[This Transcript is Unedited]
Hubert H. Humphrey Building
Room 305A
200 Independence Avenue, S.W.
Washington , DC 20201
Welcome, Introductions, and Recap of NHII Workgroup Work Plans - Dr. Lumpkin
Overview of ASPE NHII Activities - Dr. Yasnoff
Overview of ASPE NHII Conference Plans - Dr. Yasnoff
Discussion of NCVHS NHII Workgroup Suggestions for Conference
Agenda Item: Welcome, Introductions, and Recap of NHII Workgroup Work Plans - Dr. Lumpkin
DR. LUMPKIN: A little bit of housekeeping, why don't we go over the agenda for today. We have on our agenda not a lot of detail but I would hope that we can do a few things, the major focus of this is that at our last meeting we kind of saw the upcoming conference in summer as being an important milestone as part of our process of developing the next iteration of the NHII vision. That vision is a roughly seven to ten year long term vision that we have as part of our work plan to get it completed over the next 18 months to two years. At that time because of the pressing desire to get the recognition of the fact that if we are in fact going to play a role at the conference we needed to get about the business of making our recommendations on how the conference can help us achieve our goals and Bill has been nice enough to consider how he's going to maybe make some modifications in the conference planning to accommodate us. So that's going to be a major focus of our meeting.
The other part is to really begin to flesh out some of the issues that we described. One being the concept of models, another being the issue of new dimensions and how we want to go about fleshing those out, and the third being looking at the areas of overlap between currently existing dimensions. Did I miss anything?
DR. DEERING: That's it.
DR. LUMPKIN: Okay, so that's what we hope to achieve today, the goal is to get out of here by 3:30 and I am always, pretty much I've always kept to that goal so we can plan on 3:30 as being the latest time in which we'll complete. We'll have lunch for about 45 minutes at noon, roughly, and we'll sort of follow the work as we go from there.
So why don't we start off with having now procrastinated enough and start off with introductions. I'm supposed to do it first, I'm sorry, my name is John Lumpkin, I'm senior vice president of the Robert Wood Johnson Foundation and chair of the workgroup.
DR. DEERING: I'm Mary Jo Deering, I'm the deputy director in the Office of Disease Prevention and Health Promotion and the lead staff to the workgroup.
DR. STEINDEL: I'm Steve Steindel, Centers for Disease Control and Prevention, staff to the workgroup and liaison to the full committee.
MR. BLAIR: I'm Jeff Blair, Medical Records Institute, and I'm a member of the workgroup.
DR. STEUERLE: I'm Gene Steuerle from the Urban Institute, also a member of the workgroup.
DR. YASNOFF: Bill Yasnoff, senior advisor for NHII and liaison to the workgroup.
DR. KAMBIC: Bob Kambic, I'm on Dr. Yasnoff's staff.
MS. WILLIAMSON: Michelle Williamson, National Center for Health Statistics, CDC, and staff to the workgroup.
DR. GORDON: Mark Gordon from the American College of Physicians.
DR. KILE: Frank Kile, American Dental Association.
MR. ALFONO(?): Bill Alfono, Blue Cross/Blue Shield Association.
MR. LARSON: Ed Larson, independent consultant.
MR. PART(?): Michael Part, Office of the Secretary.
MS. BEBEE: Suzie Bebee, ASPE.
MR. WEIN(?): Mark Wein, Department of Veteran's Affairs.
MS. ZIGMAN-LUKE(?): Marilyn Zigman-Luke, AAHP/HIAA.
MS. SHARP(?): Nancy Sharp, American Nurses Association.
PARTICIPANT: [Inaudible.]
MS. JACKSON: Debbie Jackson, National Center for Health Statistics, staff to the full committee.
MS. ADLER(?): Jackie Adler, staff to the committee.
DR. LUMPKIN: Good. Okay, why don't we start off, Bill?
Agenda Item: Overview of ASPE NHII Activities - Dr. Yasnoff
DR. YASNOFF: As the committee knows there's a --
DR. LUMPKIN: The phone, who's on the phone?
DR. FERRER: That's okay, this is Jorge Ferrer from CMS.
DR. LUMPKIN: Oh, great.
DR. FERRER: A little bit under the weather but Steve Steindel went and breathed on me last time I would be okay.
DR. LUMPKIN: We all feel that way. Anyone else on the phone? We appreciate your consideration and also your infirmary of being on the phone with us.
DR. STEINDEL: Jorge, our field epidemiologist will be visiting you in a matter of minutes.
DR. LUMPKIN: Anyone else on the phone? Okay.
MR. BLAIR: I think we were thinking that Stan Huff was going to log in on the phone, and Marjorie.
DR. YASNOFF: So as the committee knows there's a rather long, hour long detailed presentation on NHII that's now archived on the web, everyone has the address. For anyone who hasn't seen that address it's at, there's a link to it at the ASPE NHII website and the address of that website is on the slides that I'm going to go over now. But in the interest of brevity I want to do a very short presentation to start with.
So I basically want to cover two things, I want to essentially review the information that we have on the net national savings from NHII and this is based on a study done by the Center for Information Technology Leadership at Partners, and that study is actually going to be presented in its final form at HIMSS, so the numbers I'm giving you are preliminary. But we asked them to look at the cost and benefits of a ten year implementation of NHII looking at three components, the inpatient EHR, outpatient EHR, community health information exchange. And fully implemented after ten years the net national savings were estimated at a little over $121 billion dollars, divided into about eight and a half billion dollars net for inpatient EHR, over $34 billion a year for outpatient EHR, and over $78 billion dollars a year for community health information exchange.
MR. BLAIR: So when you say the net savings it may be net as of the end of the ten years but there's going to be continuing savings of over $100 billion a year after that, is that correct?
DR. YASNOFF: That's correct and that net I believe includes not just the maintenance but also the cost of replacing equipment and so on.
DR. LUMPKIN: Let me just clarify that again, so the total is $121 billion over and above the cost of installation and maintenance.
DR. YASNOFF: That's right, in other words the actual savings are more like $140 or $150 billion and it's assumed that the cost of maintenance and operation and so on is in the neighborhood of $20 or $30 billion so this is the net savings after full installation. Clearly if you look at the ten year analysis there's clearly substantial investment required to get to that point.
DR. STEUERLE: And this is an annual or a ten year total?
DR. YASNOFF: That's annual, $120 billion dollars every year. So the way we're, so I wanted again to share some thoughts with you about these three --
DR. STEINDEL: Bill, if I recall correctly you sent out a draft of this to the group --
DR. LUMPKIN: Hello?
MS. GREENBERG: Hi, this is Marjorie.
DR. LUMPKIN: Hi, Marjorie, we're just starting.
MS. GREENBERG: Thank you, sorry I had to be a few minutes late.
DR. STEINDEL: And if I recall correctly most, a lot of these numbers were derived from the Santa Barbara Study, are there any other numbers that are used in this?
DR. YASNOFF: Yes, there are some other numbers but I believe they did rely heavily on the Santa Barbara information. As I said, the complete report in its final form is going to be released next week at HIMSS and these numbers I'm told will not be substantially different but they will change a little bit.
DR. FERRER: This is Jorge Ferrer, those numbers that you relate to, we did some studies like that at CMS and they're very similar to the numbers that we also have and I'll be happy to share that report with the group.
DR. STEINDEL: That would be great because I'd like some confirmation on the Santa Barbara numbers.
DR. LUMPKIN: And if I could just throw out one number, a couple of other numbers, I think the estimates for the incremental costs, not the reimbursement cost but the actual cost to the health system of covering all the 44 million uninsured is somewhere in the neighborhood of about $36 to $60 billion dollars, so it kind of puts that amount of money in perspective.
MR. BLAIR: Could I just ask another? To the best of my knowledge there was no way to wind up really quantifying the savings in clinical research and that that number is not in there, is that correct?
DR. YASNOFF: Yes, and actually there are a number of areas where we know there will be savings but it's not currently possible to quantify those savings and so this estimate I think, at least, based on the data we have you would expect that the actual savings would be more then this.
DR. STEUERLE: You're going to give us some breakdown, like how much of this is just savings on administrative input costs versus estimates of improvements?
DR. YASNOFF: I wasn't going to do that --
DR. STEUERLE: I just see you've got some other charts, I didn't want to jump too far ahead. Why don't you go through those first?
DR. YASNOFF: I'm trying to present this at a high level at the moment and I'm particularly, since the information that I have is preliminary I didn't want to redistribute any of the details again, just a week before the final study is available and so when the final study is available I think we can talk about it at the next meeting or in a conference call or via email in terms of the details.
Let me say that the data that support these estimates are not unequivocal, solid, proven, repeated, repeatedly observed numbers. These are estimates, some of them are based on expert opinion, but it's the best information that is currently available.
MS. GREENBERG: This is Marjorie, I'm sorry because I kind of came in I know in the middle here, could you just say what the study is that you're referring to?
DR. YASNOFF: This is the study that I've talked about here before that was done by Blackford Middleton and his colleagues at the Center for Information Technology Leadership showing that full implementation of the NHII would result in net savings to the health care system of over $121 billion dollars per year. And now I'm going to talk a little bit about the three components.
So the first components is the inpatient EHR where savings are estimated, net savings at about $8.5 billion dollars, and the characteristics to remember about inpatient EHRs is that most of the benefits of those implementations go to the institution itself, and the larger hospitals have already invested and our continuing to invest but there's clearly a problem with capital, particularly for small and rural hospitals so that's an issue. Now some of the larger hospitals indicate that capital is a problem for them also and that may be an issue from their perspective. But the fact is that many of the larger hospitals have invested and our reaping some of these benefits.
I should say overall this $121 billion dollars in benefits, the other thing we don't know about it is we don't have a good breakdown in detail as to who gets the benefits, so some of the benefits, you can't assume that all these benefits necessarily mean reduced health care costs because some of the benefits may in fact represent additional charges, which may increase health care costs, so I want to make that very clear.
MS. GREENBERG: And does this include also estimates related to population health, public health --
DR. YASNOFF: No.
MS. GREENBERG: Or is it just clinical? Because you said complete implementation of the NHII --
DR. YASNOFF: As I just mentioned to Jeff clinical research is not included, public health is not included.
MS. GREENBERG: Okay.
DR. YASNOFF: Those are just not included. So when you look at the outpatient EHR the estimated net benefits are a little over $34 billion dollars a year and it appears that most of the benefits of outpatient EHRs go to the payer, or another way of looking at it is the benefits go to whoever is at risk for care. So if providers are capitated they get the benefits because they're at risk, but whoever is at risk gets the benefit. In particular what that means in a practical sense is there's essentially no business case, or no good business case, for EHRs in physician offices, particularly in small practices. In larger practices you can make the case and many larger practices have done that, but the small office, four or five physicians or less, it's very, very difficult.
DR. COHN: I'm sorry, can I ask a question now? I just read something in the AMA News just last week where they were talking about explosion of EHRs in small practices. How does that relate into the business case you're describing or is that cause for reflection about this?
DR. YASNOFF: My interpretation of the percentage of physicians who are using EHRs in their offices is very small, the data varies from five percent to maybe 15 or 20 percent. And I think there is evidence that more and more physicians are making these investments.
The way I interpret those data is that despite the fact that the business case is weak, and you can show that particularly in a larger practice that over a five year period the physician will come out okay, but it's not a strong business case. So my interpretation of that data is even though the business case is not good, or in some cases non-existent, physicians are so interested in improving quality and safety that they're making the investments anyway. And I think the experience in Maine where the payer provided incentives for acquiring EHRs and then everyone acquired them, and in addition they offered incentives for improved quality which was then easy to produce with the EHRs, I think shows that if you want rapid and widespread adoption of EHRs in the ambulatory world that the folks that benefit, namely the payers, need to transfer some of that benefit back to the people who are expected to pay which only makes sense.
MR. BLAIR: Just a tiny refinement on this, it doesn't reflect your final conclusions, but there's an additional motivating factor that has been showing up in the small solo practices extremely powerfully and that is that the work flow improvement is allowing them to do the same amount of work in a shorter amount of time now, the thing is that since the reimbursement doesn't necessarily increase, your point is still correct from a business case issue, from a financial issue the business case is still weak but the efficiencies are also there in addition to the quality and safety for physicians.
DR. YASNOFF: Right, so essentially since physicians for the most part are doing piece work and are reimbursed per piece so to speak the better the EHR is in meshing with the work flow and improving efficiency, that essentially improves the business case because there's a direct correction between time and money.
MR. BLAIR: The thing is the small solo practices in many cases are very much afraid that if they're able to do things for less money that they'll be squeezed down and those savings will flow to the payers, so they're sort of not mentally counting that but they're doing it anyway because at least they're able to get home at an earlier time. That's a perception problem.
DR. YASNOFF: Some people call that the spouse effect.
MR. BLAIR: Yeah, anyway, I didn't mean to, it's nothing that changes your data --
DR. YASNOFF: That's perfectly correct and I think that part of the take home from that is that EHR systems need to be carefully designed to improve and facilitate work flow and that is an important characteristic in promoting adoption.
DR. FERRER: Bill, this is Jorge Ferrer, two comments on your presentation. My understanding on the Blackford Middleton study was that initially he was very CPOE centric and then as he moved into the electronic health record and that the benefits were considerably greater moving away from just a CPOE model. Do you have an observation of that? The folks in demonstration at CMS when they've had to do these packages to offset the budget neutrality of OMB, probably a $20 -- million dollar investment of $100 million dollar net, or is a $100 million dollar net to the office base settings to the Medicare program, and I also have those studies I can share with the group. And that's some of the work that the folks in Stu Guterman's shop have had to do when they're putting together the package for OMB regarding what will it cost the Medicare program to do a “huge” demonstration and what would the savings be to the actual payers themselves.
DR. LUMPKIN: And just another piece of that, under the Medicare Reform Act there are also requirements on CMS for doing modeling and on pay for performance for quality, and one could argue that the discussion we just had about the reason why physicians are going with just a quality related issue, that even without direct incentives for an EHR that having incentives to improve quality, one of the tools to do that is an EHR may also drive some additional conversion.
DR. YASNOFF: Jorge, I should mention that Stu Guterman is also working on the data from Maine because the three year program there that resulted in widespread EHR adoption should, is believed to have reduced costs for Medicare, but we don't have that data as yet but that's hopefully coming.
So moving on to the third piece, which is the large --
DR. STEINDEL: Bill, I have just an aside question, is there any evidence that shows that the increase in ambulatory care EHRs may be impacted by the generational change that's going on in the physician age population? That we have people who are more attuned to using information technology and would accept it more readily?
DR. YASNOFF: I have not seen any data in that regard, that's been predicted for a long time and I personally do not think that that is a major factor any longer but I have not seen any data, that's just my opinion.
DR. STEINDEL: I've actually seen it in the rural areas, where you have younger physicians there embracing computers.
DR. YASNOFF: I do think there's some reason to believe that exposing physicians to electronic health records in training will have an impact on what they expect when they finish their training and we can talk about that as potential policy change.
So the largest sector in terms of sort of the largest part of the savings is community health information exchange and if you think about it the reason for that is that it's only by exchanging information in the community that you can deliver complete electronic health records at the point of care. If all the providers have their own individual electronic health record systems they still only see a portion of the patient information. A good analogy is to financial information. If you go to your bank, assuming you do not have all your accounts at one bank and all your assets at one bank, if you go to your bank they will be cognizant of the accounts that you have at that bank. But if you want financial advice and you go, expect your bank to provide you with financial advice or you go to your financial advisor, you have to provide information about the accounts you have at all banks and all your real estate holdings and all your other assets and liabilities in order to get good financial advice. And so what we want physicians to be able to do is to be our medical advisors and therefore we want them to have a complete picture of what's going on.
DR. COHN: Bill, I hope you don't mind us asking questions, but has the community health information exchange assumed some level of decision support for information support or is this just --
DR. YASNOFF: Yes.
DR. COHN: -- giving them the information?
DR. YASNOFF: Actually both the outpatient EHR and the community health information exchange do assume decision support because much of the savings relates to decision support and the implication of that as I'm sure you understand very well is that in order to provide decision support the information has to be in a form that is computer interpretable which is essentially for practical purposes means it has to be in some kind of standardized form. So if we send information to physicians as free text they may be able to look at it, they may be able to understand it, they may be able to even integrate it for multiple sources, but we will not in general be able to apply decision support techniques to that information and so it make standards even more important.
DR. COHN: Is there an environment where they both have, I mean obviously you get decision supporting inpatient EHRs, outpatient EHRs, I'm trying to think if I know of a model where everybody is comfortable enough with the data coming in that they're actually throwing decision support on data coming from outside sources.
DR. YASNOFF: The only place that could be happening would be Indianapolis and I don't think they're doing that yet.
DR. COHN: Okay, so some of this is an extrapolation.
DR. YASNOFF: As I said, this is not based on multiple hard observations over a long period of time, a lot of this is estimates and opinion.
DR. STEUERLE: Could I just ask you in this last category for the community health information exchange, is the saving due to pure administrative records, the pharmacist doesn't have to make as many phone calls? Or is it due to something along the lines of repetitive procedures wouldn't necessarily be engaged because now people would have shared information? Because you're saying it's not a public health estimate --
DR. YASNOFF: This is not public health --
DR. STEUERLE: This is basically just savings.
DR. YASNOFF: It's the latter, it's that, you know the person at the CT scan and you have the images, so you don't have to do it again. You know that they had the hemoglobin A1C done so you can look at it, that's really where the savings are.
DR. STEINDEL: And Bill that was part of my question, if I recall correctly a lot of these numbers came from the projection of elimination of duplicate tests based from Santa Barbara --
DR. YASNOFF: That's correct.
DR. STEINDEL: The question that I had on that is were the Santa Barbara numbers calculated on the basis of charges or the basis of cost? And we know there's a big difference there.
DR. YASNOFF: They were calculated on the basis of cost.
DR. STEINDEL: Cost.
DR. LUMPKIN: In this particular chunk of this pie to what extent have they been able to differentiate, you say that there are benefits to all but it sounds to me like some of the methodology would indicate that most of the benefits, or a good chunk of those benefits are going to accrue to purchasers, the financial payers. Is that --
DR. YASNOFF: That's right. There was a very carefully done study in Santa Barbara of the administrative savings only, not clinical, so most of the savings are clinical. But they did a very, very detailed study of the administrative savings and they found that all parties benefited. In other words there were administrative savings beyond the cost, well beyond the cost to everyone. Now some of the players benefited more and the problem with that analysis is it only looked at the administrative savings which is only a small part. Clearly we know that a lot of these savings are from reducing duplicate tests and x-rays and those savings again are going to accrue to whoever is at risk for care, in general the payers but really the purchasers, because the payers in a sense only pass it through to the purchasers. So I think in that environment what, I would say you're undoubtedly right when you look at the overall savings that it does accrue to the payers and purchasers for the most part but there are savings to others.
And let me give you an example. If you look at the amount of time that physicians spend looking for information and you calculate carefully the savings there when you have complete information delivered at the point of care all the searching for information time is gone. Not just searching physically but even searching through the pages of a paper record and that's a substantial and real saving to the physicians. So they really do benefit. You perhaps recall having done that once or twice.
DR. DEERING: I have a question about the one beneficiary who no one has mentioned and everybody knows what I'm going to say, it would be the consumer and the patient. And I realize that this study may not have looked at it and I guess what I'm putting on the table is I think it would be very interesting, it would have to be probably a much more prospective modeling effort then a retrospective analysis. But given the fact that the major cost shift that's going on right now and the influence of the parties behind that cost shifting in the name of consumer driven health care, if we are looking at this from a combination of both cost savings to some parties, any party, and expand that to include the consumer and patient. And secondly if we're looking, if another purpose of doing this at all is to identify drivers then it seems to me that strategically it's a great error not to invest as much intellectual effort in understanding what the implications are for the consumers and patients as for the payers and providers and all the administrative types. So I just hope that in future research that we will certainly encourage people to look in those directions.
DR. LUMPKIN: Let me just sort of respond to that a little bit because one of the things that we have to say is that the current changes in health care is that consumers are paying more out of pocket. Depending upon the pricing structure, which tends to penalize people who pay out of pocket more then they penalize those who negotiate discounted rates, but if you look in a somewhat different structure then in fact the individual who is now through an HSA or some other thing now becoming a major purchaser of care, some of those cost savings that we think about in the payer category actually would be shifted to the consumer.
MR. BLAIR: Could I support what Mary Jo I think is trying to say, I may be reading more into it then your intent, I think Mary Jo's point may be touching on benefits to consumers beyond the financial ones in the sense that there's broad frustration with our health care delivery system from the consumer standpoint, especially folks that are not well versed in how our health care delivery system works. They see delays, they see themselves bounced around from provider to provider, they wind up being refused care for reasons why they don't understand, they don't have access, up until now they haven't had access to information in a way that they could understand it or whether they could have some intelligence in choosing their providers. So I think there's a whole array of benefits that the NHII can offer to consumers, which I think we ought to articulate because not only because there are benefits but because there's distrust.
And I think that, and actually this was something I was just mentioning to Bill before we started, we know that there's certain folks that are distrustful of how this information will be used and because all of us don't have those motivations we tend to think that they're either irrational or we know that some of their reasons for doing this are not true. And it's very easy for us to dismiss the level of distrust that's out there. And I'm not saying it's a majority of our population, I don't think it is a majority of our population. But distrust is a very, very poisonous and powerful opposition and I'm bridging on what Mary Jo was saying because I think we have information which we haven't really pulled together and organized to create a picture for how NHII will benefit consumers of health care and it's an opportunity that I don't think we
should fail to take advantage of. It's just a matter of pulling it together, some places it's quantifying it, some places it's financial, some places it's weight, some places it's improvements in privacy and security, which is extremely important that we have to articulate clear.
Mary Jo, did I go too far?
DR. DEERING: Thank you.
DR. LUMPKIN: But I think that as we did in the original document we need to appropriately frame the discussion and I think what Bill's presentation is doing, I'm not sure it's as detailed as he thought it might be in the discussion, we're really actually covering some of the pieces of what we want to do which relates to the financial modeling. And I think we're also teasing out some other areas for additional analysis that we may want to look at as part of the process of developing our report. There are some significant changes going on in the financial arrangements in health care and it may be that either through ASPE, through AHRQ, through foundations, that some of this analysis can be done so that when we get ready to do our report the issue of the financial impetus to move to interconnectivity interoperability throughout the system, that we can really make a compelling case. And I think different then the last document where we made a compelling case on what it can do for patients and providers in the public health system on a operational well being level, hopefully the next iteration will have a lot more analysis on what this will mean at a dollar and cents level too, to interweave and combine the two.
DR. STEUERLE: Can I express, part of what I think is going on here is the analysis we have here is what economists would call an impact analysis, it's not an equilibrium analysis. By way of analogy economists would say if you put a tax on consumers or a tax on producers in a competitive market it doesn't matter, in the long run you'll get the same results as to who pays because there's a shifting of who pays. Same thing for subsidy, and the same thing goes on here, is this is really an impact analysis given a current cost structure of where is the initial saving show up. But as soon as that saving shows up then there are adjustments in the market, insurers start competing at the new price level, hospitals start providing at different prices. And in that type of market hopefully you expect the consumers to get a fair amount of that benefit and this really is not an equilibrium analysis, it's really just an initial impact analysis. For long run what you want to talk about is what does it do in general for the economy, productivity, consumers, and everything else and that's where the benefits start enearing(?) to them, and it might take place actually quickly.
MR. BLAIR: That's an excellent observation.
DR. LUMPKIN: And that's the kind of analysis I think we would want to do as the next phase, I think all of this builds upon each other.
DR. YASNOFF: So let me say that in general to the extent that consumers are at risk for care, and obviously that is occurring more and more, then savings will accrue to them. But let me also sound a cautionary note in terms of methodology with these studies. These are very difficult to do and even the data that I'm showing you is as I said is not based on absolutely solid evidence and so while I agree that we need to do as much as we can to assess the benefits and I'd love to see an equilibrium study of this --
DR. STEUERLE: I'm not arguing it would be easy to do, I'm not going that far.
DR. YASNOFF: I understand, but I think, I'm not sure that it's possible to do but even if it is I think that from a strategic perspective the benefits of this are so substantial that while it's important to study all aspects of the benefit and to quantify it as best we can and I think over time we're going to have more and more data to do that, that shouldn't stop us from taking a subset and developing a very solid case based on a subset of benefits, not because the other benefits aren't important but because this subset is amenable to study and solid quantification, that's my only point. Next time I'll report with more detail.
DR. LUMPKIN: I think we'd all be fascinated when the report's released to look at copies and things.
DR. YASNOFF: We'll arrange that.
DR. LUMPKIN: But thank you for sharing the preliminary because obviously there's a lot of interest.
DR. YASNOFF: So in the context, I'm sorry, the points with respect to community health exchange are that there's substantial benefits to all but there's a first mover disadvantage, so whoever starts loses, so everybody kind of has to do it together. And in part because of that there's a need for seed funding and this, developing these community health information exchanges is really the focus of current federal activities, because that is where there's a clear need for seed funding and where the bulk of the benefit appears to be. So I wanted to present that information as context for our strategic plan and what we're doing in the various areas.
So I'm sure you all remember very well the six point strategic plan we're following, inform, collaborate, convene, standardize, demonstrate, and evaluate. Under inform we're doing lots and lots of presentations, I recently presented AAHP/HIAA, I'm going to be presenting to Premier and to the National Managed Care Congress and many others, which I do have them recorded in my planner if anyone has questions, quite a few. I'm personally doing my best to keep the airlines in business.
We do have a website that has not been updated as much as I would like, in part because of the Continuing Resolution we were not able to get support for that but we now are in the process of doing that, I did mention this video archive of the NHII presentation. We're also going to be developing a communications plan and I'm very happy to tell you that Dr. Robert Hogan from Kaiser in San Diego, a very experienced family practitioner, who also has been a spokesperson for Kaiser and has had extensive media training and done lots of writing is going to be with us from March through May and is going to be focusing his energy on our communications plan, so we're very happy to have him on board. And I'll be happy to bring him to our next meeting to talk about that.
Under collaborate we had, as I think I mentioned in my last presentation, we did have an employer stakeholder meeting on January 16th, the employers are very supportive of NHII and in fact several of them urged us to move forward even faster noting the problems with health care costs and access that they felt this would assist in addressing. We're planning a number of other meetings, we haven't got them all scheduled, but we are planning a requirements discussion on March 29th and I'm hoping we can spend some time talking about requirements today, followed by an architecture discussion and also stakeholder meetings with health IT vendors, with consumers, and we're also planning to bring together some experts on this business case issue to see if we can at least get consensus as to what we know solidly from the information that's available.
We're also establishing a collaboration with the developers of local health information infrastructures, we're having conference calls with those folks and I should say there are more then a dozen of those that are in some stage of development. We're going to be setting up an electronic collaboration space and establishing a formal community of practice so that we can maximize the sharing of lessons learned and we're going to actually have a contractor who will assist in that activity.
Under convene we are planning for the NHII '04 meeting, I'm happy to announce that the contract has been awarded for logistical support and we're having our initial meeting with the contractor tomorrow. And our tentative date is mid-July and again, it's tentative but we're hoping to do this July 20th through the 22nd but that's not final.
DR. COHN: When do you expect to make that final?
DR. YASNOFF: As soon as possible, it's contingent on the contractors signing an agreement with the hotel and that will be the first, second, and third point on our agenda tomorrow with the contractor.
DR. COHN: So there is space available, it's a question of doing the contract.
DR. YASNOFF: That's right.
MS. CRONIN: Bill, could I ask a question on your previous slide about the community practice contract? How is that going to relate to the resource center that we set up under AHRQ?
DR. YASNOFF: I have been trying to get information from AHRQ about what they're doing with their resource center and I have not received any, so I don't know. But I'm unaware that they have any plans in this regard --
MS. CRONIN: What are you trying to do with this just so I understand because it sounds like there's overlap, or they could help each other.
DR. YASNOFF: Community of Practice is an active process that facilitates exchange of information among people who are doing similar work so it involves having calls, it involves setting up a work space where people can share documents and also have subject matter based conversations, it also involves face to face meetings to create social capital and make sure that people have informal opportunities to exchange ideas. And again, I am not aware of what AHRQ is planning --
MS. CRONIN: Well, I know they've had several meetings with ASPE to talk about it so --
DR. YASNOFF: There has not to my knowledge been a meeting to discuss that, I have been asking for that. If there was a meeting where they discussed this I am not aware of it.
MS. CRONIN: [Comment off microphone.]
DR. YASNOFF: There's been nothing substantive that we have learned about what their plans are.
MS. CRONIN: Well, I'm sure there will be.
DR. YASNOFF: I hope so, that would be nice. So the other thing I should mention about the convene function is I'm happy to let you know that the final manuscript summarizing the recommendations from NHII '03 has now been submitted for publication so we'll see what happens. I will let you know.
DR. COHN: Bill, does it require publication for it to be made public?
DR. YASNOFF: At this point if it's public it will not be published, in other words making it public would, making the manuscript public would jeopardize publication.
DR. COHN: I was just observing that --
DR. YASNOFF: Let me say this, the slide summary of the recommendations essentially is, those are the recommendations. This is just a narrative that goes with that so there's nothing that you don't know that is, everything related to what the recommendations were is already on the public record, so we certainly don't want to keep those secret but the manuscript itself needs to not be made available until a decision is made --
DR. COHN: And I think I was maybe reacting, a number of us were part of a meeting with the National Quality Forum of two years ago, it was with the IOM talking about the issues sort of like we're talking about now and I just earlier this week finally received the report on my desk and I barely remember the meeting any longer much less the recommendations, so it was sort of on that level of worrying about the timeframes.
DR. YASNOFF: You will see when we get to the discussion of the meeting plans that in the meeting plan for this year there's no contemplation of any write-up afterwards at all, so we're not going to do that again.
So under standardize, I think all of you are probably aware of the HL7 effort to develop the standard functions for the EHR, we're expecting a ballot starting mid-March through mid-April, that hasn't been finalized but that's the expectation at this moment. We're also have begun the process of setting up a contract with HL7 to develop an EHR interchange standard that would allow exchange of complete records or subsets of those records in a standardized way essentially to deal with the transaction, send me Mary Jones entire medical record. And while you can do that now with HL7 transactions on an individual basis it's not very convenient and it's certainly not standardized.
That interchange standard will essentially provide basis for easy interoperability between systems, we're expecting to award that contract in April and HL7 has told us that this will take them about 18 months. So we're looking forward to that activity and I think once we get that started it may be relevant to have HL7 come in and talk about exactly how they plan to pursue that, either to the Subcommittee on Standards or the workgroup or a combined meeting, up to you.
DR. DEERING: Is that an ASPE contract?
DR. YASNOFF: Yes. Under demonstrate, I know that AHRQ proposals are due April 22, I believe that's the date for those solicitations. On our part we're planning to provide some LHII start-up awards this fiscal year, some very small grants, an example of one of those might be in the national capital area. We're also planning to establish an LHII technical assistance contract this year to provide easily available technical assistant to whoever may be developing an LHII and again, there may be overlap there with the resource center but I don't know so I'll look forward to finding out. And in addition, as you all know, the President has announced an additional $50 million in his request for the FY '05 budget for development of LHIIs and we're beginning to develop the RFA for that and we anticipate that those awards will be in the neighborhood of a million dollars each and will require some community matching funds but we're pretty early in our thinking in that regard.
Evaluate, we have some work ongoing in terms of what are the options for aligning the financial incentives and also with respect to requirements for long term care EHRs. In the long term care arena there's been very little development and very little penetration of EHRs and we're looking at that issue. Also this issue as we've already discussed to improve the cost benefit analysis with respect to NHII, and I appreciate the input and thoughts, there are a number of studies that are in progress that we are expecting will provide some good data, we're following those. I think that the AHRQ awards related to research on value will be very helpful when those results come in, which will be sometime, and as I mentioned earlier we are planning to convene a small meeting to review the business case information and see if we can get a handle on what is the solid evidence where we have clear cut data that is let's say at a high standard of reliability versus things that are estimates and guesses.
So that essentially summarizes the things that we're working on. So I'll be happy to answer any questions, and I'm sorry I went over.
DR. DEERING: You were interrupted by people like me, and at the risk of being a broken record it did just seem to be here as we again look at policy options for aligning financial incentives, once again to most of that policy analysis always looks at what can be do for the payers and the providers and given the proportion of total health care costs that are paid out of pocket by consumers and the increasing proportion that that may or may not represent, to be sure that they're factored in there in those policy analyses because I know that also from the point of view of adoption many of the big providers, certainly I know this was true with DOD but not of VA of course so it's different there but have viewed it as vital strategically to get the consumers on board very, very early because if they won't go and use the stuff, they won't get their information on, they won't go there and use it to schedule their appointments or do their prescriptions, so again, I don't want to beat a dead horse and I know this is something that there's been very little work done on today.
DR. YASNOFF: And I agree completely, I think we need to look at the financial impact on consumers. There's been a lot of discussion in various meetings about how, when, how and whether to bring consumers into this and I certainly don't have the answers. I think clearly the benefits to consumers are substantial, I don't think anyone given the likelihood of receiving recommended care, the likelihood of errors, the problems with records, I mean you talk to anyone with a serious illness and they'll tell you how they carry around their own records. So I think the benefits are very, very clear. The one concern, well, one of the concerns that I have is I would not like to see consumers get all excited about this too early before we can deliver anything to them because I think then we may end up with consumers who get excited and then are disillusioned --
DR. DEERING: An integrated strategies that bring them --
MS. CRONIN: Yeah, for example, I think if payers were aware of the certain level of demand and if they were to believe that there'd be a decreased switching rate if in fact that took a lead and established a sophisticated system that consumers had developed a high level of satisfaction with then they'd know they'd be maintaining market share perhaps over time and that would be sort of an integrated way.
DR. STEUERLE: Along the same lines it seems to me if there's a way, unless this could be dangerous but if there's a way of generating consumer demand so the consumers think if this is in place in my hospital, my doctor's office, whatever else, I'm going to get better health care that demand could be a very strong incentive for people to react.
DR. YASNOFF: I think the way that it's playing out at the moment is that in those communities that are building local health information infrastructures, in organizing those activities they are actively bringing in the appropriate folks from the community and consumer groups, and I think that in those contexts the consumers are very effective in encouraging the payers and the providers to figure out how to agree to share information so that these problems with duplicate tests and errors and failing to give recommended care can be addressed for them. So we're certainly encouraging, although it hasn't taken much encouragement, but we're encouraging those organizational efforts to always include consumers. And while I'm mentioning those groups that need to be included we're also encouraging them to include public health and to think about public health not only in the context of a provider, which the public health department often is, but also in the context of monitoring the health of the community. This is one of the things that happened in Santa Barbara, the public health department was included from the very beginning of the project but it was the part of the public health department that's a provider. The folks who, the epidemiologists who monitor the health of the community were not included at the beginning and so the system was not designed to provide the kinds of monitoring that it could provide, now they're having to retrofit it, so we're making that point as well.
DR. STEINDEL: Bill, I have a question about the potential ASPE money going out, the $50 million dollars, and just a comment on thoughts, I realize you haven't put together the RFAs. One of the comments I have on the AHRQ grants that are going out now is there's a very limited amount of money that's available for what I'm going to call stuff, hardware, software, etc. Are you thinking about providing more money for what I've euphemistically called stuff?
DR. YASNOFF: Yes.
DR. STEINDEL: Good, thank you.
DR. YASNOFF: Very much.
DR. COHN: I was actually following up on the consumer discussion and all this stuff and obviously I always whenever I hear the word consumer I get a little confused because it's not a very homogeneous lot in terms that we're all consumers so it turns out who a consumer representative is, can be somewhat of a thankless task --
DR. YASNOFF: It's not you, Simon.
DR. COHN: Well, actually, you're right, I actually am a non-consumer of health care services, so thank you. I do my best to avoid it. Having said that as I look at all of this stuff and I'm listening to sort of Jorge on the phone, are you still there?
DR. FERRER: Yes, I'm here.
DR. COHN: I mean it really seems to me that the lead activity in all this stuff which somehow not being mentioned is really the Medicare program and our Medicare population, many of whom are significant utilizers of health care, we have an early identifiable payer, we all have a self interest in making sure that the Medicare system survives and prospers so hopefully we will all take advantage of those services, some of us sooner then later. And I guess I'm looking at all of this stuff and I'm just sort of trying to figure out in my own mind why the close connection and interest don't really align around assuring that our Medicare population really is well served by all this stuff, I guess if I was thinking of people, of consumers, I'd be looking at a group that maybe was reflected by our Medicare population. And I guess I would be looking at that as really the first case sort of moving forward as opposed to sort of the more homogeneous we'll take care of everyone. I don't know, I just sort of present that as sort of an issue or maybe a shading of all of this.
DR. YASNOFF: You'll recall that the Information for Health Report recommended creating an office that would coordinate these activities and of course as you well know there has not been an office created and there is no official coordination of these activities.
DR. DEERING: I was going to ask Jorge quickly, isn't there also within the Medicare Reform Bill, I don't know the dollar amount but an equally huge component for chronic disease management that has an IT component, so is another potential driver of this?
DR. FERRER: That's section I believe 771 --
DR. YASNOFF: Actually there are a number of provisions in that bill that relate to this but the issue is one of coordination and we certainly are trying very hard within the existing HHS structures to provide that coordination, particularly internally with HHS through the new Council on the Application of Health Information Technology that Kelly is the executive director of, we're trying to make sure that all these various initiatives are coordinated but it's quite challenging. I'm sure you would agree it's quite challenging but if you want to disagree go ahead.
DR. LUMPKIN: Let me throw out one piece and then move in a slightly different direction, and that is that we shouldn't forget Medicaid either, and particularly since this might be an opportune time where every state in the nation is looking at their budget and it's education and Medicaid, the potential for cost savings through certain investments may actually find a very attentive group.
DR. YASNOFF: And actually the Medicaid is planning to do, or actually has funding to build an information architecture and they're on my list to talk to in terms of trying to rationalize their approach to their information needs with building local health information infrastructures and I'm hopeful that we're going to be able to take advantage of that. So that is a very good point because not only are they there but there's a substantial funding there in the information technology arena that could presumably be applied to move this forward.
DR. VIGILANTE: The other point dealing with consumers and talking about subpopulations to identify, if you look at children, if you look at children's special health care needs, ten, 15 percent of the kids accounting for over 40 percent of the costs, a lot of duplication, a lot of lack of coordination that could be facilitated by just this kind of technology. So as we think about subpopulations in which we are likely to get measurable results because of the huge gains that may be potentially achievable that would be another one that I would earmark.
And thirdly, when you talk about coordination the other sort of whole other silo to be thinking about and you touched on it a little bit when you talked about monitoring the public health side would be the whole syndromic surveillance activity that is very relevant of course to preparedness but is not really doable without sort of electronic capture of clinical information at the primary care level. And again, yet again another point of coordination and pots of money out there that could be leveraged as well.
DR. YASNOFF: That's a very difficult coordination issue, I've certainly made that point at every opportunity and I think you're absolutely right and it's not possible to monitor electronic information streams that don't exist and so by making them exist we provide that as a possibility.
DR. STEUERLE: I'm going to draw another little analogy here, there's the debate in the tax community as to whether IRS ought to pay people five dollars if they'll file electronically, the reason that they would want to pay five dollars is because when IRS gets your records and has to re-key punch them in not only do they make errors but it costs them a substantial amount of money and so their net saving could be substantial, there are reasons having to do with privacy and vendors that are still preventing that type of thing. But I wonder how far we are from the day where we wouldn't be addressing a point on Simon's notion with Medicare or maybe Medicaid, or Medicaid for children if there's some expansion, where we would suggest that the Department consider possible small subsidies to providers who do certain types of, when they file for other people if they indicate there is some minimal amount of structure available. Now that's not unrelated to how much of that structure we feel like we can standardize at this time, there may be 1,000 things we want and you may decide it's only 50 of these are decent enough that we can sort of say that this structure has to at a minimum have some record sharing on X, Y, and Z, but I really wonder how far we are really from that day where we address that type of potential subsidy of the system and whether in line with cost savings whether that subsidy might be designed in a way that would product net saving for the government.
DR. LUMPKIN: Let me throw a couple of ideas out and then we'll have a little bit more discussion and then we're going to take a break and go to your second part if that's okay. The first is you mentioned that you're pulling together a group to improve the cost benefit analysis of the NHII, and I would just like to recommend that Gene be invited at the very least to that session.
Second is we're starting to talk a little bit about models and Gene raised the issue about the IRS and their little payment conundrum that they're discussing. Well, that may have some implications on models that we may want to look at for dissemination of EHRs. Bill mentioned very early on that rural hospitals, inner city hospitals, tend to be capital poor. And many of the models that exist of EHRs tend to be with capital purchase by the provider entity, whether that be the hospital or the individual providers, there are other models along the ASP model and there are certain, clearly there's a number of currently existing models for payment systems and so forth where ASP will do the billing and do all the back office kind of things without you having to purchase their hardware and software, you're essentially doing it on an equerious(?) basis. And a model where there is a premium, a negligible mil, a penny or something premium on these kind of transactions may map into a business model that would not lead to capital investment but would lead in use cost investment that may allow cash poor clinicians, hospitals, community health centers, to actually get on the bandwagon without having to make large capital outlay. So I think we need to play around with that as we go into the model.
And then the last item I wanted to raise has to do with the $50 million. And there's a new postulate that I ran into when I came into the world of philanthropy, which actually, it's kind of new, Don Berwick is the one who coined it at a meeting I was at. And we were looking at quality improvement programs and how we could do grant making and the postulate goes something along this way and he may deny ever doing this but he said if the innovation make business sense then why do you need a grant, and if it doesn't make business sense then the grants probably aren't big enough. And so in looking at the community interoperability that we want to foster I would encourage ASPE in looking at that grant program to say what is in fact the obstacle that will allow sustainability and replicability of these models and to focus the grant making on those obstacles rather then the kinds of things that ought to be part of the business case.
DR. YASNOFF: Couldn't agree more. I think that this is the same, as we look at the options for pursuing this this is the same type of analysis that we're doing and as I said our focus is on building these community health information exchanges. The evidence that we have so far is that once established they not only pay for themselves but actually generate substantial savings for everyone. So the issue is if they generate substantial savings for everyone why aren't people building them. Well, in fact they are trying to build them and the issue is that the evidence for the substantial savings is not as strong as you would like. The timeframe of the substantial savings is a number of years and there is this first mover disadvantage which makes it difficult to bring these efforts together. And so consistent with that our thinking is that you need some seed money but it needs to be matched by some money in the community get these things going and so essentially the way you can look at that is that the expectation is that the seed money will be more then returned to the federal government through savings to Medicare and Medicaid.
DR. LUMPKIN: Or another model may be as a revolving fund, that if you generate a revolving fund the concept is that these things just need the seed money to do it and over time that they will more then pay that back because the concern is that $50 million seems like a lot of money but it's not when you start trying to apply it over the country and how are we going to accelerate the development, and if a successful revolving fund model is developed then those in the private sector may want to look at similar kinds of privately funded venture capital that may fund these kind of initiatives.
DR. COHN: I was going to make a comment, I guess, and this is probably for after the break because I think all of these questions really are better on the architecture and all of this stuff. I obviously want to hear more from you about your overall strategy, which is really local health information infrastructure development because I'm not sure, that's one way to demonstrate value but I don't know that that's, I need to be convinced from you that this is really the right way to go recognizing that there are actually all these other elements of the NHII being put into place, HIPAA, e-prescribing, privacy and confidentially, all of these other things, so the questions is is yes, I mean you're right about monies and support and all of that but is that even architecturally the right way to go in terms of making the business case. But that's really an after the morning, after the break conversation.
DR. LUMPKIN: And that's a good segue into our break unless someone has an overwhelming --
MR. BLAIR: After the break I have a comment to make about one of the options that you mentioned with ASPs.
DR. STEINDEL: John, just a very quick comment. My question to Bill concerning the distribution of the ASPE funds was that I felt that the AHRQ grants was a little bit too constraining and that I wanted to see some flexibility in line of what you were talking about, so people who are applying for these grants can look at the barriers in their communities and approach them in a way that would be appropriate for the community, which is why I was asking about hardware/software connectivity issues and things like that because the AHRQ money is very limited in that area.
DR. LUMPKIN: And I suspect though that we're not going to spend a lot of time, we're going to try to come up with a report that's going to be in the long term timeframe and certainly if we have an opportunity.
So we're going to do when we come back is Bill's going to start, open the discussion on architecture, I think we can as part of that discussion --
DR. YASNOFF: Meeting, we have to do the meeting first.
DR. LUMPKIN: Talk about the meeting first and then after that when we have time to talk about some of the architecture because that relates to the models I think we can go back to Jeff's discussion about ASP because I think that's tied up in there. Okay, let's take a 15 minute break.
[Brief break.]
DR. LUMPKIN: Okay, let's go into the meeting in mid-July.
Agenda Item: Overview of ASPE NHII Conference - Dr. Yasnoff
DR. YASNOFF: Thank you. What we did in the interim since the last workgroup meeting is we put together this information, essentially a draft plan for the meeting, let me review it briefly and then ask for your comments and questions. Basically there are two major goals, one is to report on progress that's been made in the last year and the other is to continue to evolve the agenda in a more detailed fashion. And one of the things we're trying to do in this meeting is to explicitly acknowledge that there are both topics that need to be discussed and stakeholders that are interested in various topics and we're differentiating those this year, last year we kind of put them all together.
So after quite a bit of internal discussion we came up with a list of eight topics that we thought needed the most urgent attention, governance, finance, standards, architecture, privacy, metrics, public health, and research. And then the stakeholder groups that we defined, and again you can define more but we kept it to eight and it's for logistic reasons and we can talk about that, are health care providers, health care settings or institutions, employers, public health professionals, payers, vendors, consumers, and researchers.
So the meeting, if you turn your attention to the schedule, I think it's easier to follow what we're trying to do from the schedule, we thought it would be good since this is now the second meeting we didn't want to repeat basic material about the NHII at the meeting but we wanted to give new stakeholders the opportunity to be exposed to that material so we programmed in a tutorial the evening before the start of the meeting for those people who wanted to take advantage of it. And then on the first day we plan an opening keynote and I'm hopeful that we will be able to get Secretary Thompson to do that, and then I'm planning to give a presentation basically summarizing where we are with respect to the NHII. Then the first plenary would be devoted to the topic of local health information infrastructures and would include presentations from Santa Barbara, from Indianapolis, and also from Nancy Lorenzi who did that report on the organizational issues involved.
Then we would start the breakouts and the first two breakouts would be by topics and the other difference with the initial breakouts for this meeting versus last year are that in each topic area we would essentially start with whatever we have from prior work, so there are some governance recommendations for example from the '03 meeting, we would bring those to the governance topic for this coming meeting.
The other difference is that we're planning this time to use professional facilitators as opposed to asking people in the field to act as facilitators. A couple of reasons for that, one, we wanted to give more, when you're the facilitator you don't really get to participate in the meeting and that seemed to be a problem, and the other thing is we felt that with professional facilitators the facilitation would be more neutral. But we will still have the concept of invited experts in each group so we'll identify some folks who are particularly knowledgeable about a given area and ask them to commit to attend those particular breakout sessions.
Between breakouts one and two we have another plenary, which is devoted to a summary of the benefits and we hope we can have Blackford talk about his latest study, also about safety and decision support and whatever information we have on the business case. So this is basically benefits, safety benefits, business case.
Then the evening we're hoping we'll be able to have a reception and dinner and also there will be some preliminary reports generated by the facilitators in the topic breakout groups basically saying here's where we are now with these topics and you'll see how that feeds in on the second day.
So then the second day we begin the day turning our attention from topics to stakeholders, and the idea of the opening plenary, which really is two panels, is to have stakeholder panels. So we have eight stakeholder groups identified and we'd have two panels with four stakeholders each and we'd ask each representative of a given stakeholder group to say here's where we're at, here's what we think about the NHII, here's what we like, here's what we don't like, here's what we don't understand, to basically get the different stakeholder perspectives in a plenary session.
And then the third breakout session would not be by topic, but it would be by stakeholder and everyone would be asked to go to the appropriate stakeholder session and review the draft results of the first two topic oriented breakouts and provide input into all the topics from that stakeholder perspective. Now whether this is going to work or not I don't know but bear with me and we can talk about it, suggestions are welcome. I'm sure you agree with the theory.
And then after that stakeholder breakout we have lunch and then go back into the topic oriented breakouts for breakout four and then for the last breakout essentially saying okay, now we had our preliminary results of the first two breakouts, we had this input from the stakeholder groups, how can we put that together and make sense out of it and generate some recommendations that we can report on the third day.
And then the plenary between sessions four and five is what has been labeled private sector, the idea in that plenary is to have a panel with all the private sector efforts around working on NHII so we would have someone from Connecting for Health, from eHealth Initiative, from NAHIT, from HIMSS NHII Task Force, from AMIA, there are a number of different groups and let each of those groups indicate what it is that they're doing, where they see themselves fitting in, and whatever else they want to say in a short period of time.
So then after the last breakout then the second day in the evening would be time for the final reports to be done, the professional facilitators would not be the ones delivering the reports, each group would elect a representative from the group or somehow select a representative through an as yet to be defined process, a peaceful process, who would then be the spokesperson on the final day.
And then day three would essentially involve two plenary sessions for reports, just as last year's meeting did, but the change this year, and this is something that the workgroup has to agree to, is that both those plenary sessions would in effect be official hearings of this workgroup. And the advantage of that is that that means that those sessions would be recorded, transcribed, hopefully we could even arrange for live broadcast on the internet with some advanced notice, so that all the results would be immediately available and public, no write up would be necessary, just want to make that point very explicitly. And also I think that the participants in the meeting would have the assurance that their input was going to exactly the right place immediately.
I think the one concern I want to share with you about this is that the, since we'll have at least eight reports and perhaps more if we have to split some of the breakouts into two groups because of size, so we could potentially have as many as 16 reports, which is actually last year we had I think not 16, we had 14 reports, there isn't much time for questions and so in order for this to work, and I know this is going to be a difficult sacrifice, but the workgroup would have to restrain its normal propensity to ask questions. But I would suggest that, obviously there are going to be a number of questions and so the workgroup might want, if this is agreeable, might want to think about scheduling some hearings subsequent to this meeting at which perhaps some of the same people are invited and then to provide time for questioning.
So this is kind of an overview of where we've gotten in our thinking and I'm anxious to hear your feedback, questions, suggestions, observations.
Agenda Item: Discussion of NCVHS NHII Workgroup Suggestions for Conference - Workgroup
DR. LUMPKIN: Let me try to structure a little bit, let's first spend a little bit of time talking about the goal, focus on that. The second thing we want to talk about are the topics, the third would be the stakeholders, and then let's talk about the time arrangements. Is that agreeable?
DR. YASNOFF: Sounds great. My only constraint is as I said before, whatever feedback the workgroup has on this meeting we need to get it done today.
DR. LUMPKIN: That's right, and that is our goal. Speaking of goals, do we have any comments on the goals that's listed here on the document?
MR. BLAIR: There were two goals --
DR. LUMPKIN: Three, let me read them to you. The goal of the meeting is to move the NHII agenda forward by reviewing the major issues raised last year and reporting on progress made in the last year. Two, by focusing on topic areas which are key components of the NHII. And three, by involving stakeholders in developing the way forward.
DR. YASNOFF: Actually may I make an edit? I would call this topic areas that are key issues related to the NHII because I think people may misunderstand components.
DR. LUMPKIN: Got it, Jeff.
MR. BLAIR: Thank you.
DR. COHN: I'm looking at this, obviously goals at a certain level everyone can agree with because no one really knows what they are, and I'm sort of looking at this and it's hard for me to argue with anything that I'm seeing here. I guess I was reflecting that, and once again I may be getting a little confused about the purpose of the meeting versus what we're doing in the workgroup versus our long term plan, but I think we have all observed that one of the issues with the NHII is that the vision is such a high level that everyone's feeling a need to sort of move it into more substance and Jeff has described this as models, I describe it as more substance, so that you sort of know what's in or out and sort of what the direction is. And I can't tell looking at these goals or really at the overall agenda whether or not that is one of the intents of this meeting, to sort of move that discussion forward. So is that a goal here and is this somehow in here in a way that I don't, I mean is that one of the key issues of the NHII?
DR. YASNOFF: I think we can, yes, and I agree that the language probably does not state that sufficiently. The idea is to take the agenda that we developed last year, which was at a very high level, plus what we've learned which is a little in the last year, and move that agenda down to a more detailed level. And so that's one of the reasons why after the kind of overview opening session we immediately go to a session on LHIIs, focusing on that approach to actually building the NHII, which we can talk about afterwards. But so yes, the idea is to make it clearer then it has been what this thing is and what it would look like and I think the best way to do that, well, first of all we can, as I said we can rewrite the goal statement a little bit but by having both Santa Barbara and Indianapolis come in and say here's what it looks like in our town, here's what it looks like in our town, I think you begin to get a better picture of what it is.
One of the smartest people I had the pleasure to work for taught me that a vision is something you can see, it's not some vague thing, and so my expectation is that we're actually going to see demonstrations of what this looks like at the meeting.
DR. VIGILANTE: I think that's exactly right, maybe we should reflect that in some way in that we're trying to either capture, I don't know if we know they're best practices yet, but instantiations or examples or data or concrete evidence of progress and pitfalls, information people can use at a very pragmatic and granular level saying this what we're doing at Santa Barbara, this kind of worked, this wasn't so great, and start to develop that community of shared experience, by sharing experience, and I'm sure that's what you intend, but maybe some more focused language around that.
DR. YASNOFF: I just jotted down, using the agenda from last year as a starting point increase the detail, increase its detail and specificity. But I think what you're getting at, that's the previous point, what you're getting at is reporting on progress and sharing lessons learned from the past year. I should say one of the side activities that we're going to do probably day two in the evening is to have, there were some evening meetings last year of specific groups of interest and I suspect they'll be a number of those. But the one that I'm most focused on is a meeting of LHIIs, people who are working on LHIIs, with our community of practice contractor, essentially a kick off meeting for the community of practice to talk about what needs to be in a website, and presumably they'll have a website mocked up and show what it is and a little bit how to use it, talk about what topics need to be discussed, how people want to access it, and those kinds of issues, so an actual working meeting of the people who are the builders of this to begin some of those detailed issues with respect to sharing.
I think we have to be careful in the general sessions that we don't get into too much of that because many of the people who I think are going to attend this meeting are those, my expectation is that many stakeholders who were not able to come to the meeting last year are now aware of this and are going to be coming, essentially being exposed to this for the first time. And so getting into some of the really detailed lessons learned in the LHIIs is not appropriate for people, for example, for national payers who are just thinking about the issue as a whole for the first time. So I want to be sensitive to that as well.
DR. STEUERLE: I like the structure, I like the design, I like taking a look back and forth between the topics and stakeholders. But it seems to me that the crucial issue as to whether this works or not has to do with the way the sessions themselves are run and set up in terms of what the moderator is asked to do, what the people going to the sessions are asked to do specifically as opposed to just going into a session and everybody sort of just saying what's on their mind. And I don't have exactly what that list of questions or specifications for the moderator should be but I think some of them are already coming out in this discussion. It would be very good if right from the front somebody said we'd really like people to step up and tell us what are the best practices out there. For me a statistics and information gathering session, of course we could use an information session as sort of what don't we know and why don't we know it, which is always a tough question to ask but there's way of perhaps phrasing questions, the sessions to develop them. For instance I would love to have some very specific questions on obstacles, the extent stakeholders or providers or whatever out there come up to say what are the obstacles you face, name the critical obstacle that you face, general or specific, to doing the type of development you want, I would love to have that type of set of bullets or laundry list or whatever come out.
DR. LUMPKIN: So you would add to the goals identification of obstacles to interoperability or adoption or --
DR. YASNOFF: I would leave it as identification of obstacles, because I don't care what the obstacles are related.
DR. STEUERLE: I'm a little concerned with whether you list it as a goal, how exactly is the session itself organized to elicit this information, what particular questions --
DR. LUMPKIN: But the genesis of the directions to the facilitators and the leaders will be based upon the goals of the session, so I think the clearer we are on kind of where we want to focus them, that gives them a clearer task to accomplish.
MS. RIPPEN: I think for each of these it's going to vary because each of these pieces topics are in a different place in the continuum of being ready for prime time and preparation, so for example the architecture meeting, there is going to be a meeting on requirements and we're hoping that you're going to provide some input on requirements, which is a requirement for an architecture. And so there will be something for people to react to for that meeting and the purpose of that breakout is to then move it further along. And all of the information of where we are right now actually will be posted on the website, the conference website before the meeting so that those people that are going to be in the breakouts can kind of understand what is the state of the art. For privacy, for example, I know for Connecting for Health a lot of work was done with regards to that, and then also a lot of work was done in some of the LHII demonstration projects where they even have agreements and they have kind of protocols for ensuring privacy, so in that case all of that would be made available and the focus of that group would be flavored by where that group is. So even a question as far as obstacles, each one is really going to be different and it's not just a session on where we're giving you the obstacles, it's well, what's next. Some, they already have the obstacles identified so the question is well how are we going to overcome them.
DR. YASNOFF: Last year as you recall we had a very structured approach to the breakout groups where there was a document prepared and distributed a month in advance of the meeting that basically for each area said here's where we are now, here's where we'd like to go, here's what we see as the barriers, and here are either some potential recommendations or a framework within which recommendations need to be developed. That was distributed in advance and used as the basis for the discussions. So this time we will do, we will also prepare material in advance, it's not going to be as Helga said the same for each group, and we're not exactly sure yet what the format will be, but I agree completely, we are not going to have any of these breakout groups start with essentially a blank page. We're going to say here is where this area is at the moment and here, in some cases we may say well here's where we want to go and we want you to think about how to move to that, or we may say in some areas these are the ten obstacles that have been identified, we'd like you to make recommendations for how we can overcome these. So there is some work that needs to be done prior to the meeting to be sure that we have the material necessary to provide to the attendees to make sure that the breakouts are productive. Steve?
DR. STEINDEL: Bill, my initial comment on the plenary session, I thought, I really didn't have --
DR. LUMPKIN: We're focusing on the goals.
DR. STEINDEL: We're focusing on the goals?
DR. LUMPKIN: Hold that comment because we'll come back to it.
DR. STEINDEL: Then focusing on the goals, I think to get to the goals, I'm concerned about the organization of this meeting focusing on topics. There's four sessions related to topics, breakout sessions on topics, and only one stakeholder, and I think we need to reverse that. I think we need to find more information relating to the goals that we're talking about, about how the stakeholders are reacting.
DR. LUMPKIN: So you would be arguing on the structure not on the goal.
DR. YASNOFF: So let's hold that, that's a good comment.
DR. LUMPKIN: Which is to change the mix between topics and stakeholders.
DR. STEINDEL: I'm looking at the goals that we have now and I'm thinking that I want input on these goals from the stakeholders.
DR. LUMPKIN: Okay, we'll come back to that when we talk about more of the structure. Mary Jo?
DR. DEERING: I'm goal oriented here so I'm on task here, and this is a question about the relative balance between the focus on the LHII and the NHII. Clearly there is a lot of reason to capitalize on the energy and instantiation to use that term that exists around the LHIIs and there's a lot that can be drawn from it. What I've heard as you've talked though is something that isn't entirely clear and one way or the other I'm suggesting that it could be help to be clear. It's almost sounding as if the meeting in its broad goal will be to focus on reaching the NHII through LHIIs, as the chosen strategic path and that everything about the conference will be oriented in that direction.
DR. YASNOFF: That's exactly right.
DR. DEERING: I think it's important to put that on the table because I think that there's some concern about are we missing what have been, I'm picking up on your comment earlier, Simon, and yours about Medicare and Medicaid, does this mean, again, understanding that some years you focus on some topics, but does it at this crucial point in time lose us an opportunity to use this venue to look at the barriers, issues, lessons learned at the national level. So that's what I would put out for discussion.
DR. COHN: -- Steve may jump in, obviously I'm trying to hold my tongue a little bit only because this gets to be the architecture discussion of like exactly what we're doing, I mean I've been looking at this sort of like you and wondering whether the topic of this is really LHIIs moving towards the NHII, or whether we're really talking more broadly about the NHII and all of the pieces, and once again I guess I have an expansive view of this but I think HIPAA is part of it, I think e-prescribing is part of it, I think privacy and confidentiality are part of it, I think all of these various factors, I'm actually wondering where the VA and DOD are because I'm not sure in my own mind I think that there is such a major differentiation between an organization of their size and complexity putting in an EHR that is really so different then Indianapolis doing something with one of its scope or Santa Barbara, and are those all part of the mix that we're talking about. But that's really a question that's really an architecture discussion so it's hard for me to focus in on what we're doing here until we sort of come to a common vision of at least the architectural options or how we want to describe it.
DR. DEERING: Just to show you how it translates here, I didn't know if it was even a typo, but under governance, jumping to topics, it's on governance of LHII so again, that gets us away from the opportunity to perhaps have looked at some of these other issues.
DR. STEINDEL: But we are on goals. Mary Jo did a wonderful job of articulating I think what in the back of my mind when I made the statement about focusing this more on stakeholders because in the goal statements that we have here it's NHII and I was having the same sense as Simon and Mary Jo that this was a focus on LHII.
MR. BLAIR: Let me preface my comments that I'm very much aware that as we move forward Bill and his team have limited resources and also other constraints. And to be honest with you I may not know all of them and the rest of us may not know all of them so I'm offering my comments and suggestions with the caveat that I realize Bill has to pull this in with whatever limits or constraints, either time, resources or political that he has to deal with.
I think that Nancy Lorenzi's document on the two different LHIIs is useful but they are different and the reason it's useful is that they are so different and they're with respect to what we could do today and during the next two to three years. But those things don't say where we want to be seven to ten years from now and I know it's really, really hard, this gets really hard to wind up saying where do we want to be seven to ten years from now.
Now our report, our NHII, NCVHS's NHII report, which is two years old, it set forth a vision and last year, at least it's my perception, we took that vision and we had people comment on it and Bill, I think you got a lot of good feedback not only in the session in July last year but you held additional stakeholder sessions where you continued to get more information and that is valuable information and one of the things that you have as your goal is to give them feedback on it. And I think that that clearly is a valid goal, an important goal is to say here's the feedback and here's the progress, the only piece in my mind that is missing, and I think it's a very important piece because I think, rightly or wrongly I think there's a lot of people who are going to judge our progress in terms of putting the flesh on the bones of the vision.
So if it's possible some way to take all that feedback information and say we've listened to all of you, here's all the stuff you've given us, and I've now begun to formulate them into some hypothetical models or proposed models or straw person models, and they're starting to look like this in terms of where we want to be seven to ten years from now. And if we say that right at the beginning it says that last year's meeting was successful, it provided information that enabled us to put flesh on the bones of where we're going. And I think that a lot of people are looking for that as a measure of whether we are making progress, just the fact that we got feedback is not enough for a lot of people to think we made progress. I mean it's a good forum, we listened well, but if we don't pull it together into where we're going then I think there's going to be some folks rightly or wrongly that are going to be critical of us and we're starting, NHII is beginning to move into the political arena and we have to, and the piece is, let me go back to the LHIIs, I think they are valuable, I think they should be on the agenda, but if we don't at the beginning of the session to the degree that we're able to begin to say here's where we want to be seven to ten years from now then we can't, then we have no critique, no metric to compare the LHIIs as to the degree to which they are addressing the needs.
So let me kind of turn that back to you because Bill, I don't want to make a demand that is unrealistic or beyond your ability to deal with but could you please reply to my suggestion that at the beginning we do the best effort we can to say here's where we want to be, I said models, different people could use different words, I use models because I didn't want to say all the way to a detailed formal architecture, I don't know if it's possible for us, that's obviously two or three years away, but I wanted to get beyond the point of just being a vision so I thought maybe models might be a word to say a step forward, but something else to put flesh on the bones.
DR. YASNOFF: I think it's an issue of timing, I agree with you, I think that well, hopefully today when we're finished, unfortunately we have a timing issue and that is that the plans for this meeting have to start now and the organization for the meeting has to be laid out now, even though we have additional discussions we need to have, not just here but elsewhere about requirements, architecture, and vision, and those are going to go on between now and July. My intention at the beginning of the meeting is to set forth what at that time is the best available consensus vision of where we're going to be in seven to ten years, it will not be complete, but hopefully it will be something. I can't do that today because there's more to collect.
MR. BLAIR: The other thing I want to react to with what you said, first of all I want to thank you, the second piece, the best available, and maybe it still would be a vision it will just be a better defined vision and maybe that's the best we'll be able to do at the time. But I do think it is critical that the meeting start with that best available refined or more detailed vision that people could not only begin to react to but at least they could wind up looking at all of the other work efforts and say are we all heading, marching to the same drummer.
DR. LUMPKIN: Let me suggest maybe a way out of this, because we're really talking about two different things. And it may be, I notice that in talking about the topics and the breakouts we talked about two per topic, what if we were to segment those topics which seem most appropriate, I think that there are a number which sort of, for instance one topic would be governance involving key stakeholders to develop the LHII strategy and another one would be governance in relationship to NHII. So the two breakouts would actually be different in focus although they would both be discussed in governance. We could probably walk through and look at finance, and similar on finance, I think we'd want to look at maybe some financial issues related to the LHII and the broader long term financial modeling questions that we're looking at for the NHII. How does that strike folks?
DR. VIGILANTE: One could argue that the same group should be thinking about both things simultaneously because ultimately they have to dovetail, they have sort of a reflective relationship on each other.
DR. YASNOFF: Maybe it's unavoidable and what we should just do is stop and have the LHII discussion first because I think it's actually a very short discussion and if people are amenable to that, it's not, well, we only have a few minutes to lunch but we do have the afternoon to discuss this and I think I'm pretty confident that if we resolve that that we'll have enough time for feedback on the meeting.
The issue is this, it's an implementation issue, how do you implement an extremely large scale what eventually amounts to an IT project. And of course it's not, HHS is not the implementer but we want to show people how it can be implemented. And basically there are three approaches that have been articulated and some variance of those approaches. The first approach is the do it all at once national approach I'll call it, where you have a central database for the entire country and everyone connects to that central database. The second approach is this kind of regional approach where you essentially have what I would term a layered architecture where in each region you have the ability to meet a set of requirements in terms of delivery records with decision support and so on. And then at the edge of each region you provide a set of services that are standardized that allow you to connect to the other regions and service requests that occur between regions. And we're not quite finished defining exactly what those services are but it's clear that you can have, you can build an architecture in a layered fashion that allows you to expose a set of services that then would essentially create what amounts to a virtual national network without a central database.
And then the third approach is what I call the, what has been termed the peer to peer approach, where you essentially, the Natella(?) approach if you're familiar with the music sharing algorithm where everybody who has information becomes both a server and a requester of information, there's no index whatsoever, and the queries go out and they are disseminated to all the servers and the results kind of filter back and there's no index whatsoever anywhere but everyone just connects.
So in analyzing those three options, and actually there are more, there's some variance particularly in the local, the regional option, there's some variance in terms of whether regionally you have a local database or whether you have a local set of pointers, and I'm just going to leave those alone for the moment.
So let me go through the options, let me start with this Natella network option, this is a Napster without a center, those of you familiar with the Napster model, essentially it's a peer to peer network model where you connect but there's a central index and so when you ask for a song, when you connect, everything that you have on your system is indexed and included in the central index and so when you say I want so and so song the central index is searched and then you are connected to whomever has that particular song and it's transferred to you.
But the Natella model has no such center and so in that case when you want to search for a song a message goes out to your kind of nearest neighbor and then your nearest neighbor sends it to his or her nearest neighbors and it kind of proliferates to the network. And every server in the entire system has to do its own search for your song and then for the most part has to send back is a null response saying no, I don't have that. And it's relatively easy to show and there are papers that I would be happy to share with you from the computer science literature, that when you get up to about a million with this model something like 99.99 percent of the CPU cycles of all the servers are devoted to searches that have null results and you need about 100 times the bandwidth of the entire internet in order to transmit the requests and the results and therefore it is infeasible, it just cannot be done. So that model cannot be built. And I'd be happy to discuss this in detail with anyone who wants to see the numbers but that model cannot be built and actually the reason the Natella model was created was not to solve any computer science problem but rather to solve the legal problem that if you needed to avoid an index so there was no one to be sued.
DR. LUMPKIN: Let me just sort of interrupt so I can understand the models. The Napster model that you're describing was the center, is that equivalent to your number one model?
DR. YASNOFF: No, the Napster model actually can either be, you could do that as a national model if you wanted or as a regional model, but this other model is essentially the one with no center.
DR LUMPKIN: So that would be, the Napster model could be a 1A or a 1B in your architecture.
DR. YASNOFF: That's correct and in fact you can look at what's done in Santa Barbara as a Napster model where you have an index in the center. So the model with no index cannot work, it's infeasible, cannot be built. Then you're looking at a national model or local model, the problems with the national model are either having a national index or a national database is politically infeasible, just not going to work. It's bad design because you create a single point of failure and even if you had back-ups you're still creating a transaction volume to wherever that server is that is very, very dangerous in terms of scope. I mean you're dealing with perhaps millions of transactions per minute to one place.
It's well known that the probability of failure in any IT project increases exponentially or faster with the size of the project and therefore when you do a project that involves the entire country like that your probability of failure probably starts at 99.99999 percent. And I would point out that even in the UK where they have single payer, and it's all government controlled and they could build it any way they wanted, they in fact are taking the regional, they've divided the country into five regions and they're setting up only a very limited, very limited national database although they're hoping eventually they can get to a limited database and in fact if you're in one part of the UK and you go to another part they're going to know very little about you. They also haven't worked out the between LHII communications.
So the national solution has these implementation problems. In addition you have to look at health care and say what is the benefit of having the information from someone in New York available in Florida. It's well known in health care that health care is primarily local, 95 percent of health care is local. And so what you're doing is you're greatly increasing the scope of your project, you're creating potential nearly insurmountable or insurmountable political difficulties, to get a benefit that is miniscule, that's just not where the benefit is, the benefit is in the local area.
Actually I'm finished because that leaves me with the regional approach and I'm happy to either have questions or eat lunch.
DR. LUMPKIN: Let me try to, I actually have a question because there are other models that I didn't hear discussed and let me say that one of the models that came to my mind is the problem with the Natella approach is that the number of peers becomes close to infinite --
DR. YASNOFF: Well, no, when the number of peers becomes large the traffic and the CPU requirements become infinite.
DR. LUMPKIN: But if you consider a model where some of the peers may be LHIIs, some of the peers may be Kaiser, VA, you start having a limited number of peers that would then only have to search a limited number of places so that you would have redundancy. So if I live in Santa Barbara and I'm a member, and I'm a vet who also has Kaiser coverage then I would show up in their central directory for all three of those entities. And if you're in Medicare you'd have another, potentially, and then it may be the national or it may be based upon the intermediary. Is that a third option or is that somewhere in your number two option?
DR. YASNOFF: I think that the question you're really asking is in this regional model how do the national players fit in, I think that's the architectural question you're asking. I think that the model you're proposing has the disadvantage, I think I can show you that with the regional model you essentially minimize if not eliminate searching for records that do not exist, essentially you can architect it so you never do a search for records that do not exist. And I would posit that any kind of NHII model that results in a substantial computing burden to all systems that are connected to it for searches that produce null results is going to be not infeasible but it's going to be at a substantial disadvantage in terms of a model that avoids that. And the model, your model would result in a substantial number of searches that would not, any time you don't, you can't definitively know in advance where the information is that you're trying to find you're going to impose a substantial computing burden that is going to be unacceptable.
DR. STEINDEL: John, my comment on this is I think there's a lot of discussion that we can have from a computer science point of view on the architecture of the exchange of clinical information, which is what the LHII focuses on and Bill's presentations on the LHII focuses on, how do we move clinical information from one location to another location. But I think what we've proposed as a vision to the NHII extends beyond clinical information and the LHII structure, while it may work depending on how it's architected within the clinical environment, does not work that well in a lot of other environments and we need other architectures --
DR. YASNOFF: Like what?
DR. STEINDEL: -- to exchange information there, for instance public health --
DR. YASNOFF: It works perfectly for public health.
DR. STEINDEL: Research, no, there I disagree, we have other information that we need to exchange, it doesn't work well in the consumer arena.
DR. YASNOFF: No, I disagree.
DR. STEINDEL: See, I disagree with you, and I think that's the problem with the discussion, that's why it has to occur --
DR. YASNOFF: But let me focus the discussion --
DR. STEINDEL: Bill, let me finish. Because you and I disagree on this and I'm sure there's other people in the community that disagree on this, is why the meeting can't presuppose that the LHII is the structure for the NHII.
DR. LUMPKIN: Jeff.
MR. BLAIR: I'm going to try to pull a John Lumpkin on this one, and I think that the LHIIs and Nancy Lorenzi's analysis of the LHIIs has a great deal of value in helping us understand what could be done during the next few years. I think that maybe some of the reactions that each of us is having is that I think we have to be careful to not begin the meeting with the idea that the LHIIs are the answer. They may offer value to address some or part of how we begin during the next few years to get to the final image of seven to ten years from now but I really think that, and I know I'm getting back to the same point, is I think we have to say, and maybe, I'm just going to throw out another possibility based on what you offered, Bill, it sounds like we've developed a pretty good list of requirements and we know we have a pretty good list of constraints from what we had last year and gathering this year. If we can't come up with models for where we want to be seven to ten years from now maybe the next best step is that after you wind up saying the vision you wind up giving a more detailed set of the requirements and the constraints of where we want to be seven to ten years from now so that when you then go into saying and here's one, here's some examples of some good things that are leading towards that, because that then becomes the goal, and then you can wind up showing LHIIs and people will put the LHIIs in context and they'll say how well do they meet the requirements and what areas do they not meet the requirements on and maybe that would help.
DR. LUMPKIN: Simon.
DR. COHN: Bill, actually I appreciate the conversation, I actually sort of agree in many ways with what Jeff is saying. I'm listening to what you're describing and it seems to me that this is really part of the conversation that needs to occur at the July meeting because I don't myself necessarily buy into everything you're saying. I think LHII is an important tactical piece of moving forward, which I think is what Jeff is saying, I guess I'm sitting here in my own mind going well geez, we have HIPAA transactions going all over the country using standards, da, da, da, da, da, geez, that's not an LHII thing, that's a national thing. We're going to be starting to work on e-prescribing, which I think even you admit is really a key part of something when we establish NHII and --
DR. YASNOFF: But no one is going to be sending an e-prescribing transaction from New York to California.
DR. COHN: Well, but I think the approach being taken on this one appears to be at least state wide if not regional if not national, at least based on what I see as the conglomerations around the payers. So I guess what I'm describing is something that's a lot messier then what you're describing and I think that somehow, and whatever architecture we put together somehow has to deal with all of these pieces coming together.
MS. WILLIAMSON: After listening to your presentation about the different approaches it seems to me that that would be a wonderful way of approaching the architecture topic that we have listed, maybe to put those three perspectives, those three types of approaches, and have others provide feedback on those and other models. But to --
DR. VIGILANTE: Let me just preface by saying that my bias is actually very sympathetic to Bill's perspective and I actually sort of lean towards the notion that the NHII is going to be constructed, it's going to be a bottom up construction project in the context of nationally established standards and policies and whether it's HIPAA, whether it's messaging standards or whatever, and even if we can't agree that it will happen that way or not I believe what will happen is that communities will just surge forward, and whether we think it's going to happen that way or not, they're going to do it because they're already doing it. However, it's clear that in our little microcosm there is some disagreement as to whether, we need to hash it through I think to bring other people on board with that perspective, with the kind of perspective that I have and that you have and maybe that's the problem, and maybe the meeting really has to be structured in a way to allow people to go through the thought process to arrive at that point where you're already at, which frankly I share. And I think for the purposes of having a good meeting and bringing folks along and maybe discovering things that you and I are not seeing, maybe we just need to structure the emphasis of the meeting in a different way, maybe that's what we're really talking about here.
DR. YASNOFF: First of all let me say I didn't make up this approach, this approach was what was recommended at last year's meeting and what came out of the recommendations from the IOM. I didn't come to this with any bias as to how it should be implemented. I think there's some confusion about the relationship between how you build a thing like this and how you interface to organizations that have a scope that are beyond local, and I think if we could divide that out we could have a useful discussion and highlight that. I would be delighted to hear a feasible alternative approach but I have not yet heard one, from anyone anywhere in terms of how this could actually be built with a reasonable probability of success. Now there are these issues about how you address national goals and how national organizations fit into these things, which I'm happy to discuss. But in terms of actually building it the idea that you could build this nationally as a single system, I mean I'm happy, I think that's something we could certainly discuss at the meeting but I think that there's no chance that that would be successful, none.
DR. LUMPKIN: Let me just push back and we'll go around the room again, and not so much to disagree but to raise a significant concern about the approach that I hear you taking, and the concern is is that the suggestion that I made of these kind of things that are a little bit more amorphous, whatever that is. You made the statement that there is no reason for e-prescribing from New York to California, I think I might disagree but my concern is is that if you build a system with the assumption that that will not occur you're setting limits and you're setting constrictions upon the scope of the system. And that unless we have a broader image of where this system, and I won't argue that in the near term moving towards developing these may be the way to go and a major focus, but we need to have this broader context so that when we build this box 640k doesn't seem like the biggest it could ever conceivably get. And that would be my concern about doing this parallel track of having just moved from one region to another I know that there are key issues of, if going to emergency departments, if my son were to go into an emergency department, whether or not he's had a tetanus shot, there are certain things that are all part of another region with an overlay of some public health registries. Increasingly now we're seeing disease registries, chronic disease management registries coming into place, there are all these kind of other entities which would need to have an interface at both the regional and the national level. I just think that that's perhaps maybe the concern but I don't see anybody disagreeing with that.
DR. YASNOFF: It has to do with requirements versus architecture and this is why if you look at a set of requirements and you agree that this is the set of requirements so that for example your requirement on e-prescribing is you want the local e-prescribing transaction to be very simple and easy, you want the remote one to be possible but it might take a little longer or be a little more difficult for example, or you may allow it to take a little longer and be a little more difficult. But if you can agree on a set of requirements then you can discuss architecture in terms of does this architecture meet the requirements or not. Whereas if you don't have a set of requirements then it becomes what is commonly termed in the IT industry a religious discussion where it's whether you should have, whether things should be lumped or split or whether regions means towns or cities or states, so this is why the requirements are so important. But if there's an, and maybe we need to finish this discussion here and I'm happy to discuss is the rest of the day, but unless there is a feasible plan to approach building the NHII in a way other then with local and regional components, unless I hear that, and I still haven't heard that, that's the approach that we're going to take.
DR. LUMPKIN: Okay, let's go to Gene and then we'll go around the room.
DR. STEUERLE: My focus is mainly on what's going to happen at this meeting, it seems to me that we do have in place at a small level a development of an LHII infrastructure building toward NHII and the meeting, the discussion of part of the meeting is going to be on LHII, what information do we want to get out of that to make that process work. And it seems to me those questions can be asked in a way that's independent of our views as to whether Defense or VA or Kaiser or somebody else is going to build some other structure as well. However, we would want those groups, or whoever the groups are, to tell us as we develop the NHII using your language, what are some of the requirements that they would like to see out of local development that might help them. Now not saying they're going to get it but we'd like to know what they put at the very top of their list, that's one question, what are the requirements other people want, that's the local, but other stakeholders or not, but what other people want.
And then a second issue that I don't know whether this particular meeting is going to be able to answer but it is a crucial question is then who is going to sort of be the deciding, the deciders in which these requirements indeed are acceptable or not acceptable, so that if you do give a grant to a local community to build an LHII you're going to put on them you can build it but you have to have these minimal, you have to meet these minimal requirements. And I don't know if it's necessarily HHS, I mean it could even be something as requiring some of the communities to get together and decide some things. Maybe that doesn't work but the question of who decides to me is sort of a second level issue and those are the things I think we want to build out of that particular section, what are the requirements people want on this as it's being developed, and then B, how do we figure out who's going to decide what those requirements are.
DR. YASNOFF: Can I make a brief comment? HHS is not going to impose requirements on people, either with respect that you must comply with standards or you must build things in a certain way. This group in its report recommended that this be voluntary and that's what's being done. And what I'm trying to do is listen to what the stakeholders are saying, which is that they want to build these local infrastructures, and trying to support the stakeholders and what they want to do anyway.
DR. STEUERLE: Just a clarification, you're saying even when you give a grant to a local community there is no --
DR. YASNOFF: Oh, no, when we give a grant then if you want to take money then you're going to have to --
DR. STEUERLE: That's what I meant.
DR. YASNOFF: But that's voluntary, you don't have to take the grant.
DR. COHN: Well, this is America --
DR. YASNOFF: Build whatever you want.
DR. COHN: That's right, exactly. And I guess having said that you continue to make reference about building the NHII, I guess I sort of sit here and wonder kind of who's building this and I would recognize in American obviously this is something where things sort of evolve and come together. I guess I'm a little worried, and once again this is probably a conversation that ought to be a wider group in July, but it just seems to me that there's a whole lot more complexity and there needs to be a lot more flexibility in how all this comes together because I think even though you sort of dismiss the concept of national e-prescribing players, I think as we hold hearings that's what we're going to see, or certainly at least large regional players, we're having ASPs where Indianapolis is just a locality that the web connects to. For Kaiser, I have to tell you, now once again we are in multiple different locations but I consider a LHII in Santa Barbara and another different LHII in Portland and another different LHII in Denver to be almost more complexity and concern then something where there's sort of uniformity, if I were a payer I would, I mean how would I ever pay differentially based on, if I were covering multi states I mean how would this ever play out. So I think there's a lot more complexity here --
DR. YASNOFF: But the complexity is in the requirements not the architecture.
DR. COHN: No, well, I'll just stop now.
DR. LUMPKIN: Steve.
DR. STEINDEL: I think what we're hearing around the table is what we're looking at is the NHII as a system of systems and the LHII is one part of those systems and what you're saying, Bill, is we do need requirements, we do need to know how these systems need to interact, but I think people who are putting these systems together need flexibility on how they create a system. Now if your term for a system is an LHII, and Kaiser might be an LHII, then maybe I'd agree with your terminology, but right now the terminology LHII seems to be very constrictive, it's Santa Barbara, it's Indianapolis, those are the type of examples we're giving and I think that's what's raising a lot of concern. But if what we're looking at is a system of systems I think we're all in agreement on that and I think we're all in agreement that what we're looking at is the requirements for interchange between those systems. What I was struck by is in the talk that you gave at Utah that's on the web and when you were talking about the LHII concept and when you make the statement that we need to link LHIIs together and there are ways to link LHIIs together, we haven't solved that problem yet but it is a problem that's probably solvable. But then you went ahead and you made the contention that we will benefit greatly even if we don't link them together and one LHII that's on the interface of another LHII prints out the patient's report and hands it to the other LHII. Now I personally think that that is not a step forward, and if we're working with an architecture that that's the end result we have a problem.
DR. YASNOFF: Please, come on. Now I made that point because the benefits of delivering complete information primarily accrue in local areas, and, if we had an LHII, this is what I actually said, in every local area of the country and we never were able to connect them, which is not likely, in fact almost vanishingly unlikely, we still would be much, much better off then we are today where most medicine is practiced in an information free zone. And let me address --
DR. VIGILANTE: That is correct by the way, just so you know you at least have one ally in the crowd.
DR. YASNOFF: The issue with national organizations and how to interface national data to this, and I've been meeting with the stakeholders and hearing these things, the issue is if I'm a payer, if I'm a national provider organization, if I'm national public health, I want to not have 300 different interfaces to these LHIIs. We need to have standard interfaces to the LHIIs so that the information can flow easily to and from national organizations. That takes care of the problem without having the complexity or the scale of building national databases that's likely to fail.
DR. LUMPKIN: Let me just sort of see because I think I'm being confused by this conversation where there need not be confusion. And it ties in, just an analogy for those of you in public health, it ties into the whole concept of community and you do you define a community, for which a community is an affinity group of individuals, which could be geographical, it could be based upon race and ethnicity, it could be based upon a whole host of factors. If we apply that very broad concept of community to this entity that we're talking, I want to stay away from the LHII, would that be a fair statement that this entity could be geographical, it could be based upon affinity, it could be based upon payer, it could be based upon any number of factors?
DR. YASNOFF: Yes, and in fact it is based on the affinity of geographic location based on the observation that most health care is provided within a geographic location, and therefore by using that affinity to group records you minimize the retrieval time for complete records for people in a geographic area.
DR. LUMPKIN: Okay, let me come back to that. Is there agreement that whatever these affinity groups are that there needs to be a standard way for them to interface, to look up data from one group to another, to share data and move transactions, to move e-prescribing, do we agree on that?
DR. YASNOFF: Yes.
DR. LUMPKIN: Then I think the heart of the disagreement is whether or not the basis in the affinity group is geographic, it can only be geographic, or should be restricted to geography. With this being a set within a set in that what I'm hearing one group is saying geography can be one factor but there are other factors, and the more narrow, the subset of that is saying geography is the prime factor. Is that a fair summation --
DR. YASNOFF: That is a fair summation.
MR. BLAIR: I have one other piece to that and hopefully this will add into this, what you're summarizing --
DR. LUMPKIN: And that's okay because you're next on the list, Jeff.
MR. BLAIR: I think it is not just the ability to share information but also that the information systems can interpret that information with the same meaning a la what we were driving at with the PMRI terminologies, that we have the same semantic interpretation of the data when it goes from one geographic or regional entity to another, so I think Bill is agreeing with that, too, so it's not just sending the information but able to interpret the meaning consistently anywhere in the nation.
The other piece that I as going to say, Bill, clearly the reaction of the workgroup, we don't want you to run into this meat grinder in July, and so sometimes it isn't so much that the ideas are the problem it's the way we either sequence them or articulate them or label them. Because I really don't have a major problem with the ideas you're putting forth. My thought is to put them in a context, and the reason I keep coming back to the seven to ten years and the requirements, I'm now switching from the word model to requirements because I get the impression that you don't really have the time with the staff and everything that's in place now to have a set of models of where we're going to be seven to ten years from now, but maybe if you wind up saying the feedback you've gotten from all these folks, say here's all the requirements of what the NHII is, in other words what you wind up saying is the NHII seven to ten years from now will meet all of these requirements, okay, and you could add a little bit more detail on them, make them really more hard hitting, and you're now taking a step beyond the vision of what the NCVHS report is, you're getting flesh on the bones.
You're saying the NHII seven to ten years from now, all these requirements, and it will operate within these constraints and this is to me as important as meeting the requirements and part of this is getting back to what Mary Jo was offering us, where as the constraints start to specifically articulate, not a national database, that the ownership of the record is in the private hands, a lot of the constraints would be things that would make the consumer and the public feel safer, and maybe that will go a long way to meeting our goals.
And then the last thing I would say in terms of trying to make constructive suggestion on this is that you then wind up coming forth and you're starting with okay, this is the NHII, here's the requirements and the constraints, okay, and then you offer LHIIs as a path, one of, not the way but one of the ways that looks promising to help us begin to get there. So the words are a little bit different, it's not saying that it's the only way and it's not saying that LHIIs are the NHII, it's saying that they're a good valuable useful path, people have been doing good work, there's things we could learn from these things. And that way I think that people will object less, they can see the value as a way of where we start from now during the next few years, we could start with LHIIs as one of the ways to get there.
Now I don't know if this ameliorated some of the concerns of others here but maybe we could get some reactions to that.
DR. COHN: I don't think we're going to solve this one before lunch.
DR. LUMPKIN: Mary Jo's name was the last one I had on the last round, we're going to listen to Mary Jo and we're going to come back after lunch.
DR. DEERING: The simple thing I think to take one thing off the table is, and I think where I disagree most strongly is I have never heard anyone say in five to ten years we are going to build a national database, so I think the national model you posited is a straw horse, straw man, straw horse, so you can take that off the table, a dead horse, so that's off the table so we all agree we're not going there.
And the only other thing that I --
DR. YASNOFF: Mary Jo, could I ask, is that really right, does everybody agree?
DR. LUMPKIN: Well, I think there's agreement on that but we need to talk about model 1A, which is the Napster model, does anybody think that a central national index is feasible in this country? I personally don't think so. Okay, so model one is completely off the table.
DR. YASNOFF: So a central database and a central index are both off the table. Everyone agrees that that's not worth discussing.
DR. LUMPKIN: And option three is off the table.
DR. DEERING: Right. But from a policy point of view and a public policy point of view, not a private investment point of view, there is enormous implication between saying that we are going to help build these regional LHIIs, however standardized they are, and to focus your public policy energy and dollars there versus saying we think these are a great thing but where public policy is going to focus on is the interfaces between them and the communities as you, not LHIIs but the communities as you have defined it, so what public policy chooses to emphasize from the get go is how to link everything while acknowledging that these communities, be they geographic or otherwise, are important in helping to identify the architecture. So I just wanted to say that, I think that's an enormous difference for the government to decide which it wants to emphasize because if you fail to emphasize the second, and you just say LHIIs are such a good starting point that we want to put our money into that basket for the next three years, without taking, simultaneously focusing the same level of attention on the interfaces among the groups, both the national horizontal groups and the other affinity groups, then you could have lost an extraordinary amount of momentum.
DR. LUMPKIN: Let's go to lunch.
DR. DEERING: I would like to make an announcement, the availability of a document here, the infamous HL7 draft standard.
[Whereupon at 12:32 p.m. the meeting was recessed, to reconvene at 1:25 p.m., the same afternoon, February 18, 2004.]
A F T E R N O O N S E S S I O N [1:25 p.m.]
DR. LUMPKIN: Okay, where we've come to is just a little reality check, our goal, really our ultimate goal at this meeting was to reach some decision on where we're going to be on this meeting, we're scheduled to go to 3:30 but I've discovered I've got a 4:00 plane, which I thought was at 5:00, so we're going to finish at 3:00. Or you guys can go on without me you may decide. But I think the major focus is on, let me just say that we've had a lot of very important discussion that will help us as we work on the other issues that we had talked about which was the models, looking at the new dimensions, looking at the issue of overlaps and certainly on the other issue of architecture which we spent a fair bit of time. I don't think it was non-productive and I think we've sort of worked down to the key issue of, which I think might be useful for you Bill to sort of say where you think your fundamental approach is on the overarching issue of the conference.
DR. YASNOFF: Essentially my assumption going into the conference and the approach that our activities are taking is based on the recommendations from IOM and from the meeting last year we're saying that you need to build these regional infrastructures, in other words use geographic affinity as the fundamental system element that brings things together and create interfaces to national systems that are absolutely standard so that the fact that there are multiple local ones does not create pain for people, for organizations that are not local, of which there are many, but the patients are local and the health care given is local, and in order to be able to efficiently deliver complete records locally you need to have a local structure, and we know the local structures can be built. And so that's the approach we're taking and the meeting is designed to further that approach, that's the assumption behind the meeting. So if that's wrong then obviously I want to hear about it but that's, I don't want to hide the fact that that's the assumption behind the meeting.
MR. BLAIR: I think that if you go forward with that, not that that ultimately is not, that's all good stuff in there, but there's going to be some portion, and maybe a majority of that meeting, which will wind up saying wait a second, we haven't signed onto that yet. And what you want to do is you want to build consensus and I think that this is, at least in my mind, I think what a lot of us are winding up saying is to try to say okay, what the IOM has offered contributes, LHIIs contribute, but if you come forward and start to give the impression that they're the answer I think a lot of people haven't built, you haven't built the consensus in the health care community yet. And I'm not saying that it's wrong, I'm just saying the consensus isn't there and you'll get throwback and instead of building consensus you'll get pushback. So if you characterize it the way I think we're suggesting you characterize it then I think you could wind up offering these as good ideas on the way to get there, not the way, but one of the ways to get there. And then I think that you will find people tending to agree. I don't know if I'm speaking for the rest of the group or not.
DR. STEUERLE: I think a lot of our debates the last couple of hours meeting time have been over semantics and I think a way to get around even this last debate, Bill, is basically to go into the meeting and say look, LHIIs are being developed, we now are requesting specific grants that we're going to try to develop them further, so since this is a very important stage towards the development of NHII, however you might think it will be, here's an important stage, we want to have a particular focus in this meeting on how to do this and how to do this well, and then go to the constituents or whatever and ask them how can it be done given their own needs, preferences, knowledge base or whatever else. It's a semantic difference as opposed to saying this is the way it's going to be done as opposed to here's something that's happening right now, let's see how we can do this well.
DR. COHN: Actually, Gene, I actually disagree that it's a semantic difference, I think everybody's been trying to make it a semantic difference but I think that there's actually sort of some fundamental different views going on here. And I guess I'm a little concerned, I guess in my own view, I think we all agree that local health information infrastructure or whatever we call them are critical pieces of an NHII, the question is is there more. And I'm not hearing that there's, I'm hearing that being the issue discussed and I guess I'm not, I'm not coming away from this conversation feeling that there is no place in the model for sort of that more. Now I'm willing to hear or see models that sort of put into place all of the pieces that we've all been talking about but I guess, to me this is almost at the level of a goal of the meeting, and if the goal of the meeting is to promote LHIIs as the way everybody should go that should be one of the bullets there. I guess I had thought a key piece of this meeting was to sort of talk about how all the pieces, the importance of the various pieces and how they fit together, and I'm hearing about a very important piece but I'm only hearing about at least from my view one piece of the puzzle here.
DR. LUMPKIN: I think that we have a problem as a committee, and the problem that we have is that I think that this approach is not consistent with the way the committee has functioned in the past, and not to say that the conference is bad but the way we have functioned is before we had the conceptual model of the NHII we conducted hearings and say what should the conceptual model be and have people come and talk to us. This meeting is operating under the assumption that the path to the NHII is through LHIIs, and then how do we get that done. Our committee has not conducted hearings to that point, we have not taken a position to that point, and I'm a little bit concerned that if we were to pose this as a joint action that that would be a break from the way our committee builds consensus.
DR. YASNOFF: I think, first of all on your point, Simon, clearly LHIIs are not all there is, there needs to be more and we need to think about it. But we need to do something while we're thinking and clearly building LHIIs in itself is a good thing, and we know it can be done and it makes sense for a number of reasons. But yes, there is more, and we need to think more about what that more is and particularly in the context, in this context it gives you a context to think about it in which is what are the services that all the LHIIs need to provide in order for us to do the things on a national scale and between the LHIIs that we know we need to do.
In terms of the approach the committee has taken, no, the committee has not held hearings, but this is now an implementation task and essentially the meeting last year was a point of input and there have been a number of other points of input, and I've shared with you the stakeholders meetings that I've been having and again, I didn't come to this with the idea that we were going to build LHIIs, I actually came to this rereading several times the information for health report, and seeking in that report guidance as to how to implement. And that report was really not at a detailed enough level to provide that so what we're trying to do is to provide some kind of strategic direction leading to actual implementation.
And I think that it's clear as I said earlier before we started that perhaps, or I won't even say perhaps, it's clear that our thinking about this is ahead of the stakeholders, I think that's pretty clear from the discussion, I think that's a fair conclusion, whether it's right or wrong, but it's clearly ahead. And I think that we certainly recognize and appreciate the importance of bringing the stakeholders together because the right answer is not the right answer, the right answer is only the right answer in a situation like this when it's been arrived at through a process that everyone feels comfortable with, that people feel that they've had a chance to have input, where they've had a chance to consider alternatives, where there's been open and transparent debate and discussion and so on. So I'm all in favor of that.
On the other hand I'm in the position of being asked to move this forward as quickly as possible and so one option is to turn this meeting into essentially a review from the ground up of the recommendations from last year, we could start from scratch and say here's what we developed last year and let's review them all again starting from the very beginning. And that's a possibility, if that's the advice of the committee we'll take that into the account, the workgroup.
But on the other hand I think in addition to the assumption that goes into this meeting of the direction we're taking the funding that is being provided also is behind that direction and so it's almost disingenuous to go into that meeting and say well, we want to hear from you how this should be built when all the funding for this is essentially directed towards building LHIIs.
So I'm trying to, I think that, I clearly perceive that there may be actual disagreements about this approach, but at the very least there's a communication terminology issue and if I come to this workgroup with people who have been thinking about these issues for years and find this level of concern then this worries me about what will happen, what is likely to happen in a larger stakeholder group where they have not been thinking about these issues for years. So I'm very concerned about that.
DR. LUMPKIN: I think that, and I'm going to try to say this as precise as I can, I don't think that the strategy that you're taking in your position in HHS is a bad strategy, that one of the pathways to building the NHII vision is through trying to get people to get together on a regional basis. There's been some very important developments in that. Our task is to try to pull together a broader longer term vision. At our meeting when we last met we thought that there was a potential that doing, that we could do both at the same meeting. I'm just posing that it might be a problem trying to do both at the same meeting where you have a clear task that you have to do.
Our role and responsibility as a committee has not been to put forward a federal agenda, but rather to help shape the federal agenda. And once the federal government has taken our advice, which they have on the NHII and clearly funds are available for an important grant program and they're running with it, what we have done is to say okay, now what else do we need to think about as a nation. And I think that's what we're trying to do as a committee. And so I want to just sort of say that this is not necessarily saying that you're going off in a wrong direction, but whether or not the functionality of either trying to do both at the meeting would require a somewhat different structure, parallel tracks, potentially could take away from the focus that you want to try to move forward a clear directed agenda, that there are other ways for us to do this through hearing process and so forth, but that we certainly had a very I think fruitful discussion that clarified a lot of issues in relationship to where our input as a committee may be best to help move the agenda forward. Mary Jo.
DR. DEERING: Well, I am not so pessimistic about the ability to accomplish in two directions, again I said from the beginning I certainly also see why it is timely to have a concerted focus on LHIIs, they are being built, a lot of money is being poured into them, and it is perfectly appropriate to take some time to look at what needs to be done for them to do well and for them to be able to talk to each other in the future. And why could it not be possible for, I mean picking up your term of two track, that one of the, that the output of the LHII work is not only, and in fact perhaps not primarily at the conference to focus on the architecture and all these other governance issues as regards to the creation and development, strengthening and implementation of the LHIIs per se, but to have either a large or some portion of that effort be focused at the same time. This is going to be the biggest gathering of LHII folks that there's going to be. We would miss a great opportunity if someone, if all the thoughtful people around the table did not also devote their attention to these problems that the committee wants to see answered, which are where are the architecture and governance issues around the interfaces, and to have someone come out of that meeting saying okay, some of us have been buried up to our noses because we live in Cleveland and we want to build one of these and we want to learn from all that. But there are so many thoughtful people there who could be perhaps as they listen devoting their attention to beginning to identify what the issues are, not necessarily the solutions but where are the issues, how can we state the requirements for these interfaces, and that that's where the final hearing is, is that at the end of the meeting is they come to you and they say we've heard about all of these LHIIs and this is what you're going to do and this is what we've heard we think needs to be taken to the national level to make it come together. So I just put that out as a possibility.
DR. LUMPKIN: Jeff.
MR. BLAIR: Maybe my failure to see the expression on people's faces has led me to believe some things that I didn't, are not correct.
DR. LUMPKIN: Or not.
DR. COHN: We're not smiling, Jeff, if that's what you're wondering.
MR. BLAIR: I had offered what I thought was an accommodation, Bill, that would allow you to meet the objectives and missions that you need to meet with this meeting but to do so in a manner that I thought would avoid the same kind of problems that you're facing in this workgroup here. And I articulated them and maybe, I couldn't tell whether you were saying yes, Jeff, I can do those things and that will help fix it and we will have a common meeting ground, or whether you just listened and those are things you really can't do. Could you please clarify?
DR. YASNOFF: Well, I think that although the strategy, the LHII strategy is clearly in place and there needs to be a report on progress in that area, aside from this one plenary session on LHII I actually agree that the meeting is, the time of the people at the meeting is best spent not focused on specific LHII problems but focused on figuring out what are the issues for the NHII, which may include LHII related problems. And I especially feel that way because I think that increasingly the LHII internal specific problems are going to be handled in a smaller separate domain of people who are building those and that the attendees at this meeting are, I mean at the moment I can identify 12 or 13 LHIIs, maybe by July there will be 20, and so if each one is represented by two people that's 40 people. But I expect there may be a 1,000 people at this meeting and if that's true half of them will not have been at the meeting last year and I think that the discussion needs to focus on the NHII issues, and I have no problem with that. Does that answer your question, Jeff?
MR. BLAIR: Maybe, let me be explicit. Is there a problem when you address the meeting at the beginning for you to articulate, as detailed as you can, the requirements for the NHII seven to ten years from now and the constraints or caveats for how it might be built seven to ten years from now a la not a national database, not an identifier, all of those things especially the things that might address the concerns of consumers --
DR. YASNOFF: I have no problem with that.
MR. BLAIR: -- and for you to then wind up indicating that LHIIs are one promising way for us to start to move towards the NHII seven to ten years from now and that the requirements and constraints, you'd be looking for the LHIIs to if not fulfill all those requirements and constraints at least they're moving towards the requirements and constraints, and if that's the case --
DR. LUMPKIN: And I think though you can go a little bit stronger, which is that's the horse that the federal government is riding, or HHS is riding.
DR. YASNOFF: Well, let me say I think I would want to introduce it as this is what we think we know about what the requirements should be for seven to ten years but that I would say the purpose of this meeting is to further articulate that as a product of the meeting of the stakeholders and in particular to feed into the work of this workgroup, which is to generate a report describing in detail the vision for seven to ten years. In other words I wouldn't presume to say oh here it is because that's, so that's fine, and I think that the LHII approach clearly can meet a number of the requirements, and since the requirements even then, even after some additional meetings and so on at the time of the meeting will still be draft requirements, it will not be possible to make any kind of a statement saying that LHIIs meet all the requirements and clearly they do not. I can tell you that right now they do not by themselves.
DR. STEUERLE: I stand corrected by Simon in terms of using the word semantics, I'll take that back. But I do think you can add the one sentence to what you just said to say regardless there is moving taking place right now, there are decisions being made with respect to LHIIs, and that's why we want to gather information in particular on that subject at this meeting, not only but just in particular, because there's movement taking place anyway.
DR. STEINDEL: I have a question with a statement that was just made concerning the purpose of this meeting, one of the purposes, and put in connection with that was to articulate the vision of what's going to happen in seven to ten years, and I would look more the purpose of this meeting, one of the purposes, I think we've enumerated several purposes, is to provide information so that we can move forward in articulating the vision and we can do that through our normal hearing processes, etc., I think the NHII Workgroup is probably going to be placed where that vision is going to be articulated, and I would look at this meeting as providing information.
And this gets back to a point I made earlier in the organization of the meeting and as Bill pointed out in his Utah speech, one of the problems that came out of that meeting in just terms of the mechanics of the meeting, is that each one of the breakout sessions tended to discuss issues that were supposed to be in another breakout session, and this is a standard problem with these types of meetings. Simon's laughing because in the breakout session that we handled this obviously happened.
And so what I was looking at this and I was looking at the topics and the stakeholders, I mean we may discuss changing one or two here or there but basically I like that organization. What I had a problem with is focusing this meeting around topics, I think we've heard a lot about these topics and what I would like to hear is the reaction of the stakeholder groups to each one of these topics.
So I might organize the breakout sessions focusing on stakeholders and asking our professional facilitators to explore these various topics within those stakeholder groups, and then what we will hear at the end of the session in what we're conceiving of is an open meeting of the NHII Workgroup, what we'd hear from them is the visions of each one of the stakeholder groups as they apply to each one of these topics and it will provide us information to move forward in a consensus basis weighing what the various groups think about and providing us with maybe topics for future hearings.
DR. LUMPKIN: Let me sort of refine that a little bit because I think that, not hearing disagreement but I think that a key part of that is that while we're trying to define the vision, having an open statement by Bill, head of NHII for ASPE and the Department of saying this is what my vision is, that's a very important part of that, or our vision or so forth.
DR. YASNOFF: I would say this is what we've heard from the stakeholders.
DR. LUMPKIN: However he wants to phrase it but the important thing is is that the keynote should espouse a vision, it gives us something to talk about --
MS. RIPPEN: Just with regard to the stakeholder thing, my concern, when I talk to people about NHII and all the meetings that we go to, there is a sense of urgency in the respect of I don't have time to not move something forward. My concern with having it based on reactions of stakeholders, because in theory all the stakeholders are part of how we're going to arrange it, should all be represented in each of the topical areas, is that certain topical areas have to be moved along and if you can actually leverage the 1,000 people over eight hours, 8,000 hours worth of expertise move something forward, you may look at something different then a response to something from stakeholders. I'm not valuating, I'm just saying it's different.
DR. LUMPKIN: And I would add, I'd be a little bit concerned because one of the values of this conference is having interaction across stakeholder groups, and I could see changing the mix but perhaps maybe balancing it between the two but I don't think you want to lose that cross stakeholder problem solving focusing on --
DR. STEINDEL: My big objection is I'm looking at this and I'm looking at four breakout sessions focusing on topics and one just on stakeholders, and I think that's an imbalance.
DR. YASNOFF: This reminds me, there is one detail here that I neglected to point out a difference with the meeting last time. Last time the breakout sessions were one hour each, all these breakouts are an hour and a half because the feedback was there wasn't enough time to really get the topics fully discussed.
I think you make a good point, Steve, and my concern, along the lines that John mentioned is, the overriding goal of this meeting is to bring the different stakeholders together to coalesce on a vision around the topics. But I certainly would entertain a suggestion to have one more of the breakouts along stakeholder lines and then use the last one as kind of synthesis. I think that might work, so I hear what you're saying.
DR. DEERING: I wanted just a clarification that could help get to what Helga said, and I know certainly that's where Bill was coming from and where Jeff was coming from, we need to start getting on with it. And the point of clarification was I think you mentioned it and I just didn't hear it in enough detail to understand, how many advanced reports will be commissioned and circulated to people before they get there?
DR. YASNOFF: Eight, being the topics, the topic areas.
DR. DEERING: In my mind that, Steve, I never thought I would be one to be less audience based then Steve in this group so maybe it's like if Nixon can go to China, I can say here, I'm not sure I would want to see it mostly stakeholders because I agree that, it's time to give the stakeholders something very robust to react to and I would not want to shortchange the development by technical experts, area experts, whatsoever, they're not going to have the final say but at least let them move it as far forward as they in their professional abilities can, before you just go out to the stakeholders and just get their ideas of the visions of governance and all that, give them something to chew on. So if indeed your eight papers in the topic areas are very, very robust then number one, it means that if there are two stakeholder groups they're not just sort of talking, they're really reacting to something very concrete.
DR. STEINDEL: I feel they do have to react to something concrete.
DR. LUMPKIN: Let me suggest that I think that we've kind of reached some agreement on the goal, that we'll be looking at the vision, we're also going to be doing some focus on the LHII as an important step forward, that maybe we can look at the topics, I just think that there's a topic missing, and I'm just surprised that Mary Jo didn't raise it which is the patient, the personal health dimension.
DR. DEERING: I did raise it already and I was told well, you know.
DR. LUMPKIN: Well, no, you didn't raise it in the right part of the discussion.
DR. DEERING: It's much better coming from you, you see?
DR. LUMPKIN: But I think that something there on a patient focus, patient centered look at what it is we're trying to do.
MS. CRONIN: I'd like to add also that last year patient safety was a focus and I'm wondering if it falls within metrics this year in terms of how is it actually impacting the system, but there's a pretty big focus last year and prescribing and a lot of good things came out of it, so it seems like it should fall under one of these areas.
DR. YASNOFF: Well, we're certainly not ignoring it. I think with respect to the personal dimension I guess I want to understand why that doesn't get reflected in the consumers as stakeholders view, I'm just trying to understand.
DR. LUMPKIN: There are, if you don't design a system in the beginning to provide and to enable a patient to manage their own clinical information, and to have decisional support and you don't include that in the metrics, then it's going to be much harder to try to engineer that on the back end. And it's not just an issue, it's a cross cutting issue, it's not a stakeholder issue, and we want to promote it and that was one of the key things about our original document was to promote this as being, to elevate it to being one of three cross cutting issues that we dealt with.
DR. DEERING: I have it. Can I jump in?
DR. LUMPKIN: Sure.
DR. DEERING: As I was thinking about these eight papers and I was thinking about the guidance that's given to the facilitators within the groups and especially let's, the eight papers are going to be topic oriented, right? If the guidance to the people who write the papers is that there are certain elements of their tables of contents that are going to be standard like it was last year, then maybe it's important to focus on what the table of contents of those eight papers is, one of them could be it seems to me the personal patient component from your perspective in their given area because it's important to governance, it's important to metrics, etc.
Another thing that would be very important for them to bring out in that table of contents so that this is what people started from talking about is as you discuss your issue be sure to have a major section that's devoted to what are the interface issues, within governance, within architecture, within public health, as you write your paper about that be sure that you've got a section that talks about this interface issue so that everybody's discussion is focusing on that.
DR. LUMPKIN: I think that that's of value but I think that if you don't have it as a topic area it will just get lost.
DR. YASNOFF: And I think the lack of orthagonality if you will, if there is such a word, of these, the topic versus stakeholder area as shown by the fact we have public health in both places, so point noted. And having eight topics is I mentioned earlier --
DR. LUMPKIN: Logistics issue.
DR. YASNOFF: That's right, and research as well, and so --
DR. STEINDEL: Can I make a comment on the eight topics? We stated a given earlier in the day that there's not going to, we don't need to talk about there's not going to be a national database, there's not going to be a national database, can we take standards out of the topics list?
DR. COHN: I think that was talked about pretty extensively last --
DR. STEINDEL: I think that's a given.
DR. YASNOFF: That's okay with me but I would really appreciate a formal recommendation from the group to that effect --
DR. STEINDEL: Mary Jo went to China earlier and I'll go to China this time.
DR. YASNOFF: -- because I'm concerned about I understand why and I agree with it, but I'm concerned about the reaction of the standards community if that's done.
MR. BLAIR: Well, if it's included within the architecture that we have interoperability and data comparability, maybe that's all we need at this level for this meeting, and here's, oops, I'm switching sides, too.
PARTICIPANT: So Simon and Jeff are both opposed to standards.
DR. COHN: I was going to say, I actually think it's one of the discussions in one of the plenary sessions, that relates to sort of where we are, what are the issues, what's going on because there's a whole bunch of stuff going on, I don't think it needs to be discussed as a topic but it needs to be more reported on, there's HL7 stuff, there's this, there's that, I mean so that's really what needs to happen.
DR. STEINDEL: And I don't think we should ignore it but I think it's just a given.
DR. COHN: I don't think it needs a brainstorming for a couple of hours to figure out what's going on.
DR. RIPPEN: There are different perceptions of standards and what that might mean to different people, so standard vocabulary, standard interchange, but there are other types of standards, for example decision support, if you're going to design a decision support application that you can send out everywhere, there are authentication sorts of standards with regard to how you're going to do it. So if the purpose of the standards topic group is just to say we need standards it's kind of not very relevant. If it may be to identify those that really reflect on a requirement and really moving forward on really being able to have a system like that it goes a little further. Either way you could argue that it's under architecture but I'm just saying that there are pieces of this that we may not be thinking about.
DR. COHN: I think our picture of the standards would be a reasonable combination.
MR. BLAIR: I have two suggestions, one is to accommodate the fact that we won't have standards as a separate topic we broaden the architecture topic so that the information technology topic in the sub items of architecture and standards underneath it, so that's one thing you could do. And then the other thing, and I'm way out of my element with this --
DR. LUMPKIN: That hasn't stopped you before, Jeff.
MR. BLAIR: That's true. And I'm going to preface this a little bit that up until now we've basically been thinking of this almost within the medical informatics community and the health care delivery community. I am suspicious this is an election year and this may, this meeting may be covered from a much broader perspective and I think that in trying to think of that broader perspective we have a list of our topics and I don't think the consumer is at the top of the list, and I think we ought to move that to the top of the list.
DR. COHN: As a stakeholder or as a topic?
MR. BLAIR: Well, as a stakeholder and if there's topics that are of special importance to consumers they ought to be moved to the top of the list.
DR. COHN: I think that brings up the issue of the personal health dimension being one of the topics. I was actually also going to suggest, and this is just sort of, we talked about putting together standards and architecture as an item, I'm actually sort of thinking the governance and finance as a single item, too, I don't think that there's, I don't think there needs to be differentiation there.
DR. YASNOFF: I tried that before in the 2001 spring annual meeting and it doesn't work because what happens is people talk about finance and they just won't deal with the governance issues, they just ignore them, so that's why they're separate. Now the, and it should really be called financial incentives because it's policy, because the problem with having finance is that the inevitable recommendation is we need more money. Okay, well you don't have to have seven hours of discussion to say that but the real issue is what are the merits of various types of policy options for financial incentives. The governance area I think is extremely important but there the question is can you really make any progress with this in a discussion, or if not, I mean I think that the criteria for including topics are those areas where we need stakeholders to get together and work together to further our understanding of what needs to be done and there's a high probability that such a discussion would in fact accomplish that. And I think that's why leaving standards out makes sense because I think that we have a lot of consensus about what needs to be done, we don't really need to discuss that anymore. But I'd be concerned about combining both governance and finance.
DR. COHN: Well, it sounds like you're actually agreeing with me though, you're sort of saying geez, we're not going to get anywhere with governance but if we put them together we wouldn't talk about it anyway.
DR. LUMPKIN: On this point?
DR. VIGILANTE: It's related to topics.
DR. LUMPKIN: Let me just sort of go back on the governance thing, I think though there maybe some LHII specific governance issues that will bear having discussion because when you get down to that level delineating who needs to be at the table and directing those kinds of projects, the national entities, the community groups, the consumers, I think there can be some very fruitful discussions that will get sidetracked if you try to do governance and finance.
DR. STEINDEL: I totally agree, I mean the two key examples that we focus on in Santa Barbara and Regenstrief are governed totally differently and the various types of models and groups that need to come together, it needs to be brought up, I would not eliminate it.
DR. VIGILANTE: As I'm thinking about it I'm not sure this is a stakeholder issue or if it's an issue that's woven through several topics but the idea of at least calling out in some way the special challenges that face certain populations particularly the rural health environment and the health disparity environment, and I'm not sure if, it's sort of different then everything that's there and I don't know how to quite integrate it here, I guess it could be under public health, it could be under financing issues, it's a little diffuse. On the other hand there are unique challenges in implementation and in LHIIs that serve those populations and those places and I don't know quite how to make it more visible.
DR. LUMPKIN: I think, if I could suggest, I think that's a very important point but it may be one point that would fit with Mary Jo's suggestion of being, of the papers and the facilitators making sure that that's an issue that's discussed because it really is cross cutting.
DR. STEINDEL: My comment relates somewhat to this and can be an encompassing area and I'm looking at public health under topics, we have the public health professionals I assume are the ones that are in the stakeholder group, and I would, if we're going to talk about public health under topics we might want to expand it into the area of population health and broaden it where we can include disabled populations as one of the issues and how the NHII can help and move it away. Because when you say public health and you say it in this area what is going to go through everyone's mind is PHIN --
DR. LUMPKIN: And bioterrorism.
DR. STEINDEL: And I think we want to broaden the topic.
DR. LUMPKIN: If I could summarize, I think, maybe this is just me, we've decided to put the patient and consumer in the topics, to drop standards, to change public health into population health, and to incorporate in that some of the discussions of vulnerable populations.
MR. BLAIR: What about moving consumer and personal health records to the top of the list?
DR. LUMPKIN: And of course by being in the topics alphabetically, the first in our mind, consumer personal health dimension, number one is always first in the list when you alphabetize.
MS. RIPPEN: A comment, just one with the governance that we discussed earlier, there are actually interesting governance questions at the NHII level, especially as it relates to national databases, federal government information and others, so again there are different spheres of governance that need to be addressed.
DR. LUMPKIN: My concern about there is we need to be, if we do get into that we do need to be very focused because it will go back to a discussion of having an office for the NHII in HHS, we've been there done that, I'm not sure there's going to be value added --
MS. RIPPEN: You have to build on something else.
DR. LUMPKIN: If it's going to be on the national level it needs to be fairly focused and circumscribed.
DR. COHN: I was actually going to bring up Kelly's issue about patient safety, did that get included in here and I just missed it?
MS. CRONIN: Population --
DR. COHN: Well, I don't think it's populations --
DR. YASNOFF: The question I have there is what do we have to discuss or recommend with patient safety? I mean I'm asking that as a question --
DR. LUMPKIN: But I think Kelly's comment, which is that we need to make sure that that's included in the metrics discussion, is I think the way that that should be dealt with, in the metrics.
MS. CRONIN: It seemed like one of the logical fits from the quality of care and patient safety, whether it's part of the evaluation components of each LHII or it's part of the table of contents --
DR. YASNOFF: The assumption, I think the IOM said it very well in the last report that you're not going to get improvements, major improvements in safety and quality unless and until you have an NHII. So that's now, we're not going to talk about that, and I think that probably that is a good, metrics is a good place to put it. I mean in other words there's no point in having a long discussion and saying well we should have NHII to promote quality and safety, that's a settled issue so that's a waste of time I think. But a good discussion is what are the quality and safety metrics we can use to assess the progress of NHII, that seems to me to be an unanswered question that needs discussion.
DR. STEINDEL: There's really two areas in the topics where I think patient safety needs to be discussed, one is the area of metrics, where we're measuring what's going on in the area. And the other is what Helga brought up earlier and that's the problem is we do not have good standards for distributing the patient safety system, decision support algorithms, etc. --
DR. LUMPKIN: So that would be architecture.
DR. STEINDEL: -- and that would be in the architecture area.
MR. BLAIR: Everyone in this room knows what the word metrics means, but this will probably get media coverage and there's probably even a lot of reports don't know what the word metrics means.
DR. COHN: Well, maybe measuring progress --
MS. CRONIN: Evaluation impact --
DR. STEUERLE: At the risk of being repetitive I'd like to go over at least a couple of questions I think I'd like to see in several of these sessions if not all of them. One of them, which may sound small but it brings back the LHII thing is are there requirements that we should be making on LHIIs who get grants from the government in these various areas, I'd like to know whether there's some small things we should be doing right away, I think that's a legitimate question. A second one we've brought up several times is what are the constraints in these various areas that are preventing movement forward and hopefully the moderator will not, the instruction to the moderator, not just the big concerns that we need more money, but if only John Lumpkin would chair five more years, not chair, even small things that would move us forward. The third one I'd like to be clear, I like that we tied in the finance to be financial incentives but there are a lot of other incentives that can be put in, and the incentive issue should come up in almost all these topics, what are the incentives at the state, federal, Medicare, whatever level, that might help promote progress, I'd like to see, obviously you have to decide which of those to put in but I'd like to see something on those --
MR. BLAIR: Gene, what if instead of saying financing we refer to that as incentives, one of the big incentives is financing but then there's other incentives.
DR. STEUERLE: I guess my fear is is that in some cases you might want to narrowly talk about incentives with respect to privacy or metrics so the question is whether separating it out --
DR. LUMPKIN: No, I think that that gets us away from the issue of the federal government should just pay for it --
DR. YASNOFF: Again, it doesn't take seven hours of discussion to come to that conclusion.
DR. LUMPKIN: And we know what the response will be on that one.
DR. YASNOFF: Takes even less time to get the response.
MS. CRONIN: Can I ask a quick question about process? Who do you plan to have draft these papers ahead of time and will there be some type of internal review process here so we can make sure that we're more or less thinking that it's comprehensive or on point?
DR. YASNOFF: I'm open to suggestions, that has not been, we have not finalized that.
MS. CRONIN: The reason I raise it is I was a little bit frustrated by the process last year after a day and a half, two days, talking about a lot of good ideas on patient safety I'm not sure a lot of it actually got captured and I think the group was going off on tangents way too much --
DR. YASNOFF: You're talking about captured at the meeting?
MS. CRONIN: Well, I don't think we stuck to the baseline information that was put together but then in the end I don't think it was captured either so I think there needs to be some kind of way throughout to make sure --
DR. YASNOFF: We're trying to deal with the issue at the end by having professional facilitators so we're more hopefully objective about capturing what happens at the meeting. In terms of the process for creating these documents, again, I'm open to suggestion, we haven't really finalized that. Last year there was a process where the track chair and the facilitators and the invited experts go together in advance and had a number of conference calls and did that. This year the initial thought was that since we have in these areas sets of recommendations already that it would be a relatively easy process to say this is what we have from before, and just putting that together and providing that to people. That is probably overly optimistic but we haven't really thought that completely through so ideas are welcome.
MS. CRONIN: Well, it's likely that we'll have some new information to add from what was done, synthesize in the fall or whenever it was done versus --
DR. YASNOFF: And let me say I think that, because you mentioned how this is handled within the department, I think the purpose of this meeting is to as much as possible elicit input from the stakeholders and so what we tried to do last year and we'll try to do again this year is to not try to start the stakeholders essentially from the department's position, whatever that is, and so we really don't want to have these paper, last year the papers were not at all clear within the department is what I'm getting at.
MS. CRONIN: And I don't that's necessarily still a problem, it's just that at least from my perspective, and granted I was coming from one agency then only involved in a certain number of initiatives, but to me it did not seem comprehensive last year and the people who were facilitating, some were very good and others were not, I know you're going to address that.
DR. STEINDEL: Just a point of process, Bill, the facilitators are also going to produce a report from their sessions?
DR. YASNOFF: No, the idea is that within the sessions there will be a selection process for someone, someone will be nominated to essentially --
DR. STEINDEL: No, I was just thinking of writing up something.
DR. YASNOFF: I assume yes, they will do that, and they will essentially do the work of actually preparing the slides with the person who's going to do the presentation.
DR. LUMPKIN: We're kind of moving on to the mechanics of the event, which is fine because we're transitioning and we need to be moving and transitioning. I'd like to throw out an idea about day three, which is the report back. And you raised your issue, which we all questioned, about questions. It would seem to me that given the timeframe that we could, well, a suggestion and a problem, first a suggestion. That we would break for lunch and then we would hold from 1:00 until 3:00 a meeting of the committee to which we would invite the workgroup chairs for then having questions and answers and discussions.
DR. YASNOFF: I have no problem with that, the only problem with extending the time is I don't have the budget to feed all the people who attended the meeting.
DR. LUMPKIN: Well, the conference would close --
DR. YASNOFF: As long as the conference closes I'm fine.
DR. DEERING: But don't people pay for their food in the registration fee?
DR. YASNOFF: I would have to raise the registration fee in order to cover that final lunch.
DR. LUMPKIN: I think we want the meeting to end, let the meeting end, and then we can reconvene a meeting of the workgroup, depending on we either have questions or discussions, talk about next steps, gives us a chance having heard all that because frequently, and this is a problem when we do hearings, we do hearings and we never have time to synthesize it.
DR. YASNOFF: This will be particularly frustrating because you will have had hours and hours and hours of input, I'm sure you'll all be exploding with questions.
DR. LUMPKIN: That's the easy part, now the problem, the problem with day three is if that is a hearing of the committee it has to be open to the public.
DR. YASNOFF: Fine.
DR. COHN: And broadcast over the internet.
DR. LUMPKIN: And broadcast over the internet, which is also fine I'm sure.
DR. YASNOFF: I don't think those will be problem, I mean what we can do is we can arrange to, hopefully we can arrange with the hotel to just use the same room that all those people were in, which will already be broadcasting over the internet if the morning was a hearing --
DR. LUMPKIN: I'm saying the morning session has to be open to the public.
DR. YASNOFF: Oh, I see what you're saying, is that, why are you concerned about that?
DR. LUMPKIN: I'm not really, there are people who may have paid a registration fee who will be attending and someone who will, as long as it's clear that someone who shows up that morning and says I want to sit in --
DR. YASNOFF: I don't think, the only issue, first of all we could, I'd be willing to dispense with the 14 Marines at the door keeping people out who don't pay, so I'm willing to do that. Second, the only cost issue in inviting the public is that it's probably going to be a coffee break there and so maybe a few more cups of coffee would be consumed and I don't think that's an issue. And the third thing is my guess is that practically everybody in this world who's interested in this will be registered for the meeting anyway.
DR. LUMPKIN: I feel I've got to adhere to the law. Mary Jo?
DR. DEERING: Well, I have a logical thought in the sense that we certainly hope after all the intellectual effort that's gone into day one and day two and it's feeding into the workgroup we certainly want the product that's delivered to the workgroup to be the highest possible caliber, so I'm thinking of one small logistical suggestion because the breakout topics don't end until almost 5:30 the night before, and at 8:00 a.m. you've got them starting to report to you, so I'm thinking of perhaps adjusting day three, and that's sort of where I was going, that at a minimum your big closing speech would come at 8:00 to 9:00 at which time your breakout leaders at least have that time to meet and polish up their reports, they don't need to hear, the people who have to report out to the committee following. I'm trying to give them a little bit of time other then 5:30 p.m. to 7:30 a.m. is I guess what I'm getting to and how can we give them --
DR. YASNOFF: I'm sure they appreciate that but this is, actually they'll be better off then last time because we will have these professional facilitators helping them so I don't see that as a big issue. The other thing that can be done is there are always certain of the groups who take a little bit longer and what we can do is we can rearrange the order so that the people who are done can report, I think people will be interested in listening to the closing speaker and I would hate to shut people out of that --
DR. DEERING: Well, they wouldn't be shut out necessarily if you switched it around, and in fact you'd still have a brief closing figure, but anyway, just an observation.
MR. BLAIR: We've been blessed with a few things so far, one of them is that up until this point all of those of us who feel as if the National Health Information Infrastructure will be a tremendous benefit to this country has received broad support and it has received bipartisan support. I do understand, Bill, there's certain things within the Administration and there's a reality, but one of the things that I think would be beneficial is if we could do whatever we can to keep this a bipartisan thing and will Senators or Congressmen of both parties be invited to attend either the beginning or the middle or the end or something to reflect, or even to say a few words if possible, to reinforce the bipartisan support for this?
DR. YASNOFF: That would be wonderful. I think last year we did have a couple of staffers who participated as either facilitators or invited experts. I certainly would be delighted if I could get commitments from anybody on the Hill to come talk any time at one of these meetings about anything. And so that would be wonderful. If people want to attend the meeting, that would be great too.
DR. LUMPKIN: I think if Jeff is suggesting as part of the program, I just have a concern, and last year at the Connecting for Health there was an attempt to have the Secretary and then to have Howard Dean talk about his platform and he gave his stump speech, and I just think it's difficult in an election season that as much as you try to do that you have no control over those folks and what they say and so the best thing may be in the middle of an election is not to have any come. Now that would be different, if the President wanted to come and address the group I think we would be hard pressed --
DR. YASNOFF: I don't think that will be requested, you will have the opportunity to voice your opinion.
DR. LUMPKIN: Or to even worry about voicing my opinion, because if he came I'm sure I wouldn't be in a position --
DR. DEERING: One opportunity could have been that under all the legislative support a lot of it gets to incentives, so if there were a way to get the various staffers of the people who have sponsored the key piece of legislation into that breakout session, or to incorporate their views into the paper that's circulated, then what you've done is you've laid out how all sides are coming at it and so at least the going in information is balanced.
MS. CRONIN: And you just have to be careful to make sure that you had equal representation from both the House and the Senate.
DR. YASNOFF: I need to ask a clarifying question on this afternoon session of the committee, who exactly is it that you want to invite to be available for questions? It's the people who presented the reports?
DR. LUMPKIN: Yes.
DR. YASNOFF: So when those selections were made we would need to make every effort to select people who would be available through that timeframe if we do that.
DR. LUMPKIN: Well, my thought would be is not to leave it to chance on the reporters, because I thought I heard you say when you first opened up that there would be a selection --
DR. YASNOFF: There would be an eligibility criterion that you had to be willing to stay for that presentation.
DR. LUMPKIN: My thought is there would be a designated reported, designated by the planning committee prior to the meeting, so that we can pick somebody who we think will be reasonably neutral in their presentation, doesn't have an ox to gore in the report back --
DR. YASNOFF: Who's that?
DR. STEINDEL: You've just eliminated everyone --
DR. LUMPKIN: One whose bias is within acceptable limits --
DR. YASNOFF: And well known.
DR. LUMPKIN: But I think it would be, we've all been to those meetings where we know how the selection goes, okay, who wants to do it, who just went to the bathroom, okay, you do it.
DR. YASNOFF: So what you're suggesting is that that be designated in advanced. Point well taken.
DR. STEUERLE: A very tiny observation, we often have sessions where we do have a lot of people sort of set up as roundtables so you feel like a participant, but sometimes we set it up by going a little by going to three or four people and saying I want you to make one comment at the beginning for no more then three minutes and set up two or three people we know we want to hear from. The advantage of that is then they prepared ahead of time, they don't just sort of come into the meeting and speak off the top of their head. You don't have to do this but if there's some sessions you've got some participants, stakeholders, whatever, you really want to hear from you might go ahead and say hey, I want to call on you very early on to make a comment, you can also use them to set a standard for how long you want people to talk, no more then three minutes, no more then one point or something, but set up two or three people. But again, I think that's an option, you don't have to use it but I would consider it. You often get some good comments out early and get the discussion going well as opposed to just hoping that the session sort of takes off as you want it.
DR. YASNOFF: I'm inferring from the discussion, and I want to be sure to ask the question specifically, that the workgroup agrees that this final session from 8:00 to 12:00 with a break will in fact be an official meeting of the workgroup, I didn't hear that but the inference was that people agree.
DR. LUMPKIN: Yes.
DR. YASNOFF: So I will work with the folks on making sure of the logistics and given that you want to then have another meeting afterwards we'll have to keep those logistical things, keep the microphones, internet, all in place for after lunch as well.
DR. DEERING: Can I just ask a point of clarification, then what you have listed as closing is no longer the closing and that's out?
DR. LUMPKIN: No, that's a closing --
DR. DEERING: But that's a full hour and 45 minutes. So you have that as a new plenary, the committee adjourns, the committee meets 8:00 to 10:00 on your current schedule, it adjourns, and then you've got your outside speaker --
DR. YASNOFF: The closing really is supposed to be 30 minutes, I mean this is basically a closing speaker so somewhere in there the committee would adjourn and then there'd be the closing speaker and then the meeting will be closed and then the committee will then reconvene after lunch.
DR. LUMPKIN: The meeting will end. So the meeting will go from the beginning of the morning until right until the closing, the workgroup portion of it, will recess for an hour and a half, half an hour for the closing, hour for lunch, reconvene.
DR. YASNOFF: Correct, that's the idea. I also wanted to go back to a couple of other suggestions and clarify, it was suggested that we need like a progress report on standards, here's what we've accomplished and so on, the plenary time is very limited but I approved two lunch and one dinner slot, is there any objection to putting in such a progress report in one of those slots?
DR. COHN: That could be an exciting real topic --
DR. YASNOFF: Well, what we could do is have the standards presentation before lunch is served and so you have to sit there in order to get your lunch.
DR. COHN: I guess I'm looking at plenary one where you're talking about recommendations from last year and describe progress made over the year to date, and I guess I'm not sure that I think that standards would not be well accommodated in that, I guess there's various levels of standards discussions but I hadn't expected you to get into the 12 choices between decision support standards but more HL7, EHR --
DR. YASNOFF: So what you're saying is in the overview of the progress you want to have an overview of what we've done in standards but you don't really want to discuss each of the HL7 messages and how they're formulated.
DR. COHN: Yeah, that was sort of my view, but then again we will obviously in the topics under architect, architecture, whatever we call that --
DR. YASNOFF: So I'm glad I asked, so standards is too exciting a topic for a meal.
DR. VIGILANTE: Didn't Indianapolis present last year?
DR. YASNOFF: yes, they did.
DR. COHN: Indianapolis presents every year.
DR. YASNOFF: Yes, and actually Santa Barbara presented. But this year I'm going to push them more, last year the presentations were more of an overview and this year I'm going to push them a little bit to show us a pseudo demonstration of how the system would work or scenario or something.
DR. COHN: I've got a real odd question here about that because I see them and the names keep coming up again and again and again, maybe you can explain to me why we keep looking at them as opposed to, I mean there's the VA, there's DOD, there's all of these other entities that are doing similar things. Now the differentiation is is that they are, there's a difference in governance but that's really the main differentiation here, and I guess I'm wondering, you want them to specifically talk about governance or you want them to talk about the abstracted diagnosis and procedures that they're shooting back and forth to each other, what --
DR. YASNOFF: These two examples that are, those are the ones that are most advanced doing exchange of information in geographic areas. And in fact the VA and DOD are intra enterprise systems, whereas Santa Barbara and Indianapolis are inter enterprise community based systems, and so they're fundamentally different. And actually if you look at the VA, and I haven't, I think the DOD is actually quite similar although I haven't looked at them as extensively, the VA actually is regional systems. The VA does not have a uniform national system and if you get your care at one VA and you go to another they only recently could get your record at all and they can't transfer it electronically or apply decision support to it locally, so it actually is regionally based as well.
But the other problem with the VA, beside the fact that it's within one enterprise, is that it doesn't show the issues that you run into when you deal with a community having to have agreements between multiple entities in terms of sharing information and having to do deal with all sorts of different types of entities. So I don't see it as a particularly good example, I mean if you, even if the VA was perfect in every way I don't see how presenting that helps people to then move forward because they say well that's nice for the VA but I'm not the VA what do I do, whereas when you look at these community models you can say wow, that's what Indianapolis did, I can do something like that or I can do what Santa Barbara did, I mean I have a community and --
DR. COHN: Just be aware, I mean I'm fine with what you're saying but what you're really talking about are governance issues as opposed to functionality issues so just be aware of that being sort of the differentiation, which is fine.
DR. DEERING: And that suggests something else, Bill, because everyone knows that the VA and the DOD are behind in bringing their own systems together. Would it be at all helpful anywhere here, certainly not in the plenary, but is there anything of value since we've now determined that the sub-theme or super-theme of this meeting is the interfaces among things, the lessons learned from the challenges they are facing in trying to bring their systems together. Why aren't they further along? Why are they five years behind? And would they be willing to say it in public?
DR. YASNOFF: I'm not sure that really, I don't think in an environment where there might be children we can talk about that.
DR. COHN: But the VA is working on their next generation system, which is meant to address these issues.
DR. YASNOFF: I understand, we can have an off-line conversation about this --
DR. COHN: That's fine, I just wanted to push you a little bit --
DR. VIGILANTE: In Maine weren't they doing sort of a demo project where they were giving physicians incentives to adopt --
DR. YASNOFF: Yes.
DR. VIGILANTE: To me that is actually a pretty interesting experiment to highlight and it's new, and that might be one I might either add on or substitute for one of these others. That incentive issue really gets to the heart of it and they have some outcome metrics --
DR. STEUERLE: My comment, you could line up some extra little speakers after the incentive structure to have somebody from Maine --
DR. STEINDEL: I was thinking the same thing, we might want to turn this into a little bit broader plenary session and have it with a spectrum of LHII speakers, in various stages of development. And one of the things was I was just picturing seeing Mark's videotape again, Mark Overhitch(?) --
MR. BLAIR: I want to glom onto this one because Bill you challenges us before where you say you didn't hear alternatives to LHIIs and I'm not thinking of this as an alternative but of things that are complementary, supportive, additional things that are not LHII but are moving us towards the NHII, and we have a plethora of state initiatives being passed for e-prescribing, for CPOE, the Leap Frog Group, all of these other initiatives that all contribute and I feel like it would dramatically strengthen the ability for you to get buy in at the beginning, for you to recognize all of these different initiatives, in addition to LHII, and then when you focus on LHII I think there would be far less concern, anxiety, resistance, if you do it that way. And especially all of the states because that becomes again a bipartisan support.
DR. YASNOFF: Well, the state information exchange projects fall into the same category but I agree, we need to highlight these various things. I'll remind you there's a whole plenary session on private sector initiatives where things, Leap Frog would be one of the things that would be represented there. But I agree those need to be highlighted, and the Maine project is clearly an important thing to highlight and thank you for bringing that up, and actually they're not moving to an LHII.
Can I ask one other question about a recommendation that was made earlier that I would have to clarify?
DR. DEERING: This has to do with Santa Barbara so very, very quickly, one of the things that I've always wanted to ask is have the two of them sat down together and looked at their systems and said what would it take for us to talk to each other.
DR. YASNOFF: No, because there's no benefit to them to do that, the only people who --
DR. DEERING: You have just answered a very important question --
DR. YASNOFF: There's no benefit for Santa Barbara and Indianapolis to exchange information except for the system developers in Santa Barbara and Indianapolis who probably will travel back and forth and might need medical care.
MR. BLAIR: That's true at this time, but seven to ten years from now I think the national expectation is if I'm taking a vacation in one place I want my medical, and on and on and on --
DR. YASNOFF: So one of the strategic things that we're doing that I didn't get down to that level of detail is, and I presented this here before, is we need to provide some grant support for people to begin hooking together LHIIs so that they can start addressing these problems and recognizing that while today there's no benefit to hooking up Indianapolis and Santa Barbara it's an issue of scale where once 95 percent of the country is hooked up then there is a benefit so we have to start solving the problems --
DR. STEUERLE: But they might have very strong incentives to make sure they are hookable, whether it's to each other or to someone else, if the consultants are going back and forth sharing information so that their system is not going to be outdated two years from now --
DR. DEERING: But all the ones that are coming along, too, I mean after all you're not talking to just the people living in those communities, the whole purpose of this conference is all the other people who are building LHIIs, so it's to give them that information.
DR. LUMPKIN: But I think the approach that Bill is talking about, which is using grant money because there is no business case, to encourage them to do something that they wouldn't normally do --
DR. YASNOFF: At this time.
DR. LUMPKIN: -- at this time, and the importance for us doing that is that there will be lessons learned that will help guide the issue of interoperability between these kinds of entities.
DR. DEERING: As you as you, again, I think we're all saying the same thing, but there would be no purpose to giving these grants without making it, let's see, I think it was you or was it Jeff who said what are the requirements that you are writing into your grants from the beginning so that they talk to each other and that's where I got to the problems, the lessons learned, between Indianapolis and Santa Barbara, what can you learn from that so when you write your requirements and all those who are just starting out now, they don't create another 20 stovepipes --
DR. LUMPKIN: It's a matter of the chicken or the egg, until you give the grant to some entities to learn how to interrelate you can't put the requirements into the grant application that they do interoperate. And if you do then you have to increase the size of the grants because you're dealing with something for which there is no business case and at some point the cost of doing, of getting the grant is less then the value of the grant itself, so you say okay, do I just do it or do I get this grant that's going to put on so many requirements that now it no longer becomes cost effective for me to implement this initiative.
DR. STEUERLE: I do think Mary Jo's question refines still a question because these two systems, anybody developing a system faces a lot of risks, the risks are what happens down the road one, two, three years from now as to whether the system they develop now is going to have the interfaces they want so they don't have to reconfigure, so there is a discussion it seems to me, it might not be a discussion about whether you guys created an interface between each other but there is a discussion, what problems do you have in common, how much did you talk to each other, how much do you talk to other people developing systems so as to avoid these problems. I think there are, they must have had these discussions and they must have some lessons learned that are in common.
DR. LUMPKIN: Well, I'm going to have to move us on because I really need to leave in about five minutes, you've got one question and then we're going to talk about next steps.
DR. YASNOFF: My one question is going back to Steve's comment about having, devoting more of the breakouts to stakeholder specific discussions versus topic specific discussions. I don't have a sense, I know where Steve stands but I don't have a sense of where the rest of the group stands on that issue.
DR. LUMPKIN: My understanding is what I heard you say was that you were looking at instead of going four and one, of going three and two.
DR. YASNOFF: But I'd like to hear whether the group is indifferent, supports that --
DR. COHN: Which side three, which side two?
MR. BLAIR: Well, in general, a three and two is more of a balance --
DR. LUMPKIN: I was just judging by body language that there seemed to be some general acceptance of that, and maybe that was presumptive.
DR. STEINDEL: John, I heard two comments on that, I hear going three/two and the assumption is it's three topic and two stakeholder, but I also heard another one that was two and two and a synthesis breakout --
DR. LUMPKIN: What's that?
DR. STEINDEL: I don't know, someone mentioned it.
MS. RIPPEN: It's the same as the three and two because the third, the synthesis is then the original topic group trying to pull together the comments of the stakeholders to address the issues or recommendations they raised and to the final recommendations.
DR. STEINDEL: So it's basically two/two and conclusion.
DR. LUMPKIN: It there support, two/two and a conclusion? I think we've had a very good discussion, been very frank, we kept the recorder awake. But I think the work product is certainly worth all the effort we put in today, I think we've got a plan. What I'd like to suggest is that we have a meeting scheduled I think at the next full committee meeting --
MS. JACKSON: I though you sacrificed the breakout, I'll double check that, we couldn't get everything in, I thought with this meeting we were okay unless you wanted to meet --
DR. LUMPKIN: Well, I think we have some next steps work to do so let us try to work on scheduling something perhaps in April, we can try to set up some times, probably it would be better not to just try to do it in the normal hour that we would have, that would just be kind of frustrating, so we will try to set up, send some polling around and see if we can meet in April. As we're trying to move forward in 18 to 24 months of developing this report we're going to have to meet a little bit more frequently then we have in the past. We still have on our agenda to discuss then at that meeting the new public, the new dimensions for the models and the issue of the overlaps.
DR. DEERING: So you are agreeing that there will be no March meeting, we will not try to --
DR. LUMPKIN: We gave it up, I remember that --
[Whereupon at 2:52 p.m. the meeting was adjourned.]