[This Transcript is Unedited]
THE NATIONAL COMMITTEE ON VITAL AND HEALTH STATISTICS
Hubert H. Humphrey Building
200 Independence Avenue
Washington, D.C.
MR. COHN: Good morning. I want to call the meeting to order. This is the first day of two days of meetings of the National Committee on Vital and Health Statistics.
The national committee is the main public advisory committee to the U.S. Department of Health and Human Services on national health information policy.
I am Simon Cohn, the associate executive director for health information policy for Kaiser Permanente, and chair of the committee.
I want to welcome the committee members, HHS staff, and others here in person. Of course, I want to welcome those listening in on the internet, and remind everyone, as always, to speak clearly and precisely into the microphone, so those on the internet can hear you.
With that, let's have introductions around the table and then around the room. After that, I will make some brief remarks and then we will get into agenda review.
As we do the introductions, for those on the national committee, I would ask, if you have any conflicts of interest related to any issues coming before us today, would you so publicly indicate during your introduction.
MS. GREENBERG: I am Marjorie Greenberg from the National Center for Health Statistics, CDC, and executive secretary to the committee.
MS. WARREN: I am Judy Warren, University of Kansas School of Nursing, member of the committee, and I am not aware of any conflicts.
MR. HOUSTON: I am John Houston. I am with the University of Pittsburgh Medical Center. I am a member of the committee and I have no conflicts.
MR. REYNOLDS: I am Harry Reynolds, Blue Cross Blue Shield of North Carolina, a member of the committee and no conflicts.
MR. ROTHSTEIN: I am Mark Rothstein from the University of Louisville School of Medicine, a member of the committee. I have no conflicts.
MR. TANG: Paul Tang, Palo Alto Medical Foundation, member of the committee, no conflicts.
MR. VIGILANTE: Kevin Vigilante, Booz-Allen Hamilton, no conflicts.
MR. LOCALIO: Russell Localio, University of Pennsylvania School of Medicine, and no conflicts.
MS. MC ANDREW: Susan McAndrew, Office of Civil Rights, privacy liaison for the subcommittee for privacy and confidentiality.
MS. TRUDEL: Karen Trudel, Center for Medicare and Medicaid Services, liaison to the committee.
MS. MC CALL: Carol McCall with Humana, no known conflicts.
MR. HUNGATE: Bob Hungate, Physician Patient Partnerships for Health, no conflicts.
MR. WILLIAM SCANLON: Bill Scanlon, Health Policy R&D, member of the committee, and no conflicts.
MS. CARR: Justine Carr, member of the committee, Beth Israel Deaconess Medical Center, no conflicts.
MR. HUFF: Stan Huff, Intermountain Healthcare and the University of Utah in Salt Lake City, and no conflicts.
MR. FITZMAURICE: Michael Fitzmaurice, Agency for Health Care Research and Quality, liaison to the full committee, staff to the subcommittee on standards and security.
MR. STEINDEL: Steve Steindel, Centers for Disease Control and Prevention, liaison to the full committee.
MR. BLAIR: Jeff Blair, Medical Records Institute, member of the committee. I am not aware of any conflicts.
MR. JIM SCANLON: Good morning. I am Jim Scanlon. I am with the HHS Office of Planning and Evaluation, and I am the executive staff director for the full committee.
MS. SQUIRE: Marietta Squire. I am the CDC National Center for Health Statistics, and I am staff to the committee.
MR. TROUTMAN: Allen Troutman representing the FHA program office.
MS. WOOLEY: Sherry Wooley RSO(?).
MR. RITEMAN: I am Adam Riteman(?), intern in Dr. Brailer's office.
MS. JONES: Katherine Jones, CDC, National Center for Health Statistics and staff to the committee.
MS. BALINTOSKY: Danielle Balintosky(?), the National Journal.
MS. MOIRER: Gwyneth Moirer(?), SPH intern at National Center for Health Statistics.
MS. JACKSON: Debbie Jackson, National Center for Health Statistics, CDC, committee staff.
MS. ROGERS: Ann Rogers, writing and editorial consultant, and I worked on the populations report.
MR. KYLE: Frank Kyle, American Dental Association.
MR. LEE: Dr. Tad Lee(?) newly appointed senior health information privacy outreach specialist, Office for Civil Rights and Health and Human Services.
MR. DICKMAN: Barry Dickman, Department of Veterans Affairs, Veterans Health Administration.
MS. FRAZIER: Judy Frazier, American Optometric Association.
MS. BURKE-BEEBE: Suzie Beebe, ASPE.
MS. DICKERSON: Audrey Dickerson, HMS.
MS. SOROS: Nancy Soros(?), Government Health IT.
MS. GRANTHON: Miryam Granthon with the Office of Minority Health and staff to the populations committee.
MR. SHEEN: I am Tony Sheen(?) with the consulting firm, Point in Care Partners.
MR. ALFANO: Bill Alfano(?), Blue Cross Blue Shield Association.
MS. NOLTE: Emily Nolte, National Opinion Research Center.
MR. SOROS: Jim Soros, ACMS.
MR. RUDDY: Dan Ruddy, American Health Information Management Association.
MR. COHN: I want to welcome everyone. As a comment, before we do a general review, I just want to make a couple of comments about the activities of the last several months.
I am, of course, reminded that at our March meeting I observed that this will be an interesting and, I think I will add an exciting time for the full committee.
As I think as we reflect on things, many of our recommendations, including the need for increased HHS leadership in health information technology moving us toward the NHII are coming to pass.
Since our last meeting, Secretary Leavitt has unveiled his 500 day plan, which includes really as a centerpiece the unveiling of the next phase of the HHS health IT strategy.
This phase will also unfold over the next 500 days and include convening leaders to coordinate public and private health IT efforts, developing strategies, contracting for studies, funding prototypes and demonstrations to enable health IT.
I know David Brailer will be talking about this later when he meets with us this afternoon but, from my view, really what we are talking about is an acceleration of activities already underway that we have been sort of shepherding and really speak of, I think, our vision from our documentation, information for health, a strategy for building the NHII, which we published in 2002.
Really, what we are talking about is beginning to use health IT to help bring health care into the information age and transform the health care system and improve the health of all Americans. I think this is something we can be very excited about, and we support his efforts.
The issue I, and the executive subcommittee, have been working on really how we can best support the secretary and the department going forward in what I would describe as these changing and really accelerated environments.
The executive subcommittee, with Jim Scanlon, Marjorie Greenberg, Debbie Jackson's help, and a number of others of you who have helped provide some input into our thoughts, have helped assist me with preparing briefing materials and, more important, thinking through how we could help and provide leadership and value in this new environment.
Indeed, because of our content expertise and experience in this whole area, indeed, we really laid the framework for a lot of what is going to be coming forward. We have a lot to contribute.
In addition, we have a reputation for strategic focus, as well as having an open collaborative process and the ability to deliver timely, thoughtful, practical recommendations that are supported by both the public and private sectors.
Yesterday I met with the Secretary to brief him on the NCVHS and discuss ways we may be able to assist in going forward.
I want to share with you that it was a very productive and positive meeting. The Secretary is very interested, as you know, in interoperable HIT, and expressed his appreciation for our work, which has really laid the foundation for these next step initiatives.
While clearly these new initiatives are just unfolding, I think it is safe to say that we will play a significant role in the next phase of the HHS health IT strategy going forward.
As I have commented, this is an exciting time, and I want to acknowledge all of you for your hard work, I think your dedication to the task and, probably most important, your commitment to an improved health care system and, of course, a better America which will result from that.
Again, thank you for all of your help, and I think we will move forward. We will talk about this, obviously, as the day goes on and tomorrow, as we look at our various work plans and discussions of subcommittees and all of that.
I think in front of you, you also have briefing materials that we shared with the Secretary that I thought you would all find interesting, both a transmittal letter and a two-page letter that, once again, was produced with a lot of your assistance.
Now, on another note, since our last meeting, I have attended a meeting of the National Center for Health Statistics board of scientific counselors.
They are a very impressive group ably led by June O'Neill. who has just arrived. So, welcome. I am very pleased that June has decided to become the NCHS liaison representative to the NCVHS, and obviously I want to welcome you.
I am also, on the advice of Don Steinwachs, appointing Bill Scanlon to be our liaison representative to the board of scientific counselors.
Bill, I want to thank you. I know you have a very busy schedule, to put it mildly, and I am really delighted that you are willing to take on this new responsibility. So, thank you.
MR. BILL SCANLON: I am looking forward to it.
MR. COHN: Now, with all of that, let's move into the agenda review, and we will talk, I think, further tomorrow about executive subcommittee actions, and the results of the first meeting we had, and then talk about our plans for the upcoming off-site.
This morning we begin with an update from the department, Jim Scanlon from ASPE, Karen Trudel from CMS, and Susan McAndrew from OCR. Obviously, thank you for joining us.
Then we will have an update from June O'Neill and Ed Sondik, if he is here, from the board of scientific counselors.
After the break, we will begin discussions of the population report. I want to thank Vicky Mays -- is Vicky Mays here today -- Vicky Mays, a former member, for her leadership and persistence in completing this report, as well as, obviously, Don Steinwachs, the chair of the population subcommittee, for helping move this to a place where it can come before us for action at this meeting. So, thank you.
This will be followed by a discussion of the NCVHS 2003-2004 report, and we will talk a little more about that when we get to that report.
Now, following lunch, we are pleased to have David Brailer, the national health information technology coordinator, joining us for an update on current initiatives and issues, and I am sure we will talk some more about all the various activities going on.
This will be followed by a briefing on the federal health care architecture, by Leroy Jones of ONCHIT.
The final presentation and discussion before the full committee adjourns today will be by the Commission on Systemic Interoperability.
We are very pleased to have Scott Wallace, chair of the commission, joining us to update us on the progress of that activity.
I should, I guess, disclose, although I don't think it is necessary for full disclosure, I actually am a member of that commission, but I will certainly defer to the chair, and I don't think there is any conflict of interest associated with that.
Now, after adjourning the plenary session, we are going to have two subcommittee and work group meetings, which we will discuss as we move through the agenda today.
I just want to remind everybody -- and I will say this a couple of times -- tomorrow's subcommittees and work groups meet at 8:00 a.m. and, more important, the full committee is meeting an hour earlier than usual, which is 9:00 a.m., and we will sort of talk about how that day will progress, as I said, before we break today. Marjorie, would you like to mention the dinner? Please.
MS. GREENBERG: We will have our dinner social, as we always do on the first night, and we are going to be going to Rosa Mexicano, which the executive subcommittee did a site visit, a pilot test there, and it was very satisfactory.
I believe it is right at the Gallery Place metro stop, is it 7th and I?. It is right across from the MCI Center.
The people who know are not here at the moment -- 7th and F. Could I just have a show of hands of who is planning to join us?
[Dinner logistics discussed.]
MR. COHN: With that, why don't we move into the update from the department and I think, Jim, we will have you lead of, please.
Agenda Item: Department Updates. Data Council.
MR. JIM SCANLON: Thank you, Simon, and good morning, everyone. A number of things, as Simon indicated, have occurred since we met in March, I believe it was, and I don't want to steal David Brailer's thunder, but I will just remind everyone of the Secretary's announcement on June 6 of the health IT strategy and initiative.
Then I will talk about some of the department-wide data and statistical policy activities, including some focus on population health statistics, at the data council and among our agencies.
At any rate, let me start with the Secretary's announcement. On June 6, you will all remember -- I think you have press releases and background material in your briefing book -- the Secretary announced his plan and strategy for moving forward on health information technology to transform and support improvements in the health care system.
There were several elements of that. I will only mention them briefly. I think, as Simon indicated, the cornerstone of the effort is the formation of basically an advisory committee.
I sort of think of it as captains of the health industry, 17 members who that would be called the American Health Information Community.
HHS would appoint the 17 members. The secretary himself has indicated that he wanted to chair the group itself.
Interestingly, it is chartered for two years, and it could be renewed for additional years, but the goal, I believe, is to have this transform into a public private kind of an entity.
I don't know exactly what the governance would be, but some sort of a public private entity down the road, and certainly within five years.
I think we have -- Simon and I were discussing this -- I think we have all indications -- I hate to make predictions -- but we have every indication that the NCVHS would be formally involved with that committee in some specific ways. So, we hope to have a very solid relationship.
Much of this work, as you know, builds on the previous work of the NCVHS, and the department. It seems like timing is everything.
Many of the ideas that we are seeing bearing fruit right now, you will remember, were kind of initially incubated and thought out through the NCVHS data council and other groups within the department back in the early 2000s but timing, again, I think is everything.
So, we really are entering kind of a new stage of the more specificity and some specific directions in terms of the health information technology initiative in the United States.
I will leave the rest of the details to Dr. Brailer, who will be talking more about this later today. Let me turn over to the area of population health statistics.
Actually, it is more than just health statistics. It is health and human services and economic statistics as well.
Within HHS, as you know, we have the data council periodically reviews where we are with all of our major health statistics systems, our major surveys, and so on, and we are just completing that process.
Simon, actually, attended some of the data council meetings where we went through this, and we are entering the next budget planning year, fiscal year 2007.
So, I think budgets are going to be tight overall. I think you all know that, but we are not looking at any big increases, any big initiatives, for the most part.
It looks like, at least, the initial focus is that most of our major statistical systems and data systems are being supported and protected, at least, at the current services levels, which is a goal, which is certainly the first goal, we always have, to nurture and protect our basic statistical systems.
There are some improvements planned, although, again, there are no major initiatives, that we can identify so far, although again I will caution you, we are still looking at the budgets in detail, and there are always surprises, but in general I think that is the theme we are seeing.
The data council will be sending some recommendations next month, probably, early, to the departmental leadership on themes for the 2007 budget.
In the population statistics area, the data council, over the past probably eight months has identified about five areas for what we are calling data improvements and enhancements.
In each of these areas, we started some initial assessments and, in some areas, we have actually made some improvements, put some initial investments in, or had some subsequent discussions about how we can improve the area. Let me mention those to you this morning.
The first area -- this is not in priority order -- has to deal with prescription drug data, prescription drug utilization and expenditure data.
We have focused on some of this in association with the medicare part D benefits, but some of it more broadly.
We are trying to look at needs for program and policy data in those areas, as well as research needs and statistical data needs there.
We have a number of enhancements that are already underway. For example, we have put some additional resources into the medicare current beneficiary survey, and we have some analyses planned from some of the other surveys.
This is actually prescription drugs per se. Not many of our surveys actually get that much detail, but we do have some.
A second area -- this is certainly an interest of my boss, Mike O'Grady and others -- is national health insurance data, particularly health insurance coverage data and the uninsured.
As you know, we have about three or four surveys that each give you different dimensions and estimates of the health insurance coverage and related issues, and most of them have other focuses as well.
There is an interest now in seeing how we can understand some of the differences in the estimates among those four surveys, and reconcile differences, or at least understand why they differ, and then to make some improvements in terms of measurement and coordination generally.
For example, we are planning a web site, where we will probably pull together all of the data on health insurance here in HHS and in census. So, it will just make it easier for folks to know when the data is coming, what it means, how to interpret it and so on. So, that is a second area.
A third area is the whole state data area. Here, this has always been a difficult area. It seems it is -- obviously, priority is always on national data here at the federal level, but there is interest in improving, where we can, state data on health care access, health care utilization, and health insurance. So, there we will be looking at how we can improve that.
Often this is through over-sampling or extensions of our national surveys. In some cases we allow states, encourage states, to buy into our national surveys. California, for example, did that, and now they have their own California health survey. A couple of areas there where we are trying to do this.
Again, we are trying to do this in a budget year where there is not a lot of new money available. So, it is going to require some refocusing and some focus on what we can do within budget constraints.
The fourth area is, again, improving data on income and assets. Many of our surveys collect this kind of information.
We don't make -- in HHS we are not the primary statistics agency for making estimates of income and assets, obviously, but income and assets are a major policy variable for most of the other programs we do deal with.
So, we are looking at, what is the nature of that kind of data we collect now in our major surveys, and then how do they compare, what is the quality of that data, and then what are some ideas for moving forward with enhancements.
Then the final area is certainly an area that the full committee has been very much interested in. We are looking at, again within the budget constraints, how can we move forward in the area of race and ethnicity data to eliminate race and ethnicity disparities in health care.
There we are looking at, again, what we can do analytically, what we can do in terms of dissemination and web sites, and then what we can do in terms of some improvements that we have had in the pipeline.
For example, the health interview survey that you are all familiar with, in 2006 will be undergoing a major redesign.
Actually, it turns out that the redesign substantially improves the capability to make some estimates for some of the race and ethnic populations and subpopulations.
So, we are looking at what we can do there and sort of as resources permit, what kind of actual improvements in data collection we can look at.
Just briefly, our privacy and confidentiality committee under the data council, again, is active. I think we are going to have them look at -- this will probably be an internal study, but they will be looking at best practices, current and best practices, for confidentiality and research and statistics. Most of our agencies have statutes and other policies that they employ.
Finally, in my office, under the data council, we have initiated a study to look at the area of data standards, but it is data collection standards and measurement standards.
For example, in our surveys and our surveillance systems, in our research activities, what is the nature of the standards that exist.
You are all familiar with them. There are standards for asking race ethnicity questions. There are standards for collecting age data. There are standards for collecting sex and gender data. There are standard classification systems for diagnoses, for procedures, and so on.
So, we have a contractor who will be looking at what do we now do in our surveys, in our major surveys, what are the potential opportunities to incorporate further standardization and comparability into our surveys, and then to make some recommendations and opportunities for integration. I will stop there.
MR. COHN: Any questions?
MS. GREENBERG: Thank you, Jim. Not surprisingly, my ears perked up on the standards. Is the contractor going to be looking at the standards that are used for these -- I guess you are talking about a number of the demographic and associated variables that are being used in the clinical and administrative world, such as HL7 and X12?
Increasingly, there is discussion of, when we have electronic health records, you might be able to feed some of the data that we now rely on surveys.
I certainly don't think they will replace the need for surveys, and I think the surveys generally are at a more advanced stage in collecting these demographics.
So, it is not necessarily that they should adopt what is being used by these standard development organizations, but it seems it is very important to have an interaction between those environments.
MR. JIM SCANLON: The whole strategy, I think one phase of the -- they are just different legs of this stool. One of them will be to look at, in our major surveys and major data collection systems now -- surveillance -- to what extent are we using any sorts of standards.
These are often called statistical standards in the statistical world. Race ethnicity is one of them. There are standard classifications for various things, for statistics.
Where there are not standards, there are conventions that we have agreed on for how we will collect data.
So, we want to make sure, number one, that what are we collecting now in the major surveys, the major data systems, and these are our work horse data systems. These are the ones that really make up 90 percent of our national statistical resources in health.
Then we will be looking at what are the standards that are available at the same time. There, we won't just confine those. We will clearly look at statistical standards, but we will look at standards in the health care world generally.
It has always been a strategy of ours that we would try to link population based surveys with administrative data where we could.
In fact, we have been doing this for decades. I hope people know that. We have always had, and we have included in our population based surveys, the capability to do that, and we have asked for -- we typically ask for consent of the respondents right at the beginning to do that, the health interview survey, for example.
So, we have always thought it part of our strategy that, as the administrative and clinical, further down the line, standards and data became more usable for statistics and research purpose -- this often takes quite a while -- that we would have the capability to link. So, we would be looking at whatever standards would make sense in that area as well.
MS. MC CALL: Just to extent that a little bit further, the theme of interoperability, technologically it is important and, if you think about it, it is important with respect to language and standards and taxonomies and all of that.
Have you had any discussions about when there is more than one convention, or more than one published standard, about creating a mechanism that helps people walk from one to another?
MR. JIM SCANLON: This is a classic problem. You know, if you have two surveys, you get two estimates, if you have three, three estimates. It is the same with actuaries.
MS. MC CALL: Thank you.
MR. JIM SCANLON: It is complicated because, in many ways, it gives you a different perspective on the same problem, and in other ways they look like there is obvious duplication and it is actually confusing to policy makers.
You know, is the number of uninsured 20 or 45 million people. So, I think -- and I think we will look at that in terms of, there are not as many standards, unfortunately, as we think.
We made up some in HHS, conventions we agreed to a while back. We followed the OMB race ethnicity standards. We have a convention for collecting date of birth. It shouldn't be that hard, but we had to standardize that.
Even sex, oddly enough, when we looked at, let's say, our 30 most popular data systems, there were probably about six variations of ways to do it. This includes the odd things like, where it is undefined or undetermined or something like that.
Demographic is probably one of the major areas where you get the best pay off, particularly age groupings, where we generally try to correspond to the census, so that you can compare.
I think this will clearly come up, Carol, where we have more than one, and any guidance -- I think we will try to get a sense of what do people think is the best or the most useful, and then we will have to see how we can sort of get people to move to one.
Interestingly, in survey research, there are sets of measures for cigarette smoking, for example, what constitutes a current smoker, and in substance abuse, what constitutes a current user.
There are sets of questions that have more or less become the standard way of asking it, although clearly we don't ask it in the same way in all of our surveys. So, we will look at how much we can get into that. Income is another area. We ask it in many different ways.
MR. BILL SCANLON: In terms of trying to improve the information on people using private insurance, because I know we have a lot of information on the public insurance side, have there been discussions about the potential of using the federal employees information, even though it is not a representative group of people in terms of being able to identify a wide range of people, a lot of different markets?
It seems that there is a potential there, on a routine basis, to combine it with some of the survey information we have, that we could get maybe a better, richer sense of what is happening on the private side.
MR. JIM SCANLON: If you are part of the federal employee health benefit program and you fall into one of our surveys, and we have claims -- we collect claims data -- then it would come up automatically.
In general, we haven't systematically used the -- we have used it more for specific policy research. For example, in ASPE we just finished a study on the federal employee health benefit program, how do they implement mental health parity requirements, and we used federal employee health benefit information there.
We don't otherwise use it. I am not aware that we use it in a more systematic general purpose statistics basis, but I think we should really look at that.
MR. LOCALIO: Jim, I am going to direct this question to you, but maybe it applies to others. It seems there are four ongoing initiatives that have to do with privacy and confidentiality, the one you mentioned, privacy and confidentiality subcommittee on the data council is looking into various matters.
The first priority of AHIC is going to be to make recommendations on how to protect privacy and security. Mark, in the subcommittee on privacy and security here, has been looking into those matters for a long time, and the subcommittee on populations here has been looking into some of these issues with regard to access to data.
What is going to be the formal or informal system or structure for making sure that the right hand knows what the left hand is doing, knows what the right foot is doing and the left food is doing, so that we have some consistency.
MR. JIM SCANLON: First, I am happy that we actually have four groups looking at privacy. Usually we don't even have one.
Each of these, I think, have different perspectives. To be honest, in privacy, I think we are at a point where we really do have to look at exactly -- given where people want to head -- this is in the HIT world, not so much research in statistics -- I think there we do have a well thought about body of statutes and policies and practices.
I think we are -- I don't know. We are just going to have to communicate, but the data council's group is looking at, number one, its Health and Human Services Privacy and Confidentiality issues, and it is largely an internal focus about how we, number one, coordinate internally and, number two, when we do have privacy issues, we have a way of dealing with it internally.
The NCVHS committee really has a much broader advisory function. The other two, I think they are in formative stages. I don't know where they are going to go. I think you are right, we have to find a way to have all of the information coming together.
MR. COHN: Anything else? Well, why don't we move on to Karen Trudel. Karen, thank you very much for joining us.
MS. TRUDEL: Thank you. I am going to talk about various aspects of HIPAA and touch a little on e prescribing and some of the e health initiatives that CMS is working on right now.
So, let me start with HIPAA. I am happy to report that the attachments proposed rule, claims attachments -- HIPAA claims attachments proposed rule -- did go to OMB on May 30, and based on their normal review schedule, our tentative publication date will be September 23. So, we ar happy that we have been able to move that along.
The national provider identifier enumeration system did go into operation on May 23, as planned, and at this point we have enumerated about 22,000 providers successfully. The majority of them, as you can imagine, are from Florida, California, Ohio, New York, Texas and Tennessee.
This is a one for one enumeration. Almost all the applications were received via the web based application system.
The bulk enumeration process where we will be able to enumerate groups of providers will begin in the fall time frame.
We have revved up our outreach process as well, and I am happy to report that last week we had our first HIPAA round table call that discussed only NPI issues.
It was very successful. We had about 1,500 connections on the line, and our next one is scheduled for late September.
In terms of HIPAA compliance at this point, again, over 99 percent of our inbound claims are compliant. Eighty-one percent of our remittances advices going out are in a HIPAA compliant format.
What that means is that 81 percent of our trading partners are able to receive HIPAA compliant formats. Less than 30 percent of our coordination and benefit transactions are going out in compliant format at this point.
It is primarily because we have recently switched over to another coordination of benefits contractor, and a number of plans made the decision that they only wanted to test once, and they were going to wait until the coordination of benefits contractor was up and running, and then would do their testing and go live.
So, we are seeing some increase over the past months, and we expect it to rise sharply over the next quarter or two.
The real time 270-271, which is the eligibility query and response, is undergoing testing at this point. We are testing with several very large clearing houses.
The testing is going very well, and we are expecting that we will have a regular EDI based real time 270-271 capability coming from the new data mart by September.
Shortly thereafter, we will have a web based process where providers can use the internet to do 270-271 queries as well, on a one by one basis.
So, that is compliance. Let me talk a little bit about complaints. At this point, we have received a total of 334 complaints on transactions and code sets. About 190 of them are still open.
The vast majority still are based on the fact that a compliant transaction was rejected by a trading partner, although we are starting to see that the transactions that are included in the complaint, that are the basis of the complaint, are moving from the claim to the query response transaction.
So, we are starting to see complaints about 270-271, 276-277, which is encouraging because, again, that is where much of the return on investment is expected to be generated from.
Also, we have received a whopping big 13 security complaints since the compliance date in April. Interestingly, seven of those were crossed over to us from the Office for Civil Rights, based on our dual processing complaint agreement. We are working through those.
Let me talk about e prescribing for a little bit. We are still working on the final rule, and are getting much closer to working on the request for applications for the e prescribing pilot that is to be carried out in calendar year 2006.
We are working very closely with the Agency for Healthcare Research and Quality, AHRQ, and they have helped us enormously with setting up the proposal for getting the applications in.
They will be doing much of the vetting and scoring for us. So, we will be using their normal process for doing that.
On the e health front, I am also happy to report that the Office of HIPAA Standards is now officially the Office of E Health Standards and Services. Our name change was published in the Federal Register, I believe, last month.
We are continuing to work on both strategic and tactical planning to pull all of CMS' e health activities together.
One thing in particular I would like to report to you is that we are planning a CMS open door forum, which is similar to our HIPAA round tables.
Normally, open door forums are geared toward a particular provider or population -- hospitals, physicians, et cetera.
This one will be an open door forum on the concept of personal health records, and what CMS' role would be in the personal health records space.
We expect to have that, I think it is tentatively scheduled for July 21, and Simon, I believe, is going to participate in that open door forum, to lay the groundwork, based on the material that NCVHS has already gathered, in terms of personal health records, so that we are not starting over.
We are using, again, as always, the NCVHS experience, and knowledge, to lay the ground work, and we are going to be hopefully getting perspectives from plans, providers, provider organizations, beneficiary organizations, vendors of personal health record tools, to get a good idea of essentially where CMS could play a productive role in helping to move along with personal health records. I think I will take questions now, if you have any.
MR. BLAIR: Karen, thank you. It is really nice to see progress on so many fronts. I have a question, but I realize that a lot of the members of the subcommittee may not be familiar with either history or some of the terms, so let me just do a very brief preface.
During the last four years, or five years, NCVHS has been very much involved in evaluating, selecting and recommending standards, especially with respect to clinical data, as well as the HIPAA, which is mostly financial and administrative data.
Those standards have been evaluated and pretty much recognized as CHI -- consolidated health informatics -- initiative standards, which the latest RFP for standards harmonization indicates will be the foundation of how we move forward.
So, now that you know what CHI standards are, I can ask my question to Karen, and it will make some sense to the rest of you.
Karen, can you give us any kind of a -- you gave us an update on the HIPAA, the adoption rate of the different HIPAA transaction standards, and in short, can you give us an update of the status of the CHI standards at this point, in terms of who is responsible, how it fits into the broader picture, and how it will relate to the federal health architecture, as well as to the new RFP for standards harmonization.
MS. TRUDEL: That was a lot of big questions. I will supply part one of the answer, and defer to Lee Jones, of the Office of the National Coordinator, who will be speaking this afternoon, to supply his perspective on the issues as well.
We do defer to the federal health architecture, and the Office of the National Coordinator, at this point with respect to CHI, because the CHI initiative has folded in as a work group under the FHA, which, if one stops and thinks about it, makes perfect sense, because clinical terminologies and messaging standards are a basic building block of any kind of an architecture for health.
It is difficult to provide compliance numbers with respect to CHI standards in the same way that we do for HIPAA.
HIPAA, if you will recall, was industry wide, and there was no kind of phasing in. It was for certain specific administrative transactions.
The implementation for CHI was deliberately made longer time. It was to minimize risk and to minimize cost. The concept behind it was that we would only implement, or look to implement, CHI standards in systems when those systems were up for a major redesign or a new system was being developed.
So, because I don't have the denominator, it is very difficult to give you a progress report. I think what I can say is that agencies in this federal health space are definitely looking to make sure that they have incorporated the CHI standards into their architectures, into their information technology review processes, into their contract language.
I know CMS is in the process of doing many of those things. I know, for instance, DOD has done many of those same things, too.
I would say that DOD and VA, in particular, are working on implementing CHI standards, because they have certain specific program initiatives that they are required to do by a date certain. So, that is really the best answer I can give you, and maybe we can elaborate on it this afternoon.
MR. COHN: Thank you, Karen. Jeff, you can get a chance to re-ask it this afternoon.
MR. REYHOLDS: Karen, as it relates to NPI, have most of the providers that have gotten NPIs to date single providers, or have you seen institutions step forward and, if they have, how do you see the make up of that versus the way they used to do business, as far as numbers are concerned?
MS. TRUDEL: I am sorry, my numbers don't break down that way. It is just by web and paper and which the top states are. I can't answer it, Harry, sorry.
I would guess that many of them, though, are individual providers, because there is some question in some providers' minds as to how they are going to structure themselves if they are institutional providers, in terms of requesting numbers. I know that medicare has not put out its guidance on that yet.
MR. FITZMAURICE: Thank you, Karen, for the good update, very comprehensive, as usual. For years, CMS has had an internet policy for submitting claims, but has not implemented the policy.
I wonder if CMS is moving in the direction of permitting claims to be submitted through the internet. Do you have any pilots or plans to let the contractors or the intermediaries, the carriers, do this? How does that stand?
MS. TRUDEL: That is really a very big question. When you look at web enabled transactions, there is a huge infrastructure that goes under it, in terms of data centers and security and other things.
What I will say is that we are definitely moving in that direction. We do have a couple of pilots that are already happening which are not accepting claims over the internet at this point, but are providing better service to providers in web enabled areas, like claim status information via the web, the ability to download a remittance advice in a PDF file.
We are definitely moving in that direction, and I think the overall strategy that the agency is working on to modernize medicare fee for service, to modify our infrastructure, will inevitably lead us to the place that we will have a much larger web presence than we have in the past.
MR. COHN: Thank you, Karen, very much. Sue McAndrew?
Agenda Item: Privacy Rule Compliance Update.
MS. MC ANDREW: The privacy team within the Office of Civil Rights continues to work on reinventing itself. Part of our move forward, I am very happy to introduce Patrick Hadley, who has joined us. This is his first week. So, he is getting to meet and greet lots of people.
Patrick comes to us from the Indiana state department of health, where he was the privacy officer there for two years.
He is taking over the outreach function and the public education function within the privacy team. So, hopefully we will begin to be more proactive in the areas of our outreach efforts, and how we communicate with not only covered entities, but with the public at large, and will have a much more structured agenda for speaking engagements, and turning out responses to correspondence, and other inquiries that we get, and will stay on top of our technical assistance.
So, he will be wearing many hats. He is getting used to them all, and we are going to try to treat him gently for the first couple of weeks, so that he thinks this is a really great job that he has gotten. Then the reality will set in.
MR. COHN: So, we shouldn't ask him any questions yet.
MS. MC ANDREW: We are very happy to have him. If you -- this is really the position that Kathleen Pfyffe had in the early days of the team, before she moved on to Dr. Brailer's operation.
Okay, I am trying to remember my timing on this. Earlier this month, we did issue some new guidance on the web concerning how protection and advocacy programs that operate in all states, I believe, can achieve access to protected health information in order to do their interventions and advocacy on behalf of mentally disabled and other persons in need.
They -- essentially, the protection and advocacy statutes do require entities to share information with them. So, most of what they do will meet the permission in the privacy rule where required by law, disclosure.
We have made that clear in an FAQ, and hopefully this will ease some of their access problems to information, so that they can effectively advocate on behalf of their clientele.
On the other policy front, I would say the common period closed last week for the HIPAA enforcement rule. This is the rule that will govern how we move forward jointly, both CMS and OCR, on both claims management as well as working up a case for a civil monetary penalty and notification requirements to entities, as well as hearing rights, if we do impose a civil money penalty.
I understand that we received somewhat less than 50 -- around 50 comments on this rule making. So, we are looking forward to being able to move rapidly through the common analysis and coming to a final rule on schedule, which will hopefully be out this fall.
On the privacy complaint side, in addition to identifying and referring seven security rule complaints to our friends in CMS, to date, as of the end of May, we had received over 13,000 complaints.
I ran the numbers this morning, and we really are up over 13,600 complaints. We have continued to maintain a closure rate of 65 percent.
MR. BLAIR: These are complaints of what nature? I don't understand.
MS. MC ANDREW: These are complaints alleging privacy rule violations.
MR. BLAIR: From any and all sources, 13,000?
MS. MC ANDREW: Yes.
MR. BLAIR: So, it is the whole bucket.
MR. JIM SCANLON: Cumulative.
MS. MC ANDREW: Cumulative, yes, since April 2003. So, that means that to date we have closed some 9,000 complaints.
The allegations continue to run to form. Again, impermissible uses and disclosures continue to top the ranks of the things most complained about, as well as the lack of adequate safeguards.
We still get complaints about access, denial of access, to write to their records, and we are getting an increasing number of complaints about the fees that are being charged for the access to records.
The fourth most frequent thing complained about are potential violations of minimum necessary, and concerns that authorizations were not obtained when they were needed.
There has been no change in the types of entities complained against. That continues to be private health care providers and general hospitals and pharmacies, outpatient facilities, as the four top entities, and then group health plans continues to be the fifth most complained against group. We have referred 211 of these complaints to the Department of Justice for potential criminal prosecution.
In terms of trends, I mean, for most of this year, we were running, on average, between 140 and 145 complaints a week, and this is distributed across our 10 regional offices, although Atlanta continues to get the lion's share of these complaints.
I think they still are running fairly true to the population distribution that is reflected in our 10 regional offices. So, it is not like people in Atlanta are more cranky than other people, or more privacy prone. It is just that is where the population is.
In June, there has been a slight downtrend in the number of complaints, and we are averaging only a little over 100 a week.
So, I don't know whether that is because the numbers aren't quite complete for June, or whether the summer is beginning to set in, and we may get some relief in terms of the influx of complaints. We are seeing just a mild downtrend and we will see if that holds.
MR. COHN: Thank you. Questions?
MR. HOUSTON: I will ask my typical question, which is any news on statistics that we had talked about before.
MR. JIM SCANLON: A little louder so we can hear you?
MR. HOUSTON: A question regarding on any update on statistics we have asked for before?
MS. MC ANDREW: I think only -- the only hope on the agenda in that area is that we do have vacancy positions out.
It also is summer. So, we have summer interns. So, we have this additional manpower from unusual sources, which we can -- which we are going to be using to work with the complaints data base, to see --
MR. HOUSTON: You have my suggestions, still?
MS. MC ANDREW: Yes, I still have your suggestions, although they are in danger, because one of the things we are doing is, we are moving offices. So, I am trying to make sure that I don't lose important pieces of information.
MR. COHN: You have asked that for how many years now?
MS. MC ANDREW: Not years, but about a year.
MR. BLAIR: What was it that you are asking for trends on?
MR. HOUSTON: There was a variety of just trends in terms of types of providers, just information on types of provider types of complaints, just to get a sense of where really the focus of issues were, so as the privacy subcommittee sort of explored and continued to deal with this issue, that we could try to understand really where were the issues arising, and try to just, again, figure out what our agenda should be.
By the way, if you do have interns, I would be more than happy if you would like to engage me, I would be more than happy to talk with them, work with them, in terms of trying to put the statistics together.
MS. GREENBERG: Pro bono?
MR. HOUSTON: As a member of this committee, I would be more than happy to spend a little bit of time to make sure we get the statistics right, or the queries right.
MR. BLAIR: That is a generous offer.
MR. TANG: I have a question. What do you anticipate the impact of the DOJ ruling about whether an individual can be prosecuted or not, what is your interpretation and how do you think that will impact either the complaints or the resolution of those complaints?
MS. MC ANDREW: I am not sure that it will have any impact in terms of the complaints that we are receiving. I think the referral percentage was not that -- the criminal area was not a large proportion of those claims in any event. So, I am not sure that that is going to have much impact in terms of what OCR is seeing.
In a sense, I think that, because of the peculiar relationship between OCR's civil jurisdiction and the justice's criminal jurisdiction, that their clarification that that also -- the criminal jurisdiction is also limited to actions against covered entities.
We will push some types of complaints back over strictly into the civil arena. I think, though, they have made clear that, although it is -- I mean, the statutory interpretation is that both jurisdictions look to covered entities as the actor for both sets of sanctions, that this is not -- that individuals can still, in many ways, still be culpable, and subject to criminal sanctions. Under HIPAA in terms of, however, a corporate entity, it falls out in terms of individual responsibility.
MR. COHN: Sue, can you get closer to the microphone? I think I am hearing most of what you are saying.
MS. MC ANDREW: In many of the criminal cases that have been referred, I think people need to remember that there are other kinds of criminal statutes besides HIPAA that would apply to many of those actions.
I think identity theft or just general theft or fraud statutes may well continue to implicate some of the individual bad actors.
MR. ROTHSTEIN: Sue, I could be wrong, but I don't recall your mentioning in the past that minimum necessary was the source of the complaints.
Maybe it is something that the level has increased that you have noted. I am wondering whether you could characterize those complaints for us and, assuming no -- because it is such a broad area -- I was wondering whether you could just pull out those complaints and have someone take a look at it.
Our subcommittee on privacy and confidentiality is planning to hold hearings in the fall on minimum necessary, and it would be very valuable to us if we could have a better sense of the nature of those complaints that you have been receiving.
MS. MC ANDREW: I think it really has always been the fourth major area of complaints for some time. So, it is not that it is new or increasing.
I can check the numbers to see if it has -- I don't think it has necessarily spiked more recently. The only thing that I recall off hand in terms of the characterization of those kinds of complaints -- and we can have someone look into that for the committee -- is that the -- it came up a lot in the context of incidental uses and disclosures, where there may have been a complaint about activity in a waiting area, or someone in line in the pharmacy, and whether or not the disclosure was properly within our permission for an incidental use and disclosure, which is conditioned on having observed minimum necessary standards and appropriate safeguards with respect to the underlying disclosures.
For instance, if someone complained that a receptionist was speaking in too loud a voice and was revealing their health information in an area that wasn't sufficiently private, the complaint would be categorized as potentially -- lack of safeguards and potentially minimum necessary.
MR. ROTHSTEIN: So, you don't have a separate category for violations of the incidental disclosure. They would be captured under minimum necessary.
MS. MC ANDREW: I think it is likely those would be -- the issues would break out into a possible impermissible use and disclosure, a possible violation of minimum necessary, a possible violation of safeguards.
MR. ROTHSTEIN: That is helpful, and we would very much appreciate any breakdown you could give us.
MR. BLAIR: We have Bob Hungate, and then Harry Reynolds and Jeff Blair, and then we are going to need to move into the next area.
MR. HUNGATE: Susan, maybe you can help me with an answer that I would like to be able to give. I tell people that I have a little involvement with HIPAA, and I immediately get all these daggers thrown in my direction.
It is my feeling that, as we have moved from paper processing into this more electronic world, we have given a lot more visibility to complaints.
So, when you hear a number of 13,600, that sounds like a lot of complaints. If you thought about the total number of transactions that went on, it is a very small percentage.
Do we have any feeling for what the real base is that this percentage relates to? Is there any way of really saying what the relative significance of this number is? I think it is very, very small, the percentage of events.
MS. MC ANDREW: I think it is small relative to the millions of providers and the counts that we made there, and the thousands of health plans, or hundreds of thousands of health plans that are out there.
So, compared to the potential universe of just entities that are potential covered entities, the number is not that great.
You magnify that by the number of transactions that any doctor, pharmacy or health plan engages in, in any given day, and that further would magnify it.
We certainly have not seen to date any kind of core repeat offenders. So, most of these complaints are against the provider A and then fixes that and you don't hear back anything further about that provider. Other than a few, for instance, pharmacy chains, there is not a lot of repeat complaints.
MR. REYNOLDS: I want to play off John's continuous question, which we all agree with, but I think it might be perceived that this is really needed just for the committee.
I think, more important, what we found in transactions in code sets, CMS has been very, very open in their communication and willingness to share the information and what is going on, and that has allowed the industry to learn.
So, the 13,000 complaints, then, get dealt with, with individual institutions and they learn. There is no learning out there on how to deal with the privacy of significance. It is everybody interpreted it and then they went and did their thing.
I think what is more important with this information getting on the street is that it will be a way for institutions to learn and prove themselves.
I think every institution that implemented this really wants to do it. They have spent a lot of effort and time, and they also want to learn, as to where they might have thought of it differently or, whoops, that is not what everybody meant it to be. I think that is really going to be the ground swell positive of the report, not making John be quiet.
MR. HOUSTON: That will shut me up.
MS. MC ANDREW: I would certainly agree on both points. One, what we have found through our complaint process is entities are very cooperative, and they really want to do the right thing and resolve the complaints and get to yes.
So, I think that has contributed to our ability to have closed as many complaints as we have had, is based on the cooperation of entities to do the right thing.
We certainly also agree that there is a lot of good information that will inform policy as well as practice in those complaints, not only the closures, but some of the open complaints.
We have had an interest in being able to tease out that data and find a way of communicating it in a useful manner, and it helps, though, I will say, to have the committee's nudge to keep that in front of us as we try to sort through all of the priorities that we are dealing with on a day to day basis.
MR. HOUSTON: I will be happy to continue to ask the question.
MS. MC ANDREW: I look forward to that every time I come here.
MR. COHN: Jeff, I think you have the last question in this session.
MR. BLAIR: Thank you. Susan, you have had a difficult job to do with respect to these things, and thank you very much for keeping us updated on the status of the legal complaints.
You just mentioned that there is a new entity that is now going to be available, which is going to be responsible for education and outreach.
I think you mentioned, I think I heard you say that that would be to the public at large. Could you tell me what the purpose or the message is?
I think it is a good thing. I just want to make sure that I understand the purpose and the message and the scope of reaching out to the public, to try to help the public understand that there is something that has been done to protect the privacy of their personal health care information.
The only survey that I know that tried to measure public trust in having their health care information form compare to the value of electronic health records seemed to indicate that the public at large was divided, almost half in half, which I think is a major concern to us moving forward to transform health care into the information age, if we cannot significantly increase public trust that their health care information is being protected. So, can you tell me a little bit more about the outreach and education that is being planned?
MS. MC ANDREW: I just would clarify for you, Jeff, that what I was announcing is the fact that we now have Patrick Hadley joining the OCR team to lead that effort.
That additional resource will allow us to pay specific attention to shaping the message going forward, not only for the public at large, but also how we communicate and what we need to communicate to the various industry sectors that are covered and have to comply with the rule.
I would hasten to mention also that this is Patrick's first week, and Simon had promised to hold all hard questions until perhaps our next meeting.
So, I would defer your question until that time, where we may well have a report for you about what those priorities are.
MR. COHN: Susan, thank you for that very deft handling of that last question. We don't want to scare him away since he is just starting.
I want to thank all three of you. This has been a very interesting conversation. I do want to apologize to committee members because of the time frames. My job is to keep everything on time, or close to it, anyway.
I am reminded, in September, we will provide more time for this particular session, so that we can really spend some time talking through some of the issues.
I think we are all a little frustrated that there really was not enough time to really get into much here. So, we will just make sure that we start adding more time to this starting in September.
Having said that, we are going to move on to the next topic, which is an update on the Board of Scientific Counselors, and Ed Sondik, welcome, we are pleased to have you, and June, I think we have already welcomed you both as the liaison and to give us the briefing. So, thank you for joining us.
Agenda Item: Update: NCHS Board of Scientific Advisors.
MR. SONDIK: Thank you. I have the very pleasant task today of introducing the chair of the Board of Scientific Counselors of NCHS.
I am not sure I have met all of you, but I am Ed Sondik of the National Center for Health Statistics, and now we have met.
When we have talked here before, and I have updated you on activities in NCHS, we talk about the roles of the National Committee on Vital and Health Statistics, and the NCHS Board of Scientific Counselors.
Our goal is to make these two organizations complementary and close to one another, and I am very pleased that Dr. Cohn attended the last meeting of the board of scientific counselors and Dr. O'Neill is here, and we are both going to be attending the meeting later this summer, the executive subcommittee.
I think I am very pleased about this because I think it puts us headed in the right direction. Then I would like to make one other comment, actually, just before we break, if I could, very briefly.
I would like to introduce Dr. O'Neill, who is the Wallman professor of economics and finance at the Baruch College, the City University of New York.
I know I mentioned this before, but I will just emphasize it again. When this board of scientific counselors was created, one of the changes in a proposed roster that was made here in the department was a very strong suggestion that the roster include people with an economics and health economics background.
That turns out to have been, I think, an exactly right move. It has been very useful to our discussions, and I think it has added a perspective to NCHS, while we report data on health economics, our actual direct involvement with that, our involvement with the health economics community has not been as strong as it could be.
So, we have changed that. In fact, there is a major meeting taking place in a couple of weeks from now, where we will be -- a health economics meeting -- where we will be fully represented, I am happy to say, and we will be discussing what NCHS and the data that we have can do to help health economics. So, with that, Dr. O'Neill.
MS. O'NEILL: Thank you, Ed. I, too, would like to thank Dr. Cohn for attending our BSC meeting. I think it was helpful in forging closer relationships.
I also would like to thank Vicky Mays, who has attended our meetings from the inception, and her participation, we have also really appreciated that.
Aldona Robbins was our representative to the National Center for Vital and Health Statistics and Aldona has now transited off the board.
We have staggered appointments and hers happened to come up, but we will be identifying a new liaison to the NCVHS.
Now, in terms of BSC activity, I will very briefly summarize. We haven't been around long enough to be reinventing ourselves. We have been trying to invent ourselves.
It is always a difficult task for a new group that is not quite sure how you can be useful, and we spent really the initial meetings -- I guess we have had -- when did we start, 2003 -- so, we haven't had that many meetings -- acquainting ourselves with the national center.
I think everybody on the board of scientific counselors has had familiarity in one way or another, but we never really knew about all of the activities that go on at the national center, because they are large.
The health statistics have become really a vast statistical enterprise, and given the importance of health generally in the economy, that was bound to happen.
At any rate, so our initial discussion was sort of finding out what was going on, and taking up some issues that came up along the way.
One was the obesity issue which was, I guess, to some extent an embarrassment of the data being used initially by a government official in a way that turned out to be not correct.
You know, thinking about this particular episode, I think is useful as a way of, how does information get spread around.
It is one thing for a reporter to say something that turns out not to be correct, but for an official to make a fairly dramatic statement that turns out to be not correct, is somewhat more -- and the issue is still percolating.
I think the current issue of Forbes Magazine has an article bringing it up and rehashing it again, and interpreting it as an effort by CDC to get more funding by coming out with a dramatic announcement.
So, the issue is by no means dead, and I guess that is something that both we and the NCVHS should be sort of thinking about, trying to -- I think just the episode in itself is going to have a good effect on announcements being checked carefully or things that are written in prominent places being given careful checking out.
We have recently embarked on what we expect to be sort of a major portion of our work as scientific counselors. We should be applying scientific standards to reviewing the various activities and programs in the national center.
We are beginning to do that. We are starting first with vital statistics, and the mortality component, which seems to be more self contained, as a first excursion into doing an evaluation.
It would be one that is sufficiently contained that we felt we would be able to handle it, and learn from our experience doing this.
At our last meeting, we began -- we developed a protocol way of evaluating programs, and we expect at the next meeting to begin this evaluation and to appoint reviewers, which I will come up with in a minute.
Now, these would involve an external board of reviewers with expertise in the particular field, who are representative of important users.
We will probably have three for the mortality, for the vital statistics on mortality. We would be happy -- we haven't yet appointed these reviewers, but would be happy if anyone had suggestions for someone who is an expert in mortality vital statistics, who would be a good reviewer.
Now, the particular protocol that we developed, we are looking at three dimensions of the program -- program activities, the information product. The second is the capacity resources of the center for dealing with it, and the third dimension is the efforts to improve.
Within each of these dimensions, we will ask -- the review panel will be asked to address three questions. The first is the current status, where are we now, what is the program doing.
The second one is quality, which may be a really important one, is how good is what we have been doing, are doing, with this, in terms of the program.
The last one is responsiveness; to what extent are we meeting the needs of the users. Now, during the summer, we hope to get this underway, so that at our September meeting we may be able to get a preliminary report of the reviewers and, if all goes according to plan.
Then we will continue from there for a final report, and perhaps start with another review. So, that will be a large chunk of what we are doing.
I guess those are sort of -- we have also been concerned, generally speaking, with the resources available for health statistics, and how we might impact on that.
From my experience with government statistics before with the budget, the easiest thing to cut during a time of budget crunch are data and basic research, but data in particular because it really doesn't have a lobby group out there, or lobby groups, that can effectively lobby for resources.
It is the public as a whole, and they can't come to congress. In fact, the public as a whole probably isn't really quite aware of the use of statistics or the importance of statistics. It is not something that the average person deals with.
Of course, there are users and, to some extent, they are organized, but professional associations typically don't like to lobby and really can't be counted on.
So, it is an issue. We, as a committee, that might be something that we would think about, if we felt that resources seem to be short changed, because the health statistics needs are growing. They are not shrinking.
It is important, and that might be something that we could do, together with the NCVHS. That might be one thing. At any rate, are there any questions that I might be able to answer?
MR. SONDIK: I would direct the board to I guess it is tab three, where the roster of members of the board of scientific counselors is contained.
I would say, just related to resources, I think it relates actually to the next agenda item right after the break, in that one of the ways that the board of scientific counselors, in addition to the detailed review of what we do and how we do it, that one of the ways that the board can be helpful to us, as well as NCVHS, is in helping us to make trade offs.
The agenda being proposed in the next report, I think, is an important one. I don't think it is overly ambitious, actually. I think it needs to be done.
Given the reality that June just mentioned, of the budget, it means that there are trade offs that we have to make, and both of these organizations can be very helpful to us in helping us determine how to make -- giving us advice on how to make these trade offs.
Just one other point about the obesity issue that was mentioned, what I would say to that is science marches on.
It is extremely important in NCHS that we have a strong science component, and I must say it is one that I am very proud of and, in discussions with Dr. Gerberding very recently, I must say she is also very proud of that component as well.
We continue to use our resources in new ways, and to try to get at the issues that are really of critical importance to policy makers.
It is science, and things happen in science in which new results may look very different when compared to older results. That is why we do that in a public forum, in fact, to debate these issues.
MR. COHN: Just speaking as an individual consumer as well as everything else, I want to thank you for the publication of your results. That is a personal view.
MR. STEUERLE: This is a question for you, and I guess it is a question for Simon, because I have posed the same question to him.
In so many areas of life I think our principle problems often come, not from knowing what to do but not doing it, but not knowing what we don't know.
In the area of health statistics, it seems to me that all of us probably around this table have some area where we really think there is some statistic that must be gathered, but it is simply not.
You heard a very minor example just a second ago with respect to more broadly the issues of the cost of HIPAA and how these privacy things are playing out.
Are data being gathered there? I have a complaint that nobody could even tell me, with health costs going up by eight percent a year, who is being paid what. Do we have eight percent more providers, or what providers are being paid more? We don't even have that statistic.
You will hear later some concerns about the populations subcommittee about data that we are not gathering on the allocation for health care.
I wonder, between our two committees, I mean, who sits down and actually sits down and not just sort of looks at particular pieces of data and examines how to refine them and inform them, but I really wonder if we have some organized way to ask these questions, at a crucial level, what data aren't being gathered, so that your committee or our committee can actually make those recommendations to say, here are some vital pieces of information that are missing.
This is an organizational structural issue, but it has bothered me. I haven't quite figured it out, maybe just because I am naive.
MS. O'NEILL: That is a really good idea, I think. It is possible that, within each of the existing programs -- and the third component of these reviews is what should be done to improve -- and one of the items would be data that are not collected.
It may be that there is no program that could encompass certain kinds of information, and I think that would be a useful thing to do, but we should talk about that.
MR. SONDIK: I think it is an excellent suggestion. We have actually formal ways of doing this within the center for the various components, but in a sense, it is component specific, program specific.
We also have a more overall approach when Health U.S., which actually conceivably could report some of that information, that we would work with our colleagues in other agencies to develop.
It is conceivable it could be in Health U.S., and there is a formal process for the review of that, but it strikes me that it would be very worthwhile to discuss this, perhaps at another meeting, as to what mechanisms we actually are using, and how we could be sure that we are asking the question, if you will, the old Mayor Koch question, how am I doing, that we ask it in the right way and in the right venues, so that we get the things that -- so that we get at pieces of information, the questions that may not fit the current structure.
MR. COHN: Certainly, Gene, that question makes me very happy that you are on the population subcommittee, because I think that is one of the focuses of that subcommittee.
MR. STEINWACHS: I was looking for an update on the how the reorganization is going on in CDC, and affecting NCHS, and also I guess the question of whether or not the board of scientific counselors, if that is one of the things they are looking at, too, is the organizational positioning and the interrelationships between the center and the new structures.
MR. SONDIK: I am happy to answer, very briefly, having just returned from Atlanta hours ago. Actually, the board of scientific counselors has heard a great deal about this.
I have been wearing two hats over the last eight months or so. I have been the acting co-head, really, of the coordinating center in which NCHS now is one of the three components, along with two new centers, one on health marketing and the other on health informatics.
We have been standing up these centers, as I think you have heard before, and looking for heads for them, and I am happy to say, I think we are getting -- I know we are getting -- close to the heads of these two new centers.
So far, I think this has been very positive for NCHS. Our budget has not been affected in any way. We continue to have very strong support.
For example, in 2006, the budget for CDC is projected to go down, but the budget for NCHS is flat. So, you have to look at that as positive. It is not what I would like, but it is positive.
Given how much the CDC budget is projected to go down, it actually is a very positive statement. I have a number of discussions going on that relate to informatics and NCHS, which I think is very important.
I talked to Dr. Brailer, for example, and his relationship between informatics and CDC and what it is that we are doing in NCHS, and I think that is all very positive.
So, I would say so far I think things are fine. Our mission, if anything, is stronger because of the new goal structure for CDC that is being developed.
It is very clear that we have to have an independent arm that will tell us how well we are doing -- we being CDC, but also the country is doing toward these goals.
The goals, I believe, are going to relate very much to the health people. I think they will perhaps be formulated in a little bit different way, but clearly they are not going to go off in any brand new direction.
I think things are really coming along. What we talk about now is the new CDC as opposed to the futures initiative, because all of the structures are -- well, essentially, they have all been put in place now.
Now it is a matter of doing business with a new budget structure which is aimed, by the way, at guaranteeing that our program will not be tapped to death, as happens in federal programs, and other programs, for that matter.
The program funds are now very explicitly outlined as opposed to before, in which they were intermingled, if you will, with the business services and other funds related to leadership. This breaks them out. So, I think we are doing fine.
MR. COHN: Great.
MR. SONDIK: Just before we break --
MR. COHN: Carol, real quick, did you have a quick focused question?
MS. MC CALL: It is actually more a comment, and I will be very brief. Just a follow on to the question asked earlier by Eugene, which really had to do with some themes that we discussed at our quality summit.
We had a two-day summit earlier, actually, this month, and one of the things that we found in this area of not even we don't know what we don't know, that will always be the case and there will always be new discoveries.
We discussed at length the need for, and the desire for, mechanisms that actually explicitly and formally transfer the new knowledge and share it as it is, in fact, discovered, that that becomes a very important part of the whole HIT effort and a lot of the statistical efforts.
It is very much related to standards, to your point, and in a scientific world, standards will emerge, things will change. They won't necessarily be gradual.
So, as we put forth our work plan, we are very interested in mechanisms that are in place today, and how they are working and what seems to work well and what doesn't work well and kind of who is doing what out there, as we move forward in our own work plans and work toward some recommendations.
MR. COHN: Thank you for the comment, well said. .Ed, I am going to give you about -- I hope you are making a brief final comment.
MR. SONDIK: Fifteen seconds. Marjorie, did you mention the publication of this volume?
MS. GREENBERG: I didn't.
MR. SONDIK: This volume called Health Statistics, Shaping Policy and Practice to Improve the Population's Health, has just come out, edited by Dan Friedman, former member of the NCVHS, Ed Hunter, who lives down the hall here and at NCHS, and a former CDC-er, Gib Parrish.
This grew out of the work of this body, and the data council, and I am really pleased. You all should feel like new parents, in a way.
It has a stellar set of authors here, including Ms. Greenberg. We hope that it really will help with the foundations for health statistics, and will really represent the academic, if you will, foundations for this and be very, very useful to us as we move this enterprise and profession along. So, congratulations to you all. If you didn't know that it was coming, here it is.
MS. GREENBERG: A number of the authors are either former NCVHS members or staff to the NCVHS, possibly as much as half, or people who have presented to the NCVHS. We will plan to order copies for all the members.
MR. COHN: My congratulations to all. It looks like a wonderful book.
MS. GREENBERG: Just plan to read it on the way back to San Francisco.
MR. COHN: Exactly. What I want to do is give everyone a break. We are running, as you can tell, a little bit late, despite my best efforts here. We will take a 10-minute break and come back at 11:00 o'clock.
[Brief recess.]
MR. COHN: The next session really deals with two reports. The first piece is the population report, eliminating health disparities, which is an action item for this committee meeting.
I just want to welcome Vicky Mays back. Thank you so much for being here, one of our former members, and I guess now a consultant working on the project, but really, one of our former committee members, and Don Steinwachs.
Also, after we are finished with that discussion, we will spend a couple of minutes talking about the NCVHS 2003-2004 report.
Don, I think I will hand it over to you and let you sort of give some people some high level perspectives on this, and then we will talk more about it.
Agenda Item: Populations Report - Eliminating Health Disparities.
MR. STEINWACHS: Thank you very much. I appreciate all the input of all the members of the whole committee, and very much the hard work of the populations subcommittee.
I told Vicky that she ought to feel like a mother that she brought forth this -- we figure it is just a four year gestation period. So, not bad.
MS. MAYS: Not even elephants gestate that long.
MR. STEINWACHS: Let me just give you this high level overview, and then we will open it up for comments, and I am hoping that we are very close to closure on this. I know that there is some specific word smithing and so on, and we welcome very much all comments.
The first hearings by the population subcommittee actually date back to June 2001. Then, in 2002, hearings were held that talked about federal issues and the federal perspective on the capture of race and ethnicity and the use of the data.
Also, a hearing was held in September 2002 in Denver, focusing on American Indians and the capture of information that could be useful in looking at health and health status issues for American Indians.
November 2002 there was a hearing in Philadelphia on the state needs for race and ethnicity information, and some of the issues that states face in trying to develop useful information, and this got into geocoding, and issues of geography, as well as the capture and access and use of data.
In May 2003, and in November 2003, hearings were held that were specifically concerned with the capture of information on health for Native Hawaiians and other Pacific Islanders, and part of this got into the recognition of how heterogeneous these groups are, and some of the very specific challenges of having data that are thick enough, and ones for which privacy doesn't really become an issue, that they could use in order to understand health issues, and whether or not health is improving.
All of that is brought together in this report which has two major recommendations. As you have seen, one recommendation specifically talks to enhancing the quality, reliability and completeness of data collection and data integration on race, ethnicity and linguistic subpopulations in the United States.
The second recommendation talks to improving the infrastructure so that it is possible for people to get the maximum use and access to the data and that there are ways to disseminate the information so that it maximally gets to users.
Within this framework of the two recommendations, we recognize there is some overlap when you talk about the issues of quality integration and you talk about infrastructure.
Our foot forward, based on the hearings and the considerations of the subcommittee is a series of strategies recommended that include strategies that talk to what can be done within the department, between the department and other government agencies, the federal government and the states, and with the private sector.
So, these strategies really are quite far reaching. We have tried to make them as specific as possible, so that they provide useful guidance and, again, if you look at the appendix and the materials that are on the web site, actually, they are all very well anchored within the context of the hearings and what came forward to the committee around all the special populations and both federal and state needs in this area. So, let me stop with that and open it up for comments.
MR. COHN: Let me start by just sort of giving everybody how we are going to discuss this. This is not an occasion for word smithing at this point.
I think whatever we pass or decide to vote on will, of course, be subject to further word smithing coming forward.
This is a time, if people have conceptual issues or conceptual problems with the document, things that are beyond word smithing or questionable in their significance, I want to assure you if you don't like a word, or you think a sentence is off or it needs a paragraph placed or a comma, we can handle that off line. So, with that, we will open the floor up for comments.
MR. TANG: I congratulate the subcommittee for a really, really fine job and fine report. It was a good read. When I think about this and reflect on what you said, I see four categories in terms of gathering this data.
One is how to ask for it. Another is how to collect it and store it in a way that usable. A third is how to interpret it and a fourth is how to protect it.
I think you addressed all four of those categories in the report. The only thing I would submit for your consideration is to emphasize a little more on one and three, which is the asking problem and the protecting problem.
The asking problem, it seems like -- and you called it out in terms of ways to increase self reporting -- it seems like that is a major obstacle.
Clearly, we have to deal with the information and the granularity and the specificity and the standardization that you are requesting, but how to get people to self report, I think you can see both ends of the spectrum, people who are afraid of being discriminated again, as well as people who don't even want it to be considered at all even if it could favorably enhance their chance as some thing, and then there is the middle.
It seems like that is a major barrier, and I don't know to what extent you can explicitly ask for studies to look at how to encourage those things. You did talk about it, but again, it is just a matter of emphasis.
Then, on the other side, how do you protect it once you have gotten it, coded it, and used it, in formulation of health policy, certainly, in the privacy subcommittee we hear about how other health information is maybe used and reused in different ways.
It is certainly something that could be of concern to a population, and how can we work on assuring them that their information is protected, and helping them understand for what purpose it is going to be used, and for what purposes it can't be used, those kinds of things. It is a matter of emphasis.
MR. STEINWACHS: Let me just pick up on that and make sure -- we have tried to address those. I think what you are saying is that there could be a different kind of emphasis placed on some of these.
At the same time, I guess, we felt we could only go so far based on the hearings and what we had heard at that point in time, and this really brings together about three to four years of that.
I am just, I guess, throwing this back to you, and again, this may not be what you think is the appropriate thing to do.
The points you have made also, it seems to me, play into things that this population subcommittee might address as it moves on, because this doesn't end the issues that relate to race and ethnicity.
This capture, I think, has done just what you said, identified there are some serious problems, and we talk about people's willingness to do it.
If it was just -- I was hoping -- and you can correct me -- that if it was somewhere either in conclusions or executive summary, a little bit of word smithing, we would very much welcome that.
I was hoping it wasn't a matter of trying to reshape specific strategies here at this point, or the overall recommendations.
MS. MAYS: I thought your suggestion is a very good one. It is in there, and what I hope would be is that someone either like NIH would pick it up as a research agenda -- because we actually suggest it as research.
Also, if the linkages that are suggested here take place, say the linkage between HHS and the Bureau of Census. The Bureau of Census actually has some work on this. NCHS actually has dealt with some of these issues in terms of their studies.
I think that the strategies that have been suggested, that if they were to be put into place, would actually answer what some of your concerns are.
I agree, probably the two biggest issues are if people will tell you their race and ethnicity, and then what do we need to do to assure them that they are not going to be treated differently because we have that piece of information.
MR. STEINWACHS: At the very least.
MR. COHN: I guess I should ask, Paul, I am seeing you nodding your head. Does that mean what they have said is sufficient, or does there need to be, at this point, some changes to the document?
MR. TANG: Yes, and again, it wasn't something that was not in there. It is a matter of emphasis and perhaps a way of diffusing questions that could be raised as you read through this the first time. I think that is more my point.
MR. COHN: Maybe there is a way of framing the executive summary.
MR. STEINWACHS: Anita and I were whispering here. A little word smithing, I think, will do what Paul is suggesting.
MR. COHN: Paul, thank you. I think, once again, it might help improve the executive summary, which is really the place where this all gets set up.
MR. VIGILANTE: This is, by no means, criticism of the report, because I am on the committee and I wouldn't criticize it.
This is something that is in the report that I just wanted to bring into somewhat bolder relief in light of Jean's comments, actually, about where we should be looking for things where we think we may not know enough.
The report, one of the main themes in the report, or suggested strategies, is to produce greater linkages between different kinds of data sets.
It does recommend a linkage to the Department of Education. This is one that I would just like to, while Dr. Sondik is here, to kind of pull out a little bit.
As many people sitting here know, one of the best predictors of the health status of a population is their highest level of educational attainment, on average.
The strong association, some have suggested that there may be even some causality associated with actual education in achieving health status, and have posited that one way to improve health status is to actually just increase, not the health intervention, but increasing level of educational attainment.
By and large, the same populations who have health disparities have educational disparities. So, I think that particular linkage is extremely important, both in the government space, to be linking health data and surveys with educational data and surveys, and also in the academic environment.
The more we can link those, the more I think we can identify strategies for improving health disparities that are somewhat outside the health bucket, and health people don't necessarily always think of them.
You go to a baker, you get bread. You go to a health person, you get a health solution like access. Really, the problem is more holistic than that.
By incorporating educational interventions in our unending quest to improve or mitigate against health disparities, I think, is an important national agenda. One person's point of view.
MR. COHN: Maybe I should let Don or Vicky try to respond. I am trying to see whether it is in there.
MR. VIGILANTE: It is in here.
MR. STEINWACHS: I think it is in here. Kevin is putting some additional emphasis on it. Very clearly you see in this report that we ought to be doing linkages that get out of just health, and you could think of linkage as labor, education and other areas.
MS. MAYS: I would just say, I think we have listed several different linkages that could benefit, and I think what Kevin is doing is emphasizing the one with education.
I think, again, this is like one of these wonderful moments in terms of having Dr. Sondik here, because it is not just work to send to the Secretary, but it is the emphasis that you see in other areas, like the work of NCHS.
At least when I was on the committee, we would get U.S. Health. I think you said earlier that may be a place that, when this comes, to actually see if any of those types of analyses are there, and to send it back and suggest, if they are not, to do them.
MR.COHN: Well said.
MS. GREENBERG: I just can't resist comment on this as sort of the committee historian around the table, not just to give you a little history lesson, but also to think about future agendas.
I believe it was in 1992 that this committee recommended that there was essentially a lack of any kind of socioeconomic variable in the uniform data sets that were used for administrative data, hospital and ambulatory, et cetera, and that looking at what the typical ones are -- and of course those are discussed in the report -- the one that is a high predictor and perhaps the most feasible to collect would be highest attainment of education, seeing that it was unlikely that you would start collecting income or even -- with all the problems with coding -- occupation, et cetera.
That, I don't think that recommendation was ever adopted in these administrative data sets and, of course, one solution is these linkages, if they are possible.
Also, now that we are moving more into electronic health records and looking at the sort of core data you might want in a personal health record and an electronic health record for quality, et cetera, I think it is worth revisiting some of those earlier recommendations, because the committee has a long history of feeling that that would be a positive thing.
Obviously, we have moved beyond that to socioeconomic position, et cetera, and there is a whole lot more to collect in surveys.
When you get down to administrative data, or when you are very limited in what you can collect not in a survey environment, then it is a good thing to revisit.
MR. COHN: That is a comment; right?
MS. GREENBERG: I think it could be on the agenda of several subcommittees in the future.
MR. COHN: I just wanted to clarify. Ed, I think you had a question or comment.
MR. SONDIK: Just a comment related to these. I may be missing it in the report, but while there is discussion of linkage, it comes across as linkage within the department, as opposed to the point that you were making, at least as I interpreted it, that there could well be data sources outside.
Then, of course, there is linkage and linkage. One of the real challenges is in linking surveys in which the respondents aren't the same, but that is just a challenge. That is all that is. Clearly, it can be done.
In fact, in one survey, the survey on family growth, the last production of that survey had an allied data set. I always blank on the name of it, that was a data set that gave information on the locale, on resources.
MS. GREENBERG: Oh, the HRSA data set, the ARIAS?
MR. SONDIK: They particularized it so that it could actually be used with the data that was actually collected in the national survey on family growth.
I thought that was a terrific step forward. I can't tell you at this point exactly how it has been used, but I think it is very important, because particularly in that survey, it gave information on the educational facilities, the health facilities, and a variety of other things that would conceivably be important as you look at these patterns.
My point is, I think you could make a stronger point in here about linkage on both levels, outside of the department and the challenge of it, which fits definitely within the structure, and the fact that there is linkage and linkage.
We ought to really be pursuing how to make the most of the data that does exist. I am convinced we don't always have to go out and collect new data. It would be ideal, but clearly we can't do that.
MR. STEINWACHS: We very much agree with you. We tried to capture that, but I think you are saying it could be strengthened.
On the bottom of page 15, top of page 16, where we talk somewhat about socioeconomic status, and variables, as well as others that could be found in the Census, the American community survey, current population surveys, and try to begin to talk about linkage to put in some of those. I think what you are saying is this could be strengthened.
MR. SONDIK: I think it would add another flavor to it, to mention surveys that are not the census activities.
When I think of the census, I think of something that is very broad brush. When I think of something from the Department of Education, for example, of Justice or whatever it might be, I think more of specific topics, if you will, thank demographics.
MR. STEINWACHS: Let me just finish. Maybe, I think, again, we could make it clearer, but we also talk about surveys also should capture information on a range of contextual variables found to be explanatory, health differences such as social support, social networks, social cohesion, community involvement, perceived financial burdens, differences in health status, foreign born, U.S. born individuals, and so on. Maybe what we can do is take this and --
MR. SONDIK: I though the way Kevin said it was compelling. I think the way it is written is less so.
MR. SONDIK: We can do some editing here, word smithing.
MS. MAYS: Probably the word smithing is linkage. I think the way that you said it allows there to be an emphasis of, it is not just across agencies, but the linkages that have nothing to do with collecting extra data, but have to do with facilitating the ability to be able to do linkages across surveys. It is very friendly word smithing. So, I think it is fine.
MR. COHN: Vicky, I guess I would ask on this one, do you feel that that information is already in here?
MS. MAYS: Again, I think it is one of those where you put another sentence that is explanatory to the front of it, and you give an example of a couple of data sets.
MR. COHN: Okay, well said.
MR. STEUERLE: I was just going to say, just follow up on that, maybe we should just put in some parentheses, a couple, two or three examples that people might suggest to you.
One of my favorites is, I have been involved with the linkage of the survey of income program participation with social security records, and we have been able to figure out the effects of mortality on benefits.
It is not a pure health issue, but health is there, but we haven't linked to the medicare records. It is an ideal example of something that would give us a lot of information.
It has education status, it has lifetime earnings, and if we could link it to the medicare records, we would have at least some health outcomes, although we wouldn't get the younger population. We could give three or four examples like that. I think it might make clear that there are different types of linkages.
MS. MC CALL: Very quickly, I think that the structure of the strategies and the recommendations are going to be well suited to enhance this.
If you look at essentially one-A and look down at what is listed there in one through eight and, in particular, in probably the first four, it is really about conferences to get people together so that best practices are shared.
Maybe just adding some specific recommendations, if you look at number four, this is really about mechanisms, to work not only with other agencies, we could broaden that, and it is also on practices, not only on methods for collecting, but also on classifying, and cross walks between one type of classification in an existing data asset and another, so that they can become linked and, therefore, looked at and understood in combination.
So, if we just enhance them in those specific ways, maybe again with some specific examples of what we mean, I think that the way that this is laid out can naturally be enhanced to call forth those types of partnerships and those types of linkages.
MS. CAIN: I had just wanted to comment that NIH has been taking that approach in several different areas for several years, and a couple of examples.
We are collaborating now on the ECLES B early childhood longitudinal survey birth cohort, which is a Department of Education survey, had very little health information in it, and NIH has sponsored the collection of health information.
Another one that we have, many years ago, co-sponsored were the Bureau of Labor Statistics surveys, national longitudinal surveys.
Again, at that point, there was very little health information. We supplemented it, and have been long-term sponsors of those to include health information.
MR. COHN: Thank you. Were there any hands? That is how it is with reports sometimes. After so much, it is hard to focus on them.
I want to just sort of comment from my own reading of this. Obviously, there is word smithing that needs to be done, but overall, I think it is an excellent report, and I think it has come a very long way and has gotten very well focused.
So, what I am hearing is probably that last percent here that we are sort of dealing with at this point, as well as recognizing that there are other things that are beyond the scope of this document.
I guess we should ask, I am hearing things that are probably -- Don and Vicky, give me your sense. It sounds like a little bit more than word smithing, what we are describing, but are these things that we have just talked about things that could be worked on in the subcommittee and brought back, just to show how those changes would be incorporated?
MS. GREENBERG: Do you mean tomorrow?
MR. COHN: That is what I am wondering, or should we take a different path on this one, or if you feel they really are word smithing, then we can sort of deal with them in another method.
MR. STEINWACHS: I guess I mainly saw it as word smithing.
MR. COHN: If, indeed, it is word smithing, one option that we have is to actually pass this, refer the changes to the executive subcommittee, let them do the final fiddling and then we can be done with it. I see people nodding their heads at the second one? Jeff, please.
MR. BLAIR: This draft letter has been worked on for quite a long time, and I think that everyone who has read it feels like it really is done very well.
Could I express my sense that, even though there might be some word smithing, that we would make every effort to try to get the full committee approval for this at this session, so that it is not deferred another three or four months.
MR. COHN: Jeff, am I hearing this as a motion to pass?
MR. BLAIR: No, maybe what I was expressing was more of maybe a strategy, that if there is -- it is that idea of let's not let the perfect be the enemy of the good. I think this is already very good.
MR. COHN: Okay. Jeff, I think you may have derailed us a bit, because I think what we were moving toward was the idea of potentially bringing this forward to a vote at this point, with the idea that the executive subcommittee would do further word smithing on it and approve it.
MR. BLAIR: May I withdraw and I apologize?
MR. COHN: That is fine, but if you have an alternative motion, we are happy to consider that, or make that motion.
MR. BLAIR: I would like to move to approve this draft.
[Motion seconded.]
MR. COHN: With further word smithing to be performed. Is everyone comfortable with that? I don't think there will be changes that occur by tomorrow that are going to make any significant difference in this.
If anything is beyond word smithing or as Kevin described it, emphasizes something that is already there, it will come back to the full committee.
MR. SCANLON: You mean to the executive committee.
MR. COHN: Well, no, if there is anything that is a substantial change, it would come back to the full committee. If it is word smithing, an extra sentence here or there that just emphasizes things, the executive subcommittee will handle it. Is everyone comfortable with that? Is there a second?
MR. HUNGATE: I second.
MR. COHN: Very well, all those in favor?
[Vote in favor of motion.]
Opposed?
[No voices heard in opposition.]
Extensions?
[No voices heard.]
Well, congratulations.
[Applause.]
MR. STEINWACHS: Let me just add my thanks to staff, because there was tremendous work, along with Vicky, and we had a writer, Anne, who were working to bring all this together. So, there was a lot of teamwork.
MR. COHN: Again, the chair and the full committee express great appreciation to both you and Vicky for your work on this.
MR. STEINWACHS: Simon, I don't know whether we have time now, but if we did, the subcommittee would very much welcome suggestions for how we can most effectively disseminate this report.
At least our sense of the audience -- and I think Ed was getting at this -- is the department is important, within the department, but to get outside to other departments within the federal government to be able to disseminate to states, to interested groups in the community who might see this as providing some direction for how they can work with government agencies to better use the data and get the access that they need, and the ability to analyze and understand relevant data.
MS. MAYS: I just want to make one request, because it is something that we heard really clearly in our hearings, particularly with the American Indians, is that we not just have it in a form that is up on the web, but that we actually print it up.
One of the comments we got was, especially for a document that will be kind of this size, that they were just not able at times to rely on technology as the only way to receive information.
I think if possible, Marjorie, I don't know whether or not, as reports are, to have a little executive summary and then the whole report kind of thing, so that it can actually be mailed out or given to people.
A lot of the people that came are like some of the community groups. If that is possible, as part of a dissemination strategy, that we heard from our audience that it would be really useful.
MR. STEINWACHS: Certainly if we could find a way to disseminate it in a hard copy form that is nicely packaged.
MR. SONDIK: I was just going to say that the committee could certainly send it to Kathy Walman at the OMB for distribution to the federal statistical agencies.
She meets regularly with those and chairs the interagency council on statistical policy. It would, I think, be at a minimum very interesting for them to see the work of this committee on this topic.
That would disseminate it throughout the federal statistical system. It could also take another channel -- this is obviously up to the Secretary -- but at the cabinet level.
As a product of this committee, you advise the Secretary, and the Secretary could share it. Certainly by going to the ICSP, it will go to the other statistical agencies, including Census, the Center for Education Statistics, and so forth.
MR. COHN: Other thoughts or suggestions?
MS. TRUDEL: I just wanted to follow up on something that Ed said. I am looking at the Secretary's 500 day plan, and this report certainly does link up with the idea of closing the health care gap and eliminating inequalities in health care. This fits right in here.
MS. GREENBERG: That is a good suggestion for including in the letter of transmittal.
MR. COHN: Other thoughts? I guess I would sort of pipe in that I know that NCHS has a users meeting. It may be something to --
MS. GREENBERG: Are we having one in 2006?
MR. SONDIK: Yes, we are.
MS. GREENBERG: We could certainly disseminate it there.
MR. COHN: Things like that, as well as the public health data users group, which I think you are one of the founding members of, might be a useful place also to get it out.
MS. GREENBERG: We exhibit at various meetings, like the National Association of Health Data Organizations, APHA, et cetera.
So, if we can get it reproduced in a hard copy, then we can have some copies there, and refer people to the web as well.
MR. SONDIK: The data council, of course.
MS. GREENBERG: Of course. The transmittal letter will be to the Secretary with a cc to the data council. I think, as we have done with other reports, it would be a good idea to ask Don to present it to the data council, and possibly bring in Vicky for that as well. Jim isn't here right now, but we know the executive secretary of the data council would agree.
MS. MAYS: One more suggestion I would have is that most of the individuals that came to the hearings -- Audrey, am I correct -- we have e mails for them. It might be useful to be able to just send them an e mail telling them of the availability, and they can either ask for it or go to the web site.
MS. GREENBERG: Who is this?
MS. MAYS: I think we have probably a different group of people who actually came to the hearings. I mean, we had one of the hearings where we probably had over 100 people attend, we had other hearings where we had a lot of community groups attended.
Each time they signed in, they got e mails for them. I think it is like giving back the report so they can see it.
MS. GREENBERG: Actually, if we reproduce it, we can send copies to all of those people. We have certainly done that in the past, and I think it would be appropriate.
MS. MAYS: Thank you.
MR. STEINWACHS: Thank you very much.
MR. COHN: Thank you. Congratulations.
MS. MAYS: Thank everyone for their hard work on this, also the staff. I also wanted to make sure they were acknowledged in terms of helping bring this together.
MR. COHN: Now, our next item is the 2003-2004 report.
Agenda Item: NCVHS 2003-2004 Report.
MR. COHN: I am actually divided. I am uncertain of how best to bring this forward to you. Let me tell you my sort of blunt analysis of it, and then I need your guidance in terms of how we bring this forward.
I think overall this is very good, but I think the recommendations for HHS policy research agenda and the looking ahead need some significant redrafting.
MS. GREENBERG: And we need the preface and the forward.
MR. COHN: You need the preface and the forward and probably a picture of John Lumpkin and you need all of those other things.
I think, given that, I think we will maybe have this be an actual action item for September, but I think we wanted to get confirmation from all of you that the first part, which is the great bulk of the document -- really goes up to page 16 -- is really fine, which is my assessment at this point, but we do want to not have to re-discuss that in September if we can avoid it.
MS. GREENBERG: Particularly the subcommittees, we have had some interaction with you all, obviously to try to make sure that it reflects your accomplishments and agenda, et cetera.
That would be all the way up to page 16. So, we will -- unless we hear otherwise today, we will assume that it does, and then we need to work on those last pieces.
MR. COHN: Anybody have any comments on this? Maybe we can talk about the research and the looking forward.
MR. STEINWACHS: Simon, I would agree. I thought mainly, at least when I was reading it, the looking forward, I thought, was something that each of the groups would want to pay some attention to, to make sure that really, certainly for the populations subcommittee, that is part of it, and I am sure the quality work group, too, we would like to make sure are in here.
The accomplishments, I thought, were well stated, and the role of populations in this I thought also came across very nicely.
MR. COHN: Okay, good. Any other comments on the first 16 pages, and then we can talk about maybe the research and then actually looking forward and then back to research.
Does anybody have any other comments about the first pages? I thought standards and security looked well represented, privacy did well, quality I thought reflected accurately what was going on. The NHII work group, obviously, was also referenced. I think it is actually very well put.
This actually may be some help that maybe we could ask the population subcommittee to think about a little bit. Now we are talking about the research agenda.
I know we had gone from trying to list out every research item in the last five, six, seven years in any of the documents in here, which didn't come out.
At least from my view, it didn't sort of make sense. These were like bulleted items pulled out of various reports.
MS. GREENBERG: It was out of context.
MR. COHN: It was out of context, and some of them looked sort of very dated in the recommendations. It is really not what we wanted to talk about.
I guess to me the real question is, I think we are all in favor of a more robust research agenda relating to HHS information policy, but then the question is, well, what are we talking about.
I guess I would look maybe to the population subcommittee. Once again, it is something that is maybe a little different than just reflecting on previous documents, that isn't a litany of very specific items, but is more either high level things that we need to be looking at or whatever.
I am sort of thinking of sort of bullets with a sentence or just bullets or whatever, either as examples or whatever, that might help finish this off.
The wording in here is really not bad. It is just that it sort of doesn't come to a conclusion, as best I can tell, in terms of a research agenda. I guess maybe if we could get some help, would that be a reasonable request?
MR. STEINWACHS: I am sure we would be happy to do so, certainly.
MR. COHN: Especially with bounding the activity.
MS. GREENBERG: The other thing is, it does strike me that a lot of the populations letters or reports that are referenced here, I think you picked up on the recommendations that you thought were the most salient or whatever in this report now.
I think not only the population subcommittee, but all of the subcommittees that have put forward recommendations for research in the past need to maybe periodically revisit those, and see whether this work that they want to do to try to take this to the next step, or to bring it up again.
The way this all started was a discussion that we had at the executive subcommittee, and there are very specific recommendations that are made, and particularly in response to a request from the department or from congress for recommendations.
Generally, we know what happens to those, or at least to some extent, and there is a more direct response, but with some of these research recommendations, which you can't just implement on a dime, they kind of are out there in cyber space, and there is not a good sense that they have a home or that they are responded to.
So, I think that it is hard to capture. I think the language that is here attempted to capture that to some degree, but I guess I still feel it is appropriate for the different subcommittees to look back at some of these and say, is there further work we need to do, first of all, to find out has any of this research been undertaken and, to the extent that it has, learn more about what the findings were and, to the extent that it hasn't, do we want to raise this again in another venue, so that they don't die.
MR. COHN: But that is not really a part of this. That is not this report.
MS. GREENBERG: That is not this report, no, and I mean it might be the way to just deal with it. I think it relates to looking ahead, actually.
MR. COHN: You are right, that may. Obviously, I am thinking of this one at the level of, we might have privacy or -- Jeff, maybe you have some help on this one.
MR. BLAIR: I don't know if I have help so much as sort of a basic question. We have different mechanisms for providing status information, reference information and other mechanisms for making our recommendations for action.
This report confuses me a little bit, because I have always thought of this as kind of a status or reference document.
It may be a weak mechanism to make any kind of recommendations and, in this case, recommendations for a research agenda.
So, if this is a good mechanism to set forth those recommendations, could somebody -- can somebody clarify that, as to why we would be doing those in this document?
MR. COHN: Jeff, you bring up a point for all of us to ponder.
MS. GREENBERG: Interesting point. We have, in the past, we have used the annual report as a way to highlight -- I remember a special section we did on socioeconomic, I think, status in one report. So, we have done that. So, there is some precedent for that.
What you are saying is, this is maybe -- I guess I was kind of saying that, too, although you said it better than I did, that this is maybe not the best mechanism.
I am thinking that maybe, when we did think about using this mechanism to try to highlight some of those research recommendations, it maybe wasn't the best way to do it.
That is why I was suggesting that another way would be to revisit some of them and then maybe resurface them as a letter recommendation or something like that, where they would get more attention than in a document which is primarily historical, although we do always have something in it about reflecting on not only the past but also the future.
So, I think I agree with you, that if there are specific recommendations that have been made in the past and we feel they have languished, this may not be the best way to revitalize them.
MR. SCANLON: Yes, this is a way to guarantee they will continue to languish, especially on page 17. I think the other issue is that, you know, in a way, by trying to highlight them here, it is sort of suggesting that these have priority over -- that these are the only ones, and these have priority over anything else, and I don't think that is the case.
I thought we talked about using this as a basis for, if you are serious about an analytic agenda, that you would use that as the basis for moving forward.
Some of these, honestly, were not taken up because there was just no interest. Why would you come forward again, when you probably have some new ideas now, after a benefit of the year or so. I honestly don't see the purpose other than documentation, to highlight these.
MR. BLAIR: Could I then make a suggestion, given the reactions to my first question. I think maybe the linkage is that, in order to make a compelling case for investment in research, the information, the historical information in this report could be helpful.
So, maybe, if we later have a separate recommendation letter, with the single purpose of setting forth a research agenda, that this report is an attachment or an appendix to support, and put in context, the need for the research agenda.
MS. GREENBERG: I know some of the subcommittees right now, like the NHII work group, are looking at contributions to such a research agenda.
I think Jim makes a good point, that this was kind of an exercise in which we tried to go back to see what was there. It may serve a purpose for a future research agenda, but it may not add that much to this report.
MR. HUNGATE: I want to try a different tack on the committee, and think about what I regard as a centrality of the Healthy People 10 year program, around the health of the population.
We are talking about population health, and it seems to me that we are also strategically talking about public private partnerships.
I would like to find out if the healthy people structure of looking at the health of a population is used in any other way by other organizations.
In other words, there is a way of looking at the health of the population as put in the Healthy People 2010, and it is a repeated way of doing it.
It deals with race, ethnicity, the variables that are within that. That structure, it seems to me, could be useful in the private sector for people to look at the health of their populations.
I would like to find out -- and this is a macro kind of a question -- whether that is happening, whether that occurs. Does that make any sense?
MR. COHN: I hear what you are saying, Bill, but I think you are beginning to convince me that this is not part of the biennial report, but is a separate investigation if we would decide to go forward on it.
I mean, that is what I am hearing. I don't in any way disagree with what you are saying, but as I am listening to it and looking at that, that isn't this report. So, I agree, and you are beginning to convince me that we should take the whole section out.
MR. STEINWACHS: So, Simon, I wonder, can we drop this section or can we just have something that indicates that, within all of the reports and recommendations and so on, there are also considerations given to what are needs for new research, new methods, new information?
MS. GREENBERG: And if the committee really does want to take this seriously in the future, or make a serious effort, it could just be referred to in the looking ahead section.
MR. COHN: I think what we can do is -- I think what I am hearing is, we are not going to spend time with the population subcommittee trying to come up with a research agenda.
We will look through the first couple of paragraphs here. If there is something still left, that sort of talks about the importance of research, but leave it at that level, and we will see if that is even valuable. Otherwise, we will remove the section, and we will bring that back to you in September and discuss it with the executive subcommittee between here and there. Does Susan have a comment on it? I think that is where I am sort of coming to with this conversation.
MR. STEINWACHS: That would make sense to me, at least.
MS. KANAAN: This is Susan. I do strongly favor the idea of removing this section. I think it is anomalous in all sorts of ways.
It was worth the effort. It seemed like a good idea at the time, but I think it is clear to everyone that it doesn't really work very well. It needs much more development to be meaningful, and the more it is developed, and the better it is in its own right, the less appropriate it is for this context.
I like the fact that you are thinking of creating a separate document for discussion for the research agenda. Certainly a reference to the importance of the research theme can be included in one or two places in the report, even if we remove this entire section.
MR. COHN: I think we are all smiling, and I think you have all helped us to remove a problem. Carol, did you have a question?
MS. TRUDEL: I am in full agreement with this particular approach.
MR. COHN: Okay, now let me then move on to looking ahead. Obviously, I think it is important for us to have a looking ahead section.
My own view is that it needs to be informed by the agenda and the sort of work plan of the subcommittees and full committee for the next year.
So, rather than it reflecting certain things -- a hearing that we may be doing or an item that we have already just finished up with and whatever -- I think it is the place where we sort of lay out the types of things that we are going to be working on, really, going to the future.
I realize there is a little bit of a disconnect, that this will be September 2003, whereas this is 2003-2004, but this is the art of writing, of course, we know, and the art of putting together reports. My own thought is that, as you all know, the executive subcommittee is meeting in August.
MS. GREENBERG: And Susan will be there.
MR. COHN: Susan will be there, and part of that work is to really look at what our work plan is going to be, going forward.
So, the plan would be to have that for August, get that into the looking ahead section, so it doesn't become specific hearings, but more initiatives and things that we are going to be looking at, areas that we are going to be investigating, whatever, and that that is what is here. John Paul, you are looking at me like you disagree. So, go ahead.
MR. HOUSTON: I am just wondering if we try to segment it more specifically by committee or work group, because I think -- there is over-arching strategic direction of NCVHS, but then I think each committee probably sort of has its own.
It is not clear, when I read through looking at this, it is sort of like a rambling this is what we are going to do sort of thing.
MR. COHN: You mean, like it is now? That is right. That is why we are not passing this today.
MR. HOUSTON: I mean actually subsetting it out, sort of a subsection by subsection.
MR. COHN: You know, John Paul, I agree with what you are saying, which is probably there needs to be notation of which committees are taking which leads.
I think one of the things we are trying to do this year is to bring everybody sort of so that we all look like we are one committee, and be able to talk about sort of global and various other pieces. We will see how that works out.
MR. HOUSTON: I agree with you. I mean, I think there certainly needs to be the over-arching strategic direction of the committee, but I still think there are things that are happening within the different subcommittees that are very separate and distinct.
MR. COHN: I guess, are you willing to have those be reflected in the looking ahead section but reflecting on the specific subcommittees?
MR. HOUSTON: I think so.
MR. COHN: Then I agree.
MS. GREENBERG: Another alternative is -- well, you can do both things, and we have done this in the past, and I think Susan and I talked about the pros and cons.
There are these sections of the report which are basically topical but aligned with each subcommittee or work group.
At the end of those sections, one could put some subcommittee or work group specific kind of future things, and then have a looking ahead for the whole committee.
I am not necessarily recommending it, but I am saying that one could do that, if you wanted to emphasize that.
MR. COHN: We can figure that one out. I think either way would work with John Paul's suggestion. Harry, you had a comment?
MR. REYNOLDS: Yes, I worry a little bit about the looking ahead. If you just take the events of the last three weeks, I think what is important is, obviously, we talk about what we did in 2003 and 2004, and the agenda, and say what we are doing now.
Looking ahead, a little bit along John's comments, we have subjects, we have responsibilities, we have coordination efforts and other things.
I think, as you look at where everybody is going to play going forward -- and that is one of the issues that we had as we looked at AHIC and other things -- being at all specific in that category, if somebody were to pick this up, it could look like we are out of the mainstream.
It could look like we are going the wrong way, because this is moving so fast, and the actual directions and the subjects and the issues are changing continually, and one that wasn't a priority two weeks ago, all of a sudden, may become the same issue, and it is not even mentioned by us. So, it is like we looked ahead and really looked the wrong way.
MR. COHN: We were facing backwards when other people were looking forward.
MR. REYNOLDS: I think the accomplishments stand on their own. I think the structure of the committee -- kind of what we did for the Secretary, the structure of the committee stands on its own. There is what it is here for.
I hesitate very much to really get specific by committee, and I really hesitate to get real overly specific about actual subjects or functions, because we could look like we diverted clear off the track.
MR. COHN: I hear a first and a second, we have Carol and we have Don, and then the good news is that we can refer this over to the executive subcommittee to figure out what we are going to do.
MS. MC CALL: One opportunity, to play off what Harry was talking about, is to, in any sort of looking ahead section, I would recommend, at best, we foreshadow some of the themes, given what is happening out there, and how dynamic things are right now.
There are some specific themes that we know we want to pursue, and I think that we can use this to call that out.
To go into too much detail not only begs this looking in the wrong direction fatality we might incur, but it also buries the lead.
When we do have those work plans and over-arching themes across NCVHS and also details within each subcommittee, they will deserve to see the full light of day in their own right. I would hate to see them as a coda on the end of a document that really starts out by summarizing the past.
MR. COHN: Carol, thank you for your comment.
MR. STEINWACHS: This was Don's tongue in cheek suggestion. I know in some branches of science, the scientists are smart enough that they do the research and then they write the proposal to fund that research, but that allows you to do the next research to write the next proposal.
So, if we move this report slowly enough, we will say we look forward from 2004 to the future in 2005, and it turns out that is exactly what we did.
MR. COHN: I think with these comments, I want to thank you all. I think you are providing much better thoughts than I had had when we started this conversation.
For example, removing things is always a great joy to someone who is fundamentally something of an editor in one life, as well as, I think, the concept of I think high level looking ahead.
It does -- to try to do with themes and all of that, but short, is probably an appropriate way to end a document like this.
So, I think we will work on it. I think you provided a lot of very good guidance on this. The executive subcommittee will review this, and hopefully we will have a finished document.
Really, the only thing we are talking about on the last couple of pages, and given that we have gotten rid of pretty much a whole section, probably the last couple of paragraphs, and we will bring that back in September for action. Finally comments, and then we will take a break.
MR. STEUERLE: I sort of heard Don saying -- I don't know -- that maybe it might be better to go ahead, like last time, if we are not going to change the substance, to go ahead and give you permission to get it out without coming back in September.
MR. BLAIR: I would support exactly what Simon just indicated.
MR. STEUERLE: You do want to see it again in September.
MS. GREENBERG: What is Gene suggesting?
MR. COHN: Gene was actually suggesting that this actually be passed with the executive subcommittee working on the looking ahead section. That is what he was suggesting.
MS. GREENBERG: I would rather bring it back myself. I mean, if we weren't meeting again until November I would say yes. Since there is less than a month -- in fact, that is a little bit of a concern -- Susan, I hope you are able to work within this time frame -- but we are meeting the third week or something of August, and then we are meeting the second week in September. So, the timing is such.
One thing that I think the executive subcommittee can, I think, decide on this, but the forward obviously, being from John, will be more reflective on where the committee has come and all of that. it will not be looking forward, really.
Sometimes the preface or the forward by the current chair is an opportunity to kind of look ahead, and you wouldn't have to have a looking ahead portion in the report. Just do that in the preface.
MR. COHN: I think it is time for lunch, everybody. There is nothing here we are voting on today. I want to thank you all. We will adjourn for lunch and reconvene at 1:00 o'clock.
[Whereupon, at 12:05 p.m., the meeting was recessed, to reconvene at 1:00 p.m., that same day.]
MR. COHN: We are pleased to welcome David Brailer, the national coordinator for health information technology.
David, thank you for coming and joining us. I think I have said this before in public fora, but I really want to again congratulate you on both the great work you did in developing the framework and, really, beyond that, turning it into actual deliverables, strategies, work that is really beginning to accelerate what is going to be going on with health information technology going forward.
Obviously, we are delighted that you are here to join us, and I am looking forward to having you update us on sort of what has happened over the last couple of months, please.
Agenda Item: Update on Office of the National Coordinator for Health Information Technology and RFI.
MR. BRAILER: Thanks, Simon, and thank you all for having me. This has clearly been a very busy few week period with respect to health IT, and I know that, in the spirit of NCVHS and probably your all's longest standing goal in driving this forward, I just want to thank you and congratulate you for the work you have done in really bringing this forward.
I know, when I talked to your executive committee, I learned a new term that I have been testing with some of my friends.
If you are all not schlepping yackas, then I encourage you to do so, over the great work that is being done by so many people.
Also, as you know, the announcements that have come out have been the result of a very large number of very talented federal leaders that have, I think, been struggling somewhat in the wilderness up through the past year.
One of the challenges and the real privileges we have had is bringing that group together to be a very focused and enabled group to really start driving real results. So, I think there is a great deal of excitement overall.
Let me play backwards now and talk about kind of where we are and how we got here. Three weeks ago, we released a summary of the RFI that was put out in November 2004, asking for a lot of feedback about the framework for strategic action and the related activities.
That RFI summary completed a setting of a foundation. I view the foundation for the actions that have since been announced to be three-fold.
The first is a clinical foundation, and this clinical foundation has been boiling forward in the past six years, since the Institute of Medicine report that came out about medical errors, and the indelible linkage to health information technology that they made.
It has been enhanced by the administration in its outlook for the use of health information as a driver of consumer choice, the promoter of safety of the American public, and as a mechanism for ensuring that we can begin getting new market forces put into health care.
This clinical foundation has become apparent to many people, but we have supplemented that with two other activities.
The first was a business foundation. Last month we released the health care leadership panel report and this, as you know, was the report from the CEOs of fortune 100 businesses, where we went to and asked to questions:
Do you, as large employers, believe that health information technology is a necessary and urgent investment to help us deal with issues around health care quality and cost efficiency;
Secondly, do you, as leaders of industries that have had substantial industry transformation around the use of information at the point of service, believe that health care will follow the course that you followed, and deliver the kinds of sustained productivity growth of many of your industries -- retailing, telecom, banking, financial services, financial services, et cetera. Would you enjoy those same benefits.
The answer from the health care literature panel, to both questions, was yes. Yes, we do think that there is a need and there is an urgent opportunity, a chance to transform the industry and get the kinds of results. Secondly, IT can do that, and we think that we don't see fundamental differences.
That report is on our web site, at hhs.gov/healthit. It is a very thoughtful summary of the economic issues surrounding health and IT but, in many ways, this laid a very solid sense that health IT is not just about quality, it is not just about safety.
Those are obviously hugely important, but there is an economic component here regarding the competitiveness of our economy and the use of scarce resources.
Finally, the third piece, which is, if you will, a technical foundation. Many of the questions that were asked, and certainly the comments that came back, really helped us understand the boundary of reasonable thinking around technical issues.
The process of reviewing it, with nearly 200 federal employees working intensively over the course of several weeks, helps stimulate a level of dialogue and a level of collaboration that I think was unprecedented before in any of the efforts that we have had, in terms of the federal vehicle coming together and understanding what it could and should do.
While many people who read the RFI summary that we published saw it being followed only three days later by RFPs, I think it is fair to say that we were looking at those RFI summaries very early on, as early as February.
The RFPs that flowed, flowed directly from those, and we saw months of analysis and discussion that led to the direct linkage between those RFPs and the RFIs that came out.
There are a few take always from the RFI summary. First, health information sharing should be decentralized using the internet, make sure that it is not centralized data bases, and let's certainly not build over again what it is that the internet brought to us.
We should use uniform communication standards that are open, to be able to allow for the kinds of structure of health information.
We should have a governance process that reflects the needs of both public and private stakeholders. This should not be government dictated, nor should it be just left to the devices of the health care market.
Information should be patient-centric, and we should evaluate the safeguards that are in place to protect privacy and that, over time, incentives that drive adoption need to be considered.
The announcements that we made following that, as I said, flowed directly from them, and they were mechanisms to address the market failures that have resulted in the non-adoption of health IT.
We think that these actions will set the framework for a very significant public private process that will allow infrastructure to be developed, that will allow processes to unfold, and key drivers of interoperability and ultimately of adoption be put in place, without the need to have new regulations or requirements, or to dictate the outcome of the process in a way that would traditionally be seen as our role.
The announcements were several-fold, and I will just highlight each one. First, we announced the formation of the American Health Information community.
This is a federal advisory committee that will be comprised of 17 commissioners, roughly half federal agency heads and the other half from the private sector.
We are still working on membership criteria, but we want this to be a place where public private decision making comes together.
While this invokes the federal advisory committee process to make it completely open and transparent, this is a body which is collaborative, a decision making body that uses a recommendation vehicle.
We see this being very closely aligned with other efforts that we have underway, not the least of which being NCVHS, federal health architecture, consolidated health informatics, and clearly the RFPs that we issued.
We will be releasing the charter for the AHIC shortly and, from that, there will be a call for nominations, and we want to seat that commission as soon as we can, certainly in fiscal year 2005, if not with a month or two to spare before fiscal year 2005 comes to an end.
We announced an RFP for standards development organizations to come together with doctors, hospitals, laboratories and other users of health information, and develop a process to harmonize standards.
This RFP asked for processes to be developed and evaluated, so we can understand how we can build on the respectful standards development organizations that are in place, and allow us to have an accelerated process for having a uniform and single set of standards, and a road map for those being put in place quickly.
We released an RFP for a process to be developed and evaluated relating to the certification of technologies, starting with ambulatory electronic health records, but moving through other types of health information technology and ultimately infrastructure that connects them all together, the architectures.
This RFP asked for entities to determine criteria, to subject actual products on the market to those criteria, and to report to us what they found, not only about the products, but about what that changes in the market and how we can build upon that.
We have an RFP out asking for entities to come forward with proposals or architectures that allow nationwide connectivity among certified electronic health records, a capacity to have seamless sharing of health information, as would be wished by the patient or not, in those cases, that allow a single point of connectivity for labs, pharmacy, imaging and related information.
It is our expectation that we will award up to six contracts to have a diversity of architectures developed in the public domain and to have prototypes actually tested, and those can be then subjected to an evaluation process, so we can understand what the nation's capacity for health information sharing could and should be.
We have an RFP out to convene state leaders, to begin exploring state level and enterprise level variations in security and privacy, the challenge here being preservation of the flexibility that is inherent in state and federal law, that does not impose a single regimen for privacy and security, yet allows enough standardization or harmonization of those practices so that we have seamless interoperability.
We want to avoid the paradox that flexibility comes at the cost of interoperability, or interoperability comes at the cost of flexibility, as we advance the nation's security and privacy regimens.
We already have underway a project with AHEMA, to begin developing modern fraud detection techniques that are using electronic health records.
The question here is how we can take advantage of an emerging health information infrastructure in the United States to begin developing much more forward looking fraud prevention mechanisms that can work at the point of care. So, we don't have to rely on fraud prosecution long after the fact. We can make this a lower risk activity for anyone in the private sector.
We also are looking at following through on the other recommendations that we have made around developing architectures for the storage, management and accessing of medical knowledge part of the national infrastructure, and exploring the economics of the adoption gap, understanding how the gap between large providers, who adopt electronic health records, and small providers can be closed in a way that levels the playing field, brings these technologies into common place, and helps us understand how to do so in a way that stimulates competition and health information technology, and ultimately competition or performance value that uses these technologies.
Finally, we will be continuing our efforts to study and monitor health information technology adoption. There are a number of surveys that are underway.
These surveys have highly disparate findings, all suggesting low levels of adoption, with an adoption gap that is stratified by large versus small.
We don't have a consistent and regular mechanism for tracking adoption. So, we will be coming forward with further specification on how we will be doing that between now and the end of this fiscal year.
This is a very busy time. Many of the things that my office has worked on since the day I came to the federal government have happened in the past three weeks.
We are now following through to ensure that the RFPs can be completed and contracted before the end of the fiscal year, that the AHIC becomes operational, and the key mechanisms for tying it to the RFPs and to the other government apparatuses are underway quickly, and we can take advantage of the environment that has been created by the very strong support that health information technology has gotten from people in cities and rural areas, in all quadrants of the United States geography, from both political parties, from at least now two branches of the federal government, and from state and local government leaders, as well as the private sector.
So, thank you all for your vision and your leadership, your steadfastness, your support of my office and what we have been trying to do, and very much for your leadership going forward.
I think it is fair to say that the dynamics of this will continue to accelerate for the foreseeable future, and your activities will be called upon more and more, to be able to make sure that we are going in the right direction.
In the end, we have pursued an interoperability forward strategy, which means that we are putting much of our effort in ensuring that, as we begin to close the adoption gap in the United States, it will be based upon truly interoperable health information, that we have the capacity for doing that out of the box.
So, this will take a great deal of work for all of us to be able to achieve that. Thank you all very much for your time.
MR. COHN: David, thank you. Questions? Comments?
MR. FITZMAURICE: You mentioned, David, a standards road map, and we will hear later on from the council on the systemic interoperability, which is charged with developing such a standards road map.
Is there coordination and collaboration between your office and this council, so that whatever they take can be used within the federal government?
MR. BRAILER: Very much. The commission on systemic interoperability has played very much hand in glove with what we have done, and I will call out two specific ways.
One of the things that we felt was critically important to be done was to have a very compelling end stage vision for what it is that health information technology will do from the perspective of the patient or the consumer and/or from the end users even the professions.
I think very much the commission is going to be able to chart that, and to define that will be very important, and we see that as being one of the key hand offs to the AHIC.
In many ways, the AHIC would be the successor to what the commission's work has done, to be able to see that through and implement it.
Secondly, I am certain that the commission will come forward with a variety of recommendations, that we would see the AHIC filtering and prioritizing and making implementation decisions on, or making recommendations to agencies or to my office or to our contractors, to be able to follow through on.
So, we certainly await their report, and look forward to translating that into the actions that are necessary in the context.
I think very much it is a very critical piece because, if it wasn't done by the commission, I think the AHIC would have months and months of work to be able to do that same work, which could delay the activities that we want to get underway.
MR. ROTHSTEIN: Thanks, Simon and David. I have two questions. One deals with the transitional issues that are going to be very difficult in terms of moving extant paper records to an electronic file, or do we start today and just forget everything in the past.
I was wondering about whether there was some process or work group or way that those issues were going to be resolved.
The second one is, in the RFP that you are talking about for architecture design, is an issue to be considered adopting contextual access criteria for medical and non-medical uses? I haven't seen that, and I was wondering where that is.
MR. BRAILER: First, regarding transition, we have not made that an element of our, if you will, federal or national plan.
We have looked at a lot of organizations, some of which are represented here around the table, and how they have gone about the process of going from paper to electronic.
Some are more or less detaching their future electronic infrastructure from the past. Others are having really heroic efforts to convert the legacy past into an electronic future.
Others, in what seems to be predominantly taking advantage of the first visit with the patient to bring key elements left to the judgement of the physician.
This is, in fact, one of the reasons in most research that there is a transitional productivity decrease for clinicians, because of the one time transition of records into the electronic infrastructure.
We see that really being a process that is left to the private sector to determine the best way to make that transition.
I don't think we add by being proscriptive about how that should be done. We may be able to add by providing ideas or processes or suggestions about best practices.
We are also watching what federal agencies are doing. You know, at least two federal agencies are involved in transitions from paper to electronic process now. They seem to be following that same middle road.
So, we have not defined that as an element, but we will certainly take that under advisement, to go back and double check to make sure that we haven't left something that is, if you would, a critical national enabler that we should look at.
With respect to the RFP, I just want to first caution that I can't go beyond any of the text that is in the RFPs to provide any commentary except what is there.
I will say that the architecture RFP starts with the presumption that we don't know what we don't know. Those RFPs ask for architectures to be defined, as well as business processes supporting those, so that we can compare the multiple ones that are developed, and begin understanding what it is that we need to know to be able to succeed in this effort.
Unlike electronic health records, where I think it is possible to have a very meaningful discussion about what are the elements, features and functions of an electronic health record that we like, and what we don't like, and what should be there and what should not, every time I have had the discussion about connectivity architecture, it is a highly hypothetical and theoretical discussion.
So, we want to start bounding it by real reality. Since reality doesn't exist, we have to create it. This is what those efforts are like.
Therefore, with your question, along with very many others, we did not specify what has got to be there and what doesn't, because we don't want to preordain the outcome.
We see these as very focused, innovative research, to come back with what the issues are. So, we can then begin defining the questions for further efforts.
Suffice it to say that one RFP will not create the infrastructure that we need, but this is the critical enabler to be able to do that.
MR. ROTHSTEIN: Let me just say that I appreciate your not wanting to tie the hands of the architecture designers.
It may be that, at some point in the future, to build in the necessary privacy and confidentiality protections, that your office may have to be somewhat more prescriptive, in the event that those designers don't put a priority on incorporating those features that we deem essential.
MR. BRAILER: Yes, I appreciate that, and let me just say two things about that. Actually, I will say three. I certainly hope that anyone who is involved in the development of that architecture, regardless of whether they respond to our RFPs or not, read the enlightening reports that have come from both NCVHS and particularly the privacy subgroup.
I think that it raises a lot of questions that ultimately, I think, innovation and software have to answer, to some degree.
Secondly, there is a dependency that we called out in that RFP between the architecture innovation and the certification process in another RFP.
We expect the architectures to be handed off, to be reviewed by a separate group, by the certification collaborative, to be able to determine what it taught us about our ability to specify what the functions and features of an architecture should be.
I would certainly expect that group to not be bound only by what is put before them. We want them to be more normative, but this creates a starter kit. To that extent that they can do that, great.
Also, the AHIC will be watching this process, which is an end stage group of users who are connected to not what can be done with technology, but what needs to be done to have a meaningful protected asset for the American people.
From that perspective, there is at least built into this process two levels of check, to make sure that things that, in a more narrow sense, architecture thinkers didn't consider, that they get bolted back in.
We will see how that process goes. We are going to be managing it to make sure that the result comes out with at least the right questions being addressed, and we will evaluate then where we are with respect to the need for more iteration.
MR. REYNOLDS: Thank you, David. I have enjoyed hearing you a number of times. Now I am actually getting it. You mentioned three foundations, and there is one that keeps coming up in the discussions I am in that may fit into one of these but it doesn't appear to right now for me, and that is called the culture.
You have the situation -- and Mark touched on it some and you touched on it -- where we need information to do the right kind of medicine. We need information to make the right kind of decisions, whether it is e prescribing or anything else that is going on.
You have got people who may want to hold back information. You have got the liability of the doctor, you have goth the liability of the patient, you have got the liability of the other people involved.
So, the whole culture, we are looking at business, clinical and technology, but there is a whole culture that is going to have to adjust to this whole thing.
The American public, in many ways, deals well, and not so well in other ways as technology takes off, and there are plenty of risks and plenty of benefits.
So, where does that fit in here, and the education of that, and really bringing people not just that the RFP works, but that this is really something that is going to make a difference.
MR. BRAILER: I think in a way it is kind of the real question here. I view -- my view of what it is we are here to do, I think, will provide some commentary on that question, although I think, in the end, I have made this comment in the public before.
The years that I spent at the Wharton School taught me, if nothing else, that no strategy or no policy can change culture. It is the other way around. Or, as is commonly said, culture eats strategy for lunch.
I think this is the case, but in many ways these cultural issues in health care are what are really at question.
What I see as being the absolute back stop of cultural change is young physicians and young consumers. I won't define what I mean by young, but remember that interns who started an internship this year were born the same year the IBM PC came to market.
I view this group as the absolute back stop on not tolerating what we tolerate in health care on a daily basis. They have come to a world where everything that they do is on line, is connected, is shared, is socially networked.
I cannot imagine that they would tolerate in their clinical practices anything else. Likewise consumers, who are making treatment choices for themselves, who have reported in surveys their great and growing dissatisfaction with showing up to a doctor's office, an emergency room, a hospital, a site of care, and have them fumble around and not know information about them.
It will be the ultimate back stop on whether or not the consumer would ultimately allow this to occur. So, in many ways, the question that I face is two fold.
First, how do we create the enablers, so that that cultural phenomenon can take center stage. In many ways, I see health IT as an enabler of that. It allows it to happen.
To me, a great short coming would be if we came to a dawning of recognizing that we could have a better way in health care, that the culture wanted it, but it couldn't be delivered because of technical capacity, we would have failed today.
The flip side question is, how do we accelerate the cultural phenomenon. To some degree, there is a little bit of build it and they will come.
If people can see the future before them, it accelerates it. Luckily, in health care, we have at least 10 percent of our providers starting to do, if you would, the right thing, electronic environments.
It may not be fully interoperable. It may not have the kinds of clinical decision support back stops that guarantee better value, but it is a step in the right direction.
So, a lot of our efforts are not just on making it possible, but making it accelerated. I don't know that we want to wait for the whole cultural generation change to come through.
I know that is very much where you are. So, I see the chance for us to create, if you would, tipping points, or flexion points that could accelerate this, but I have not stated direct accountability, because so many of the factors for that piece are out of our control.
I think, in the end, the health care industry has to decide what it wants to be. Does it want to be consumer focused. Does it want to be market driven or does it want to be increasingly a government agency.
All of these things rolled together, I think, are going to make determinations, but I am pretty optimistic that the factors that we see are getting more and more resonance with the public.
Just this month nearly every major news weekly had major focuses on health information technology, and they did what we want them to do. They talked about this from the perspective of what it means to real people in their lives.
I am just astonished at how many people come to me now with personal stories about how their personal health record or their physicians e mail communication or the e prescribing that they got did something real and meaningful in their life.
Those stories are so tangible and so real that I can't imagine that they won't circulate at least through the, if you will, a large sector of people who regularly consume health care. In the end, there are factors that are out of our control, and we just have to accept that for what it is.
MS. MCCALL: Thank you, David. A couple of things. First, just to set the stage, we had had a wonderful two day summit here, and heard a lot from people that are wrestling with the very same things that you are seeking to transform.
One of the things that we heard from Dr. John Helumpka(?) -- and he is the new CEO of this Massachusetts REO -- and he has a gorgeous system there, interoperable, at least within the state.
He came to us and he said, you know, it is exquisite, and yet I still am missing something, and what I am missing are a lot of measures and metrics around quality and value and all of that.
We heard another gentleman, also very eloquent, say that when you think about metrics, that as you design your system, you can design it along a spectrum.
You can design it at one end for accountability and to measure. You can design it at another end to learn, if that is its primary purpose, to begin to, as you would say, fill in.
We don't even know what we don't know, and we can kind of at least begin to know what we don't know at some point.
So, all of that is kind of back drop to say, within the RFPs that you have sent out, two questions. Where are you focusing on that particular knowledge management discovery and how to incorporate that in.
Then a second question would be, I think about demand and I think about ways that we can, to the cultural point, how can we ignite it.
If we can ignite demand on the part of a person, where is that in there. Then I suppose last, what can we, in NCVHS, how can we best contribute, assist, aid, align with this work.
MR. BRAILER: It is a great question. Let me first talk about, with respect to reporting what is not in those RFPs. There are still pieces to come.
The implication of taking an interoperability forward strategy is that pieces that do speak to demand are not there.
The reason is that, if you would -- I think we have a unique opportunity before the demand components take off, to get the pieces in place for interoperability.
I say this because, while a good outcome would be lots of doctors using electronic health records, a better outcome would be lots of doctors using electronic health records to meet minimal features for security and having clinical decision support in place.
An even better outcome would be doctors using those kinds of products that are connected to a back bone that basically lets information be shared as the patients allow it to be shared.
MS. MC CALL: I actually meant demands on the part of a consumer.
MR. BRAILER: Okay, good, I appreciate that. So, to the specific question for reporting, I see -- and many people here do see a direct relationship between pay for performance and IT adoption in two ways.
First, many of the pay for performance programs that are being tested, if you would, not just under government oversight but just in the private sector have line items.
Ten to 20 percent of the performance increment is based on health IT use, and that clearly becomes part of the subsidy or part of the, if you would, offset for using those tools.
The flip side is, it is very clear in those programs that you can't really have substantial reporting requirements without having infrastructure in place in the practices to do the reporting.
The challenge there is agreement on what metrics are to be reported. That is, again, inherently not a technology question.
I think it is, through our discussion, a cultural question about who are we watching and in what way. I think that there is clearly something there, but I think there is a bigger question that I will just focus on, which is should the capacity to report data be an attribute of the electronic health record.
Should it be an attribute of the architecture that connects them. This is one of the questions that we would like to have an answer to.
I am concerned about a large number of different hopes and expectations for how, when physicians have electronic records in place, we will get vast, precise amounts of timely, quality metrics.
We will get substantial amounts of information about what is going on with the drugs they give their patients and the potential for adverse events.
We will get lots of information that will help us monitor outbreaks, manmade or natural, and you know, having made many statements like that, and then have software engineers walk away from me rolling their eyes, we get to a world that I call tyranny of the denominator.
What I mean by that is, it is pretty easy to figure out how many patients are on a certain drug, how many people have a certain symptom, all the things that we like to count.
The problem that I always see us coming back to is, what is the universe of people who could have this, so you can begin measuring rates, whether it is people on a certain drug, people who are walking in with certain symptoms.
That data often requires gyrations or tasks performed on information that are very difficult to do. In an electronic health record, with its computational power, the data that is available and the content around it, you can make significant assumptions about how much data is structured versus contextually reported.
Therefore, I think we should be cautious about our expectations. One of the things we will want the AHIC to look at, and certainly, I hope, your third question, that NCVHS will look at, is what are reasonable expectations around the capacity to report across these various areas, how those are done over time.
I also think a separate question that we are going to be asking our contractors to look at, and we will be dialoguing in AHIC and I hope here is, is that something the electronic health records should do anyway?
If we are going to be building a national architecture, shouldn't it be handling reporting, so that we don't have this overhead imposed on the physician's practice, or overhead that is imposed on these products that we are trying to lower the cost of, so that they work at a price point that doctors can afford them.
I don't know the answer. I am just concerned about the question, but you are very much striking to the very heart of what we really will get out of this from a public health value over the course of time.
I think there is real value there, but it has been shown that we have got to be, I think, realistic about what we can report over time.
MR. COHN: Do you have time for one more question? I think Gene Steuerle had a question, and then I think we will wrap up.
MR. STEUERLE: Thank you, David, and congratulations, again, on all the progress you have made. It is quite remarkable.
This ball that a lot of people have been pushing up the hill, particularly you and your staff lately, is starting to roll down the hill.
You mentioned that demand may increase fairly rapidly in the future, and you are hoping to get slightly ahead of that demand curve in terms of some of the things that you prepare.
One area where the demand is increasing, if you don't mind my raising it, is in the political sphere. We now have at least two potential presidential candidates quickly claiming that they want to be leaders in this area, including Frist and Hillary Clinton.
We have Newt Gingrich jumping in. You have a lot of politicians jumping in, and you have even your own budget and the Presidential budget going from $87 million to $125 million.
I see this budget as potentially increasing fairly rapidly. At least, from my experience, the way to claim you are a leader in this area is to spend slightly more than someone else does.
I am wondering if you have given any thought -- I don't mean that entirely cynically. I am just wondering, have you given some thought to how that part of the ball rolling down the hill might be guided, in terms of, if there is going to be additional money that is going to be increasingly put into this, even if it is only in the tens of millions.
How can that best be spent, not only with respect to RFPs to outsiders, but perhaps spending within government agencies, and to make better use of the learning within VA or the Defense Department or other departments.
I am just curious whether that is part of what you are dealing with, and whether you have any strategy or tactic for going forward.
MR. BRAILER: Gene, I am pondering, not what the answer to your question is, but what share of it I can actually say.
By the way, I apologize that I never got to answer the question you posed to me at the federal reserve conference a couple of weeks ago, because of all the other questions, but that one I would rather answer than this one.
I am, to this day, I marvel at the level of support and the increasing senior political figures that view this as an important area.
I think one of the enduring successes that I wish I could take credit for, but I think is perhaps more happenstance than anything else, is that there is an increasing level of interest in doing something here, not just federal figures, but state governments, local politicians and others.
I think to some degree it is because of the components of a clearly defined problem and a pretty clearly defined solution, although I think I would be the first -- and maybe of you would be probably even ahead of me -- to say the problem is not quite that clear and the solution is clearly relatively fuzzy, because health IT is a means to an end, and it is not an end.
Having said that, we have been so much in a mode, since almost the day I started, of keeping the agenda protected and moving forward, and marshalling it in the face of just unparalleled kinds of adversities that we have come across with our appropriations, collection related things, and transitions, that I have not stopped to ask what happens if we come to a period where our ability to be creative and resourceful is the rate limiting step, and not our ability to get the resources to succeed.
I will say this. The RFPs that we have put out, these are well thought out. I think the federal team that worked on these spent a lot of time making sure that not only each piece worked, but the system of pieces came together to create something, and that it nudged the private sector in the right direction, and played the role that both the President and the Secretary have laid out for us to play, which is a catalyst, but there is a lot more to be done.
I think the same is true with the issues on the adoption side. While that has not been the focus of what we have done, there is a lot to do.
So, I think the very specific questions will come down to what we learn from this process. Where will we go with an architecture that I think that is going to be substantially expensive to build.
The vision I have is that it won't be using public dollars. I view the capacity of commercial markets to invest and, to my perspective, we want to create a market where smart capital would invest hefty sums to create a national infrastructure and have that compete in a way that it gives us the kinds of cost performance, the kinds of non-proprietary domination that we come to expect with cellular telephony and various other things.
I haven't thought about the world where we would have a lot of federal capital to put into that, because I don't like the federal control that comes with that happening. So, that is an issue that is worth discussion.
There are two other areas that I would call out, where I think there are going to be substantial needs. The first is in the safety net and in rural and underserved clinics.
I think the financial proposition there is challenging at best, and I think we have a responsibility to ensure that they come along.
I think that health information technology delivers a real health status benefit to the patients that it is used on, which also means that we have to make sure that everyone has got it.
Second, I think we are going to face a real challenge with very small physician offices, and not just financial support, but how the kind of know how, the kinds of implementation change comes to exist for them is still a question that is mostly economic.
I think we have a long way to go, and I certainly would welcome the chance to address that question for real, because it would mean that many of the things that we have tried to do to make this issue irreversible have come to be.
MR. COHN: David, thank you so much for joining us. Once again, we applaud your leadership and the success of your efforts.
Obviously, we look forward to a close, ongoing working relationship with you, as well as with the new initiatives. So, congratulations.
MR. BRAILER: Thank you, Simon.
MR. COHN: Our next presenter is LeRoy Jones, who is from ONCHIT, and you are going to update us on what is going on with the federal health architecture. Thank you very much for joining us.
Is the computer all set up for what you need? Should we give everybody a five minute stretch? Okay, why don't we give everybody a five minute stretch.
[Brief recess.]
MR. COHN: Once again, we are pleased to have a presentation on the federal health architecture from Mr. LeRoy Jones. I want to thank you for joining us, and I will let you get going here.
Agenda Item: Briefing on Federal Health Architecture.
MR. JONES: Thank you, Simon, and the committee, for having me here today. My name is Lee Jones, and I am with the office of the national coordinator, Dr. Brailer, who was just in this seat.
I am one of his senior advisors. I used to be called senior technical advisor, but I guess an advisor is an advisor after all.
Today, I am going to talk about the federal health architecture, and I am going to spend most of the time, essentially, talking about what it is and some of its history and those sorts of things, inasmuch as I am not sure how familiar this audience is with that, as opposed to, say, just an update of its activities, although I will wind that into the talk.
I am going to use essentially an off the shelf presentation to do that, but I will embellish on different points to make it more relevant to things that are going on today.
With that, I am going to discuss essentially what the federal health architecture is meant to address and what it is exactly, how the process works within the federal health architecture, and then some about the work groups that exist therein and the benefits.
Then lastly I will just talk about some of the issues that we face. As you might imagine, all the different things that Dr. Brailer just talked about and, to some extent, all the things that have been going on in the office of the national coordinator over the last year, really affect what happens in the federal health architecture, and its role going forward.
So, when we look at the federal space as it pertains to health, there are many different stakeholders, many different kinds of activities, many different agendas.
By and large, they happen autonomously within an agency or a department. So, what the federal health architecture is, is several different things.
One, it is a forum for all these different stakeholders to come together and to inform one another about what is going on with respect to health in their corner of the federal government.
Two, beyond just informing one another, it is an opportunity for them to collaborate together in order to come up with common target architectures that can leverage the best of what everyone is doing.
So, the challenge that we are attempting to meet is how we can share information and resources to improve care and protect citizens.
This is sort of the gentle path that led to where we are today, and I will talk a little bit more about some of the potholes there.
The consolidated health informatics is listed on this slide because it became part of the federal health architecture.
It is hard for me to pinpoint an exact date that that happened. I think you can count from different points along the way, but somewhere over the course of the last few months.
The work of CHI is probably more well known to this group than possibly the federal health architecture, inasmuch as CHI has been actively engaged with this group in sort of vetting the standards that were selected for the 20 health care domains that were identified by that group.
The federal health architecture was established as an e government line of business, and it really seeks to unify the conversation and architectures across the federal government as it pertains to health, and is a subset of the federal enterprise architecture in that sense.
April, May 6 in particular, when Dr. Brailer was appointed, and that whole period leading up to July 21, the office of the national coordinator was established, and the federal health architecture was deemed by HHS, who is a managing partner of that effort, to most closely be aligned with the objectives of the office of the national coordinator. So, it came under our umbrella in that time frame, and has been integrated into what we are doing.
The things that aren't shown on this brief road map are all of the different activities associated with the establishment of the office of the national coordinator that had an impact on the continual progress of the federal health architecture, and the consolidated health informatics initiative.
What I mean by that is, when it changes hands from one entity to another, there is some period of time where there is an integration.
Then, in addition to that, our office has had a particularly interesting road to get to this point. That point, being as interesting as it was, has sometimes served to obscure some of the things that have been going on with the federal health architecture and consolidated health informatics in particular. So, one thing that I will talk about at the end, in the issues, is how those things impact us going forward.
When our office published a framework for strategic action last summer, in particular there was an action, a strategy that was associated with our second goal, that is to coordinate the federal health information systems.
We thought, in ONCHIT, that this is a key portion of realizing the dream or the vision that the President has laid out for interoperable electronic health records.
We wanted to make sure that all of the health information technology dollars in the federal government were going to support or at least be supportive in a direct or indirect way, to that vision.
In order to do that, we had to have a means to coordinate those investments, and to coordinate the architectures that resulted from those investments.
So, along those lines, we included this strategy as part of the goal, and it was a natural fit for the federal health architecture and CHI.
So, the federal health architecture has been around and has the vision of providing safer and healthier citizens who have improved access to health related information and services.
We have the goals of trying to coordinate and improve coordination among all of our different partners and their corresponding solutions, and then improve those solutions to the extent possible by taking advantage of the best of what everyone has to offer.
It includes the -- it is a cross agency, cross departmental initiative. The Department of Health and Human Services is the managing partner.
We also have two other lead partners in the Department of Defense and VHA, the Veteran Health Affairs, and together they form sort of the triumvirate that represents the most spending in health IT across the government. However, there are other partners who participate actively, and certainly are at the table.
FHA, I am often asked, what does it really do, and what is it trying to produce, and what is its output? So, a simple way of thinking about what the FHA is, is a blue print of who, what, where, when, and how and why of the federal health enterprise, meaning, we want to understand all the things that are going on, and all the processes that are involved in creating this federal health enterprise, and then ultimately talk about where should we evolve that federal health enterprise to.
More specifically, we try to identify the strategic business drivers, document the business processes, define the information that is associated with those processes, make sure that we are able to deliver the necessary services across the federal health sector. We want to inventory everything that we have and measure how we move toward our target architecture.
When we look at what we are really ultimately doing, we are trying to document where we are in terms of delivering health care services as a government, and where we would like to be, and then ultimately what is our transition to those things.
I will talk a little bit about what we ask agencies, specifically, to do when they participate in the federal health architecture.
So, there is a process that we espouse, and I will show some of the steps involved in that process in subsequent slides.
Suffice it to say that the federal health architecture is espousing a process by which we develop our target architecture, by analyzing what the requirements are for the federal health space, and then trying to make sure that we address all of the areas in a systematic way that will lead to a transition toward an improved architecture, if possible.
So, we have some federal health architecture process, and what we typically see is that there are agencies and departments who may participate in the federal health architecture, but they have their own agency specific health architecture process that they are beholden to. So, they sort of participate in the federal health architecture in a tangential way.
What we are ultimately trying to achieve is to see that every agency integrates the federal health architecture process into their own health architecture process.
If every agency and department were able to do this, then as a government, across the health sector, we would be employing the same set of methodologies, the same set of techniques, and arriving at our architectures, as well as being able to share architectural components.
We realize that that is no easy feat, because the health architecture portion of an agency is usually a subset of a larger architectural mission that any given agency or department has.
So, we understand that often health is captive to larger concerns. Even within that, there may be some areas that are not aligned with the federal health architecture, nor are they aligned -- rather, they have some autonomy from the process that an agency has as it pertains to health.
When we thought about what it means to really participate with the federal health architecture, and align oneself to it, we thought there were three components.
The first of these components is a commitment to the FHA process, meaning that we want everyone to have buy in that it has value for us to come together as a health community, and to have a set of common processes to lead us toward target architecture.
So, as we started to figure out our health alignment, the first component, again, is process commitment, and we asked each agency to do several tangible things.
One is to offer a memorandum of understanding that declares a commitment to the federal health architecture. So, we want them to be engaged in more than just sort of a lip service.
Two, we want to incorporate the FHA into the formal architecture process that exists within each agency. So, we want to become integral to those processes, and not just something on the side that someone has to coordinate with.
Then we asked them to champion the FHA concerns within their agency itself. So, it is not just something that a certain set of people do, but it is something that is known and understood within each of the agencies.
Then, of course, we want to understand the role that each health architecture and supporting group within the agencies has within their organization, so that we can understand how to best engage with each of our partners.
Secondly, as we see that commitment come about, and people commit to the federal health architecture as being integral to their own process, we would expect that that would reflect itself in the architectures that those agencies produce, starting to align more closely with what the target architectures are that FHA produces.
So, as there are subsequent or ongoing versions of the federal health architecture that are published here, 1.0, 2.0, et cetera, we would expect that all the different architectures that exist in different agencies, wherever they align currently with respect to the federal health architecture, they would, over time, start to move in and be more closely align and overlap in appropriate portions with the target architectures as espoused by the federal health architecture.
As you can see, as they all come toward center and align with the federal health architecture, they also come closer to one another and can take advantage of best practices and, sometimes in some instances, even shared technology and technology paradigms.
So, the second component of what we call alignment with the federal health architecture is really an architectural commitment.
That consists of, published target architectures from agencies have FHA incorporated in them, and identified in an explicit way.
We have a progressive expansion of the relevant elements of FHA within the agency architectures or, said another way, as architectures within agencies evolve, those elements that pertain to health should start to resemble the FHA more closely as time goes on.
Then, all the artifacts that are produced, or the deliverables or outputs of the agency process for architecture, as they are relevant to the FHA, become part of the FHA repository for reference.
So, if we have a commitment from each agency to participate in the federal health architecture, and then we have a commitment to integrate their architectural process with the federal health architecture and architectural products, we would expect that to ultimately be reflected in the systems that those agencies produce.
So, each agency has some architecture, and they have systems that are based on those architectures, or they may be contemplating systems that are in the future, and aren't currently associated with an architecture.
So, what we would expect is that, because the federal health architecture has, as a major tenet, that we are seeking a target architecture, there are some systems that may never evolve using what is espoused by the federal health architecture.
This is just sort of a fact of life, but then there are other systems that will move from their current architecture that they are based on to some future architecture of the agency which, in theory, would be more closely aligned with the federal health architecture, and new systems also could target the future federal health architecture.
So, this is really the third component of being aligned with FHA, and that is an implementation commitment. We would expect that each agency can publish a time frame with milestones for migration, and express a plan for moving toward the architecture, and calling out those elements of FHA that are relevant that, once that plan is published, we can monitor progress against the plan for each of the relevant systems.
Then we can describe and catalogue all the system elements that are relevant to FHA that exist within the agencies.
So, when we talk about being aligned with the federal health architecture, it really consists of these three components: a process commitment, an architecture commitment, and an implementation commitment.
The partners in the federal health architecture have come together and partitioned the federal health space into five different domains that categorize different activities associated with health across the government.
They are access to care, population health, consumer safety, health care administration, health care delivery services, and health care research and practitioner education.
This was recently revised over the course of the last year, and has really been scrutinized and there is a hard fought agreement that these are sort of the umbrella that comprise the federal health enterprise.
FHA has work groups, then, that operate within those different domains and currently has five that I will talk about here.
There is a food safety work group, and I will talk about the positioning of the diagram in a moment, but there is a food safety work group.
They have really been taking on looking at the import process and really have had a lot of success over the last year.
There is a public health surveillance work group, and they have been doing a lot of good work in understanding what the public health surveillance business drivers are and processes are across different agencies.
There is an EHR, electronic health record, work group, and they have been busy trying to track what is going on in the private sector, and also map what the federal government is doing in relation to what is happening in the standards world.
There is consolidated health informatics, which has just recently been considered a work group of the federal health architecture. It is probably an atypical work group, in that integration into FHA is still ongoing.
Then there is an interoperability work group, which is concerned about technical interoperability among health care applications.
So, the green spikes that are going down are much more topical versus the two blue that are going across, which we believe are applicable to different domains and different work groups altogether.
So, when you look at where these fit in, relative to the umbrella of the federal health enterprise, we have these work groups that are portions of those different domains that I described earlier.
So, FHA is able to coordinate all of those disparate agendas and disparate systems that I mentioned at the onset, and we have really then taken another layer of that, which is to weave in the objectives of the strategic framework for action, to guide what we do in the federal space with respect to the federal health architecture.
So, this diagram just tries to get at the idea that, as an input, we really want to start with the business drivers, that each entity that is involved in health across the federal government has, and their requirements, and the things that are driving what they are doing with respect to health.
When I say what they are doing, I am not talking about what they are doing technically, but what they are doing as a health operation.
We then take those business drivers and we try to document all the things that are going on in terms of all the business activities and then the supporting information and data that it takes to accomplish those activities, what components of applications and other things support those, and then what technology underlies the implementation of those activities.
Once we are able to document our baseline with all of those things that comprise the architecture, we then sort of partition it through this filter of where does it fit in each of the domains, and then how do we arrive at a target architecture that leverages the things that are going on, the areas of synergy that are going on across all the different activities in the different constituencies.
We also have a filter now, which is the President's vision, which has been encapsulated in the framework for strategic action.
So, by doing all of that, at the end we arrive at a target architecture that not only supports the President's goal, but unifies and reconciles what is going on in the health enterprise.
So, if we have two agencies that are doing essentially similar things, and they are using similar technologies, we maybe have an opportunity to unify what they are doing, and better spend the dollars of the federal government in that area, as well as take advantage of lessons learned and best practices.
Ultimately, for each one of these layers -- the business layer, the information layer, the service component layer and technology layer, we end up with a reference model which describes the target architecture, and allows the architects within the individual partner organizations to go off and to build their target architectures that are specific to their designs, and then ultimately migrate their systems to those target architectures.
So, the benefits of the federal health architecture are that it promotes interoperability by trying to unify and take advantage of the commonality that different agencies have, and to express use cases that they can work toward in a common way, expedite data sharing to provide complete information, and it enables resource sharing and enhances collaboration.
There is no practical way other than these types of consensus groups to really facilitate this kind of sharing of information across agencies.
It helps secure funding for projects. Some people might debate whether it helps secure that or not, but it does in the sense that, if we can go in with a unified front and put forward a target architecture everyone is moving toward, that concept can be funded and the manifestation of the funding can happen in everyone's budget. It facilitates decision making and provides an established channel for coordinating these efforts.
So, that is sort of the nutshell of what the federal health architecture is at a high level. There are some things that we have been really working to get a handle on over the past few months.
One is what I described to you as alignment with the federal health architecture is sort of our recently adopted view in FHA of how one aligns.
It is fairly new. So, we have to continue to define that and get buy in from all of the participants, so that we can really have a unified position on how one participates in FHA. Then we have to obviously be able to monitor that alignment, and be able to measure progress against it.
Two, we have to understand how FHA and CHI relate to this new world order, that Dr. Brailer just talked about a few minutes ago.
What does it mean in the face of having standards harmonization and product certification and infrastructure certification.
What does it mean for the federal health enterprise, and how is the federal health architecture and consolidated health informatics really integrate into that world.
Then, as I alluded to, CHI's integration into FHA is a fairly new thing, and has had some obstacles, in the sense that our office just doesn't have lots of people.
We don't have lots of excess capacity to do a lot of the work. So, it has been an ongoing effort for us to try to integrate CHI into FHA.
So, I think that these are some of the things that we are working on as we go forward. So, hopefully that gave you some idea about what the federal health architecture is, and I think that one thing that we are also trying to understand, although I didn't list it as an issue is, as we start to integrate the FHA and CHI into this new world order, what is the most effective way that we can interface with this group, NCVHS, so that we can have as strong a partnership as CHI experienced in its heyday.
MR. COHN: Lee, thank you very much. That was a very useful briefing on this. Questions? I feel I should let Jeff ask the question he asked earlier today. Do you remember it, Jeff?
MR. BLAIR: I am trying to remember.
MR. COHN: You asked Karen Trudel a question earlier about CHI.
MR. BLAIR: Oh, the status of CHI, yes. Lee, by the way, thanks so much for being here and sharing the status of the federal health architecture with us at this point, that you have at this point.
Clearly, there is a lot -- you have so many things that you are trying to integrate that architecture to, and have it responsive to, that it seems like every constituent group is saying, how are you going to wind up doing this without impacting things too much.
With respect to the consolidated health informatics initiative, maybe the way I ought to ask my question is, within the FHA group right now, what is the perception of what the CHI standards are. What is their value? What role do you think they play in the FHA?
MR. JONES: The adopted standards themselves, or the group.
MR. BLAIR: Thanks for asking for that clarification, because I will just speak for myself, the feeling I have is that the CHI standards are not just a laundry list of standards.
They were developed from the standpoint of how do they meet specific health care needs, and they were also developed in terms of their likelihood of how they begin to create the information infrastructure, how they relate to each other.
The example I would give is the way the core set of clinical data terminologies were identified in a manner where they would be the reference terminology, and a lot of other terminologies that can't be migrated or changed quickly map to those.
So, it provides a lot of the harmonization and systems integration in the future, as well as identifying the standards that meet specific health care needs. Maybe by giving you that explanation I wound up revealing what I hoped you would say.
MR. JONES: So, all the things you said, that is my -- no, I guess I would answer that this way. I think that all of the work that was done by the CHI group, certainly everywhere that I have gone has been held in high regard.
People have had high expectations for the ongoing CHI process, and really have embraced the work that has already been done.
In fact, when I was talking anecdotally, I was talking to some members, some people at a conference I was speaking to recently.
They asked me about the CHI standards and said -- these were private sector people -- and they were saying, we were following what was going on, and we really were encouraged by what CHI did, and we were waiting for sort of that next step so that we could pick up those standards and move forward with them.
I think that that is what we want to happen. We want others to sort of take the lead, or pick up the mantle that the government throws down, if you will, in the form of those standards, and to adopt them even more broadly than just the federal government.
So, the context of the office of the national coordinator, certainly we have that same objective. Now, the other aspect to that is, are they complete, meaning the CHI standards.
Are they complete? If they are, then complete with respect to what. I think that CHI did a good job of outlining what they were trying to do, and choose standards for.
What our office is trying to do. in the context of these RPs that David talked about and other things, is to really establish what use cases the industry values or prioritizes closely, to identify what standards are relevant there, and where there may be gaps.
So, what I would hope would happen with CHI is CHI would be foundational to any such discussion. In terms of how FHA views CHI, I think that, inasmuch as the person responsible now for CHI is the same person responsible for FHA, Mary Forbes, you know, I think she is not very schizophrenic in how she views those things, but she views them as sort of hand in glove, the same process that is ultimately supporting the goals of the national coordinator, and now Secretary Leavitt.
So, that is a long winded way of saying, I don't think that we have tried to change what is the common or popular perception of what the promise of CHI is.
We are just trying to figure out how does it fit in, not only with FHA, but also in the larger context of what Dr. Brailer is charged with.
MR. BLAIR: Can I add one other piece, if I may? I am sort of jumping ahead a little bit. One of the explorations and projects that we would like to move forward with at NCVHS is building on those CHI standards, especially the clinical data terminologies, the UMLS and how it links to all of the other terminologies with an additional use case vision.
This use case vision is a very broad one. Actually, it is probably a set of use cases, a broad set of use cases.
I am mentioning this for you to keep in your mind because, by the time we come out with these recommendations, it may be many, many months.
We are calling on, you know, one of the individuals on the NCVHS that is especially respected in the industry for his expertise, and that is Dr. Stan Huff to take this lead on this entity, and that is to look at the fact that the CHI Standards would get us close to having clinically specific data at the point of care for the first time, and having it in a robust, comprehensive way.
Once we have that as a foundation, where you have it for patient care purposes, for the first time we could begin to look at using derivatives of that information captured once at the point of care, use derivatives for reimbursement and for clinical research and for public health.
If you think about that vision, this is another, maybe, example of where NCVHS -- we will see how it plays out, but is offering some strategic guidance and vision in terms of how health care information and policy can flow together.
If you think about that vision for a little while, you begin to think of tremendous cost savings and efficiency savings and time savings.
I am mentioning it -- I am being an opportunist, because you are beginning to think of where you go with the federal health architecture, and you are also probably going to be maybe one of the folks who begins to evaluate the responses to the standards harmonization RFPs, and you are going to be looking at the use cases.
So, I thought it would be maybe helpful or useful for you to be aware of the fact that we are heading down this path.
Now that I have said this piece, Simon, do we have the latitude of inviting Stan to add any additional comments or thoughts to this particular direction?
MR. HUFF: He probably can. He can also invite Lee and Mary to join and participate in some of the discussions, if they are valuable to you. Stan, did you have a comment that you wanted to make?
MR.HUFF: I am happy to comment. I certainly support the idea of clinical data re-use. I had a different question swirling in my mind related to CHI and these other activities.
Don't take this the wrong way. You are doing the easy part right now, which is setting the standards and talking about it.
I have seen a certain tendency with the CHI activities and other activities, for people to think -- even agencies that participated in CHI to say, well, that is for the other guys.
So, when it comes actually time to change what they buy or what they do or what they implement, they think, well, but you didn't really mean that I would change what I am doing to conform to the standard.
To me, that is the real challenge, is what is the motivation for people to change really, and do you have -- I mean, in some sense, it starts at the top, if people in these various federal departments and other things aren't really willing to change what they are doing, then this isn't going to have the impact that we hope it would have.
I mean, do you see a way forward where you could really have, if you will, authority and responsibility for this in a way that you can affect change within agencies that tend to ba autonomous at some level within the federal bureaucracy?
MR. JONES: Well, yes, in the following sense -- and I think I will try to wind it back a little into the previous comment by Jeff.
Standards, by themselves, are not enough. At least that has been our position. Usually when we make that statement we say that they are necessary but not sufficient, and we go on to talk about infrastructure, et cetera.
Another portion that we don't often talk about is this migration process that you are alluding to. I think that also gets to the relationship of CHI to FHA, inasmuch as FHA will incorporate the standards that come out of CHI into a version which becomes a baseline.
Now, as I showed in my diagram, the vision is tha people's architectures start to come closer to the published FHA architecture.
At the end of the day, FHA or those standards are, one, forward looking for target architectures, and not meant to be retroactively applied, necessarily, and two, CHI has voluntary standards.
So, people are not forced, if you will, to adopt them. So, now, having said that, that is in contrast to something, say, like a NIST FIPS process, where there is a mandatory government standard.
Having said that, why come up with standards if you don't plan on implementing them. Well, it turns out there seem to be many different reasons why.
MR. HUFF: To look good in public is one.
MR. JONES: Yes. So, I think what you are talking about is definitely an issue. Two ways that we are trying to address it are, one, what I just talked about, by really making the FHA process more integral with what the agencies are doing internally.
So, it is not just a meeting that people come to, but rather, is written into the DNA of how they do their own work.
Then, too, OMB is involved in this and has a stake. So, they, as an e government initiative, they ask for regular reporting about what goes on in federal health architecture and consolidated health informatics, and they also take elements of what they believe FHA and CHI should be doing, and write them into score cards for evaluation for different agencies.
So, that is sort of the enforcement part of it behind the scenes. Now, the question is, how to make, how to balance that enforcement piece with the practical realities of trying to implement things that are in target architectures that, by definition, need some migration path.
It is not always straightforward to say when or how an agency should comply, and you know, OMB often has a time based mechanism to try to move agencies.
I think the agencies have been arguing to some extent that you need to have some time based pressure, but you also have to take into account the steps that it takes to get there.
What FHA is really trying to do is to illuminate what those steps are, so that everyone understand what it takes to get there, and we can make some rational decisions about how we migrate from one version of the architecture to the next.
MR. COHN: Paul, I think we will let you be the last question.
MR. TANG: It mainly picks up on the two previous questions. It is still around CHI. You mentioned this merging of CHI into FHA as an issue, and I think you alluded to resources.
I guess, at first glance, one would have thought that, if you brought the CHI activity into the FHA umbrella, you would have brought the resources in with it. That wasn't true? Is that the implication?
AUDIENCE: We have lots of money but no staff.
MR. TANG: I thought people were detailed into CHI.
MR. JONES: CHI was -- so, people provided a lot of in kind sort of services, as far as I understand. You can certainly correct me if I go wrong, a lot of in kind sort of assistance and participation in CHI.
The actual footing the bill of running the program was largely borne by HHS. It was sort of borne in a side kind of way.
We did successfully get some money that could potentially pay for resources, but as was said, there is the circumstance of being in our office, the office of the coordinator.
We don't really have positions or billets where we can hire people to do that work. We did approach partners and others about details and that sort of thing, but resources are scarce all over.
So, people are willing to participate, but I think if you are talking about dedicating a person who is going to spend all their time doing that, it was difficult to find people who had resources who weren't actively engaged in whatever their day jobs were.
MR. TANG: So, they weren't so kind.
MR. JONES: I don't think it was for lack of desire. I think it was that everyone is really busy.
MR. TANG: Then the second thing is a bit of a nuance on what Stan said. You talked about actually a side effect of Thompson declaring that CHI standards would be the federal standards.
The private sector said, oh, I had better pay attention. So, the double edged sword of bringing it into the FHA is that it may appear more like a federal health architecture, and of less relevant to the private sector.
Do you see what I am saying? There may be a little bit of an unanticipated double edged sword, because part of the enthusiasm you reacted to, you said, was people were coming up to you from the private sector saying, hey, I have got to pay attention to this.
I wonder if that might get diffused a little, especially given what your answer to Stan was, which is, you are supposed to go there, but there is no enforcement behind just exactly when and who.
MR. JONES: I don't know if I would say there is no enforcement, because OMB certainly does participate actively, and they are very interested in people adopting those standards.
I do think that is a fair point, though, about the perception that CHI has sort of gone federal, if you will, and I think that is an issue with -- I think we would be more worried about that issue if it wasn't for the FHA itself being a part of the office of the national coordinator, which then has a very strong private sector focus.
So, we are really trying -- maybe I should have listed that as an issue also, is this continual blending of what FHA is into what ONCHIT is trying to do, and hopefully it would mute that kind of a response.
MR. COHN: Well, Lee, I actually want to thank you. I think this has been a very interesting conversation. Obviously, I think the briefing is very useful. I think you are hearing a set of issues and discussion items.
Now, we would like to have a close working relationship, and I am not sure if we should call it CHI or FHA, reflecting the blend that we were just talking about, but you have obviously had a lot to do with laying the foundation for that.
Obviously, we are all aware that there are still outstanding issues there, and we want it to be successful. Our subcommittee on standards and security has been the group that has traditionally spearheaded that.
You heard part of the conversation from one of the co-chairs, Jeff Blair, who was just talking, as well as Harry Reynolds over here.
I think we will be asking them to be in communication with both you and Mary, because I think it could be something that was more thoroughly explored in subcommittee work, where we hold hearings, have more involved conversations.
Clearly, there are a number of different things going on here, some of which are like, well, gee, there are all these questions left over from last time. Whatever happened to them.
It wasn't just for standards. It was really a work in progress. So, we obviously wanted to figure out some ways to be supportive and help make it successful.
MR. JONES: I appreciate that.
MR. COHN: We are happy to help and you have our support. I really want to thank you for taking the time, and obviously you have our support. Mary, anything we can do to help also. So, thank you.
Now, with that, I think we will transition to Scott Wallace. Scott, do you need a minute or two, or is everything set up? Okay.
Welcome, Scott. Scott is the chair of the Commission on Systemic Interoperability, as well as the president and CEO for the National Alliance for Health Information Technology.
As I disclosed in my disclosure period earlier today, I am actually a member of the commission, and I want you to know that it has been a great pleasure and delight. Scott is the chair, and he has done a great job.
I think we all sort of have to recognize this commission has not been around for very long, and it is already being called upon to make a report in the very near future.
I think that, given those time frames, Scott has been doing a great job. We are obviously very pleased to have you joining us today to give us at least a flavor of where the commission is now, and a view of where it is going to be going.
Agenda Item: Commission on Systemic Interoperability.
MR. WALLACE: Thank you, and I appreciate the opportunity to come and speak. Simon and I talked a little bit before I agreed to do this, just because the commission hasn't issued its report yet.
The report will come out in October. I am not in a position to talk about any of the recommendations that we are going to make because, as we speak, there is an ongoing process of trying to define those recommendations and to articulate them.
The journalistic dimension of not wanting to scoop oneself notwithstanding, I couldn't scoop myself if I tried. So, what I will do is kind of give you an overview of the process that we are going through, what we are talking about, the areas that we are focused on, and then hopefully answer questions, if you have them, following that.
As you are likely aware, the commission was created in section 1012 of the Medicare Modernization Act. It was really an effort on behalf of a number of different interest groups to avoid a situation in IT that they saw having happened in HIPAA, specifically that the federal dimension of it went forward very quickly without, in their view, sufficient input from the private sector side.
So, this commission was created as an exclusively private sector entity, to really offer to the Secretary, to the Congress and to the President perspectives on how this process of health care IT ought to work.
We have evolved very clearly toward trying to articulate this vision of health care IT. Dr. Brailer, as is typical, was far more articulate in talking to the end state of the consumer vision and all of this.
Really, it is this notion that, if you are in this little clique that many of us are in, you talk about health care IT and you talk about standards, ad you talk about interoperability and, if you talk to anyone outside of the clique, they have no clue what it is that you are talking about.
So, if there is really one thing that I think the commission can do, it is to broaden the appeal of this, not just to consumers who are non-initiated, but to some of the thousands of staffers that are up on the Hill, and to other people who are involved in government and involved in health care.
We have divided our function really into four pieces. There are slides. It is kind of an evolving notion. So, there are slides to address three of them.
The consumer piece, there is a lot that we are looking at on the provider piece, and then on the financing options.
We are trending toward -- I will keep looking to Simon to see if he nods, to see if we have got that vote lined up -- we are trending toward having a fourth section that looks at the government role as well.
The real idea around the consumer section was that there is an enormous amount of work on pushing health care IT. How do we get doctors to use it, how do we get clinics to pick it up, how do we get hospitals to deploy these systems, how do we get the payers to come in, and what is the role of employees in putting in money, and where does the federal government go.
As we stopped and looked at that, we realized that there was very little pull. Most broad based technologies don't get there strictly through a push. They get there through a pull.
Ivan Seidenberg, who is chairman and CEO of Verizon Communications, always holds up a cell phone and said, you know, we built a network for these things and the federal government didn't put in a dime.
We built this network because we put devices in people's hands, they saw a value in that. They send us money every month, and we use that money to keep expanding the system.
So, there is this idea that, if we can articulate the value proposition to consumers, maybe we can do a little bit more to pull this technology through, instead of trying to jam it all through the keyhole.
The consumer issue, we think, really breaks down into kind of three dimensions that we spent a lot of time looking at.
The first is what one of the witnesses that came in front of the commission referred to as the document game. This woman named Peggy Franks has a 22-year-old daughter with a chromosome disorder that I believe is unique in its description.
As a result, her 22-year-old daughter has been hospitalized for extended stays 13 times. Peggy, in pretty moving words, said, every time Ashley finishes a hospitalization, we begin the document game again.
Everybody kind of looked and she said, you know, the game that you have to play to get the documents together. She said, I am one of those chronic care parents. I have my daughter's wheel chair that I push with one hand, and a trolley that I pull with the other hand, carrying all of her records around.
Just getting those records requires an enormous amount of gamesmanship, and it shouldn't. So, what we started focusing on is not just these questions about technology and interoperability and standards, and not just the issues around confidentiality, but how much are we hurting regular people, not killing them because we made an error, but hurting them in their everyday life because they don't have access to this technology, because the systems are set up without them in mind.
So, a lot of the focus of the report is how do we end the document game. The second piece of this is that nonpartisan in Washington means D versus R in the rest of the world.
There is nobody, as Ed said, against this. It is just that no one really understands what it is that we are trying to do and why it is important to them.
So, how do we articulate that, in a way, and really exploit the fact that there aren't enemies of this. It is about as motherhood and apple pie as you can get.
We decided that the best way to do that, really, was a lot of personal stories. So, our staff has been out interviewing individuals, kind of regular people, in their use of IT, their experiences in health care without IT, their experiences pre and post-IT, really just to try to get this picture across, so that it isn't just about the sterile words of interoperability.
Clearly, the major fear factor in everything we do is this issue of confidentiality. We have had the wonderful good fortune of conducting our meetings during the course of the disclosures around mastercard and lexus nexus, and it seems like -- I can predict the next one, because out next meeting is July 12. So, the next set of stories is going to break July 11.
It does highlight the question of what are we going to do about confidentiality, how are we going to address this, and how will we assuage the fears of people about this unknown system, and what impact it will have on the confidentiality of their data.
I hope that you note that I am using a different word than is typically used, and it is by design. We are thinking of this issue, not in terms of privacy which, in Washington and elsewhere, is a very loaded political word, but in terms of confidentiality.
The point of creating an electronic health record is not that it not go to anyone else. We don't take doctors notes and send them to Fort Knox. You take doctors notes and all the other medical records, and we want to share that, but we want to share it in a very controlled way.
So, the issue isn't specifically privacy. The issue is confidentiality. How do you control that disclosure, not how do you always unequivocally prevent disclosure.
Then the final point is this major question around connecting patients and data. It, as well, has the third rail word of UPI. We will probably stay away from that phrase.
By and large, there is a major uniform patient identifier, the national patient identifier, all the other -- I get kind of jittery if I even utter them in this building.
There is clearly a major question that comes up, how will we link patients or consumers and their information. So, there are a lot of issues that have been raised on that. We think that there is probably an opportunity to make a recommendation in that area.
The provider issues really get to something that Harry Reynolds raised earlier, this cultural issue. From our point of view, the cultural issue really is one of consistency, and we speak of it in terms of standards, the verb, rather than standards, the noun.
Everyone right now talks about standards, which do you transfer data at 32 bits or 64 bits, and on and on, and the technical standards.
What we are really looking at is, you can't deploy consistent information technology systems into a world of completely diverse care processes, because you are trying to use a standardized tool for a non-standardized process.
So, we are spending a lot of time looking at how do you address that issue of consistency. Again, without kind of wallowing in the really nitty gritty details of how it comes across inside baseball circles, but really how do you address it in a way that regular practitioners understand.
Spending a lot of time looking at the business case for quality, it again is one of those dichotomies between people on the inside and the rest of the world.
If you track all of the consumer polls, the first thing that consumers worry about is cost. The second thing that they worry about is access. The third thing that they worry about -- and it is about four orders of magnitude below the first two -- is quality.
There is no sense of the quality and that is part of the reason that that is not a driver in a more aggressive way.
So, we are looking at what are the business case issues for quality, how can we get those out there. Then a third issue that really gets at the heart of the challenge of interoperability is that it has a dramatic impact on competition among providers.
We think we ought to highlight that, we ought to talk about why it is significant and why it is ultimately not the number one issue that providers should be focused on.
On the financial side, consumers and the money question really gets at this point that we -- I tend to like the conversations that used to go on.
The alliance would convene these different groups, and you would have a provider and a payer and an IT vendor, and you just give them each a big pile of rocks, and then you stand back, and they just stand and throw rocks at each other in this triangle.
One of the things that we thought about is, if consumers really see a value for this, maybe consumers can help to pay for this, and then we can break this triangulated rock throwing session of saying, no, you should pay for it, no, you should pay for it. There really is a source of funding there that nobody has looked at a lot.
The payers versus insurer's point is that it is increasingly clear that large employers have a point of view in all of this.
Ivan Seidenberg makes the point at least three times every meeting that he pays $3.6 billion a year for health care.
That is a different perspective in his mind than Vicky Greg, who is from Tennessee Blue Cross Blue Shield, and there are some issues there that we want to really explore.
We have been doing some research at the staff level and trying to highlight the role of health care in labor disputes.
Kind of anecdotally, I went back about five years on three major publications and checked for every single labor dispute that was covered.
Ninety-eight percent of them, which was all but one, mentioned health care as an issue in the labor dispute. So, clearly, there is a broader connection point to be made here between the role of health care IT, making health care safer and more efficient, and these broader issues around labor disputes.
The federal role in score keeping really comes down to this problem that we have, that the government can't differentiate between investments and expenses.
I am a business guy. I am not a health care guy. I came into this and was shocked, when I sat down with Kerry Weems, to go through government accounting, and to realize that they don't have a category called investment.
You know, if you spend it today, then it is spent, and to think that we have a federal government that runs on a cash, not accrual basis accounting system, is pretty remarkable.
So, one of the things we are doing is looking at how can we advise the congress on a more appropriate way to do the score keeping of the investment in health care IT.
Then the last thing is, maybe typical of the way all of the world works, people outside of our little circle are acutely aware of the failures of health care IT, of the big CPOE disasters, and some of those things that haven't worked well.
There are almost no good stories out there that are broadly disseminated about how health care has done IT really well.
So, one of the other pieces that we are doing, along with this consumer piece, is to tell some of these stories in regular words, so that people understand that, in fact, this does work, and it is workable, and we can get some successes and some benefits.
The book that we are writing, the report, we really focus on a very short set of recommendations. Dana Hazza, who is the director of the commission, took all of the old reports, the IOM reports, and all of these other commissions, and it is a fairly impressive stack. I didn't realize that health care generates quite so much paper.
They went through them -- she came walking in. I was over at NLM and she came walking in with this thing on a trolley, and I said, you know, is this Peggy Frank's medical record? She said, no, these are all the reports that we have been going through, all the commission reports.
So, I went through them all, and pulled out all the IT recommendations, and it made a stack that was a good inch and a half thick.
Out of them I think there were 10 or 12 that actually have been implemented, and it was a little bit of a wake up call to all of us about, let's not worry about putting 150 recommendations out. Let's see if we can get five. Could we get five that we can agree on that maybe could be implemented that we could measure, that we could do something with.
So, we really focused on this very discrete list of very short term, actionable recommendations. We have hired a speech writer instead of a report writer.
I spent a fair bit if time with Illinois' former governor, Jim Thompson, who was on the 9-11 commission, and he pointed out that part of the reason for the success of that commission's report was that you could read the book.
I mean, it opens -- I don't know if any of you have read it, it opens like a novel. I mean, they are talking about the bright blue sky and these guys who are walking through the airport. I am not quite sure we will get to that level, but there is something to aspire to.
The goal really is reaching all the audiences, and we have spent a prodigious amount of time talking about who are our audiences.
Clearly, it is the Secretary, clearly it is Dr. Brailer and Dr. McClelland. Clearly it is the White House and the leaders of congress who appointed all of us.
It is also more broadly disseminated than that, to all of the other people in congress and in the broad health care community, the docs who tend to think that IT is something that, if they ignore it long enough, it will go away, and also to consumers. If we can't make this message clear to people, then we have failed.
The report comes out October 24. I realize that, in government calendaring, a report that is released on October 24 means a report that is finished on September 7, which costs us five weeks and a great deal of panic at one point several weeks ago. So, it should be finished about the middle of September.
Dana is the director. You may recognize her from her maiden name, Dana Pavey. She was the health care analyst with Newt Gingrich at -- I forget the name of Newt's entity over there.
She is doing an absolutely extraordinary job, I think, putting together a team in a very short time. This all started around January, and we are coming out with a report in September.
She has got the team organized, and she is over at NLM. We are getting phenomenal support from them. As Dr. Brailer indicated, we have a very good working relationship with the ONCHIT office, and just extraordinarily good help and free flowing help from the ONCHIT staff.
There is Dana's contacts, in case you would like to send anything to her. That is the overview. I hope that is helpful.
MR. COHN: Yes, Scott, thank you.
MR. STEINWACHS: You indicated you might add a chapter on the government role. I was wondering if you were going to say anything about what might be some of the thoughts in that.
MR. WALLACE: No, not right now.
MR. COHN: Well, that was quick.
MR. WALLACE: The difficulty here, many of you may know Gary Mecklenberg, who is the CEO of Northwestern. It is at least a twice a week occurrence that I get a phone call or an e mail from Gary and he says, this schedule is just impossible, we can't do this. This is an irrational way to work, this is not logical.
I was just up and talking to Senator Frist this morning and he said, now, you guys are going to be finished on time aren't you? I said, yes, sir, we are going to finish.
So, the things that I put on here are really things that -- actually, Dana wrote these slides up. They are things that I think there is pretty broad agreement on, but it is not finalized.
The government piece, I think, is very much in flux at the moment, and I wouldn't really feel comfortable to go into too much of it.
MR. TANG: Since I have worked for Gary before, you can tell him I understand accelerated time scales.
MR. WALLACE: But I don't think he does. That is a 15-year strategic plan. I am a business guy, and I have never seen anything like that.
MR. TANG: As I listened to you -- and I think the report was excellent -- I see a lot of opportunity. I also like your approach a lot. I mean, it is typified by your hiring a speech writer, and the stories, the personal stories.
I also see the opportunity in your short-lived tenure -- because you basically can talk about some of the hard issues and get out before the rocks fly.
In a sense, you said you were a little scared about uttering UHI here. Try Chicago, and I wasn't even there.
So, it strikes me that you are on your list -- we don't know what is in your report, but you have a lot of these tough issues, like the linking, like state privacy laws that interact and contradict each other, like the need for consumer pull.
That is not controversial, but you can make some recommendations, I think, that can have some long lasting effects, partly because you aren't long lasting in the sense of having to live with local consequences.
MR. COHN: Scott might have to change his name, though.
MR. WALLACE: I have zero political aspirations. I told the Secretary, you know, I am happy to take on any of these.
MR. TANG: I actually think it would be very good to hear solid and frank and open discussion on some of these points that you raised in your presentation.
MR. WALLACE: It is interesting, the challenge that we are confronting, and we have been talking with a lot of the speech writing help, and some of the more savvy policy and political analysts around.
The question is, how do you bring up those topics without making that the focus of the report. Your report, through IOM, is a good example.
There was a huge amount of fight over whether the number was correctly 98,000 people. Well, if it is six, if you happen to be friends with one of them, that is a pretty big deal.
That whole emphasis got lost, because the fight was over, is this the right number or not. So, we are trying to figure out how can we make his broader message without getting sunk on some of these more controversial issues.
It is just kind of a common sense test. I mean, when we go and talk to regular people outside of health care about electronic health records, trying to sense what are their concerns on the confidentiality side, and how do you begin to assuage those.
MR. FITZMAURICE: Thank you, Scott. I appreciate as well your willingness to come here and give a good presentation on what you are going about, how you are going about it, and the issues.
Now, one of the things that I always thought the major charge to CSI was, was to create a road map for health data standards development and implementation.
I notice, by looking at your web site, that Bill Stedd(?) has developed a model or prototype of one for electronic prescribing. I pulled it down from your web site. I didn't see it in your slides, and do you plan to have a road map in your report for standards?
MR. WALLACE: I think that we will have several road maps. I don't know that they will be focused expressly on standards.
The logic of that, really, is that I guess I would describe it as statutory interpretation on my part. When I have been up on the Hill talking to people about what do they mean by standards, most of them don't mean what, Michael, you mean when you talk about a standard.
So, I guess two things came together. One was the realization that what we really needed to do was articulate a broader consumer vision.
The second was the realization that, with the exception of a couple of extraordinarily bright people like Simon and Don Detmer and Bill Stedd, most of the people on that commission are not really standards -- are not in a position to articulate a grand vision of standards.
I, for one, am not. If you look at kind of the experience of the folks that are on there, I think we are probably better off to articulate this business rationale and this business case, and hand a lot of that standards piece over to Dr. Brailer's office, to this standards rationalization or harmonization initiative that he put out in the RFP, and ultimately to AHIC.
MR. FITZMAURICE: I will say it is probably an impossible job to do, and to do well, and an impossible job to do in a year. I think that, to make progress and move us along would be a good accomplishment.
MR. WALLACE: Yes, we have nine months. I was really complaining bitterly about nine months until my wife was telling me about pregnancy.
MR. HOUSTON: It was interesting, in your presentation you talked about provider issues of interoperability and competition.
I think one of the things I guess I have a question about is the same concept, but with regard to HIT vendors themselves, and what are the issues that you see in terms of trying to provide interoperability.
I think we sense, at times, that the vendors don't necessarily want to play in the same sand box, let alone the providers or others. What are your thoughts on that, or do you see issues in that regard?
MR. WALLACE: My own perception, as a purchase of technology in businesses that I have built and run, is that consumers dictate markets.
I have never had a vendor of anything -- hard technology, soft technology, intellectual property -- who really wanted to work closely with three or four of his or her competitors.
So, my own take on this is that we may have some truly enlightened vendors who, motivated by the spirit of good will and harmony and life, want to collaborate and coordinate and cooperate with their competitors.
I think most of them aren't going to be that way, and I think that ultimately it is the demand for products that meet certain specifications that will lead to interoperability.
If you follow that line of logic, what it suggests is that you have to overcome the issues of why providers themselves may not be terribly keen on interoperability.
One of those little whispered around secrets is that most physicians don't really want their patients to have portable data.
It is a whole lot easier, if you have an IDN, to keep it all in the family, and keep people bouncing within your own system.
So, from our point of view, the early analysis was, we really need to focus first on how do we address this issue of interoperability as a cultural issue among providers, so that they start to spec it, and they start to demand it. Once they start to demand it, the vendors will really not have a lot of options.
MS. MC CALL: Thank you very much. This is absolutely fascinating. A couple of questions. This has been a very compressed process.
Yet, for everything that you are signalling, it sounds like it is going to be a very valuable product. So, my first question is, what were some of the elements --
MR. WALLACE: We are just trying to boost advance sales of the report.
MS. MC CALL: That is right, I am sold, if I can get an autographed copy. So, what was it about that process that made it so successful, because there may be some things that we are going to do in the next year, so where some sort of compressed process might be valuable to understand, but it may require certain things. So, that is question number one.
Then question number two is, again, you get to go away and you won't be hit by rocks, we hope, but how would you define success, then, if you have a wish. What is your greatest wish for change that you are able to catalyze.
MR. WALLACE: In terms of your process question, Dana and I spend days and days and days, kind of, looking at this and then polling different commissioners.
We had a pretty good sense of what we could accomplish, how much time we could put into the investigative phase, how much research we could compile, how many people we could talk to, how many pages we had to put up there.
Then we started talking about where the strengths and the perspectives of the commissioners were, and also what was already underway, to Michael's point earlier.
I mean, there is an enormous amount of work being done around standards, and some extraordinarily good work in terms of competitive in odd ways, but between the CCR initiative, and the HL7 CDA initiative, and a bunch of pieces along that path.
I think we started looking at what we were charged with when the statute was written, versus where the world was when we started to convene and what the needs were as we saw them.
In the early conversations that I had with Secretary Thompson and in subsequent conversations with Secretary Leavitt, they kept coming back to this point that we need a vision. There is no broad vision outside of the folks within health care.
I think that really drove a lot of it. I think Ivan Seidenberg was extremely influential in saying, I don't know who you guys are looking at to pay for this. Consumers will pay for it if they understand what the value of it is.
That was, I think, a real epiphany moment, but mostly I think we just focused on where did we think we could be effective, what did we think that we could do, which kind of leads to the second piece, what would be success.
I would be very pleased -- I guess one success is if I can get my mother to actually say Commission on Systemic Interoperability.
We call it CSI DC. It sounds a lot more hip that way. It really is, can you get people to understand the promise of electronic health records.
By people, I mean regular consumers. I mean, not patients, not chronically ill, the parents of chronically ill children. I mean regular people who walk in, who go to their physicians and say, I order my groceries on line, I pay my bills on line, I schedule my PTA conferences for my kids on line, and I just spent 45 minutes on the phone waiting for your scheduler to give me an appointment three Thursdays from now.
This is nuts, and get physicians to like the idea that, rather than a paper bag full of pill files, there is a record of the medications people are on.
I don't think that as a group -- we are so focused no how are we going to do this, how are we going to get the technology there.
The technology is not that tough. I come from a couple of industries where we have used technology really effectively. The data bases exist. You can put it in, you can pull it out, you can ship it around.
I ran a mining company from a little tiny town outside of Chicago. I could turn on production in South Africa and ship it to Namibia, and pull product out of Namibia and get it into Peru before I had coffee in the morning.
Meanwhile, I have to go through 45 minutes to find out whether my kid has had his inoculation so he can play soccer, or something. It just doesn't make sense.
I think what we have to do is get people to expect more. If we can raise the bar of expectation so that, when people walk in, they ask their doctor, why don't you have this. I would love to have people start breaking the clip boards.
MS. MC CALL: Like I am mad as hell and I am not going to take it any more.
MR. WALLACE: Right now, people don't understand this. When we talk to them, we talk to them about an interoperable data transmission system. What the heck is that? Nobody knows what that means.
If you talk to them about, you don't have to fill out forms any more, and we will know if you have got the medications, you don't have to remember which ones you took, and we will give you the reminders, those kinds of basic benefits, I think the web and electronic technology is at a point where people can get that.
If you go back three years ago, nobody trusted on line banking. If you go back five years ago, nobody trusted on line stock trading. All these things are routine and common now.
We are at a point where people can get that, and it coincides with a need within policy makers to make it available.
I think if we can spur the demand, if we can make it a common issue that people will understand, we will have succeeded.
MR. COHN: Kevin, I think you have the last question, and then we will wrap up.
MR. LOCALIO: Just a curiosity, because I think you are right, this is all contingent on creating pull in the market, and unless we do that, we are always going to be trying to push something that people just don't see the value in.
You use the example of a mother with a special needs child, which really illustrates the need, but of course that is a really small subset of people not sufficient to create a broad enough demand.
However, I would think that, in the senior population, in which there is a higher prevalence of chronic disease and frequent utilization, there is an opportunity there, perhaps, to start creating this awareness and pull.
I am just curious. Did you interface with advocacy groups for the senior population like AARP, and where are they on this?
As a matter of fact, they may have testified here. I don't know, but are they out there beating the drum for this with their constituency?
MR. WALLACE: I obviously won't speak at all for the AARP. In terms of what the commission did, we have done a little bit at the staff level.
We got, what was it, nine meetings, 10 meetings? So, we started out trying to actually have people come and testify and present information and you guys know first hand the tediousness of that, and the pace of it.
So, we haven't done it through that means. We have engaged a communications firm for the commission itself, to try to do some of that outreach, as well as to help us choreograph the release of the report.
The real goal of the report is not to see if modern health care will cover it, but to see if it will go in USA Today and whatever those morning news shows are.
MR. LOCALIO: Your target constituency is your warmest group.
MR. TANG: The IOM was pleased when we got into Family Circle, because that is the health care manager group.
MR. COHN: Well, Scott, I really want to thank you. This has been a very useful and, I think, enlightening conversation, certainly for the committee, and gives them lots to think about. I expect that we will be asking you to come back in November when we actually have --
MR. WALLACE: When I have something I can talk about.
MR. COHN: Well, actually you had something to talk about, but actually will have the final report. I know Carol said -- I think she was thinking about the success of all this stuff, well, we need to see the report to make sure, to know what we have.
I think it is a very interesting process, certainly an accelerated process along the lines of what we were talking about earlier today with the Secretary's initiatives, where things are really going to be sped up.
MR. WALLACE: I think Dr. Brailer has done a very good job of integrating this into the broader plan. One of our initial concerns -- and I have heard it expressed in things I have read that you guys have done -- is how do you make sure that what you say gets some action. The creation of AHIC, I think, gives us a vehicle to know that somebody is going to pick this up.
MR. COHN: Thank you very much. This, I understand, is the last full session for today. What is going to happen now is that we will take a break for 15 minutes. The subcommittee on privacy and confidentiality and the NHII work group comes back here.
The NHII work group, I think, will be involved with the first part of the conversation around the letter, and then the privacy committee will be dealing with plans for their future hearings.
That is sort of the plan for this room. Down in 305-A is the subcommittee on populations. Just to remind you, we have got subcommittees on standards and security at 8:00 a.m. tomorrow, as well as the work group on quality.
They are both on the third floor. The first one is in 325-A, the work group on quality is in 305-A. Then we move into our sessions.
We are going to be having presentations pretty much until noon. There is actually going to be a break between 9:00 and noon, even though it never showed up here. You can be guaranteed that.
MR. BLAIR: Could you clarify, if I may, so you are saying standards and security, as a breakout group, won't meet until tomorrow morning.
MR. COHN: Yes, from 8:00 to 8:50. That was done with your permission, Jeff.
MR. BLAIR: That is fine. I think the agenda from last week, I think, was different, and I just was making sure that I heard it correctly.
MR. COHN: Now the question I would have for you all to either decide now or decide tomorrow morning, we have groups in the morning, and then we basically don't have any action items for decision, but we do have obviously report outs from the subcommittees and work groups.
Now we can either, at noon, take lunch for an hour and come back for probably another hour's worth of work, or we can take a short break around noon, come back, and finish up by probably 1:15, 1:20.
I would actually be happy to do either. I am only reflecting on this, it is typically how we used to run the standards and security subcommittee, to try to get people out in a reasonable fashion. What would be your preference? Would people like to work through lunch?
MR. BLAIR: I move that we accept that motion.
MR. COHN: Okay, I am happy to run it either way. I just wanted to give you an option on that.
MR. HUNGATE: I would like to make sure the quality work group has a little more time than I typically take to talk about the meeting that we held earlier this month.
MR. COHN: What does that mean, Bob?
MR. HUNGATE: We haven't had our work group discussion tomorrow morning. So, I can't tell you what that is. I think we, as a work group, felt that we spent a very productive day, much at your original suggestion.
MR. COHN: And I certainly think we can give you five or 10 minutes.
MR. HUNGATE: Five or ten minutes will do it, but it I trigger more discussion than that, I won't be blamed for it.
MR. COHN: Anyway, with that, why don't we break and we will reconvene tomorrow morning. [Dinner logistics.] We will adjourn the full meeting, then, until tomorrow.
[Whereupon, at 3:30 p.m., the meeting was recessed, to reconvene the following day, Thursday, June 30, 2005.]