> Karen Bell:

Thank you, Lillee. We'll come back to more on this later.

>> Lillee Gelinas:

Yeah, because I'm not there yet. I have to honestly say I'm not sure what we would be recommending.

>> Jason DuBois:

Dr. Bell, this is Jason DuBois, I just got on a little late, and I apologize. Which of the four letters is the one you want us to take a look at? Is it the recommendation planning cover letter?

>> Karen Bell:

No, it is a letter that, it should be in your packet.

>> Jason DuBois:

I'm looking at it on the Website. You said it was up here.

>> Karen Bell:

Not this Website. It will be on our Website where one looks at the Workgroup letters and recommendations and the work of this Workgroup.

>> Jason DuBois:

Okay.

>> Karen Bell:

A memorandum to the American Health Information Community, Electronic Health Records Workgroup from Melissa Goldstein, Michael Kidney, Mike Tatelbaum and Bruce Wolff. Dated -- subject follow-up to legal regulatory panel at Workgroup's January 11, 2007 meeting, and we just received this yesterday. So it was sent out to everyone just yesterday.

>> Jason DuBois:

Okay. It's the memorandum there?

>> Karen Bell:

It's a memorandum and it will be available on the Website, this Workgroup's Website.

>> Jason DuBois:

Great, thank you. I'm printing it out now.

>> Karen Bell:

Thank you.

>> Lillee Gelinas:

Okay, great, let's move on. We're right on time to the organizational aspects that we wanted to discuss. Is Chuck Parker with us?

>> Chuck Parker:

Yes, I'm here. Can you hear me?

>> Lillee Gelinas:

Hi Chuck. We can hear you fine. And I believe there's a slide deck that supports your presentation as well?

>> Chuck Parker:

Yes, there is. I do appreciate that. What I want to discuss today, there’s a couple of issues, one is an update from the field here again working as many of you know, the DOQ-IT project itself is focused on that small- to medium-sized practice that is not affiliated, like with the academic medical groups. And to pick up on a point of what Blackford was mentioning is one of the things I'd like to talk a little today in the first part of the presentation is kind of how we are seeing acquisition being made by small- to medium-sized practices. Obviously there's that pull out the checkbook, we’re going to write a large check. But one of the things that we're getting into is how do we help them find alternative methods to afford these types of technologies? And I'm going to cover four areas and then I'm going to go into a little bit more detail about some of the ASP environments, as Stark is starting to have an implication in that area, particularly in the community-based models at this point.

Moving on to slide 2 -- I don't have control of the slide deck, so I'll just have to say move on to slide 2 --one of the things we’re seeing here, and one of the ways we can negotiate with vendors, is the stepped payment methodology, which is, you basically negotiate upfront with a vendor to create stepped payments so that, particularly we see in the first part of this is that they're not paying a full payment at first because they're not using the full application at first. So they start to kind of move through this and allow them to ramp up their payments as they go through that interim step, if you will, of the loss in productivity that they have usually, typically learning the EHRs.

On the next slide, what we see here is in the areas with the milestone payments, this is the one that we typically do see a significant number of areas of opportunity in the marketplace. And the reason we see this is that the milestones are based upon reaching defined, set marks within the contracting and implementation. We tend to see a lot of this and encourage this because in the marketplace it's kind of, it puts the vendor on the hook to some degree to reach certain milestones so that they're making sure the small vendor, I'm sorry, the small physician office can make sure that the vendor is, still has their vision in mind and making sure that they're reaching those next sets of goals that they need to. So typically you have, what we see is a like a 25 percent model, split four ways. So there’s 25 percent upon contract signing, 25 percent on the day they go live, 25 percent on what we consider functional levels of the front office, so e-prescribing, appointments and scheduling, and then also in essence lab results coming in as well, so some of these front office pieces. And then a 25 percent payment due sometime in the 90-day future afterwards, where the docs are able to achieve a certain level of documentation. It does require some upfront costs but it is staggered and allows necessarily an ability to pay for these things and here again somewhat keep the vendor engaged in the process as well to ensure things are moving forward.

On the next slide, what we do see in this case is the modular payments. Now, this is a little bit different in the sense that the application has to support that capability in essence, it has to be delivered from the vendor, by using modular payments. We see this, for example, some examples of that today we see in the marketplace are Allscripts, with their application modularity and we’re starting to see some vendors now who are breaking parts of their application apart and creating starter sets, if you will, so as e-prescribing has become a significant focus in the future, what we're seeing is we're seeing vendors uncouple that e-prescribing functionality as a first module that will then, you basically buy an additional key that unlocks the rest of the application. So we're starting to see that. It's nice in that you can structure based upon the workflow that you’re working on at that time, and it truly is a pay as you go strategy. You're only purchasing what you're utilizing at that given time.

The next model that we see is, on slide 5, is around the areas of how you actually would rent an application. This is somewhat similar in concept to what you do with an application service provider, but instead of actually renting the application and placing on a server, that application and technology all resides within the physician office. It's somewhat beneficial to the physician office in the sense that the vendor is still on the hook in these rental agreements to maintain and place the upgraded versions of the software, so in essence you're wrapping all your maintenance and service fees in this particular area. This is not unlike a lease or a long-term application use and like I said it's also very similar in concept to an ASP, it’s just that all the hardware is located onsite. It does include all the, you know, benefits of the fact it does have considerably lowered upfront costs.

The last one that I think we're seeing a significant interest in, on slide 6, is in the area of application service providers, which are hosted applications, where the services and services are hosted offsite. There's less technical resources needed at individual locations. Obviously there's a pay as you go strategy with a single source, and there's ongoing costs, though, some of the negatives are the fact you never own the license, you're basically paying a monthly subscription fee. It does have a positive tax benefit across the states and also at the federal level, in the fact that the leases can be taken off of those as a credit.

On slide 7, what we're seeing here in this instance are some models of how we actually see ASPs being deployed in the marketplace. There's those that are deployed directly by the EHR, meaning that either they own the service or have contracted directly with third party providers to offer their services. There's centrally hosted, locally managed services. This is the area that we see the most explosion of growth in, now that the Stark legislation has, the Stark relaxation has actually kicked in. And these are typically hosted within the community for an IPA, PHO, employee groups of physicians, also typically surrounded by, or defined as within a community of practice. They are typically hosted by the hospitals since hospitals typically have the data centers that have the needed redundancy capabilities built into them inherent within these communities. But it also provides a sense of locally managed services in the sense that the people who are in control and own the system are local and are typically the docs of those, some of those users that are local there.

The third area is locally arranged hosting services, and this is kind of a hybridization, if you will. It's taking a company such as an EDS, or a Perot Systems and utilizing them as a third party hosted group. And some of the reasons they do this and some of the areas we see this is where you don't have a strong physician, I'm sorry, community-based hospital system, or a single model where you may have competing hospitals in that area who are trying to offer the same similar services. And you would offer this through a third party such as those types of providers like EDS, or Perot. A benefit there is that in the third party resources they can offer more than just the EHR itself. So for example, if you want to also offer practice management services, if you want to offer, for example, e-mail services, or even beyond that some things such as lab viewers and also radiologic viewers so you can actually have those available to the physicians. Those are something that you can't get with an EHR vendor-supported ASP. So we're seeing some of these third party pieces of the puzzle show up as well.

On slide 8, just moving on through the service here. What we're seeing in this particular area, and I'm sorry, is this is some costs associated with this. This was a HIMSS report that was put together about two years ago, came out approximately 2005. It's somewhat up-to-date still today because the applications themselves really haven't changed significantly in cost. And the models themselves of how you actually purchase really haven't changed. So I would say less than 5 percent variance, difference in the models that were demonstrated in 2005 to today. But it does show you some overall costs when we talk to physicians how they can get in these applications more effectively and given that as we heard that year 1 costs are what really kill physicians and what are basically the show stoppers and so how do you actually get into these different types of applications? The one model that I didn't talk about is the finance model today, and that's really how you go out and you can use a lease or a bank, bank financing to get in the application. We typically try not to get into that because obviously its ongoing expenses are considerably higher than if you were taking a look at one of the other three models there on that particular system. So on the purchase model we do have ways of breaking that cost up as well, where you're cost shifting so years 2 and years 3 become bigger and that's with the stepped or the milestone payments as well. But this is giving you a idea and this is a tool set we help and work with physicians on to kind of create here's some costing models here for this particular area.

Moving on to slide 9, I did want to talk a little more about the ASPs and what's going on and what we're seeing in the communities here. Some of the pros of this, using the hospital or community-based EHRs, are that they can offer more than just EHR software. As I mentioned before, we're seeing them offer things like e-mail services to these physician offices in addition to, in some cases, practice management as well. It doesn't really require significant level of technical staff as well within the physician office. You know, that's one of the little dirty secrets that most of us within the industry haven't really explained, I think, in this particular area in that while there is cost savings in staff, for example, file room clerks, the issue is that if you are setting up an EHR in a physician office, it does now require some level of technical competency within that practice you have that either train staff or you have to acquire that knowledge base. There is standardization within a community of data and resource and that standardization obviously also lowers costs. So it does provide a single unified model, and provides an easier mechanism, for example, for lab companies to be able to transmit data in a more unified format, e-prescribing can be more efficient in that sense as well. And typically just referral information between specialist and primary care could be more effective.

One of the cons that we do see and this is a significant area that is actually a cost barrier in that sense is do you have high speed access, can you acquire enough bandwidth to ensure that the application can run? Because the servers aren't located at your facility you now have to have some level of high degree of redundancy or network capability connected to that network. That becomes a difficulty particularly when you get to more rural areas who aren't serviced by your typical larger Verizon, Comcast, Time Warner, AT&T areas where they don't typically have that. Now, interestingly enough, we actually see a considerable amount of high speed access available in what I would consider to be the ultra-rural areas such as Montana, far parts of West Texas, where the universal service fund has actually kicked in to enable those networks to be placed out there in those market spaces. In the con is also there's still an ownership question: who legally owns the data? And it becomes more of a significant issue once you start taking a look at the secondary uses for that data. When you're doing research, when you're doing potential quality, population health-based quality improvement measure sets as well. One of the things that we've heard before, just recently on some of the other calls is there still are tax implications for those 501(c)3 organizations in donating in that 85 percent area, being able to provide services out to physician office who are for-profit entities. This still applies in the ASP areas because in a sense they're providing a discounted service to those physicians as well. Still is a concern, still need to have some clarification.

On slide 10, one of the areas where I think we wanted to talk about here just a little more about the market space we see. Now the DOQ-IT project within Massachusetts, I wanted to note that we are working with about 34 different organizations and when we talk about organizations that is either IPAs, PHOs, or physician office organizations in other formats. The 34 that we are currently working with, all but two are creating some level of ASP. And I would say that more than 50 percent of those have started that process after the August timeframe with the relaxation issues that were taken care of at that point. I would say that most of them were investigating this, had models in place from a legal perspective but the relaxation now has accelerated that opportunity to release those to the community of physicians.

What's interesting to note is that three are mixing models to allow physician office variation, in the sense that not only do they offer an ASP but the particular vendor they've selected allows them to have both a server-based model in the physician office and an ASP, because the interaction in the back end, they have the connectivity to allow that to happen so they're offering a mixed model in the sense to meet the physician demand and/or whatever they feel from their security standpoint.

And then at least three of our communities will offer more than one vendor in an ASP environment. They're large enough organizations, they feel that they couldn’t meet the demands of the physicians, and since, for example, an IPA, where they don't own the practice, they felt it was going to be very difficult to demand that they all go to only a single vendor in that sense. I know that Micky is going to be on a little later but I did want to mention the Mass eHealth Collaborative as well in this area, in their three communities, one community went with an ASP model, one is a mixed model, the largest organization is mixed where they have ASP environments within the specific subgroups within that environment, but they do have an HIE in the background tying them all together. One of the other groups went with individual servers in a health information exchange in that sense as well. So in that sense we're seeing that there is a, even in the demonstration projects, we're seeing ASP-type environments being quite popular in this sense. Now, shifting my talk a little further back to another area on slide 11.

>> Karen Bell:

Could we just check in on a couple of questions on this piece, Chuck?

>> Chuck Parker:

Sure, go ahead.

>> Karen Bell:

Is there anyone else that has any questions that they'd like to ask at this time, or comments?

>> Howard Isenstein:

Hi, this is Howard Isenstein from the Federation of American Hospitals. Sorry for joining late. I have a couple of questions. You know, looking at the HIMSS data, I'm really surprised that the ASP model isn't significantly cheaper than the other three. From your real world experience, I mean, would you say that the HIMSS data is on the money, or that the ASP is even more cost beneficial?

>> Chuck Parker:

I would say it's, in my opinion, in what we've seen today, in the deployments we already have, it's relatively close in the market space. I would say that some of the costs that you may not be thinking of, for the, in the ASP environments, is that typically in the ASP, they take on help desk level 1 support. So in essence they become the first line of interface for the physician office. And in that sense it adds a technical cost associated with that services and software.

You know, the benefit comes when you have a significant number of physicians and that can spread the costs, the fixed technical cost and the staffing cost across the backend across a broader range of physicians. So in your, in my opinion towards your statement, yes, these costs go down if you have 200 or more physicians in a typical ASP environment on a single vendor solution set. There are even more significant advantages when you get into the 500 to 700 range, and these models do become, the costs do become considerably more compressed, more cost-effective when you're able to spread them across a broader base.

>> Howard Isenstein:

And my other question is, what you've shown is a considerable movement among vendors on what, of trying to come up with solutions that work for the small physician office place. I mean, it seems like they've definitely moved from say, two years ago, where transfers like here's what we got, take it or leave it. So are they, it seems like the competition is heating up more and is that reflected on the pricing as well?

>> Chuck Parker:

Yeah, we don't see it on the pricing though we do see a change in the way of acquisition. There's where the competition is. Most vendors feel like they're priced competitively and they feel like they really can't drop their floors significantly more than where they are. Typically they have also, most of them have written most favored nation language into their contract clauses so that if somebody else gets a better price it kind of has to affect a significant group of physician practices. They're very leery about dropping that price. So we are seeing them be more creative in how they acquire new licenses, and being able to extend these different types of models to the practices. I will say that most, the complicating factor still today is that the vendors will still lead with here's the single monolithic price, pay me upfront and that's it, and you have to ask or know to ask that particular vendor for what are the alternatives and how to get into those alternatives.

>> Jim Sorace:

Chuck, this is Jim Sorace from CMS. Have these community-based ASP models been superior at actually getting the EHRs populated with data from local data supports sources that are important? So, you know, local hospital labs, maybe even national labs, mammography centers, that type of thing. Do we have any experience on that yet?

>> Chuck Parker:

Well, it’s particularly beneficial when the community hospital is actually the commercial lab provider in this area and that's where we see a significant number of them saying hey, this is a profit center for the hospital and a way for us to maintain that by offering this as, the EHR as another model, extension. But they are very, they've been very effective in being able to get that information populated. Since it's a standardized interface, these vendors can create those interfaces just once and it makes it much easier to populate that data across. Now, given that, you do have master patient index issues that tend to have to be put in place. But that's easier here again because you're aggregating to a, you’re aggregating costs across multiple physician offices.

>> Jim Sorace:

And any similar experience with imaging and e-prescription and other types of data sources?

>> Chuck Parker:

Yeah, e-prescribing is certainly something that's been very effective in this particular area and here again because you can aggregate. In some cases we've seen where e-prescription can help pay for the systems because they're such a good benefit cost. With digital mammography, digital imaging, and other areas, yes, it's easier here again managing those services, particularly if the community hospital is engaged in those as a profit center. But even when they're not, here again providing that common location and single location for multiple docs makes it much easier in the marketplace.

>> Jim Sorace:

So do you think this might contribute to savings in the future, I guess?

>> Chuck Parker:

It should. Because you're connecting, we haven't seen that effectively proven out yet. I think you see some models such as what Partners has demonstrated within closed loop systems where it does. But we're still in that, trying to evaluate that from a community-based system whether or not it will. All indications are that it should, though.

>> Karen Bell:

Chuck, this is Karen Bell. One of the questions I have has to do with the ownership of the data. I'll pick on Blackford because he happens to be on the phone, but suppose I’m practicing back at Partners and they have an ASP model and I decide I no longer want to be part of the Partners system. Who owns my medical records? And who is responsible for maintaining them for the length of time that they need to be maintained under Massachusetts state law?

>> Chuck Parker:

That's something that we're still trying to resolve with HISPC and other areas but specifically speaking, in that particular area that becomes part of a data use agreement that physicians sign on with when they involve themselves with these particular ASPs. And what they are, what we're seeing from a legal perspective is that their data becomes part of a community. If that, if you as part of the practicing physician want to leave, you're entitled to take the data on your patients with you so there's an export, whether it’s in paper-based format, which we hope doesn't happen, or with the new CCD type of application where you're able to export it into an electronic format. You are entitled to take that data with you, but it stays as part of the community record because now you are updating part of the community record.

The important thing that we start to see with ASPs, and it becomes very critical here, and Blackford did a very good job demonstrating that without actually talking about it, is this patient-centric view of the healthcare record, and it’s one patient, one record, as opposed to the physician-centric view, which typical EHR vendors deploy today. And that once you get to that model in these communities, it becomes very difficult to say that individual record is a single provider's. So what we see in the data use agreements is that they are entitled to the data on their patients, so there's an export of that data, and they may have data from referring physicians in that record but they're allowed to take that with them. But that data does not leave the system because it's part of an integral operating platform at that point.

>>

And --

>> John Houston:

This is John Houston, can I ask one question to clarify that?

>>

Yes.

>> John Houston:

Does that also mean to say that if I'm a patient from a physician and I'm say a dermatologist, and if I'm deciding to opt out using this any longer, that I would get the entire patient record for all of my patients including visits and encounters and information unrelated to the services I provided, say, services of a cardiac, cardiologist or whomever else that is unrelated to my specialty?

>> Chuck Parker:

According to the data use agreements that we're seeing today, yes, you’re entitled to that, but there are filters that can be applied to filter that out so you don't, if you leave and don't want that data you can filter that out. But according to the rules, you would be entitled to that data.

>> Karen Bell:

What about a vendors ASP? Does the vendor do the same, allow the physician to take with them in electronic format all of the records that they have generated on that patient?

>> Chuck Parker:

Yes, and specifically within the DOQ-IT project, when we're looking at helping physicians work through these issues with vendors, we specifically delineate and say that you need to have clauses issued in your contracts that say that you own the data. So specifically, most of the vendor arrangements that we see today, is that the physician always maintains ownership of the data. They're just holding the data at the third-party location.

>> Karen Bell:

But that's, you made an interesting point. You do that as part of your work around DOQ-IT.

>> Chuck Parker:

Right.

>> Karen Bell:

A physician who has been approached by an ASP vendor may not know to do that.

>> Chuck Parker:

Right. I would say that we don't negotiate on behalf of work with the physician practices. We in going through these discussions and saying here are the outlined issues that you need to be aware of when you're negotiating these types of things.

>> Karen Bell:

So the bottom line you is educate physicians on what they should be putting in their contracts so there is a body of knowledge that you've accumulated that you can impart and maybe that's the segue into DOQ U.

>> Chuck Parker:

Yes it is. Specifically, actually, it makes a very good --

>>

Hello?

>> Chuck Parker:

Yes, can you hear me? Yes, it's a very good point. It actually is in this part of this particular area, in this body of knowledge we're delivering in the marketplace. If you want to get back to the presentation here, in essence of time, I did want to cover a little about what's going on here with this new product that is coming out in the marketplace called DOQ-IT University. And this is a product and project that was funded by CMS, and Jim Sorace, who is actually on the call today, actually he's one of our task leaders with the project that’s funded by CMS.

>> Jim Sorace:

Just for clarification, Sue is the task leader in that capacity. Go on.

>> Chuck Parker:

Anyway. In this case. DOQ-IT University was officially launched in January. They're on slide 12, I've included a link to that particular Website. This link gets you past the security at this point. And the reason I suggest that, or I provides that to you, this is our demo, working site that we work with our technical advisory panel members. This courseware actually does allow us to track and eventually will allow us to apply CME credit for the physicians who are going through this particular program. Bu this particular link gets past all that registration area. If you want to utilize this, you can certainly jump into it and see what this DOQ-IT University application (inaudible).

This project is, as I mentioned, a CMS-funded initiative to spread the learning and wealth of knowledge we've acquired during the DOQ-IT project over the last three years. And to effectively disseminate that more to those practices who and where DOQ-IT cannot reach. Or provide that for even those in DOQ-IT to be a little bit more efficient in this particular process of how do we get them through the knowledge base.

At this point care management e-learning is coming in March, one area where it's not fully vetted out yet. We're still acquiring some of that knowledge. Just so you know, this project is actually worked (inaudible) there’s a 17 member technical advisory panel that comprises members of AAFP, ABIM, ACP, and others. HIMSS is on this. There are health plans, actual commercial health plans. CMS is on this, AHIMA. And there are three solo practicing docs who are out in the practices who actually do this as well, who are on this particular committee as well. So vetting this through multiple resources and research areas to make sure that we're gaining and acquiring the knowledge.

On slide 13, it's, this is, if you click on that basic link I showed you, this is what will pop up, with the exception of the green check where I had gone through one of these particular areas. But what we see is sort of our adoption model where we take the physician practice group, helping assess where they are, helping them plan to go and understand okay once you understand where you are, where do you want to go and helping them plan for their EHR deployment.

And then there are three pathways they can work on in that planning stage which is culture change, how do we actually get the people within the practice to understand what's going on. And Karen, as you mentioned, this vendor selection piece. This is where we're helping physicians with tool sets that they can download or actually look at and take this lesson to figure out how do I help understand negotiation of these contracts with vendors. There's also RFI, RFP processes in there if they want to go that route as well. And then the bottom one is operational redesign. How do we get them through these particular areas.

And then once you get into implementation, what are the expectations for implementation, how do you actually get into implementation. Then how do you continue this process of evaluating (inaudible) and then care management is another module that will get them into these paper quality demonstrations, provide them the necessary detail to get into the things, we saw what Blackford was demonstrating with diabetes management, getting to that zero defect care type of application process as well.

So this is where we are with DOQ-IT University today as far as the high level. Each one of these, and if you go on to slide 14, basically will show you this is one called operational redesign and it shows you some of the areas of where we can get into these and the lessons contained within there. At this point there are 17 functional lessons today. We are continuing, this project started in November, in earnest in November, and so as of today we have 17 functional modules within those categories that you just saw.

In this particular one of operational redesign there are six categories. How do you do the process, what is process redesign and description of the tools. What is patient flow, how do you map it. How do you do point of care documentation. How do you manage documents themselves. What's the office communication structure look like, and the clinical processes in getting ready for care management.

So in every one of these processes, just as an FYI, care management is a portion of them. Given the fact that DOQ-IT itself is, has in its nature a focus on adoption of electronic medical records, the care management bit does have electronic process.

This is basically the end of presentation, so if you have questions about this particular section as well --

>> Karen Bell:

Chuck, this is Karen. I know that these have all been tried and true. To what extent would you say that these processes have actually been implemented and tested throughout the country?

>> Chuck Parker:

I would say that as part of the DOQ-IT project, this was part of our training we utilized. I would say that we're continually modifying these, so I can't say that every one of these processes has been vetted everywhere in the country, because this is real-time learning and we use a continuous rapid cycle development process within this learning environment. So that as we learn new processes out in the field, and so it's taking things such as in Colorado, some of the work flow redesign that the Colorado areas have done and accomplished and demonstrated. We incorporate those as we learn them and are able to aggregate them effectively. So I can't say it’s across the board been tested everywhere, but these processes are in play today in all the QIOs.

>> Karen Bell:

Thank you very much, Chuck. That was great.

>> Jim Sorace:

This is Jim Sorace from CMS. I just wanted to add parenthetically that we're making this available for physician offices that are outside of our direct IPT, or those that have already agreed to work on the DOQ-IT project.

>> Chuck Parker:

It's not limited to any, not only is it not limited to that, it’s not limited to Medicare, so any physician or physician office person would be able to log on to this. They simply need to go to the MedQIC area of, and be able to basically you have to do a search for the DOQ-IT University and anybody can log on to it.

>> Lillee Gelinas:

Karen, perhaps one of the things we need to consider as a Workgroup going forward, is spread of this. This isn't a case of development. It would seem like it would be an opportunity for spread.

>> Karen Bell:

Certainly seems that way. And now that it is available online where we all can see it and review it, I think that it may be helpful for us to all do that before the next Workgroup meeting, and spend a little bit of time thinking about how to make this information more available.

>> Lillee Gelinas:

There's a huge field uptake issue here.

>> Karen Bell:

Yeah.

>> Chuck Parker:

And this is designed to also be worked within the QIO, so not only would you be able to access this online, you can work with the local QIO to also gain additional knowledge through this tool set.

>> Lillee Gelinas:

Right, right.

>> Karen Bell:

And even the medical societies in each state. So we can really think through about ways to disseminate. Thank you.

>> Lillee Gelinas:

I think that's the operational action here.

>> Karen Bell:

Uh-huh.

>> Lillee Gelinas:

Great presentation, Chuck.

>>

Thank you.

>>

Thank you.

>> Lillee Gelinas:

Karen, just a way of point of order here, we're about 20 minutes behind but we have 45 minutes of presentation left. Is that right? We have three financial presentations about 15 minutes apiece?

>> Karen Bell:

No, they're not 15 minutes apiece. I think this is all together.

>> Lillee Gelinas:

All together. Okay.

>> Karen Bell:

Yeah. It's around one particular topic, because this particular group, and it is a group, have come together to essentially be the first in the nation to define an approach on credits for EHR use when it comes to malpractice premiums.

>> Lillee Gelinas:

Right.

>> Karen Bell:

So we thought it would be helpful for the Workgroup to hear from them and I believe that they're all on the line, is that correct?

>> Jack King:

This is Jack King, I'm here.

>> Denise Funk:

Denise Funk, I'm here.

>> Micky Tripathi:

Hi. It’s Micky Tripathi. I'm here as well.

>> Karen Bell:

Thank you. Well, I think probably the best thing to do is to let you then just jump in and take over.

>> Denise Funk:

Thank you.

>> Micky Tripathi:

Thank you very much.

>> Denise Funk:

Micky, do you want to make any opening comments?

>> Micky Tripathi:

No, I don't think so -- well, I can just do a very brief one and then I'm happy to talk about the Collaborative to the extent anyone is interested at the end. But the Mass eHealth Collaborative is running three pilot projects in Massachusetts to outfit about 450 physicians with electronic health records and launch health information exchanges in each of the three pilot communities. One of the things that we've been pursuing is risk reduction, and in particular risk reduction that could be brought about by electronic medical records and health information exchange, and wanted to try to engage a malpractice insurer to consider first evaluating that and then second perhaps offering credits to the participating physicians for, on their malpractice premiums for their participation with the electronic health records and health information exchange. And we were just delighted to work with PIAM, the Physicians Insurance Agency of Massachusetts, and Connecticut Mutual Insurance Corporation, who came forward with a premium program, with the real live premium program that we've announced in three communities and we're going to start engaging the physicians in trying to figure out how to get that implemented and see who is interested. Let me just pause there and just turn over to Denise and Jack to describe the program itself.

>> Jack King:

Great. Denise, you're going to go first, right?

>> Denise Funk:

Yeah, I'm going to lay some of the financial groundwork, and some of the background from a liability insurer standpoint, which may be a slightly different perspective than the group has seen before.

If I could go to the next slide, please. Thank you. What I wanted to lay the groundwork on was the incredible amounts of money that are currently being expended as part of the litigation, medical malpractice litigation, that goes on countrywide and in particularly in the Northeast. These numbers that are on this slide are taken from the National Practitioner Data Bank, which you may be aware collects all indemnity payments for physician practitioners made as a result of a malpractice claim or lawsuit.

This data is specifically related to 2005, the year that the most, the most recent year data is available. And as you can see, from our perspective in Connecticut, the total indemnity payments, indemnity is really the money that goes to the patient or to the estate, was almost 104 million dollars in 2005 alone. Connecticut has the dubious distinction of having the highest average payment in the country, over 730,000 dollars per case. In Massachusetts, as a point of comparison, the total indemnity paid in 2005 was 123 million. So in relative terms, Massachusetts fared somewhat better than the state of Connecticut. But in the overall context, for 2005 the national total of payments was 4.1 billion dollars. That does not include legal defense costs, which adds another billion dollars to that number. And in Connecticut, for our cases, we paid out additional 4 million dollars just for the defense costs related to those paid cases. So you can see at the outset here, the amount of money that we're talking about is considerable, so anything that could make a reasonable dent in those numbers would be helpful for, obviously for patients and for physicians, as they are the ones who end up having to pay the premiums for these cases.

If we could go to the next slide, please. So obviously from our perspective, loss prevention is a critical element of this approach. The best claim is the one that never happens. For everybody, all concerned. And the benefits of a fully integrated EHR are obvious to this audience, but it also plays in terms of either preventing a case or actually defending a case, what I will refer to as litigation decision making. The benefits of having just point-by-point legal, I'm sorry, legible, accurate, and complete treatment documentation is incredibly valuable. The first thing that happens when either a plaintiff attorney is contemplating bringing a lawsuit against a physician, and then subsequent to that our review of a case for a defense or settle posture, is the medical record. That's the focal point, initial focal point for any litigation activity. So that's key. Obviously, the systematic follow-up on test procedures, medications, all of these things are very common sense. But they are, represent a good percentage of the number of lawsuits that actually result. One that is somewhat unique on the defense side is that the EHR can prevent medical record alteration. Now, this doesn't happen very often, but when it does, it almost automatically makes it impossible for a case to be defended. That act in and of itself can trump all other elements of a case. Continuity of care. Tracking patient visits, missed appointments, compliance. All of these things are key in a large percentage of cases that we see being brought against physicians.

Let's move to the next slide and talk a little bit more about the decision making. Just as a point of departure, I'd like to point out that two-thirds of all lawsuits are closed with no payment. So that means that the vast majority of cases that we deal with, we don't ultimately pay out indemnity but obviously we do have to spend a lot of money in defending those cases until they're closed, which can take a good number of years.

As I said before, medical records are always a principal focus in malpractice litigation. Does the medical record speak for itself in describing treatment? Can someone pick up that record and follow logically the treatments, the conversations with the patient, informed consent? Whatever the key elements may be, are they documented? It's the old saying, if it isn't written down, it didn't happen. And that's particularly true when we have a bad patient outcome. As I mentioned, if the document speaks for itself, a plaintiff attorney may choose not to file a lawsuit, even if there was a bad outcome because experts can support the treatment decisions that were made and it makes it very difficult for them to pursue a case.

As I said, two-thirds of all these lawsuits are closed with no payment, so the plaintiff attorneys in undertaking these cases also need to use judgment in evaluating whether they want to pursue the lawsuit. If the medical record speaks for itself, the defense of a lawsuit may be greatly facilitated. Again, as the record describes the treatment and how the decisions were made, that can really provide substantial assistance to us in defending a lawsuit. If these things aren't in place, getting back obviously to the EHR, a lawsuit may be impossible to defend, regardless of the actual medical treatment that was rendered to the patient. We get into the classic he said, she said, patient's family recalls one set of situations, the doctor recalls another, neither of which are written down. So it becomes much more questionable as to whether a case can be successfully defended.

So taking those elements as our basic premise, we concluded that combining a sound clinical practice with an integrated EHR should have an impact on malpractice premiums, and as a result of that we came to develop a program with Jack King at PIAM, which Jack will describe, that combines these elements together to provide premium credits for physicians.

Jack, I'll let you take it.

>> Jack King:

Great, thank you very much, Denise. Just a few words about, if I could have the slide that talks a little about who we are. Great. We're a broker, we're owned by the Mass Medical Society, we started in 1993. We specialize exclusively in insuring doctors and we're often faced with having to develop special malpractice programs because physicians are frequently looking for ways to reduce those costs.

Before I go on to the next slide, I just want to set the stage a little bit because it was about a year and a half ago when a fairly large physician group in southeastern Massachusetts approached us and asked us to do, look at potentially developing a malpractice program for them. And we turned to a couple of different companies, but pretty quickly settled on CMIC and between CMIC and us we developed a program for this particular group which was quite creative, if I do say so. And it included a number of special credits for the physicians in this particular group. And one of the things that it featured and was the first time we had ever, I had ever seen this offered, was an EHR credit for all of the physicians in the group that developed or had an EHR program. And as we explained to the group, this had never been offered to anybody in Massachusetts before, and at the time we didn't think it had even been offered to anybody in the country. But after a lot of soul searching on the part of that particular group and a lot of discussion, they decided not to move forward with the program. But the germ of an idea had in fact already been created. And I don't think we realized even at the time what the implications were going to be.

About eight months later I was in a discussion with, I met with Micky Tripathi, and he explained to me, having met with some of the insurers here in Massachusetts, and I'll let him speak to this issue more himself, but he indicated that they had looked at the possibility of developing a malpractice insurance credit and thought about it and then decided not to do it. And knowing that on this particular case that we had worked on, that CMIC had in fact been potentially willing to do it, I decided to maybe bring the Mass eHealth Collaborative together with Micky to see if there may be some synergy there.

So if I could have the next slide, please. We had a somewhat interesting set of circumstances here in Massachusetts in that we had the Massachusetts eHealth Collaborative and the medical society itself needing to have a credit and urging the insurers to come up with a credit, but there was certainly local malpractice insurer reticence. And they certainly were given a lot of opportunities to do something about this. But we then had, fortunately had a potentially willing insurer in CMIC, and we happened to be a broker that was working with the physicians so that when you, when they said at the beginning we were a broker, I guess you could say we were a broker is this situation in that we brought together the willing and malpractice insurer and the Massachusetts eHealth Collaborative, and the result is something that we think is going to be very special. The program that we're pulling together here in Massachusetts actually is for the Mass eHealth Collaborative and for all other physicians practices that meet certain criteria, that have a legitimate and -- EHR. And we'll talk about the ones that we're starting with and we hope that this list will grow.

If I could have the next slide, please. And Denise, please feel free to add anything that you want on this. But basically the way the structure works here in Massachusetts is that to be eligible, to get to the EHR credit, you first have to have good claims experience already. So as you can see, participants have, need to be claim-free for at least 5 years, and 75 percent of the practice has to at least meet that criteria. And so once the good claims experience is established, physicians can get up to 10 percent credit just based on the good claims experience. Once they have that and once they attest to having the appropriate EHR in place, there's an additional 5 percent credit. And there's an additional two and a half percent credit each for having an incident reporting program and an office self-evaluation. And obviously combined there's a potential for up to 20 percent in credits here. The EHR credit itself is 5 percent.

Denise, did you want to add anything to that?

>> Denise Funk:

No, I think that's fine. I think the only thing I would add, Jack, is that we're requiring that the EHR have been in place and operational for a year. As we know, these systems have pretty good time and effort to getting up into full operation, so we want to make sure that that period has in fact passed before the credit goes into place.

>> Jack King:

That’s a good point. The way we're structuring the program also in Massachusetts, the program is open to any practice of any size that meets the criteria for the Mass eHealth Collaborative physicians, and non-eHealth Collaborative practices have to have five physicians or more.

Now, if I could have the last slide, please. The vendors that we're starting the program with happen to be the vendors that have been approved by the Mass eHealth Collaborative or have been endorsed by the Massachusetts Medical Society. So these five vendors are the approved vendors, and we're hoping that this list expands moving forward.

Any questions?

>> Karen Bell:

This is Karen Bell. Before I ask a question, I would like to make a comment. The vendors that you have listed here are all certified by the Certification Commission for HIT, so that I think that you're setting a very good precedent not only by moving forward in this direction in general, but by having recognized, certified EHRs that fill very specific criteria not only for functionality but interoperability and for security. So thank you.

>> Jack King:

Thank you. Micky, did you want to add anything to this?

>> Micky Tripathi:

No, I don't think so. I think this kind of explains the foundation of it and would rather spend what little time we have answering any specific questions that the Workgroup might have.

>> Jack King:

Okay.

>> Karen Bell:

This is Karen Bell. I have two. Number one, I assume this is applicable to all specialties?

>> Jack King:

That's correct.

>> Denise Funk:

Yes, that's correct.

>> Karen Bell:

Okay. And secondly, how do you share this information with your colleagues around the country?

>> Denise Funk:

Well, as yet we've kept it really in Massachusetts, so it's just starting to get some public recognition. So I have to be honest, I don't know that we have a national approach on this.

>> Karen Bell:

Since you are on a national call, that's open to the public, is there a particular contact person that you would be able to recognize or identify, should anyone else want to learn more about your program?

>> Denise Funk:

Certainly, Dr. Bell. I think I would probably be a good place to start. I have several people on our staff that are working on this, but I would, I think I would like to be the contact person.

>> Karen Bell:

Thank you very much, Denise.

Well, before I ask for any other questions, I really would like to thank you so much for not only the presentation today, but for moving forward in this direction. I think it clearly is sending a very strong message on how important it is to have good documentation and EHRs in place, and will be a very strong driver in terms of supporting physician adoption. So thank you again for taking that first step.

Lillee, any other comments or concerns?

>> Lillee Gelinas:

No. This is clearly a bright spot on the horizon, as we just came out of our legal and regulatory piece. So I really thank you very much. Jack, Denise, and Micky, you did a terrific job.

>>

Thank you very much.

>>

Thank you.

>> Lillee Gelinas:

Let's move on now to some of the meat of our discussion today. We've had outstanding presentations to help inform our decision-making. But we need to move now to the AHIC recommendation planning discussion.

Plowing through my documents here, Karen, the piece for this --

>> Karen Bell:

There are a couple. One is the letter dated February 16th to the Workgroup that outlines the three questions. The second is the copy of the letter that this Workgroup sent to the chairman of the AHIC dated May 19, just to refresh everyone's memory on the old recommendations that are cooking along. And then thirdly, there are a set of documents entitled testimony summary and recommendation discussion items, on each of the critical components that we are addressing: the financial business case, the legal regulatory area, the organizational, and state of the technology, and privacy and security area. And these have been designed to essentially facilitate the very meaty discussion that now needs to occur with respect to forthcoming recommendations.

And what I would suggest is having had all this material that perhaps we look at each of those critical components with the eye of asking three questions of ourselves, the ones that are on that letter. Have we heard enough testimony in this area to feel that we can make a decision about moving forward and we can make some recommendations? Or do we need further testimony? And if so, what is it? And if not, what are the kinds of recommendations we might want to think about honing in on? We do not need to make the recommendation today. We just need to begin to direct ourselves in an area where we might be interested in making a recommendation and we can get into the specifics on the next go-round. Does that make sense?

>> Lillee Gelinas:

Yes, it's a lot to absorb here. Do you want to just take the critical components, each one?

>> Karen Bell:

I think so. Has everybody got their handouts on this?

>> Carolyn Clancy:

I'll start because I have to leave a few minutes early for a different meeting.

In terms of information that we need, I think an overarching question that we're struggling with is are we at what some would call a tipping point, or are we seeing any evidence that we've crossed the chasm from sort of the early adopters to the early majority? And I'd have to say I have no idea. But it does seem to me that some information about the impact of Stark would be very helpful. If we try to frame up recommendations to bring back to the Community, the overarching, sort of underlying theme is the if the market broken or do we need to do something here or make recommendations that address what is the market failure?

Just moving on, I would make two other comments. If you start to think about what the federal government can do, in theory, the federal government could incentivize or encourage demand from the private sector through contracts with OPM, defense contractors, and so forth. Having made that observation, let me just say I think we are way lacking in a clear path here. And in fact when I think about the RFI that the National Business Coalition on Health uses, and some other tools that I've seen, you can tell that there's a huge amount of enthusiasm for IT writ large but basically they allow folks to check off anything they're doing any time, anywhere, without getting real focused about it. And to that extent, I think we need more information on what has been this experience. Are these all like little prototypes that we're hearing about today, the Illinois Blues are reported to be something with the e-prescribing and so forth. Are they just trying this because it might work or is there some way to pull together a more systemic take on this.

And then the last area, I think that we could be thinking about is electronic prescribing. Which would represent kind of a threshold leap or something from focusing on the use of lab results. On the other hand, the advanced standards will be reported to the Congress very shortly and so forth. So --

>> Lillee Gelinas:

That's great, Carolyn, thank you. Because I do agree, I think you asked a pithy question that shouldn't be lost on the group. And that is the impact of Stark and is the market broken. In the private sector that impact of Stark is one of the key discussions. I know everyone thought that maybe it was going to be a barrier buster, but I clearly don't know where we are. But I know that right now the market's not driving the work from early adopters to mass uptake. It's just not happening.

>> Carolyn Clancy:

Well, and then there's always a question of, which I think is part of that Lillee, because I've certainly heard others make the observation you've just made. And what is the lag time, and I don't think we have any prior experience to know. Is that people need to sit and cogitate six months and organize themselves in order to be able to provide these services, or in fact was this a necessary but not sufficient incentive?

>> Lillee Gelinas:

Well, you know, I go back to the presentation I forgot which one had the, I think it was an HFMA charter we were just talking about the different comparisons of financial models on a year to year basis, the hosted rental finance purchase piece, and in talking to so many physicians in the private sector, it does boil down to the finances. I was trying to really get a sense of what is the true cost of market uptake for the small practice. I think we've seen outstanding results from closed practices, whether it's Cleveland Clinic or the Veterans' Administration or Kaiser Permanente, that's a whole different deal than what the majority of the market is for the private physician.

And if the implementation cost is accurate on this graph, anywhere between 80 and 100 K, that means the average physician would have to lay off two to three FTEs to get the money to implement IT. We just haven't crossed that financial business case place yet, which was I think one of the true intents of the critical component around the financial and business case. And it was one of the key issues that was raised by this Workgroup very, very, very early on in our work. I haven't seen, and I just ask the Workgroup for your input, have we seen good compelling cases that, of pilots that really can address this financial business case for the average practicing physician?

>> Blackford Middleton:

Lillee, this is Blackford. Can you hear me okay?

>> Lillee Gelinas:

Please, yes.

>> Blackford Middleton:

In Massachusetts, I think Chuck was alluding to some of the factors here locally that have been very powerful stimulants to adoption and they frankly go right to the bottom line, if you will, for the small office environment physician. The P for P programs and other forms of incentives that increase return of withhold or provide a bonus payment for EMR adoption or use of EMR, or provide a bonus payment for attaining quality benchmarks, I think are the types of things that have not yet been adopted nationally or programmatically, that rectify part of the market inequities. I think, I don't mind using the term market failure, but I'm afraid that may not be perhaps useful in the political context or in the policy discussion. But I think we really are at a logjam, at a variety of levels, for the small office environment. And absent some kind of intervention of one form or another financially, I'm just concerned the small office environment will be very, very delayed or perhaps never adopt.

>> Lillee Gelinas:

Thank you, Blackford. You said it much more eloquently than I did. But I think we've seen outstanding case studies of closed physician systems that have great systems and great results. And it has so informed, I know my thinking, from August 2005 when AHIC was launched. But what we haven't seen is that that private physician issue, which will lag this whole project. I know we haven't read every word on the page, but Carolyn, thank you so much for getting to the heart of the matter quickly and informing our discussion. But in terms of more information that we need, is there agreement across the Workgroup that we really do need more on the impact of Stark?

>> Karen Bell:

This is Karen Bell. I think one of the problems that we do have with the Stark legislation that was alluded to a little bit earlier by one of our presenters, and that is that a number of hospitals have been concerned that they will lose their tax-exempt status --

>> Lillee Gelinas:

Right.

>> Karen Bell:

-- if they were to make significant donations. And what I can share with the Workgroup is that some of our staff, Jodi Daniel who is the, our director of policy here, has been working with the IRS, and with the American Hospital Association to try to resolve that to everyone's satisfaction. And we do believe that in the next several weeks, that issue will be resolved and hospitals will feel more comfortable that they will not lose their tax-exempt status should this move forward. So it's going to be very hard to assess the impact of Stark, though that is written into some of the measurements that we will, we have moving forward on adoption, until that actually is clear and not-for-profit hospitals recognize that it is safe for them to make these donations.

>> Lillee Gelinas:

And Karen, I'll be a little bit more direct with what I hear from CEOs of not-for-profit hospitals and their board. It’s they fear literally being thrown in jail. It's not just losing their status. It is a legal noose that is a huge fear in the private sector. So we would be well to do everything we can to eliminate those fears.

>> Karen Bell:

Well, in many ways, I think what we're talking about, and maybe this is, this may go to a recommendation, it may not, but I think we at least have this large area that Carolyn so wisely pointed to, is that we need to make sure that the intention of Stark leads to the implementation or leads to results. And part of that is tax-exempt, part of it is legal concerns, so I think we're probably, we might need some guidance or some other vehicle that will allay these fears and concerns. And maybe ultimately that could be a recommendation of this group. But I would throw it out that something related to Stark in allaying hospital concerns will be important.

>> Howard Isenstein:

This is Howard Isenstein. I mean, the regs came out on Stark and the administration said here's our solution. Last year, you know, there was a lot of talk about getting some bill with Stark language in there. I mean, I'm not sure what we can do at this point. I mean, you know, the reg is the reg, and our hospitals and others have said it's not, we're still nervous and it's not adequate. And you know, we want legislation. But that didn't happen. So I mean, I'm not sure what, short of that, what we can recommend or do about it.

>> Karen Bell:

Possibly guidance, Howard.

>> Howard Isenstein:

So have OIG, I mean, who -- the recommendation would be ask for OIG to issue guidance or what?

>> Karen Bell:

Well, since the reg is a CMS reg.

>> Howard Isenstein:

Yeah.

>> Karen Bell:

CMS would issue guidance on this, if we feel that it's important enough.

>> Howard Isenstein:

I mean --

>> Lillee Gelinas:

I have to concur with Howard, it's important enough.

>> Howard Isenstein:

And do you think that would do it, though, issuing guidance?

>> Karen Bell:

You know, we can certainly discuss that with OIG, and --

>> Howard Isenstein:

Certainly it absolutely couldn't hurt. I mean, I totally agree. It absolutely couldn't hurt. I’m just, I mean, I think that's a fine recommendation. I just, what I'd like to know, what we could also do is I think we should get a general counsel or two at a hospital or a system to say what is the guidance you want that would make you much more comfortable before we go to CMS. I mean, what do you think of that?

>> Karen Bell:

I think that's a great idea.

>> Lillee Gelinas:

I think we have to be crisp on what our recommendations are.

>> Howard Isenstein:

Right.

>> Lillee Gelinas:

If there's clear implication for us that we need to make a recommendation in this area because what's out there now isn't working.

>> Howard Isenstein:

Right. Well, I mean, I certainly can have, I mean, why don't we plan on then, I could ask AHA, and our own in-house counsel for guidance suggestions, and then also I think we should have someone in the field that is at the local level that would also help something like that for the next session or how do you want to proceed?

>> Karen Bell:

That would be fabulous. If you're willing to take that on, and tee up some names of some folks, who would be willing to do this, then we will definitely put them on the agenda for the next meeting.

>> Howard Isenstein:

Okay, I'll do this. I'll send it around internally and then send you an e-mail of suggested names.

>> Lillee Gelinas:

Great idea.

>> Karen Bell:

Fabulous.

>> John Houston:

This is John Houston. I mean, there are still, I think, for the solo practitioner in a small physician office, a lot of other issues other than simply getting some type of assistance from the hospital in order to implement EHRs in their practices. I think there's still economic issues and efficiency issues that I suspect those physicians are still wrestling with.

>> Lillee Gelinas:

John, I'm still on Page 1, the critical component business case and preparing for this meeting I have asked around this issue the fourth bullet, is there significant non-monetary value in adoption of EHRs, for the small physician practice or other ways that there could be a ROI, and to a physician they tell me unless the monetary issue is addressed, I'll never achieve the ROI. I won't get there. I can't pay for it.

>> John Houston:

Well, I understand, but I mean you're assuming that the ROI and the payment is going to come from the provider, the large providers, the hospitals.

>> Lillee Gelinas:

Oh, no, what they were saying, unless there is some relief, whether the government gives them some grant or relief, or whether it comes, wherever it comes from, that the non-monetary value is a non-issue right now. It's all a monetary issue. Maybe I'm not making myself clear.

>> John Houston:

No, I understand.

>> Lillee Gelinas:

They absolutely want to go down the ROI path. They, no one is saying it's not a good idea. Oh, it will help us get to defect-free care. But where the financial issue is is right in their pocketbook.

>> Karen Bell:

I think one of the things that we learned over the course of time and we tried to summarize some of this this for you on sheet is that it costs a lot to put particularly the certified systems in place, because they are good, they are robust. They do have functionalities and the protection in terms of security and the guarantees of interoperability as they come out.

And today with Chuck's presentation, we really can see that this is an ongoing to cost over a long period of time. Which most of the community right now believes should be borne by the physician. And I think the physicians are telling us it's just too high, they can't do it. So the real question is, are there things that we can address that will change that dynamic a little bit? One of the things that we heard in the past, that we heard were pay for performance programs, some were purely on outcome. We also heard that improved outcomes after EHR adoption can take up to three or more years to come forth. We heard about pay for use, where pay for performance programs in many ways were weighted in the beginning so that as they were adopted, there was increased payment for structural changes. I think Bridges to Excellence was a good example of that, we also heard about a program in California and there are a few others. So I think one of the things we might consider is are there, given all of the presentations we've heard and all the public testimony we've heard, is there something in that that can help us make some recommendations on how reimbursement can be monitored or changed in some way in order to better align the business case.

And I know that there's one piece of information that we haven't had before, because it's come out fairly recently, but it's the new Congressional legislation that's been passed. And I think Jim Sorace, are you still on the line?

>> Jim Sorace:

Yes, I am.

>> Karen Bell:

Reference to that and what's in it?

>> Jim Sorace:

Well, basically we have, the last Congress passed a pay for quality reporting initiative that will give about a 1.5 percent payment over a six-month period, which would be the latter half of 2007, for practices that submit data and report it through the claims-based processing system. It also provides for payment, doesn't actually specify what is to happen in 2008 and 2009, but it lays open the possibility that we could pay on structural measures in 2008. And this would include things like e-prescription and perhaps other items. And I actually forwarded you an e-mail and I can do it again but if people want to go to it, the Web sites that are, give more information on this.

>> Karen Bell:

What was that piece of legislation again, the number?

>> Jim Sorace:

I'm sorry, it was the Tax Relief and Healthcare Act of 2006, HR 6111. And it's actually posted to the Website. I forwarded, Karen, I sent you a e-mail earlier today. I don't know, maybe that could be entered into the minutes here. Or if you want, I can give it to you.

>> Karen Bell:

That's all right, I've not been on e-mail all day, so I will get that back to everybody tonight.

>> Lillee Gelinas:

Great suggestion, thank you.

>> Jim Sorace:

But basically it's for a six-month period at the end of 2007, claims-based process, and then opens up a possibility for structural measures to be reported on in 2008.

>> Karen Bell:

And structural measures could be around --

>> Jim Sorace,

I actually think if you go to the bill, e-prescription measures, use of registries, it's open.

>> Karen Bell:

It’s completely open?

>> Jim Sorace:

Yeah, those two are mentioned, but it's open and we've been having some discussions here.

>> Karen Bell:

So it is possible that some recommendations from this Workgroup might inform what could be some, an approach to paying for structural?

>> Jim Sorace:

I think that would be a possibility. I mean, I think that would be a very appropriate thing to look at.

>> Lillee Gelinas:

Any other thoughts on, we're still on our financial business case and the Workgroup recommendation discussion. We've talked about Stark, we've talked about monetary issues, adoption discrepancy between small and large practices. Any other thoughts around supporting the small practice to close the adoption gap?

>> Karen Bell:

I would just add one thing. We had, we had asked before to have an update on the VistA Office.

>> Lillee Gelinas:

Right.

>> Karen Bell:

And apparently they are still working on that. There's been a, an evaluation report that's come out. CMS, however, could not be on the call today. So we might actually hear a little bit more about VistA Office at our next meeting.

>> Lillee Gelinas:

That would be good.

>> Karen Bell:

That may help us there.

>> Lillee Gelinas:

And I think further as the staff are taking notes here what Blackford was saying around the stimulants to private physicians not yet adopted, we just need to keep those at the top of our mind and informing our discussions here.

Shall we move on?

>> Karen Bell:

I think we should, Lillee, and I think we have a few that we will construct a little bit and then get people's feedback on for the next go-around. Okay?

>> Lillee Gelinas:

I think that's terrific. If we could have just as good a discussion on the next one, that would be great.

>> Jim Sorace:

One thing -- this is Jim Sorace from CMS -- one thing real quickly and that is if you have standards for transmitting data, then I think that actually mitigates some of the Stark issue concerns, because the hospitals and whatnot can pay for the software, but if it's able to exchange with other groups that can still provide those services, it's less of a hold.

>> Lillee Gelinas:

Thank you.

>> Karen Bell:

Legal regulatory. This actually relates to the discussion we had last week, as well as some of the presentations we had earlier from folks that pointed out that there could be some legal issues. And you also have the letter that you just received yesterday. One of the things was, that was mentioned was the possibility of some recommendations to the Certification Commission in terms of how data is presented and formatted which might decrease liability and we certainly heard today from a malpractice insurer who is providing incentives through decreased premiums to advance EHR adoption. So I think that we certainly have a very fertile ground here for a few recommendations in at least those two areas. And I would just wonder if there are others that people think would be important. I also note that we had on this list clarifying some of the legal questions relating to Stark, so we'll move forward with that, too.

Any other thoughts or comments on this in terms of where we should be going, or other testimony we should need?

>> Jim Sorace:

This is Jim again. One thing I think we might want to think about is again the incentives that the data providers have to update their systems for common standards and for interoperability with CCHIT systems.

>> Karen Bell:

Yeah. I think that's in our state of the technology side.

>> Jim Sorace:

Okay.

>> Karen Bell:

We can spend a little time with that there.

As everyone reviews this document and thinks a little bit about what we've already heard, I think the real question again is we've got some possibilities here to move forward with, with recommendations. Are there others? And is there any, more importantly is there any other testimony you think you might like to hear at the next meeting?

>> Jim Sorace:

Regarding legal, regulatory, specifically?

>> Karen Bell:

Yep.

>> Jim Sorace:

Okay. No. Not for me.

>> Lillee Gelinas:

I thought the Masspro presentation today was extremely helpful, as well as the discussion on malpractice relief. That was terrific. If there's a recommendation perhaps that needs to come out of that?

>> Karen Bell:

In terms of perhaps how we might be able to move forward and engage other parties around the country?

>> Lillee Gelinas:

Right.

>> Karen Bell:

I think we can all think through a little bit about who to engage and how to engage them to make that type of an approach a little bit more generalized, generalized around the country.

>> Lillee Gelinas:

That whole notion of promoting malpractice insurers incentives to advance adoption.

>> Karen Bell:

I would also like to let you know that over the last few days, and including today, the National Governors Association is meeting, at our behest, through a contract, and they are addressing, among other things, the state-based issues regarding licensure, and other state-based approaches that could impede the free flow of information between physicians, or between physicians and their patients or providers and their patients, so we actually may have more information on that at the next Workgroup meeting also.

Any other thoughts or comments on this particular arena?

>> Lillee Gelinas

Hearing none, let's move on --

>> Karen Bell:

Okay.

>> Lillee Gelinas:

-- to the critical component organizational. This is another area where we've had a great deal of conversation. Organizational encompasses a number of issues, including all those cultural barriers, work force education and training, professional certification to HIT. We've had testimony and discussion around work flow redesign, resources, and the lack of knowledge around EHR selection practices, which increases the risk of right purchase. So once again, we will need to craft some recommendations around this particular issue. And these are just some of the questions that the staff have put in front of us to consider: are online consultant services sufficient to support adoption? Are there resources sufficient to support the adoption goal? Are there sufficient training programs available for all support staff? And how can patients be more engaged in supporting HIT adoption among clinicians?

And I had a smile on my face and was reminded of what it's taking in hospitals at least today in getting patients engaged, for instance, in reducing hospital-acquired infections and the little notes on their hospital gown that says did you wash your hands before you touched me. That's a fairly simplistic example, but engaging patients in supporting HIT adoption among clinicians may be a area we really want to put some attention to because consumer-driven healthcare, consumerism is certainly getting much more play these days than in the past.

>> Blackford Middleton:

Lillee, it's Blackford Middleton. I think that's a great thought and I'm not sure if there's some way to explicitly acknowledge or recognize a potential codependence of some kind between those PHR efforts now taking off around the country, and some are more notable than others. For example, the Dossia effort is perhaps more notable. How do they interact with the EMR objectives of the President, and the current, the AHIC recommendations, whatnot, I think might be worth some thought.

>> Lillee Gelinas:

I hope the staff captured that.

>> Lillee Gelinas:

Karen, and Judy, and team there, I have a question for you. In the Louisiana/Mississippi area, if you talk to those patients and consumers, they're clamoring to have their own record, in the post-Katrina era here where they've completely lost their record. Is there anything coming out of that part of the country with some of the recovery effort that we can learn from, where consumers are pushing for HIT adoption? As a pilot, or, that was really what we would call a disruption. Anything happening there that can inform our conversations here?

>> Karen Bell:

The best I can tell you on that one, Lillee, we're all going to be at HIMSS next week. So we will be visiting some of the sites. We are doing some site visits, and I'm sure a number of other folks on the call will be at HIMSS as well and perhaps we can report back at the next Workgroup what we find out, because we'll be in the thick of it.

>> Lillee Gelinas:

Because I was just there. There's only three or four hospitals operating. Lots of physician practices did not come back. And we hear about these pilots for rebuilding healthcare in New Orleans and in Biloxi and the Gulf Coast area, but if we could find out what is really happening, and as a result, because consumers and patients really got high motivation for wanting to own their own record. Is there anything happening there that we haven't heard about so far that could inform us? It’s a real wake-up call, I think, for all of us.

>> Karen Bell:

Certainly, we'll certainly do whatever research we can do on the topic, and thank you for bringing that up.

>> Lillee Gelinas:

That would be great.

>> Karen Bell:

That's a good idea --

>> Lillee Gelinas:

Go ahead.

>> Blackford Middleton:

Sorry. It's Blackford again. I have one other, I'm not sure if it appears here or perhaps under the technology bucket. But one of the things we've done in some of our analysis is to try to estimate not only sort of the cost benefit picture for EMR adoption and for office sizes of different, different office sizes and whatnot, but to also explicitly measure the costs of knowledge engineering, if you will, that goes along with the implementation. Chuck alluded to some of this in his presentation. We know, though, when an EMR is implemented, the clinical environment, whether it's practice staff or implementation staff or whomever, have to wrestle through what are the basic rules, alerts, templates, forms, guidelines, protocols, and whatnot that they wish to implement, even in the vendor systems off the shelf, they often as you know are incomplete in many ways, and may get a practice to kind of the first base position, if you will, but not beyond to second and third base.

I'd like to suggest one of the recommendations, and I've discussed this with Carolyn Clancy, I'm not sure if she's still on the phone but one of the recommendations might be that we compile to the extent possible knowledge in a machine-ready or human-readable form such that it facilitates or eases the knowledge engineering burden for implementing EMR. One might imagine a resource, national repository of some kind, where one could simply look up, as I sort of demoed in our knowledge portal we're developing here, look up the healthcare maintenance reminders and whatnot that you may then more readily implement into your EMR, as opposed to having discover, do the knowledge engineering, convert them into the right terms and languages and whatnot. I think this is a major obstacle that if it were ameliorated to some degree or removed even, perhaps, would facilitate adoption.

>> Jim Sorace:

Blackford, this is Jim Sorace from CMS. I agree with that wholeheartedly. I'd also like to add that we need to better understand some types of exclusions and how better, how best to document when patients, when these things don't apply to specific patient populations. That part needs to be included in the task.

>> Blackford Middleton:

Yes.

>> Karen Bell:

This is Karen Bell. Carolyn had to leave but I was at AHRQ all morning and one of the things we were talking about is the degree to which the various specialty societies as they develop their guidelines develop them not only in an evidence-based format, but also develop them in the machine-readable format and with measures that can be extracted from a HIT environment. So I don't know, again, I think it's a very interesting concept. I think it will take time, obviously, to move forward. But I think that there may be some sort of an opportunity for us to work with the clinical entities that are developing these knowledge bases, and promulgating them so that they can be done in a format that is usable down the line for CDS. So I think somewhere along the line, we're moving towards a recommendation in that arena.

What about the, and before we move on, what about what we heard today from Chuck, with respect to DOQ U. There is a lot of information that's there. We were offered an opportunity now that's available to us to look at it and perhaps we may be interested in either adding more support to that so that it becomes more widely available, we may want to make some recommendations to either push forward with that or not. So maybe one of the things we might do is everyone on the Workgroup really look at that closely, and determine to what extent it is worth further support and perhaps a recommendation. I can throw that out as well.

>> Lillee Gelinas:

We shouldn't reinvent the wheel. If we can learn more about DOQ-IT and make recommendations for spread.

>> Karen Bell:

Uh-huh. Everybody has some homework on that one, then. Thank you.

>> Lillee Gelinas:

Any other thoughts on the organizational issues? I have to admit I'm struck a little bit about solid recommendations about overcoming cultural barriers. No matter what the improvement work is, at the end of the day, culture trumps strategy all the time.

>>

As they say, culture eats strategy for lunch.

>> Lillee Gelinas:

There you go.

>> Bart Harmon:

This is Bart Harmon from the DOD. This is a suggestion framed as a question. Is there any way that you could tie together allowing provider practices to use the fact that they're using a certified EHR as a marketing tool and then also find ways to educate patients to look for providers that are using certified EHRs? Because it seems like the public voting with their feet could be a very powerful force. I just don't know how to pull that together.

>> Alicia Bradford:

Hi. This is Alicia. Can I make a comment on that, Karen?

>> Karen Bell:

Of course.

>> Alicia Bradford:

I think perhaps the Workgroup could consider a recommendation around that that would be aimed at the Certification Commission, regarding their outreach with that perspective toward providers and patients, about how to market the fact that they've adopted a certified EHR to their patients and to other providers.

>> Karen Bell:

Okay. Well, just to sum up, I think we have the possibility of some recommendations in three or four areas here. One is around the marketing piece. Secondly, is around supporting DOQ-IT, if we think that's appropriate after further review. Thirdly, we have one around compiling the knowledge base and some things of that nature. And I think that's it. So we have three possible ones that we can move forward with here.

>> Lillee Gelinas:

Yeah.

>> Karen Bell:

Okay.

>> Lillee Gelinas:

I like it.

>> Karen Bell:

So we're going to flesh them out on the next go-around and give some direction.

>> Lillee Gelinas:

I know.

>> Karen Bell:

We're going to keep on going here?

>> Lillee Gelinas:

Let's keep going. State of the technology. In previous Workgroup recommendations we have talked about interoperability, we've seen HITSP and CCHIT standards and criteria development come to the forefront. The testimony from 19 presenters to us fell into five categories. Interoperability, interconnectedness, clinical decision support, functionality, and usability. And there have been a number of issues, including standardized interfaces, assessments of usability are limited, and there's this general buyer beware in this arena. Bolded is software immaturity and lack of many EHRs with the features that are really needed by frontline care and discussions regarding EHR data elements, functionality, and so forth that clinicians need to exchange information.

So in terms of us making recommendations, during our January 23rd full AHIC meeting, the committee made recommendations for additional use case development in the areas of consumer access to clinical information, medications management, and quality. The CCHIT is now expanding into specialty and in-patient EHR certification. And their expansion road map is available for public comment through March 2nd. Are there any comments that we, as a Workgroup, should make to CCHIT in its public process? And then what other recommendations do we have? So let's start with the most obvious one here, and that is Workgroup recommendations to CCHIT in their work.

>> Karen Bell:

This has to do with, I’m going to be a little bit more specific about this one, because the timing is right on this one. They're thinking about moving into the specialty arena and how to do that and some of the specialty areas that they're looking at are additional modules related to pediatrics, they are looking at where on a road map would they put behavioral health PHR, and they're also looking at how they might move forward with certain functionalities. For instance, the American College of Cardiology has been quite clear about wanting to move forward with something for cardiologists. But when you really think about it, it's wave form capability that's important for the cardiologist, as well as DICOM, or the ability to transmit radiological studies. So there may be certain aspects that are important to certain specialties that are also consistent with other, with what other specialties need. So I think the real piece, important piece here is that the Certification Commission is really looking for feedback on where to go in this next step of certification with respect to physicians and EHRs. And what's likely to give us the biggest bang for the buck? So that's really the question that's before us, and we can do that through public comment at the Certification Commission even without a formal recommendation to the AHIC.

>> Lillee Gelinas:

Well?

>> Karen Bell:

Any thoughts on that, or is that something we should discuss more next, can't be next go-around because basically the bottom line is you'll have to go check out the, it's March 2nd, so you would probably --

>> Lillee Gelinas:

Next Friday, a week from tomorrow?

>> Karen Bell:

Yep. You'll probably want to go to the Website between now and then, see what the Certification Commission has there, and if you think that public comment is appropriate, then make it. And maybe it would be best if members of the Workgroup did that individually rather than the Workgroup itself speaking as a single voice.

>> Lillee Gelinas:

Uh-huh. When will we be able, Karen, to see what comments did come in and be able to at least consider those?

>> Karen Bell:

They will be out within a few weeks of the public comment period closing.

>> Lillee Gelinas:

Because I'd be curious to get everyone's just thoughts on the comments that did come in, and maybe we can at least lend a voice of consensus or support.

>>

Isn't our lines of communication, though, through the AHIC, and so our recommendations and comments really need to be them with regards to things like CCHIT, correct?

>> Karen Bell:

That is correct.

>> Lillee Gelinas:

Yes.

>>

So I mean, our line of communication really isn't directly to the CCHIT anyways.

>> Karen Bell:

No, but as individuals and it is public comment --

>>

I understand that, but, and I guess I understand you were saying maybe we as individuals should do things, but I think that we also need to be very careful where our recommendations go and how they need to be couched, because it would be the AHIC then some way communicating with the Secretary or commenting on the CCHIT.

>> Karen Bell:

Right, the Workgroup’s recommendation, as a Workgroup, would go to AHIC, exactly.

>> Lillee Gelinas:

All that said and done, when it's done, it would be helpful to know what the comments were.

>> Karen Bell:

I think we feel there's more that needs to be done and that can go to the Secretary.

>>

Then the next question is that, do we have the right or the ability to ask CCHIT to talk to us about recommendations once the March 2nd date passes?

>> Karen Bell:

Absolutely. The Certification Commission has addressed a number of other Workgroups.

>>

So we could ask them to characterize some of their feedback on these particular topic areas?

>> Karen Bell:

Absolutely.

>>

Then naybe we should try to do that for our next set of meetings.

>> Karen Bell:

Okay. CCHIT testimony coming up. That also may be a time to ask them, because they have not gotten into the issues of usability, but to really ask them about what their thoughts may be, or how they might be able to address the issues of software maturity and usability moving forward.

>> Karen Bell:

Okay. Is it time to move on to the last one?

>> Lillee Gelinas:

I do believe, on privacy and security. This has been a particularly important adoption issue for us to consider because both physicians’ and the public's privacy and security concerns are critical in adoption. We have certainly contemplated much testimony. We've had three presenters discuss several key aspects, and I won't read through all of the components that are in the work that you have in front of you, but significant work has already taken place in the National Committee on Vital and Health Statistics’ subcommittee on confidentiality and privacy, and we have talked about that.

Previous EHR Workgroup recommendations that were forwarded in May 2006 led to the formation of the AHIC Confidentiality, Privacy, and Security Workgroup, and you all know the focus of the CPS Workgroup. As we continue to look for strategies to recommend around policies, guidance and protections related to the inclusion of genomic data, which as you know is a key topic for the Secretary, we really understand that we have a lot more to learn in that particular area, and that we do need to address the privacy and security concerns of a very broad use of data for public health quality improvement reporting and research.

So for us, given that when we think about large volumes of patient data, I am reminded of one of the opening remarks of Secretary Leavitt before our full AHIC meeting a couple of months ago when he said can you imagine the size of the storage facility to store the genomic data of every American? And I had a mental model of this huge, huge place that would have to store that amount of data and just think about the privacy and security concerns related to it.

So given that we do now have a CPS Workgroup that was not in place when this Workgroup was first formed, are there additional privacy and security issues that we’d like to bring to the attention of that Workgroup for their deliberation? Are there any recommendations that we want to make that are independent of the CPS Workgroup? And is there a particular priority for this Workgroup that we need to discuss as well? This is a really big deal, and I'm hoping we can have some good discussion around this.

>> John Houston:

This is John Houston. Being on the CPS Workgroup, I can tell you two things because I just got off a conference call earlier this week on the meeting in that group.

>> Lillee Gelinas:

Oh, good.

>> John Houston:

And I don't know if you all know, but one of the chairs of that Workgroup just stepped down, citing lack of progress of that Workgroup. So interestingly enough, the time the Workgroup was really asking the members for some ideas as to where that Workgroup needs to go in terms of topics. Now, also being a member of NCVHS, I leaned heavily on the fact that we have this paper, this letter that we sent out in the summertime --

>> Lillee Gelinas:

Right.

>> John Houston:

-- which outlined a whole variety of privacy issues associated with NHIN. So that's really publicly what I pronounce as being what I think needs to be done next, is start going through that list. But just so everybody knows on this Workgroup, that this CPS is really looking for what do we do next, what are the big pressing issues that it needs to address very directly. And it's also I think looking maybe for some new leadership there, too, and I'm not sure how that will get addressed. But I think it's important to bring those up.

>> Karen Bell:

Thank you, John. This is Karen Bell. I think that's very, very helpful.

>> Lillee Gelinas:

Yeah.

>> Karen Bell:

One of the things that strikes me is we, through the work you've done with NCVHS and through this Workgroup, we've identified a number of issues around privacy and security. Perhaps it would be helpful if we outlined all of those and that would give everyone the option of adding anything we might have missed, so everyone would look at it and say okay, here's some of the gaps. And then start prioritizing what we think are the critical ones for the CPS to then take up. Does that sound like a reasonable approach for us?

>>

Sure.

>> Karen Bell:

Would that work for you, John?

>> John Houston:

It would. I'm going to probably stay fairly silent in some of that because I've already voiced my opinion, myself. Though, I mean, I'd be more than happy to try to provide feedback to make sure that we're on the right track with some of the suggestions.

>> Lillee Gelinas:

You know, Karen, this is Lillee. I really need to get immersed in those 26 recommendations in that letter or report. I'm, I probably haven't looked at that since it came out last June.

>> Karen Bell:

So would it be helpful if we just downloaded at least the executive summary and the 26 recommendations and just sent them out to everybody?

>> Lillee Gelinas:

That, but also here we've got a member of the CPS Workgroup here, and as with all things, we need expert opinion in order to form our recommendations, and I would really like to know if their 26 recommendations, what are the top 5, where do we go, what do we do next? Because we obviously can't address all 26, so to speak, in one lump sum.

>> John Houston:

Interesting, again, being part of NCVHS and really being intimately involved in the drafting of that letter, I can tell you that I have a lot of, was it pride and ownership of that letter myself, and I think it's hard for me even to decide which of those 26 are most important. I could probably hone it down to maybe 8 or 10 that I'd say boy, we really need to work on first. But it really almost becomes a philosophical read. When you go through that document and read through it, I think it strikes everybody a little differently what the priority is. That's part of the problem. And that's one of the things that we really struggled with as a subcommittee under NCVHS, was how do you couch these recommendations and there was a lot of good faith difference of opinion of the relative importance as well as what people's position was on each recommendation. So a lot of the recommendation ended up being couched in a way because we couldn't come to consensus because, in good faith, we just had a difference of opinion.

>> Karen Bell:

John, if we were to, and I’m just putting this out as a question, if we were to really focus on the fact that we're trying to move forward, EHR adoption among physicians --

>> John Houston:

Right.

>> Karen Bell:

-- would that help us prioritize some of those you think because it comes from one particular point of view?

>> John Houston:

Sure, I think it would. I think that that letter also, by the way, was to remind everybody, was, it was really trying to examine the privacy issues of the NHIN. So if you take the NHIN that, the global scope out of that letter, obviously the privacy issues become much simpler and much more localized. What my concern is, is that, and I think most people would agree, that especially for the small practices, the way you're going to find EHR adoption is through participation in a RHIO, or in other types of community-based programs. And I think when that occurs, or if that occurs in that way, then a lot of the issues that we are, a lot of the recommendations we made really become applicable again, so you can probably dodge some of the issues or decide to defer some of the issues based upon that scope, but I really think what it will end up happening, at the end of the day, you'll end up having to address them nonetheless.

>> Karen Bell:

Okay. Given the discussion and given the lateness of the hour, if everyone's comfortable with, again, pulling this letter forth, assuring that all the other pieces that we've talked about are included, I think we might be able to spend more time on this topic in the next Workgroup meeting. And I'm wondering, is there any other type of public testimony we need to hear here, or do we think we've got more than enough on our plate right now that we just need to focus?

>> John Houston:

Back to the letter just for one second. I'm assuming you were referring to the NCVHS letter?

>> Lillee Gelinas:

I was.

>> John Houston:

Just now?

>> Lillee Gelinas:

Yes.

>> John Houston:

Maybe one way to deal with this is to take the 26 recommendations and maybe circulate those recommendations on a spreadsheet that would allow people to rank order their importance in their mind relative to EHR, physician adoption of EHRs.

>> Karen Bell:

Yeah.

>> John Houston:

And then say okay based on everyone's opinion and their own ranking, which ones do we really think need to be pushed forward to the CPS Workgroup for consideration earlier rather than later.

>> Karen Bell:

And we would add to that, again, some of these other issues, particularly around secondary uses of data. We don't have privacy and security concerns addressed around that as well. So there are other issues as well that we can add to that list. I think that sounds like a good idea.

>> Lillee Gelinas:

You know, Karen, it strikes me in closing out this part of the agenda, that the seriousness of this issue, which is around making recommendations for these critical components, is probably one of the most important pieces of work for this Workgroup. Because the recommendations that we will have to AHIC have far-reaching implications, so I want to thank everyone. This is truly an all hands on deck effort. I ask everyone for your best thinking and your best dedicated effort as we go into round two of these recommendations, and I really want to thank you very much with the seriousness around which you've taken this work.

Let's move now to public comments, can we? Matt, do we need to put a process in place to make that happen?

>> Jennifer Macellaro:

This is Jennifer. Matt stepped away. I just put a slide up that has the number in for people who are following along on the Web to call in. Anyone who is already dialed in can just press star 1 to alert the operator. And there's an e-mail address if anybody would like to write a message after the meeting. So we'll just wait a few minutes and I'll let you know if anyone calls in.

>> Karen Bell:

While we're waiting, this is Karen Bell. Again, thanking you all for a lot of good work today. And I just wanted to call to your attention that our next meeting is Tuesday, March 20th. And there is only one item on that agenda, and it is recommendations.

>> Bart Harmon:

If I might, this is Bart Harmon with the Department of Defense.

>> Lillee Gelinas:

Yes.

>> Bart Harmon:

This may be my last meeting. I wanted to bid you all farewell in case it is my last meeting. We haven't figured out who will be my replacement on this Workgroup yet. But I'll be retiring from the military here shortly and so I wanted to say farewell and thank you for allowing me to be a part of your group and the opportunity to show you what we're doing here recently. It's been a great privilege.

>> Lillee Gelinas:

Bart, it's been a privilege to meet you personally. I so thank you for the warm welcome at Walter Reed Army Medical Center. It was a tremendous tour. Thank you for the dedication that you've given this Workgroup. We will miss your leadership and your contributions.

>> Bart Harmon:

Thank you.

>> Karen Bell:

Thank you so much, Bart. And congratulations.

>> Bart Harmon:

Thank you.

>> Karen Bell:

Also, since you made that comment, Bart, I would also say that once we get through these recommendations, you will all be receiving a letter which gives you the opportunity, because I know so many of you have done so much work and it's been very much appreciated, but we also recognize that you have another life. So as we move into the next phase of this Workgroup, which will be to move into the area of hospital electronic health records, then we will be giving everyone the option of signing on for another stint or if you feel that you have other things calling you and pulling you away, then you can let us know and we'll try to find a replacement for you all. But I just wanted to give you all a heads up that at this point we are absolutely grateful for each and every one of you. You've done a phenomenal amount of work and we've got a lot accomplished. So thanks again.

>> Lillee Gelinas:

We have an opt-out option, Karen?

>> Karen Bell:

Not the co-chairs and not yet.

[laughter]

>>

Not so fast.

>> Karen Bell:

Not yet. We have to get through the recommendations first.

>> Lillee Gelinas:

And Judy, were you saying that our full AHIC meeting, the venue is going to be coming shortly?

>> Judy Sparrow:

Yeah, I'm working on getting that hotel, et cetera, tied down. I hope to get that out to you tomorrow.

>> Lillee Gelinas:

Okay.

>> Judy Sparrow:

It’s coming, it’s just, you know, a lot of little details to attend to for that.

>> Lillee Gelinas:

Oh, I don't envy you. I can't imagine.

Any public comment?

>> Jennifer Macellaro:

There is no one calling in today.

>> Lillee Gelinas:

All right, there's no one calling in today. Any other business to come before the interest of the Workgroup?

>>

Nope.

>> Lillee Gelinas:

All right. Well, thank you to everyone, you've done a great job. You've all hung in there. We've made it through the agenda. We have given to staff, I hope, some good recommendations to keep the work going forward. Repeating what Karen said, our next Electronic Health Record Workgroup meeting will be Tuesday, March 20, please look at the AHIC Website for further information about the meeting.

So thank you again. Meeting adjourned. Have a great afternoon, everyone. Bye-bye.

>>

Thanks.

>>

Thank you.

>>

Bye.