[This Transcript is Unedited]
Hubert H. Humphrey Building
Room 505A
200 Independence Avenue, S.W.
Washington, D.C. 20201
DR. LUMPKIN: I don't think there is a lot to report back from the Markle(?) meeting, but I think what I really wanted to spend a little bit of time talking about here is kind of the next direction for this -- for our work.
One of the areas that we have been focusing on somewhat is the personal health dimension. That is an area that the Markle Foundation Connecting for Health Project is going to be looking at a fair bit of. So, the question I have that is probably pertinent to us as a workgroup is where can we add value, given the momentum that is developing around the NHII.
So, what I would like to propose is that we have a full day meeting, just, you know, the workgroup and friends and people who want to come, except for Marjorie, and start off sort of assessing in the morning where we see -- where the NHII, the development that is spawned by that, somewhat of a status assessment of the three dimensions as they currently exist. And then spend the rest of the day talking about areas of leverage that we think as a committee by holding hearings and engaging in work products we can have some impact in making sure our vision goes forward.
So, that is the proposal I wanted to toss as sort of a task for us as we move forward, given the fact that without spending, I think, some in depth time, we stand the danger of every time we think about something to do, it already gets done by the time we get our meetings together.
Does that make sense or -- I see Jeff already nodding his --
MR. HUFF: What time were you thinking this all day meeting --
DR. LUMPKIN: I am thinking, depending on schedules, if we can fit it into December, maybe like, you know, December 24th, something like that.
MR. STEINDEL: Why not do it on my birthday -- maybe the 25th.
DR. LUMPKIN: Yes, that is a good idea. No, actually I am leaving for Jamaica that day.
MR. STEINDEL: 26th. We have the meeting in Jamaica.
DR. LUMPKIN: No problem, mon. No problem, mon.
MS. GREENBERG: When were you thinking? December? This is just for the members?
MR. BLAIR: I just realized that may be a conflict because it conflicts with a holiday?
MS. GREENBERG: Yes, there is a holiday around then, isn't there? You are right, Hanuka.
DR. LUMPKIN: My guess is that if we are going to have it, it is either going to be December or February, just knowing what other things are going on with the Standards and Security meeting. They do have a meeting in December what, Jeff?
MR. BLAIR: 9th and 10th.
MR. STEINDEL: That December meeting is still the 9th and 10th. The January meeting may extend one day -- for the full NCVHS committee.
DR. LUMPKIN: I don't have my calendar to make it. So, I have already -- I raised this issue with Mary Jo before she -- where did she go? Before she had to go somewhere, somewhere important, obviously. She regretted not being here.
I think what we would do is try to establish a few days and poll for those and then try to go for a full meeting.
MR. STEINDEL: From my point of view, December, early December would still work out much better than either January or February. Then the meeting cycles start again. I know we have Standards and Security in January. HL7 is meeting in January. Clinical LOINC(?) is meeting in January. February --
MR. BLAIR: Actually, if there is a possibility to tack it on like the 11th of December, since we are already up here?
DR. LUMPKIN: The only problem with December, and I just threw that out, is that I just know that I am sure my December, a good chunk of my December calendar is already -- let's see what we have.
Of course, we could do it in New Mexico.
MR. HUFF: And in Utah.
DR. LUMPKIN: In November? You are optimistic.
MR. HUFF: In December. They are skiing out there right now.
DR. LUMPKIN: Not when I was up there a week ago, there was no skiing.
MR. HUFF: The last week we have had snow everyday.
DR. LUMPKIN: Not that I would have gone skiing because I was out there for a meeting.
MS. GREENBERG: Is anyone going to that -- December 17th?
DR. LUMPKIN: Okay. We are looking at December. Well, we will get a couple of dates. Let's see. That is on the 17th -- I am actually going to be in D.C. on Friday, the 19th. I just have a one hour meeting. I could run out --
PARTICIPANT: That would be the latest it could be in December.
DR. LUMPKIN: Friday, the 19th, is that a possibility?
MR. STEINDEL: Yes, that is a possibility. I have personal reasons why I would make the meeting if it is the 19th. That is the day my daughter comes back from school.
That week is good for me, John, as is the first week of December.
DR. LUMPKIN: Okay. Let's poll, look at the 19th and then look at some other dates.
MR. HUFF: I can do the 19th.
DR. LUMPKIN: Like I said, I just have a meeting somewhere in D.C. I would have to run out to for an hour, but you guys can --
Okay. Anything else we need to talk about?
I will work with Mary Jo and we will start trying to cobble together a tentative agenda. We will send it to everybody by e-mail and get comments and suggestions. But pretty much it would hold together that we will talk about current developments. Do we want to invite anyone to talk, to join us?
MR. BLAIR: One thing could we consider for the agenda -- you know, given that our objective is to wind up identifying the tasks that we could do that is added value that nobody else is doing, sometimes I feel as if there is a lack of continuity between our NHII report and the recommendations that we set forth.
If we could -- and maybe I didn't use the best choice of words when I said it that way. Maybe if we could look at extensions or follow-ons to the recommendations that we made?
DR. LUMPKIN: Let me run with your idea a little bit and that is that we would spend at least a portion of this meeting, reviewing our recommendations and seeing those, which we still think are forth doing, those that we think could use some extension or enhancements and we could either at that meeting begin that process or use -- set up a work plan to address those.
Obviously, one of the areas that we didn't really address in our workgroup and I know Clem has been pushing on some other folks, are the concept of LHII, local health information infrastructures, you know, micro -- you know, conceptually, you know, are we looking at this being made up of this being a monolithic, single system, which is not what we talked about, but how -- the interconnectivity at the local level.
But I think those are issues that are being raised. We don't need to debate them now, but I think we should discuss them then.
MR. STEINDEL: The report that we did deliberately stayed out of issues of architecture and the LHII connection to an NHII is really an architectural issue. I personally do not understand that connection.
I don't know what an LHII is.
DR. LUMPKIN: Well, that is a good point. But we can talk about it.
MR. STEINDEL: Yes, we can talk about it. I think it is something that does need to be enunciated and it is --you know, people are making a glib statement like that, but I think there is a lot of definitional elements that need to be addressed.
DR. LUMPKIN: Well, it all relates to the fact that we expended a lot of work. We had a report and there are a lot of people, who have adopted the term NHII. They just mean different things by it.
MS. GREENBERG: If you want to kind of see, okay, you know, what did we recommend, who has already picked up on this, what more do we want to do or where we can add value and not duplicate what other people are doing or whatever. You want to bring in the main -- the leading groups that are really running with some of this or do you know enough about what they are all doing?
DR. LUMPKIN: That is the question I just posed. Do we want to invite Markle, those folks?
MR. BLAIR: To me it is premature. It might be nice if there is a -- well, maybe if there is a briefing on what they are doing, so to speak. Okay? You know, so at least we know what some of the other initiatives are.
Maybe the reason that I said that it is premature is I am not sure our added value is best placed where some of these other activities are forging ahead. It may be in other areas of definition of pulling things together, leadership, you know -- some of the key recommendations we made was that the HHS needed to assume leadership and coordination. We never defined what leadership meant or coordination meant.
Maybe that is the type of thing we need to look into. And the other issue of architecture, do we want them to go forward? In order to do coordination, do they have to have some degree of architecture as part of that? I guess maybe I am trying to get at issues of what isn't being done as opposed to what Markle Foundation may already decide that they are doing.
DR. LUMPKIN: I think that is a good point.
MS. BICKFORD: Carol Bickford, American Nurses Association.
Is a discussion of overarching policy something that this group could be addressing? That thought was triggered when we had the discussion about what an LHII, LHIA was versus a larger network and how you share the responsibilities or the policies and procedures for interconnectivity or some of the standards initiatives related to that.
So, it is sort of -- it is an organization architecture sort of thing. Is that something that is within the purview or should be at least identified as an issue and someone should be owning it? As an example of that, there are significant issues in relation to the use of the electronic mail and instant messaging in communication for health information and its structure and its retention and its discoverability and its knowledge management and those sorts of things.
How does that fit in the policy arena? That is just an example of something that might be a policy piece. I am sort of escalating the discussion from architecture or data sets to another piece. I am just asking the question.
DR. LUMPKIN: I am not sure that that is the level which we want to have our discussion at the NHII. There may be -- and I think we ought to have some discussion about architecture, if we want to get into the architecture arena. Although I have seen many of these aspects related to connectivity as being issues that more appropriately would fall under Standards and Security, many of those kind of standards.
The issue of electronic mail and e-mail and all those things, it is a fascinating issue. I am not sure where we would discuss it.
That is a good point.
Marjorie.
MS. GREENBERG: Well, just off of what people have been saying, one of the things -- just since I have been back now from my meeting, since I have heard this from about four or five different people, that nobody -- people don't really understand how all these different things get together.
These recommendations now on administrative code sets, we get recommendations now from CHI. You have got these PMRI recommendations. You have got the quality stuff. We have got population, but there isn't a very good understanding of how all this fits together. Nobody is really explaining this or trying to put this in a kind of a, you know, conceptual frame.
MR. STEINDEL: I think Marjorie made a very important statement just now. She said people don't understand how these should fit together. That implies that they understand they should fit together.
MS. GREENBERG: They don't even understand that.
MR. STEINDEL: If that is the case, you know, that is probably what we should be looking at is starting to raise the points of how they should fit together, not the exact way to do it, but points should be considering. Because that is what we raised in the first report was points people should be considering.
DR. LUMPKIN: So, one of the things that we can then talk about and put on our agenda for our day meeting is one of the options is to go back and talk about how -- to tell the story of the vision and what has been accomplished over the last two years have fleshed out that vision and how these pieces fit together.
Because one of the things that came up -- one of the concerns with the ICD-10 change was that these things are coming out piecemeal. There is no vision. I would disagree with that. I think that there is a vision and there is a conceptual model and we saw that in the discussion of the CHI.
MR. BLAIR: If there is a vision -- I think we generally share in this room the vision, but that vision is very general. I think there are a lot of folks that would like to engage and they come from their perspectives. I think we need to put a little bit more flesh on the bones or if not us, then maybe as part of the leadership in coordination, they need to put a little bit more flesh on the bones so that people know how they engage and where they fit and what role they should play.
DR. LUMPKIN: "They" as in HHS.
MS. GREENBERG: No. He is talking about other people.
MR. BLAIR: I will give you some examples. There are a lot of good ideas and good work and there is -- I don't know when you said the Markle Foundation, if that is the Pittsburgh, Columbia Presbyterian, Connecting for Health piece, that demonstration project. I think that that is a constructive activity, but I think that their view is that it is core and that it is central. Until we take things a little bit further in terms of fleshing out that vision and the architecture, how central it is and how compatible it is with the overall NHII, I am a little concerned that HHS, who is supposed to provide leadership and coordination, that they are doing more following than leadership.
I am not sure that is a correct statement, but somehow I think that we have got to put flesh on the bones of the vision so that that type of work activity can be used appropriately and married with other pieces. Otherwise, by default, whoever steps forward with a proposal to Congress or a proposal for a demonstration project is virtually by default defining the NHII and I am not sure that definition may be broad enough or rich enough or -- okay?
MS. GREENBERG: You are the owners really in a sense of not a process, but of this vision. I mean, you are the originators -- not the originators, I mean, but you articulated it in a way that hadn't been done before, I think, and people rallied around it. So, coming back to it and then, as you said, maybe sort of fleshing it out somewhat, but also showing how these different pieces fit together or should fit together --
MR. BLAIR: And it may not -- I am not sure that it is going to be us that puts the flesh on, but if it is not us, then maybe we need to give a little more direction to HHS as to how they may go about it or what they need to do, the leadership and coordination, in putting the flesh on. There is clearly -- I think there is a little more need for leadership and coordination.
DR. FITZMAURICE: You know, in one of the testimonies last week -- well, it was Blue Cross and Teresa Dulcet(?). She was saying there is no vision and the industry doesn't know what to do next. There is no road map. I agree with John that there is a vision. We have a vision and it has been articulated.
We are also building the building blocks of standards, but in between there, maybe she is right, although perhaps not for the purpose she was saying it. Maybe she is right. There needs to be a road map and it is not something that the department can build by itself. There needs to be hearings from people in the health care sector. This is just the health plans, also the vendors, people who are having to put these together as to what needs to happen and what sequence.
Then Blue Cross said we don't need the codes because we first need a common medical terminology. Actually, I think it was the Nolan(?) report that said that and they iterated it. But there is not a sense of which standards ought to be developed after we have the whole thing improved and where it is going to fit in. And the industry needs to tell us if we have this, we could really sell a bundle of these.
How is it going to help get information technology implemented out there?
MR. BLAIR: Can I build on Michael's comments?
DR. LUMPKIN: Please.
MR. BLAIR: I think one of the pieces on the agenda that would be very helpful to us is if Bill Gathenol(?) can give us a status report and then in addition to the status report, he indicates the things he would like to do during this next year. Whether he has the resources to do it, whether he has the skills to do it, whether -- you know, skills in the -- you know, within HHS to do it. As we listen to that, we could either find out either how we help him to do the things that he wants to do, but maybe we will wind up identifying other things that he hasn't put on his plate that either should be on his plate or should be on somebody else's plate to meet the leadership and coordination piece.
MS. GREENBERG: They have been holding these meetings as kind of a follow-up to the NHII conference. They have been meeting with different groups, like Simon was saying he was part of a payer group.
MR. BLAIR: So, he may have made a lot more progress than we are aware of.
MS. FYFFE: Bill had surgery last week. So, that is one of the reasons -- it was elective. He is fine. He is actually here or at least I saw him today -- he shouldn't be, but he is. So, that is one of the reasons that he is not at this meeting.
But let's see, on October 3rd, we had a meeting with the provider stakeholders. It was a meeting by invitation to about 18 or 20 practicing physicians and we had a facilitative meeting with them to talk about the National Health Information Infrastructure.
On October 23rd, we had a similar meeting with private health plans and private health insurance companies in order to drill down with them about their thoughts on the National Health Information Infrastructure. We were planning on having a meeting in early December with employer groups, but there were too many scheduling conflicts with the dates that we had selected. So, we are going to have that meeting instead in January or February.
We will also be having similar meetings with information technology vendors and possibly with consumer organizations, all about the National Health Information Infrastructure. These are follow-up meetings to the very large conference that we had a few months ago in early July.
So, that is part of the progress that we are making in our NHII activities.
DR. FITZMAURICE: Great. Is there a report on -- maybe six bullet points from each meeting that can be generated?
MS. FYFFE: We have prepared internal reports for -- let's say for Jim Scanlon. I would have to double check to see if that is ready for the light of day.
MR. ORT: I just want to add a comment that I have been kind of keeping track of the stuff that has been going on with Bill and which I think is great stuff that he is doing. He just testified recently on Capitol Hill about NHII. So, there are a lot of activities going on, but I do get the sense when I am out there all over the place in the U.S., that there still is, you know, what is the NHII. You know, there still is a lot of confusion.
They don't know what NHII -- it is kind of an abstract concept still and I think it would be useful in a way to try and get something
-- some type of whether it is hearings or whatever, to kind of try and bring this to a little bit more of a practical level. What does this really mean in terms of where are we, how far along. I mean, there is a lot of talk about it. It is conceptual and abstract, but we don't even know -- in fact, the other day when Bill was talking, he said -- which I think a lot of people agree -- that there is no argument at this point, that everybody believes we should have an NHII. I believe most people think that.
Then he said there is probably no -- there is no argument that people think we will have an NHII. I don't think that is true necessarily. We may or we may not. I mean, it is not that simple.
People don't really know what the NHII is because it is not really a concrete entity. Is it one big national NHII? Is it a bunch of local LHIIs that are all interconnected? We don't really know, but I think that what would be helpful is to try and get a sense of what does the NHII mean in terms of from a practical perspective as of, you know, 2004, when we hit there. What are some of the things that we are doing that are pushing towards that, some practical things?
So, you know, how do the standards pieces fit in, how does the stuff that AHRQ is doing, that we are going to have our $50 million portfolio, we will be doing some stuff? It is not out yet, but how does that fit into the NHII picture?
I am just trying to get -- once, again, I am very factual and concrete, but I think that that would be helpful for us in terms of getting information, in terms of, you know, how far along we have really come, not -- you know, well, we have had a lot of conferences and these are some ideas, but, you know, in terms of really linking all this stuff together from a realistic perspective and where are we moving and what is this thing.
MS. BICKFORD: Carol Bickford, American Nurses Association.
Two things. In the listing of the testimony that has been gotten through the NHII, there was a panel related to the workgroup related to physicians and providers, but there are other caregivers, who are not included, like the three million of us, who are not physicians, who need to be thought of in this discussion.
Then in relation to moving towards an NHII, have we talked about how do we know we got there? How do we have an evaluation piece and that we have made a difference, sort of like an outcomes component and that it is a good outcome? So, it is sort of like what are the markers along the way? Is everybody just reacting and throwing the money in, well, okay, the next money comes up, another project?
Have we done the lessons learned sort of thing?
MS. GREENBERG: Yes, I asked Bill about that because when we had that meeting -- was it only a year ago now, a year ago December? It will be a year in December, right after he took his new position and we had that meeting across the street in the Switzer(?) Building. I don't know if you -- were you not there?
That is when he announced that there was going to be --
DR. LUMPKIN: Oh, that meeting, yes.
MS. GREENBERG: Yes. There was going to be a conference and all. So, I guess it had to have been last December.
We did some brainstorming about how will we know, you know, or what are the metrics or how will we know when we are there or not. I never saw anything actually that came out of that.
MR. BLAIR: My thinking is that I think our report was appropriate. It stopped short of being too prescriptive, but we are a year afterwards and I felt that the two major directives, leadership and coordination, I think it is time for us to hear from Bill, his view of what that is, his plans for what that is, his progress, his resources, limitations and all those things and for us to kind of do a milestone check. See does he need help or, you know, should there be some other entity that is doing another piece that he is not in a position to do, in short.
That is where I think we could play an added value role that, you know, others are unlikely to play.
DR. LUMPKIN: Steve and then I think we can wrap this up.
MR. STEINDEL: I think people have said what I --
DR. LUMPKIN: What I heard is is that needless to say from this discussion, obviously, we do need to have -- to spend that time and we are going to try to shoot for December 19th, if we can get that -- again, we will do the polling for the dates and see if we can get people here.
What I see as the beginning is that we want to do two things sort of as where are we now. One is to have Bill come in and talk about a status report, what are the milestones, what he would like to do or sees as being necessary to do, identify how we can help him do it and things that should be on his plate that he may not be thinking of.
As part of that, either before or after, we would do an assessment of our of our recommendations to see where we are and what is the status. Do they still hold validity? Then spend the rest of the time beginning to talk about where we can put in leverage, whether it be to develop another report that really fleshes out the vision, make recommendations or hearings, asking other people to flesh out the vision, but all those sort of pieces are exactly what we are going to try to come to some decision by the end of the day.
MR. ORT: Quick comment. I think that is a great idea bringing Bill in. He is an expert in this area. I am just wondering --
MR. STEINDEL: I would like to make a point. Bill is a member of this workgroup. I don't think we need to invite Bill to attend a meeting. I think we need to put it on the agenda. As staff to the workgroup, Bill should be accommodating to the needs of the committee.
MS. GREENBERG: Providing he doesn't have an obligation --
MR. STEINDEL: But that is an entirely different issue.
MR. ORT: Well, regardless of whether we invite him or not, I think it is a good idea to have Bill here. I think he would be a good research because he is working in this. But I would like to see, if possible, and if we could identify if there is anyone else that has maybe similar expertise, but not Bill, because what I would be interested in is maybe hearing divergent ideas in terms of what their vision is for the NHII, only because, for example, let's say Bill has an idea that the way you do this is you need to get $500 million and put it into a big community like Northern California and pay for interconnectivity and do a big demo project. And that may be something that we need to do. That might be the right approach.
But it might not be. Maybe a better approach is incentive pay for performance and pay all these providers to put in these systems and for quality -- I am not saying -- and what is the other one, advocating. What I am saying is that I would hate to get stuck into kind of one perspective. But I don't know who would be another -- but I would like the committee to think about that.
MR. STEINDEL: I think what Eduardo says is something we should pursue in later hearings. I think it is very important to get diverse input into that. I think what we might want to have at this meeting coming up in December is input from HHS and that just doesn't mean just Bill. That means HHS concerning what HHS's perspectives are on the reaction between -- for leadership in the NHII.
DR. LUMPKIN: Let me play around with that because I think that that is a good idea. The other person who came to my mind was Gary Cristopherson because he has been doing a lot in trying to pull that other piece of that together. That may be -- even though it is outside of HHS, it is within CHI.
MR. STEINDEL: There is also the work that is going on within HHS on the federal health architecture.
DR. LUMPKIN: Okay. I have got federal health architecture and then Gary.
MR. STEINDEL: I think Gary is a very productive back side.
DR. LUMPKIN: So, we have three people we are kind of talking about having come talk? Okay. I think this will be fun. Great.
Have a great dinner and see you all in the morning. We are done.
[Whereupon, at 5:45 p.m., the meeting was concluded.]