American Health Information Community
Consumer Empowerment Workgroup #22
Tuesday, January 29, 2008

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

>> Judy Sparrow:

Thank you. And good afternoon, everybody, and welcome to the 22nd meeting of the Consumer Empowerment Workgroup. Just a reminder that this is Federal Advisory Committee (inaudible) on the Internet, and there will be an opportunity at the close of the meeting for the public to make comments. Workgroup members, please remember to speak clearly and distinctly and identify yourself as before you begin to speak, and also, if you could mute your phone lines to reduce any background noise. With that, I will ask Chris or Alison to introduce those members on the telephone, and then we’ll go around the room here.

>> Christian Weaver:

Okay. Just give me one second here. And we have Miguel Touset from TRICARE. We have Nancy Davenport-Ennis. We have oh, I’m sorry. Did you want me to read the company as well?

>> Judy Sparrow:

Yeah, if you could, please.

>> Christian Weaver:

Okay. Sure. From the Patient Advocate Foundation, that was Nancy Davenport-Ennis; Kathy Ficco from St. Joseph’s Health System; Barbara Guest from the National Cancer Institute; Debbie Somers from SSA; Susan McAndrew from OCR; Ken Majkowski from RxHub; Lorraine Doo from CMS; Mark Goh from the Office of Minority Health; Justine Handelman from Blue Cross Blue Shield; Ross Martin from BearingPoint; Tom Horan from Claremont University; Myrl Weinberg from the National Health Council; Kim Nazi from the VA; Mike Kaszynski from OPM; Jason Bon I’m sorry Bonander from CDC; Matilde Gonzales from the Office of Minority Health; Karen Bell from ONC; and Josh Lemieux from the Markle Foundation; and Dr. Rose Marie Robertson from the American Health Association. Did we miss anybody on the phone?

>> Miguel Touset:

Yeah, this is Miguel Touset. I wanted folks to know that I’m sitting in for Colonel Davette Murray.

>> Judy Sparrow:

Great. Okay. Well, thank you. And then here in the room, we have...

>> Armin Weinberg:

Armin Weinberg, from Baylor College of Medicine in the Intercultural Cancer Council.

>> Cesar Palacios:

Cesar Palacios from Proyecto Salud Clinic.

>> Kat Mahan:

Kat Mahan with SureScripts.

>> Cinyon Reed:

Cinyon Reed with ONC.

>> Chitra Mohla:

Chitra Mohla with ONC.

>> Judy Sparrow:

Okay. And with that, let’s turn it over to our Co-chairs, Rose Marie Robertson and Nancy Davenport-Ennis. Thank you.

>> Nancy Davenport-Ennis:

Judy, thank you for those opening remarks. And welcome, Rose Marie, to the call. This is Nancy Davenport-Ennis. Rose Marie, I would ask if there is just an opening comment you would like to share.

>> Rose Marie Robertson:

I’d just like to welcome everyone. I think this is a particularly meaningful and important session of the Consumer Empowerment Workgroup on many levels, particularly in terms of bringing attention to special populations and the potential benefits that they might receive from personal health records, as well as the barriers and the complexities of providing those. So I’m eager to hear what our speakers have to say, as well as important work and important information about the work of the Consumer Empowerment Workgroup in general, so looking forward to a good meeting.

>> Nancy Davenport-Ennis:

Thank you, Rose Marie. And this is Nancy Davenport-Ennis. And certainly, I welcome all of you to the call today. We are particularly interested to have a session today with representatives from special populations to address us about their concerns and information concerning health information technology that is very important to them. I am certain that those of you on the call have received previously the minutes of the meeting that we convened of this Working Group on Wednesday, December the 5th, and noted that Garth Graham, Deputy Assistant Secretary for Minority Health, did present on how health IT how particularly telehealth can be used as a tool to reduce health disparities in racial, ethnic, and rural populations. We also had additional representatives to address us that particular day, and it was a result of the out(inaudible) work that they did that it was determined that having this meeting today and inviting other representatives from special populations to address us could bring great value to the Consumer Empowerment Working Group.

I would like to ask that the members of the committee approve the minutes and would ask if we have a motion for that, or are there any corrections or amendments to the meeting notes that have been distributed? (Pause) And as with our history of meetings, hearing no suggestions of amendments or changes to the minutes, I would then ask if you agree that the minutes need to be and should be accepted as presented. Will you please indicate that through your silence? (Pause) If there is opposition to the minutes, I would also ask that any opposition be brought forward so that the committee can review that. And if not, we accept the minutes as presented.

I would also like to thank Chitra there at HHS for preparing for us this afternoon a summary of some of the high points of the meeting that was last held with AHIC on January the 22nd. During the AHIC Community meeting, the Consumer Empowerment Working Group actually provided a report to the Secretary and AHIC. I’d like to share with you what we reviewed as those items that have been completed.

We showed that it was recommended that HITSP identify the technical and data standards to enable the availability of a core registration dataset and medication history. And we are pleased to report that that work has been completed.

It was recommended that a creation of additional AHIC Workgroup that would address the cross-cutting confidentiality, privacy, and security issues related to all the community charges. And we are pleased to report that a working group on privacy and security has been established, and they have convened meetings, and that the CE Working Group continues to have dialogue with them as they are moving forward in their work around confidentiality, privacy, and security.

It was recommended that HHS should promote consumer access to their personal health information in the trial implementation of the NHIN. And we are pleased to note that that work also has been completed.

There are other items that our Working Group has recommended that are still in progress, and we reviewed that at AHIC. They include the following: We recommended that federal agencies sponsor pilots for an electronic registration summary and medication history should work with appropriate private-sector health organizations to promote provider and consumer participation. And I am pleased to share with the Group this afternoon that that pilot is under way and we look forward to having a report out on that later in 2008.

It was recommended that HHS through CMS and AHRQ and other interested federal agencies and private sector that pilot programs that measure and demonstrate the value of an electronic registration and medication history to patients with chronic disease and their clinicians. Currently, CMS PHR pilot began in June of 2007 in collaboration with both AHIP and the Blue Cross Blue Shield Association. The CMS PHR pilot began in June 2007 in collaboration with AHIP and Blue Cross and CMS working with the Office of External Affairs to evaluate appropriate and effective outreach and messages. The anticipated completion date of that pilot is December 2008.

It was recommended in its final report the State Alliance for e-Health should include information on the variations involved with respect to consumer access to electronic health information and any relevant recommendations to improve this access. Initial research has been conducted on various state laws with respect to specifically protected information as it is used for the purpose of treatment, research, payment, and public health. And that work there is still work being done in this area. Most of the research has been completed by RTI and has been reported out to AHIC.

Recommendations concerning evaluation, using a standardized approach for assessing PHR use and value there were three areas in this particular recommendation that we address. Universal PHR definitions are needed, and right now, we don’t have those. PHR definitions will be available in March 2008, and then the request for proposals for grants and contracts will be further developed within this particular area.

So I think we are pleased that your Consumer Empowerment Working Group has certainly accomplished at least three items that we have now shown as completed and four that are in progress. So thanks to each of you for your input. There are particular members of this committee that have worked very hard in getting us to where we are, and we take you for that service. There is a great afternoon with presentations, four in particular, and then Garth Graham will also address us this afternoon on proposed recommendations. Your agenda reflects to you that the first presentation will be given by Dr. Gibbons, but we

>> Chitra Mohla:

Nancy, Dr. Gibbons has just arrived.

>> Nancy Davenport-Ennis:

All right, and so we are pleased that Dr. Gibbons is now with us. And Dr. Gibbons is an Associate Director at Johns Hopkins Urban Health Institute; a Director, Center for Community Health; and an Assistant Professor at Johns Hopkins School of Medicine. Dr. Gibbons, we welcome you to the Consumer Empowerment Working Group. We look forward to your remarks this afternoon. Thank you.

>> Chris Gibbons:

Thank you. I’m just getting my slides here.

>> Nancy Davenport-Ennis:

Okay.

>> Chris Gibbons:

Here we go. All right, well, let me just jump right into things. I know we only have 10 minutes or so, so I’ll move fairly rapidly.

As the first slide indicates it’s well-known to everybody here racial and ethnic disparities are an undeniable reality. But one thing that may not be generally recognized on the second slide there’s no one single cause. I mean, a lot of people like to say it’s all whatever, racism, despair you know, a lot of things. But as the third slide indicates, disparities result from complex interactions, many factors that act simultaneously and often cooperatively at individual, group, and societal levels over time. And this is an important dynamic to really understand if you’re going to understand disparities and be able to do something about them.

So on one hand, this means that a comprehensive understanding of the causes rather than a narrow understanding will require large and complex studies that yield large datasets. And obviously, right there, you’re going to have a required enhanced reliance on computers and IT. But really, that’s no surprise. It’s the other hand that I wanted to focus on today. On the other hand, part of the answer to addressing these disparities will be in developing remedies and tools to enable us to prevent disrepair, inequitable social conditions, and better address those disparities that already exist. And I do believe health information technologies and information and communication technologies that they refer to in Europe offer promise of achieving this goal.

Let me just get to the bottom line here. In the next slide, some of you may well know that recent advances in computer and information sciences have led to really absolute revolutions in medicine and critical research, the med sciences especially. And I actually believe it could do the same for disparities and preventions and social-behavioral population sciences if we similarly embrace the possibilities. Populomics is one example of an emerging field that is looking on these the potentials of technology in population health problems.

The next slide, though where most people are thinking these days is largely around HIE, electronic medical records, electronic public health records, etc., CPOE systems, e-consultation, and telemedicine. And while I think all of these are important and can have far-reaching effects, I really believe that they’re really just the tip of the iceberg, and there’s so, so, so much more that’s just not even considered.

And so what I’d like to do today is, rather than talk about one specific application that we or others may use, sort of paint a picture for you, perhaps a little vision of what the future might be, because it’s going to be a variety of tools on a variety of levels working together to achieve this end. And just give a couple of examples of some things that are out there right now. We’ve moved into an age we’re already in an age not just of always computing, but what people are referring to ubiquitous computing and pervasive computing. And as we have the term “e-health” and I’ve recently learned, in Europe, they’re starting to use a term “p-health,” which is personalized health, referring to this field, indicating progressively more and more being enmeshed with computers and information technology.

One particular technology, RFID, which is Radio Frequency Identification, I think, offers particular promise in this area. And basically, this is a technology that allows tele for example, allows telephone companies to know that it’s your cell phone that’s making the call, and therefore, they can identify you from another technology. But these types of technologies, along with mesh networks and WiMAX and nanotechnology, will usher in or are ushering in what is now being referred to as these three things here: H-to-H, H-to-T, and T-to-T.

H-to-H connectivity is the higher level of human connectivity is what we’re referring to here. Human-to-human connectivity will enable, in health care, providers and health care systems to stay in audio or visual contacts. We’re already there. That’s old news compared to what we’re talking about now. That’s your cell phones and your Blackberries and those kinds of things.

What’s upon us now is the H-to-T connectivity, in which it’ll enable providers and patients to know about the health status of individuals and populations at any time in real time. And this is coming from, you know, the miniaturization of processing power, which can then be pushed to the margin (inaudible) network, and then you have intelligent well, you have sensor technology, so now you have a computer chip which can enable you to whether it’s sensing environmental contaminants or heart rates or any other parameters, for that matter, and then wirelessly transmit it back to a physician, doctor, or health care system, wherever they may be. It’s essentially a thing, a technology, transferring information to the human, to the doctor, which is not possible.

And the final level of this, which is still yet in the future, but many people are talking about it now, particularly in Europe, is this T-to-T connectivity, which some are even referring to as “an Internet of things.” Here, you have not only the smart devices or the sensor technology, but because processing power is, one, so powerful and, two, so small, you can now program these things such that the intelligent devices will detect something and then, based on the algorithms that you program in, make a decision about things without the need for human interaction at time to time. So it’s a they’re connected by an Internet, but it’s things to things. And there are already some examples of these things: smart jackets which monitor your heart rate and blood pressure, insulin phones, smart gloves. These things are already out. The insulin phone’s actually already on the market.

So what we see here, with the at least what I see, with the advent of these kinds of things, is an unprecedented type of world, as this next slide says. In this world, you know, clinicians and researchers can understand how all kinds of factors not just clinical factors, but the factors in the community, the factors in the social realm that impact a patient’s behavior as well as health and health care outcomes can no longer be safe. Health risks are managed before they become (inaudible) and before patients ever need to go to a hospital. In this world, health interventions are not just delivered by patients taken to hospitals. They’re delivered by all kinds of technologies: Web, the game consoles, TV, cell phones.

You know, I heard a talk by the president of Nintendo a couple of years ago, and he said that over the next 10 years, his company intends to transform this whole market, because they’re going to be developing a game that even your grandmother could play. And the idea is not that she’s going to, you know, play a shoot-‘em-up game, but he might develop a cooking game or something else. It’s really a computer that can be used as a lifestyle instrument.

And my point is, we have to begin thinking that way in health care about computers, not just for the benefit of the clinician and data, but it can be very important in terms of intervention. And NHS, in England they’re already experimenting with interactive health TV. Almost everybody has a television, and now, with video on demand and other things, there can be an interactivity that has not been possible before. Can we derive health benefit from that, particularly on the marginalized and poor populations?

And then the efficacy of traditional interventions can be enhanced. It’s not only about doing new things that we can’t do, but can we do things that we currently do do them better by using technology along with them? In this world, clinical interventions can be delivered anywhere at any time, even to the homeless person who lives under the bridge. A variety of intervention genres can enable exclusive tailoring. Health care becomes proactive rather than reactive. Patients don’t delay seeking care, because they’re getting it all the time if they need it. Medical errors are rarely made. Health information is accessible in both provider- as well as patient-centric forms.

And because of these things, in my mind, over time, there exists real potential to make significant impact in the goal of reducing and eliminating disparities in health care access, utilization, and outcomes, and disparities in health status can similarly be affected. And that’s to say nothing about higher levels of disease risk characterization, clinical therapeutics, and on and on.

In the end, I think there are three basic ways that this can help. One, technology can help us understand better the complex interactions that lead to the genesis of disparities in the first place. Two, it can help providers understand better the role they play in either unconsciously or consciously producing these. And it can help finally, help us mitigate the effects of disparities, whether or not people actually change their behaviors. Thank you.

>> Nancy Davenport-Ennis:

Thank you for your presentation. And I know that we will look forward to having an exchange with you in terms of questions and answers as soon as we have heard the remaining speakers in this segment of the discussions. I’d like to introduce now Cesar Palacios, who is presenting to us today from Proyecto Salud Clinic in Wheaton, MD. We welcome you and look forward to your remarks. Thank you.

>> Cesar Palacios:

Thank you very much. My name is Cesar Palacios. I am the Executive Director of the Proyecto Salud Clinic in Wheaton, MD. And let me give you a little bit of background of the clinic. The clinic is a nonprofit organization since 1997 and (inaudible) stations in April 1998, but we’re going to celebrate our 10th anniversary this year. Proyecto is a part of an original coalition of Safety Net Clinics. There are 10 of these clinics in Montgomery County. Last year, these 10 clinics served 13,000 uninsured patients. We had a contractual relationship with the PCC, which is the Primary Care Coalition. This is a public-private partnership that works with the county government, and they manage they administer the funds. Last year, there were $7 million spent on this small coalition of 17 states and their clinics. Proyecto Salud currently has seven 14 clinical sessions, including evenings and Saturdays. The capacity of the clinic grew 39 percent just last year. We started using the electronic medical records 3 years ago in 2005, April.

The population we serve I would like to give a little bit of the information of this population, because this is a special group of people. We actually have to fine-tune many of the strategies to work with them. We have currently more than 3,000 applications, almost all of them are adult immigrants. One-third of them come from Central American countries. Close to 90 percent are Hispanic. The majority of them the language preferred: Spanish. All of them are low income 250 percent of the federal poverty guidelines, and they live in Montgomery County. There’s an increasing number of patients from African countries, slowly growing this group of patients. Seventy-five percent of our patients are female. Compared to the small coalition of Safety Net Clinics, we are a little bit different, since we have 90 percent of our patients Hispanic/Latino, but the coalition has 59 percent of all the patients served in Montgomery County who are uninsured are Latino and Hispanic. Sixteen percent are Asian in the small coalition, and 21 percent are Black or African-American.

You can see the services we provide. They are basically primary care, adult care, internal medicine, cardiology, gynecology, (inaudible) health, diabetes clinics and schools, (inaudible) services, medications, and referrals for the specialty services.

Talking a little bit about our experience in the electronic medical record, we have this the CHL Care, it’s called. It’s an open-source community health medical record, and it is used by a group of community clinics in all the D.C. metro area. The name of this is Medics. There are approximately 50 clinics in all the area of Virginia, Maryland, D.C. using this open source. It was first used by Proyecto and the other Safety Net Clinics in Montgomery County in July 2005. Before, there was a database for the diabetic patients. And last year there are several things that have been happening more or less at the same time in a period of 1218 months. Last year, this database for diabetic patients was merged into the CHL Care to have only one database for these electronic medical records. Proyecto, analyzing this situation, upgraded its IT system with computers in each room, and we started doing real-time data entry less than a year ago. The excellent result of this is that we have almost no backlog to prepare to report. The CHL Care database system is a parallel system connecting all the Safety Net Clinics in the area. There is work going on right now to connect five local hospitals in Montgomery County and some other hospitals in the Washington, DC, metro area.

Concerning the privacy and trust by using these electronic medical records, we had a patient consent that it is supposed to be understood and signed by each patient, and we don’t share the information if the patient hasn’t signed this agreement. Also, we have agreements that the providers and everybody in the clinical staff that is going to use these medical records they have to sign this consent for confidentiality.

We have also we started a bilingual newsletter last year, and we want to use it also as an educational tool. Last issue, we incorporated an article about electronic medical records, because we want to convey to all the patients the value of using this electronic medical record. There is a promotion of the Safety Net Clinics in the medical homes, in their efforts to reduce the number of patient visits to the emergency room of the hospital.

Of course, this is an ongoing effort, and we believe that by using these common databases clinical care, in addition to right now, we have the patients had the actually, less than a year ago, we started issuing this ID. And this is an instrument that is not just going to help us to authenticate the patient, but also is going to help us communicate the information of the patient to other providers clinical providers in the area, including of course the hospitals local hospitals and the health specialists.

The Safety Net Clinics basically provide primary health care, and there are a couple of projects in the county that provide specialty care. Of course, there is a challenge to absorb all this demand for services, and sometimes there is a waiting list to get special care. But this is another component that is going to be incorporated in the near future in which the referrals are made online. Actually, we started doing this online referrals.

But the next piece would be to have the specialist’s report uploaded into the database the CHL Care. I just wanted to show you a few snapshots of our database. As you can see, we have the first page. This page has to do with general information with the patient and demographics.

The second one one important component that we are emphasizing since the last part of last year has to do with self-management goals of the patient. Actually, this tool we’ve been using for a couple of years now in a diabetic school that we have, in which the patients are educated on how to self-manage their disease. And they also set specific goals. But the new thing about this is that now in the CHL Care, we can see the self-management goal of the patient, and everybody in the clinic can reinforce this goal that the patient has in every single moment or point of contact with the patient during the encounter. We have all the general information of the patients about allergies, medications, list of problems.

The next slide shows there are several windows here that we can see the findings of the current encounter, including physical exam, the objectives, objective assessment, and plan pretty comprehensive information from the patient. One new piece the next slide has to do with lab work. We currently have a contract with two local laboratories. The new thing that we are going to do this year and Proyecto is part of a pilot project with a second clinic of this regional coalition, which is to use Qwest 360, which is a software to upload into the CHL Care the results the lab results of each specific patient. So there’s not going to be mistakes by entering the data into the database, because it’s going to be specifically from the laboratory database.

Well, the next slide actually, this is supposed to be the last slide. But anyway, I’m going to talk about this. This is an ongoing effort in developing an e-chart. This is part of the proposed e-chart component (inaudible) a personal health record component that the Primary Care Coalition and the Safety Net Clinics are going to try to develop over a period of 3 years. Of course, we are trying to knock on doors, trying to get some grant funds to develop this piece. But this e-chart is going to be like the instrument to show a summary of the medical findings to share with the local hospitals. As I mentioned before, we are not completely connected yet with the local hospitals, but this is another piece that is going to be as a product of that effort, but we already have piece.

The last slide is about the referral. This is going to be a piece that is going to be also modified when we incorporate the possibility for the specialist to put into this database all the findings of the specialty referral. So we’re going to have a more efficient process to see the patient once they come back from their visit with the specialist.

Next slide talks about the opportunities that we see by using the CHL Care. First of all, two things that we can see can come because of the use of this database. Of course, the #1 has to do with our reporting system being able to easily develop reports, but not just for our funding sources. But also, we are looking to have more proactive care to have a better preventive care of the patient. This new the merged database, the CHL Care, that included the diabetic patients’ information this is an ongoing effort, but it’s going to be easier to develop; to query; to find out, for example, the number of patients with a specific age group that don’t have flu shots or hemoglobin A1c or is going to be really an excellent tool to conduct preventive and proactive care.

We see and this is under way as I mentioned to you, the referrals and request laboratories uploaded into the CHL Care a better management of chronic diseases that by the way, more than half of our patients have one or two chronic diseases. The most important is diabetes, and also hypertension problems. We see also that by using these patient IDs, one of the problems that we see at the beginning, there was concern that the patients weren’t going to be accepting the IDs. But we see it as a way in which they feel they belong to the clinic or they belong to these small, regional Safety Net Clinics. Of course, there’s a way to provide outside education, because we have the ID in use planned to be used when the patient visits other clinics in the area, in addition to the hospitals and specialists.

Some other opportunities that we see and at the present moment, we are trying to gather all the information needed to request some extra funds to AHRQ, which is the founding organization that provided the money to develop this database, the CHL Care. We are looking for the opportunity to develop the PHR piece of this component. Of course, this is a very complex piece, and but we see excellent opportunities for better communication and interaction between the patient and the providers to have, during the encounter and after the encounter, communication between the patient that we see it as a way for the patient to be more accountable for his or her health situation participation also on this. We have an ongoing dialogue to have all these pieces linked to our Web site, to the PCC Web site, or specific clinics’ Web sites. And luckily, they reacted to bring just copies of their health records of the patients to them. We are planning also to have access to computers in our waiting room, so they can check, if they want to, their information during the moment they are waiting for their visit.

Challenges that we see with the use of this technology first of all, I want to emphasize the challenging group of patients that the Safety Net Clinics in the area are facing. As you see, many most of our patients are foreign-born, many from Central and South America. They prefer to speak Spanish. There are some literacy issues even in Spanish, so in English, it’s another big obstacle. Also, health literacy is going to be a challenge. We are thinking that there’s going to be a special effort to incorporate the patient into all this educational movement for them to take advantage of these pieces of information. We don’t know exactly we want to find out, for example, how strong is the participation, not just of the patient, but the caregivers could be if they are elderly individuals, even though the group of elderly patients that we see is between 8 and 9 percent but anyway, there’s somebody else double-checking all the medical information and probably helping the patients make the decisions about his or her best care health care.

So we want to really understand the culturally and linguistically pieces to develop the PHR piece. We know this is going to be a big challenge, because it’s not just translating all this information into Spanish. We also think about the use of computers. We think positively that there are some younger generations and the patients have daughters or sons or nephews any other relatives that are computer literate, and they can help the patient to manage certain pieces of their medical record. But we are not just thinking about this piece. This piece is the one that we have ready right now.

But in the future, we’re even considering cell phones. Most of our patients have cell phones. And we wouldn’t get the other type of phone lines. It’s easier to get cell phones. There are several challenges to incorporate this piece. We are kind of far from that piece, but this is in our mind, because that might be a possibility. If it’s not computers even, we know that a lot of Hispanic I talk about Hispanics because Proyecto 90 percent are Hispanics and Latinos. But even with this group, a lot of the a good proportion of these patients really have access or access health information through the Internet. It’s not the majority. But what about health cell phones?

But there is another piece that, maybe in the future, we are going to be considering to incorporate. I don’t know about the daily call cell phone piece of piece, but I see really a great possibility. Actually, last week, we talked with a representative of our organization that was trying to get to see the possibility to work with our group of patients with cell phones’ reminders of their appointments or their prescriptions or the specific messages.

But we still have to think about developing all these pieces of information in Spanish. And apart from that, you know, we have so many different countries and groups in South America. So this Spanish has to be really understood by most everybody. It cannot be just standard Spanish. We have to really double-check the context of our patients to get a really better understanding of the messages.

But this is another piece that I just wanted to mention. I did include that piece on my presentation. That could be a possibility in the future. We don’t know for sure, but it could be a possibility. And...

>> Nancy Davenport-Ennis:

Dr. Palacios, we thank you so much for your presentation and appreciate so much that you have called forward the fact that you and your group, certainly, is looking at the use of cell phones and see that as perhaps a viable process to use in moving forward with health information technology. And I know that many of us on this call are going to have a number of questions for you to share additional ideas when we get to the question-and-answer discussion. So thank you so much.

>> Cesar Palacios:

Thank you very much.

>> Nancy Davenport-Ennis:

I do now want to introduce to us Kathy Ficco with St. Joseph’s Health System from Sonoma County. We welcome you.

>> Kathy Ficco:

Good afternoon, everyone. It is such a pleasure to have this opportunity to tell our story. So I’m the Executive Director of the community health clinics and programs which are part of the Community Benefit Department for St. Joseph’s Health System Sonoma County. And this wonderful project, using technology to improve migrant health care, was launched several years ago through a grant funded by the Rural Community Assistance Corporation and the California Endowment to link health care to housing for unaccompanied migrant workers. And our collaborative partners included Community Health Resources Development Center to develop the technology, the MiVIA; Vineyard Worker Services, a nonprofit social service agency in the Sonoma Valley that helps assist farm workers; and St. Joseph’s as the health partner.

And a little bit about Sonoma County: We’re north of in northern California. I don’t have a slide on this, but I thought I’d just share that for those that aren’t familiar. Our population is about 482,000; 19.4 percent of the population is Latino; and between 12,000 and 15,000 migrant and seasonal farmworkers are in our county, especially the higher census during the grape harvest. We’re known for the wine country. So the MiVIA is really a patient-owned electronic personal health record that we originally designed with input, actually, from a farmworker advisory committee to develop and make user-friendly for migrant and agricultural workers. And because we have a mobile medical clinic that we take out to the community, we very rapidly saw benefits for many of the patients served by our mobile clinic that have chronic illnesses. So those with diabetes, women with children who frequently lose their immunization records our CAAs, if they’re enrolling children in health insurance, would let them know about the MiVIA, and the moms really loved that feature for them. We expanded it also for homeless populations and to special-needs patience served by our mobile clinic and our mobile dental. It is Web-based secure technology, HIPAA compliant. Access is granted by the clinician to the clinicians by the MiVIA members. So they have a password. They provide their clinician with a limited access code, and that’s how the clinician is able to access their information. Next slide please.

So the MiVIA is able to store both medical and dental information. And as I said, our mobile dental clinician the dentist there really was engaged with the MiVIA, because she realized early on that sometimes the person’s first entree into the health care system was through a dental evaluation (laugh) found out they’d never been to the doctor in a long time and had some other issues. So she started entering dental information and health information like allergies, etc. It provides a photo ID and emergency card, and this was really an unintended benefit. We found out that the many of the clients we serve are immigrants. Many lack photo identification and this photo ID had the correct spelling of their name, which medical providers loved; had the correct spelling of their address; and frequently, they know where they live, but they don’t know how to spell the names of these addresses and things, so when they went to apply for a job, it kind of validated them as a person and where they resided. The local exchange bank honored it for them to cash checks. The local library, which we referred them to as a resource to be able to use the computer, allowed them to get library cards.

And a wonderful incentive that was offered with the MiVIA was providing people a permanent address by offering them an email account. And many of them really appreciated that feature. It allowed them to stay in contact with their families in Mexico. It also provides wonderful information and resource links to Medline Plus, AHRQ, and Bureau of Primary Health Care. So I didn’t provide you a lot of slides showing this, but certainly, you could take a tour at your own liberty and check it out.

But what our Promotoras would do which are kind of key to our success and I’ll tell you more about later they would, by introducing the MiVIA to them, say, you know, “Bring your prescriptions, and I’ll show you how the Internet can help you learn more about them.” And many times, clients, you know, spend maybe 15 minutes with a physician, who’s explaining a lot of things to them. They get a diagnosis of, say, anemia, but they don’t know what that means. So by working with the Promotora, they were able to go back and get more information utilizing the Internet. And with the MiVIA, you could enroll one individual or up to eight members of their family.

And with input from the clinicians, a clinician portal was created where professional entry and verification could occur. And that was because, as we rolled it out, clinicians said, “Well, it’s well and good that a client’s entering their data, but how can we trust it?”, to which I would say, “Well, how do you trust the history and the physical that you take in a doctor’s office? You know, I mean, you’re not putting them through a lie detector test.” But nonetheless, if another clinician was entering data, they’d want to know that the clinician entered that and have some kind of a verification. So there are actually two portals to the same record. Both the client and the clinician can see everything in the record. And we’ll go on to the next slide.

And so how it was created, obviously, is, we know that mobile populations access many clinics and health systems, and their care is very fragmented and disjointed, and the MiVIA really serves as the bridge, or you could even call it even a personal RHIO between disparate health care systems, especially for those health care entities such as our own that is not part of a closed system. Obviously, we expected it to help promote continuity of care. And certainly one of the biggest benefits my clinicians appreciate is the fact that, “Gee, if a patient had all the patients we saw had MiVIA’s or personal health records leaving a particular health system and coming to another, how beneficial that would be.” You wouldn’t always have to start from ground zero repeating tests that have already done before when you don’t have a person’s history. It actually engages and empowers the patient as an active partner in their own health care, and that’s because or the work that the Promotora’s do and our health care providers.

I think the MiVIA has provided an IT tool for engaging people in better understanding their health condition and owning their own information, which is very important to them. It’s different than when you get to the doctor and they keep a record on you, but you leave with a prescription and some instructions, but you don’t really take all of your health information. The MiVIA’s really their own little passport for health with their own record. Next slide, please.

So how do we go about doing the MiVIA? And I think really one of the keys for our success in working with the vulnerable population groups that we do are, #1, the relationship and trust that we have in the community. Our mobile clinics have been serving this population for since 1990, and so they’ve been entrusting their kids and their own health care to us over time. And we are blessed to have Promotoras de Salud that go out with our mobile clinic.

And you’re seeing here a little picture of Jessica actually doing a real-time enrollment with someone. And basically, she just starts with the basics with them. She’ll ask them where in Mexico they came from, and she’ll Google that site, and they’re enthralled to get to see that, or is there anything you’ve ever wanted to know about or learn about? I’ll show you how the computer can help you with that. And you know, her job is really to help enroll them in the project product, and she does that with their permission. And she helps to do the photo ID, of course, and get their emergency contact information kind of the demographic stuff. And then, once they’re seen on the mobile clinic, that’s the point at which the clinician enters more of the health data.

So over the last several years, we have 5,0006,000 MiVIA clients enrolled. And because they’re so many different the fields in the MiVIA are very user friendly, but because there are so many great links to it for people, she usually tries to check back with them and see how they’re going and make sure they’re really comfortable with it so they gain an understanding. She had one gentleman who had very little experience with a computer, and she worked with him over time as he came to the mobile clinic for his various visits for dental or medical. And over time, he got more and more engaged with the computer, and she said he said to her, “You know what? I’m going to go to school. I want to learn more about computers, and I want to further my education.” So it opens doors for people. Next slide, please.

Obviously, it’s helping to reduce the digital divide. It provides access to health and community services, clinics, libraries, English-as-a-second-language classes. There’s links to the Bureau of Primary Health care. We’ve as I said, we worked with the Farmworker Advisory Committee, and we said, “If you’re a mobile person, what services are beneficial to you?” And so links were created specific to that. It empowers the consumer to be involved in their own health condition. As I said, doctors’ visits can be pretty short and compressed. And if you’re, you know, not understanding medical terminology, it’s beneficial to know that there are resources you can access after the fact to gain more information. And obviously, we all want to promote health care literacy with our clients and engage them with them. But one of the major factors I think that we

>> Ross Martin:

Kathy?

>> Kathy Ficco:

Yes.

>> Ross Martin:

Hi. This is Ross Martin. I need to jump in for a second. Myself and, I think, someone on an unrelated call have to jump out for about an hour.

>> Kathy Ficco:

Oh, okay. Okay.

>> Ross Martin:

We’ll call back.

>> Kathy Ficco:

Okay. No problem. Thank you.

Anyway, a lot of what the clients tell us is the peace of mind knowing that their information is safely stored and can follow them wherever they go. Next slide, please.

So we’ve learned some lessons by expanding it to the homeless population. The clients were thrilled to have a concise document to store their health information. Many times, they have many little pieces of paper in the furthest reaches of their backpacks, and they’re pulling all this out, you know, trying to tell the different emergency department physicians that they’re getting their information from our clinics. We found that the homeless shelters utilize a HUD HIMS photo ID and database that is stays with the different homeless shelters, doesn’t really travel with the patient. But because both systems were Web based, we were able to copy and paste some information with the client’s permission. And the MiVIA photo ID was actually used by clients to pick up their prescription voucher at local pharmacies. Next slide.

And we expanded it to children with special needs conditions, and the parents were really grateful for this. They spent so much of their time managing their children’s health care, making medical appointments, that it was much easier to have a single repository for their health information that they could take anywhere with them. And again, if people are traversing unclosed health systems, where they’re going to a specialist, a primary care, and all of this, it’s really nice to have the MiVIA be the bridge and the conduit of information.

And there was actually a special needs patient was enrolled in MiVIA, and she was very delighted that she had this tool to store her health information. She’s a fairly, well, middle-aged adult, and her mother had been primarily responsible for managing her health care and her health care decisions, but her mom had recently passed away. And she was scared about that. And the MiVIA provided her with a resource to hold her information and gave her peace of mind knowing that now she could go to the doctor and manage her home care on her own. So I just love that story. Next slide.

People have asked us, “It’s well and good you’re enrolling all these people in the MiVIA, but how do you know that they are really using it?” And so Jessica, our Promotora that enrolls folks, actually called people back, and she called over 600 people back. Forty percent said they used the MiVIA on a regular basis. Eight percent of the clients stated they had no prior computer experience and received some basic computer training working with Jessica and then got referred to other resources. And as you can see from the slide, 87 percent of the clients enrolled do not have a computer in their own home but know how to access the resources available in their community. So it’s really amazing. Next slide.

And Dr. Gorchoff is a former Medical Director of the Redwood Community Health Coalition, and I just love his quote here that he said: “The elegant simplicity is the beauty of MiVIA, because it’s all Web based, secure....” It’s not a really expensive computer software system to purchase. And if anyone has a laptop or computer and Internet access, they can utilize this. And the goal, of course, is to be able to have doctors send the patient information anywhere to the PHR from any health information record electronic health record, and the MiVIA has been used and expanded to develop modules for self-management. There’s a health system in the Tehachapis and kind of southeast California, using it to manage the care of diabetic patients and having them self-manage their glucometers and entering that data, and a nurse is case-managing them from afar using the MiVIA. And of course, having access to this information 24/7 is so important, and I think a lot of patients that’s why the MiVIA is important to them. And the emergency card like, what if I was ill or injured or went to an emergency room? I’d want people to know what was wrong with me and how to best take care of me. And of course, following the issues with Hurricane Katrina and people not knowing their pharmaceuticals and all of that, there are certainly the MiVIA would be beneficial in the event of disaster preparedness. Next slide.

So this is the front page of the MiVIA. And again, you can go to the Web site to take a tour. And the print’s kind of small, because it’s on a you know, a PowerPoint slide, so I apologize for that. Next slide, please.

And this is just an example of the photo ID emergency card. And we take a picture it’s about the size of a credit card, and we laminate it after we put in their basic demographic information: their medications, their allergies, their physician or clinic that they go to, emergency contact information. And our partner at Vineyard Worker Services actually got a special plastic card maker, so it’s more of the plastic nature, so and they do that based upon requests from their population that they were enrolling. Next slide.

And then this just shows kind of the expansion of the MiVIA over time through our here in Sonoma County, the it’s expanded beyond our mobile medical and dental clinics to include other community clinics. There’s a family practice residency program using it as a bridge clinic for diabetics, homeless resource center, and others. In Hood River, OR, there’s a mobile medical clinic with a rural clinic and a hospital, and they actually are using it as their EMR Lite, as you would have it, where they’re enrolling all of their patients so that when the patients access the hospital for care, the hospital knows what was done at the clinic and vice versa. And then in the Central Valley, there are a couple of hospitals and three rural clinics in Humboldt. They’re using it to case manage and utilize the medication management aspects of the MiVIA, which is a JCAHO requirement this year patient safety goal, so for their patients with chronic diseases. And in Finger Lakes, NY, they have linked the MiVIA to a telemedicine project for five clinics and their voucher program, so it’s pretty exciting there.

So I think that concludes my presentation. I’ve shared some of the patient stories with you, and I am ready for your questions whenever appropriate. Thank you.

>> Nancy Davenport-Ennis:

Kathy, thank you so much for an outstanding presentation, and it’s certainly good to have MiVIA back with the Consumer Empowerment Working Group.

>> Kathy Ficco:

Oh, our pleasure. Thank you so much.

>> Nancy Davenport-Ennis:

For this presentation, thank you and best regards.

And now it’s a significant pleasure to me personally and, I know, to all of us who are on this call today professionally to welcome Dr. Armin Weinberg, who is the cofounder of the Intercultural Cancer Council as well as the Director of Chronic Disease Research Center and a professor of medicine at Baylor College of Medicine. Dr. Weinberg, we welcome you.

>> Armin Weinberg:

Thanks, Nancy, and it’s a pleasure to be here. And thanks for the opportunity to be a member of this Working Group but also present some remarks to you today.

I’ve titled this little comment “Now, Not Later,” and I think, listening to these three preceding presentations, it’s actually is a perfect setup for that. So I want to jump right into it and say that my task, as I thought, in the next slide, was to present some opportunities and challenges and the solutions to how best to implement the health IT strategies among racial and ethnic underserved populations. The perspective that I want to bring to this is 30 years focused on putting knowledge to use and also 20 years of trying to connect those experiencing disparities with those who are able to help eliminate them. The next slide, please.

This is a slide from 1975-ish that was part of what was called the First National Cardiovascular Demonstration Center. That’s what brought me from Ohio to Texas to be with Dr. DeBakey in this initiative. And he had this idea at that time that if we put scientists, educators, clinicians all in the same center, we might actually be able to disseminate the results of research in a timely fashion to benefit the community. After about 2 years of trying to head up the education effort on that, I had this slide done by a cartoonist that we had in our Medical Illustration Department, illustrating what I conceived at the time was the problem, and that is that we tended to be in our ivory castle, trying to figure out how to get that wonderful new knowledge across the moat to the people who were waiting on the other side.

I have to tell you, the perspective I want to share, however, is the good news is, we have learned some things on how to make progress here. At Baylor right now Baylor College of Medicine we have launched a new personalized medicine initiative. And part of my center’s challenge is it’s related to health information technology. I’m very interested, because I’m trying to understand how we can be sure that this not only benefits those who have access today but those who we see in all our health care facilities, our county hospital, VA, etc. So this is one part of the perspective. And the next slide, please.

This is a composite of some of the things that represent the 20-plus years of experience in health disparities work. And I use this because the Intercultural Cancer Council really does represent an organization of thousands of individuals; hundreds of community- and faith-based organizations; national partners, including many in this room, who have come together to try and figure out how to get information to people so that they can hopefully address some of the disparities that they’re encountering. We do this in a variety of ways. As you can see, we’ve also partnered with community groups, television programming, and a variety of other techniques that we feel, you know, basically, are again taking information of one sort or another. Now, I can’t tell you that the in the interest of time, I am going to go quickly to the next slide.

I think the work that’s been done by the AHIC the American Health Information Community; I’ve got it to date has been very appreciated. I went back, and I’ve been trying to read as much as I possibly can. There’s a lot of really important work that’s been done: standards, discussions about standards, the issues of privacy, trust. You know, it’s solutions oriented. I’m very impressed that the you know, we’re seeing things shared with people like that. I think there’s also an understanding that we’re talking about some of the very fundamentals about how you communicate information that is clear, safe, reliable. And I do think it’s also fair to say we’re going through a metamorphosis of the health care system of some sort, and hopefully, it’s going to be one that we all can participate in and benefit from.

So given that, however, with all this discussion, I will say that I think it’s important for us to continue to start a discussion about how we today start to really engage the communities at large, the people who are the if you will, the target of our affection. So we need to figure out how to do that more quickly, and I’m going to make some recommendations to this effect if I can. Next slide please.

So, the question, when I started to think about this, was not you know, it’s “when,” and the answer is “now” again, not “later.” And the reason, again, for this is that if you look at some of the work that’s been done in terms of getting people to adopt, you know, information and apply it something like, “Okay, I just spent 2 days at a conference that was, again, looking at behavior research and how we apply it in practice and, you know, the policy.”

And it was really clear that incentives are really important. Use is also important feedback, getting some familiarity with these things. It’s really clear that while we’re looking at some of the long-term visionary things, the future of the research, the technology by the way, the bio-analytic toilet was always one of those things that I thought was really (laugh) but I think there are a number of these things that we can talk about and work towards. But today, there are many things that we also can apply. And I’d like to again, spend some time on that, because I think this is the near term. We have to engage the public as a whole and the consumers as a whole as quickly as possible so that there is a market, so that there is a need, there’s a benefit, there’s an appreciation, there’s value given to the use of this kind of information technology, whatever form it takes. So I’m going to go to my recommendations very quickly, give you a couple of these and some examples, hopefully, that’ll make my point and finish up this in time.

The first point is, I think we should have an effort that focuses on those with limited resources and who have already joined the information technology revolution. Now I heard, again, perfect examples of this. So, I’ll tell you my thinking: that there’s programs about disparities-reducing advances project that’s being done by the Institute of Alternative Futures with a number of public-, private-, and nonprofit-sector and federal agencies participating. And they’ve been looking at some very interesting things like, guess what, studies about which of these advances we could actually move more quickly. And computers were one of the things. The Internet was one of the things.

The cell phone (inaudible) was one of those things that they concluded really ought to be seized upon now. It’s here now. It’s available. It’s used. It’s accepted. So as I was driving over here from my other meeting, I asked the taxi driver did he know what health information was or technology was and did he ever seek information from sources like this. He said no. He said, “But my wife does, because she has access to the computer at home. But I work. I’m driving all day.” I said, “If you could access it on your phone, would you maybe use it?” He said, “Yeah, I think I might, because I’ve got to wait around, you know.” So he would use it, but he didn’t have a computer in his car that he could access. So I think it just typifies the fact that there are people with these different technologies in different forms that we have to take advantage of. That is my first recommendation.

Second recommendation: I think we need to launch an aggressive set of programs designed to engage young minorities/underserved health professionals in the design and use of HIT. It’s a workforce issue. If we don’t address it in this regard, we see it in all sorts of other areas. If we don’t begin right now to try and take advantage of stimulating and developing these kind of young professionals, okay, and technicians, whatever, then it will be a missed opportunity. And I think (inaudible).

So the third one: I think we should provide health care provide incentives to (inaudible) oh, it’s not my phone.

>> Christian Weaver:

The phones occasionally will do that.

>> :

I’ll turn it off.

>> :

Right.

>> :

Cool.

>> Armin Weinberg:

Okay, so providing this, you know, to health cares with incentives again, one of the ways to really get change is to provide incentives. I saw an earlier report this week presented to the AHIC report that said one of the barriers to physician adoption of these things was, you know, sort of capital investments, the capital budget, the incentives. So I think we need to recognize if we’re going to provide these sort of things, especially for those who are serving the underserved in this country, we need to provide incentives, and those who have any opportunity should be thinking, again, as broadly as possible.

The next recommendation is to establish an implementation scheme that cuts across all appropriate DHHS and other federal agencies and programs with the requirement of public and private involvement and accountability. This has been proven now to be, I think, very effective. Look at this committee. Look at this Workgroup. You know, it’s making it happen. So I think we can do it, but we need to do it in a very systematic and aggressive way, not a passive way, not in a you know, kind of let it happen the difference between diffusion and dissemination, you know. By design, get it done, not by accident or by, you know, kind of convenience.

I think this is, again, particularly a really great opportunity when you look at the things that, you know, a lot of other agencies and federal programs are also thinking about, whether it’s HUD, transportation you know, obviously, the Office of Minority Health and HHS and other groups are keenly aware of trying to coordinate these efforts to maximize the effort, especially when dollars are tight and the challenges are significant and the opportunities, on the other hand, are here and present. So we don’t want to miss those opportunities: NIH again, CDC, HRSA, thinking about a network of community clinics. You know, you’ve got not one or two; you’ve got thousands of opportunities to reach into communities with new examples of this kind of technology applied.

My last recommendation is, I think we should empower communities to play a role in health information technology by committing funds that will support, for 510 years, plans that promote applications within existing social, health care, and service sectors that first focus on the consumer needs rather than the system’s needs. And the reason that I say that by the way, I’m sorry. That was a run-on sentence. My English teachers always told me that was my problem. But anyway, the reason I say this is that I think one of the real keys is, in any form of communication or whatever, you have to start with “Is someone interested?” And I think the sooner we can get these sorts of things we’ve heard about today, and others that I’ve seen and read about that have been shared here, into the community and applied again, I think it would be really, really timely.

This’ll help in so many ways. It will help, for example, when we get to something that I do a fair amount on is also looking at elimination of disparities in clinical trials. We have a lot of barriers that we could overcome. We get people enrolled in studies, but we have a high dropout of minority and underserved populations. Some of it is transportation simply. It’s communication. Think of what we could do if we had pods in a barber shop or a beauty shop or a neighborhood clinic or a, you know, grocery store or a pharmacy. There’s a lot of opportunity in communities where transportation is a barrier that we could overcome with a simple technology: kiosks, telephones you name it telemonitoring. You could even do teleconsultation for psychiatric you know, it’s been demonstrated over and over again where you can move into these community centers that exist churches and other centers. So I think it’s very important that we try and engage the community in demonstrating the power of this technology.

So I’m going to stop with one last slide and say that the clock is ticking. So I said the clock is ticking because I was trying to think two things. One, I was trying to think about technology and information, right? The clock is a good example of technology. It was a basic, simple device that came about to be very useful. So using it trying to keep on time here. I have 1 more minute, so I’m going to try and do this in 1 minute. And then, as you know, on a clock, you have the small hand, and that’s good at that’s for taking, you know, things like a pulse, okay? We can use it in medicine. People can use it to watch, you know, whether they’re going to make connections or make a call or meet somebody. This is information that is very basic sense. We need to have it available, and it has to be something that is, again, valued by the users as well as the people who are trying to provide it. So I think, you know, we have to make sure that people know how to tell time. And that’s what I’m talking about. The sooner we get this into the community, the sooner we get it used, people will know how to use this technology effectively, at whatever stage it’s at now, and the more demand we’ll have for improvements that will be sustainable.

So to make this for the consumer, I took a quote from my father, who is 95 and still sends me emails twice a day. Okay? (Laugh) And this is he always closes with a little word of wisdom, and this is one that I thought was very appropriate: “If I am not for myself, who will be for me? If I am not for others, what am I? And if not now, when?” And I’ll just thank you, Nancy, again for giving me the opportunity to make these remarks.

>> Nancy Davenport-Ennis:

Armin, I know that everyone on this call enjoyed your remarks, as did I, and I think we’re all looking forward now to being able to have an opportunity for questions and answers from committee members who are on the phone. So I’d like to open the phone lines for discussion, although we do need to hear from Garth Graham before we do that, according to our agenda. So Garth, let me go to you

>> Garth Graham:

Sure.

>> Nancy Davenport-Ennis:

and have you review your proposed recommendations, and then we’ll go to the discussion.

>> Garth Graham:

Okay. Thanks, Judy.

>> :

Nancy.

>> Garth Graham:

So this is a journey that we have embarked on over the past couple of meetings, not just in this form, but it’s something that we have talked about in a number of different contexts. I want to do this, you know, kind of backing up what Armin was saying. You know, we’ve all heard the old adage that leadership is going is pursuing a path where no one has been before and leaving a trail behind you. That’s essentially what we’re doing here. We’re really looking at what it is that we can do in terms of building the building blocks around making health information technology a useful tool to reduce health disparities. We’ve heard a number of interesting thoughts and ideas from Chris, Cesar, Kathy, and Armin, but really, even building on the prior conversations that we had in the last meeting, where we really kind of looked in terms of consolidating all of those the kind of the thinking and the ideologies and the generic ideas around infrastructure in terms of what are some of the recommendations that we could pull together and consolidate in terms of moving forward through this Workgroup or push through the AHIC towards the Secretary.

So I’m going to go with this and articulate the first recommendation. Next slide, please. So the first recommendation the first proposed recommendation is to proactively work to include to increase the inclusion of racial and ethnic minorities and people with disabilities in HIT delivery systems. Any development and use of HIT for patients and providers should ensure that racial, ethnic minorities and persons with disabilities are included. An example of this would be certified products and small, one- or two-physician offices in urban sites that serve communities with high racial and ethnic disparities and include racial and ethnic minorities and people with disabilities as patients and providers in these cases. What this allows us to do is even along the similar vein that Armin was talking about: You know, as we move forward with the second hand and the hour hand, the second hand actually is built in terms of the timing for the hour hand. So we’re talking about actually building the case and building the infrastructure around the strategic policies dealing with the implementation of health IT around the reduction of health disparities. So these examples actually serve as pertinent ways in terms of going, again, back to Armin’s example really moving the second hand forward. Next slide, please.

One of the things that has come up and, I think, in all these varied presentations is the issue about communication between patient and provider. (Inaudible) a variety of different contexts in terms of empowering patients, and also in terms of empowering providers, and actually serving to strengthen the linkage between the two. We heard about heard the concepts of cell phones and other mediums in terms of things that we can do to support better communication between patients in a health care system. So an example of this: We thought, again, going back to the second hand, building further building the case and supporting the use of secure messaging pilots in underserved areas. And we have to make sure that the way in which these messages or information is sent or information is delivered is actually secure. We all have building on the prior presentation from the last time we got together, recognizing that information of issues around trust and security are paramount, especially dealing with underserved communities.

The third recommendation the final recommendation, again, is kind of gleaning on some of the stuff you heard here today but also, again, going back to several prior conversations and looking at supporting public-private partnerships to market and increase education and usage of information technologies by racial and ethnic minorities through reduced health disparities. Armin was touching on this earlier, and I think Chris was also alluding to the fact that, you know, how we empower people with information is going to be key. And also is this issue of realizing that, you know, there’s a role for the public sector and a role for the private sector. There were some pretty good examples of potential public-private partnerships in terms of how we increase education and usage of information technology.

So those were the three recommendations that we thought that one of the things we did was, we got a peek at some of the other presentations before, so we were able to kind of consolidate the other thinking from this testimony period as well as the prior meetings that we had. I want to underscore the point I made earlier: The area that we’re stepping into is new. The area we’re stepping into is so brand new that I will just term that it’s in its infancy. And what we’re doing here is consolidating the argument. We are conceptualizing the vision and going about the vision with a strategy. So each of these three recommendations is really behind the vision that you’ve seen articulated by our presenters here. We’re really consolidating it into a strategy with building blocks in terms of how we move forward.

So I’m going to stop there, and I think that leaves us with about 5 or 6 minutes of some really intense questions for discussion.

>> Nancy Davenport-Ennis:

(Laugh) You’re absolutely right, Garth. And with that, the floor is open for questions.

>> Charles Safran:

Hi. Yeah, this is Charlie Safran here.

>> Nancy Davenport-Ennis:

Hi, Charlie.

>> Charles Safran:

Hi, how are you doing?

>> Nancy Davenport-Ennis:

I’m doing well.

>> Charles Safran:

I’m so I enjoyed all the presentations, and I was wondering if we might be able to get some comment from our speakers a little bit more about the promise what they think of the promise of cell phone technology. I think it was it’s been it was mentioned sort of peripherally in at least two of the presentations. Like, specifically, when one tries to put forward applications, personal health records, and others, we get criticized or there is frequently the criticism of access. And I wonder what the speakers think of SMS or text messaging as a strategy that we could deploy here and now and whether that would be something that our committee might be able to recommend, given the prevalence of cell phone technology, I believe, even in inner-city populations.

>> Garth Graham:

You want to go?

>> Armin Weinberg:

Sure. So I think a couple of things I’ll try to be brief to allow others to talk. Certainly in terms of access or, put this way, who has cell phones, you’re right: A lot of minority populations have a lot of cell phones. In fact, Hispanic populations actually use the cell phone more than any other technology. And they’re they don’t it could still be some growth in the number who have it, but in terms of having that technology and using it, it’s there. My so from that perspective, I think it’s a promising way to go.

The thought I have in general, though, with all of these things is, I think we’re so as Garth was saying, this feels extremely new, and there’s a lot of potential and a lot of excitement. But we, in some ways, might be putting the cart before the horse, because I don’t honestly think we know enough that is, scientists and clinicians about why people do or don’t use what forms of technology and then can use that knowledge to build the right kind. And so we can make text-messaging applications to send to people, but what effect will it have on behavior change? And the question before that is, you know, is that even something that potentially would work for a given group?

As just one quick example, there is some of you may be aware of the AOCR, the Association of Online Cancer Resource I forgot the exact name. But basically, it’s online chat groups and discussion groups for people with cancer to so technology they send about a million and a half emails per week. I had the opportunity at a meeting a couple of years ago to talk to the founder of that organization. It started small, and now it’s huge across the world. But he said he’s done everything he possibly can do to get African-Americans to use it. They just don’t do text-based delivery systems. And so and actually he’s beginning to look into that. Now I’m not saying you can’t get African-Americans to do it, but we don’t have a good sense about we know people have things, but I don’t think we you know, if we approached cancer research or HIV research in the way we’re doing “Oh, let’s just build this and see what happens” it wouldn’t go too far. So I think some more foundational, formative work needs to be done.

I’d like to just comment that there’s a paper that, Nancy, I bet we could get from Clem Bezold from that Institute for Alternative Futures. They did a nice paper, one that looked at the possibility of using cell phone technology that looked at some of these very issues. So we can certainly provide that as backup, I’m sure. The thing that I would say is that, you know, as we looked at that and I remember, from that paper, one thing was the quickness of the emerging technology here in what we call a cell phone. The one that I have I couldn’t turn off a minute ago, you know, can now do you know, can get the wi-fi, you know. And that wi-fi infrastructure is booming.

So you know, it’s so that would then take you to where some of the things I heard about accessing the Internet, you know, whether it’s for the MiVIA for, you know, whatever it doesn’t have to be on a computer. You could literally be doing these things from a cell phone or what we consider to be a cell phone. I guess basically a PDA at that time. But on the Short Messaging Sys what is it? SMS, whatever the last stuff I don’t remember, but anyway, “Short Message” I got you know, you could see today where you could use this for a lot of things, you know, for those who might benefit from it, or you could use it for like the airlines do, for those who may not use the text for example, a reminder of your appointment or taking a pill, which are very nice self-, you know, management techniques that can be very helpful. You can look at it for getting directions, one of the big problems: “How do I get to the clinic that I’m supposed to go to, you know, for this sort of x-ray or CT or whatever?”

So I think there’s some very fundam and that’s what I am saying, you know, it’s not unlikely that we could take some small steps where people become users, if you will in a positive sense, users of this kind of technology.

>> Nancy Davenport-Ennis:

Armin, I think that’s a good suggestion and would ask do you have if you have a copy of the paper or the title of the paper you could forward.

>> Armin Weinberg:

Absolutely.

>> Nancy Davenport-Ennis:

We’ll be more than happy to get that distributed.

>> Armin Weinberg:

Sure.

>> Nancy Davenport-Ennis:

Okay, thank you so much. Other questions or comments for the presenters?

>> Robert Tennant:

Question on the phone. It’s Rob Tennant with the Medical Group Management Association, and I echo the earlier comment: I thought the presentations were excellent. I have a question, and it was directly brought up by Dr. Weinberg, and that is provider incentives to use the technology, and you mentioned capital costs for providers, but it’s also a time issue. If we want providers to be reviewing PHRs and updating PHRs, that’s going to take time, and that’s time away from seeing other patients. So I wanted to have maybe the speakers address the issue of incentives, where should incentives come from, what should those incentives look like.

>> Garth Graham:

Well, you know, outside of my saying something else, what Chris said, and as I was articulating earlier, it’s very, very important in terms of building the blocks of a solid vision. You don’t want to put a tremendous amount of incentivization behind something that you don’t already know a lot about. A lot of things we talked about here was this idea of pilot projects and basically building the case. And that’s important because as this field grows from its infancy into young adulthood, it’s going to be looking back at some of these early case studies and some of these early pieces of information. That’s very important.

You know, when I was at Yale, we had started up a company, and we were sure it was going to work, because when we looked at all of the other companies that did medication reminders, we were astounded at the money they were going to make. And when we actually implemented what we thought we were going to do, it didn’t. And part of the reason why it didn’t work is, we had been looking at everybody else without understanding a lot about what we were going to be doing.

Why do I say that? Well, what we’re talking about here is looking at a variety of different examples and extrapolating it to the world that we live in on a smaller and a larger scale. I think what we need to be careful of, especially when we start talking about incentivization and what we incentivize, is understanding and making sure that we move in a methodologically sound way so that when we look back at what we’ve done, we can at least base it on some evidence and, as Chris was saying, some science. And then in public health, science can get fuzzy, but I think this is one of those areas in which we can actually build a solid scientific basis. Please go ahead, Armin.

>> Armin Weinberg:

Yeah, you know, I think Chris by the way, I liked your recommendations, by the way.

>> Garth Graham:

Yes, thank you very much.

>> Armin Weinberg:

But I would say that, you know, that there is I didn’t mean to imply capital was the only like I said, this was just an article that I just happened to catch the you know, the essence of from an earlier meeting apparently this week. It was reported on. But because it did talk about those issues as well, and certainly we know that with any technological advance, there’s going to or any system that you incorporate into practice, there is a cost associated with it. The hope is that you get some benefit from doing it as well some increased efficiency as well. And those are the things that evidence and experience, I think, you know, have to bring to bear, whether you’re going to get, you know, the reimbursement for taking the time to use those systems and so on.

But I tell you, I have one and this is a technology example that I saw at the University of Texas Medical Branch in Galveston, which provides health care to the prisoners through what’s called the Texas Department of Criminal Justice. And what they did is, they did an unbelievable job of taking telemedicine and showing how, with the system that they put in place, they were actually able to lower costs, okay, but provide better outcomes, more standardized care, you know, more efficiently through a distributed system, you know. But it had its startup costs, you know, and it that kind of research, you know, and experience to get it to that point. But, you know, so I just

>> :

The only reason the only thing I’ll say is, I think this is actually critical, I mean, because the startup costs are so significant here. And if we put the cart before the horse, 5 years, 10 years down the road, we could have designed these elegant systems that are very expensive and have them in every doctor’s office or wherever we think they need to be, and nobody still uses them. So we’ve got to understand not only what makes it and the other challenge is, this field is, I’m telling you, moving so fast that the challenge is not to think about what it is in terms of how we do it today. Now that’s very difficult, but how could it be, and what can technology do for us? Because it’s a problem today, it may not be a problem or it may be a bigger problem tomorrow, and it may be very different. So we’ve really got to be careful. If we don’t do the proper formative work, I think we might get lucky, but at the other hand, if we don’t get lucky, it’ll be a significant problem that could widen the gaps.

>> Nancy Davenport-Ennis:

I thank you for the question, and I certainly thank those of you on the call who sought to answer that. I would like to make a couple of comments, and that is that the issue of incentivizing the use of PHRs and EHR’s and particularly with the provider community, is one that continues to be addressed within the AHIC. And I think having these discussions within the Consumer Empowerment Working Group is helpful, and seeing that we are very parallel our thinking is very parallel with that of AHIC, I think, is also extremely important.

I would also like to say, in closing this portion of the question-and-answer session so that we can move on within our time frame here to the next presentation: Garth, I thought it was excellent, the recommendation that you made concerning the education piece of people moving forward. And of course, as a former educator, I certainly would like to at least put this question out and look forward to your response perhaps in the future. But it does seem to me that if your office could provide very simple educational information that could be used on Web sites of nonprofit organizations as well as even hospitals or community clinics or community health centers information that could be put into newsletters or be put into a slideshow for meetings, helping to educate the consumer about the benefit of PHRs and how to use them and how they are secured it would be a process that could perhaps allow a consolidation of messages so that as we try to educate the public, we are doing that through a singular point of contact, which would immediately be expanded upon by those organizations that are more involved and engaged in health IT and others and then may just be used in its pure form as it came from your office of health disparities, if they were not as engaged at that time. So I’d like to share it as a question and as a thought piece moving forward for how we

>> Garth Graham:

Excellent thought, actually.

>> Nancy Davenport-Ennis:

help to educate others. And I would now like to introduce Eileen Elias and Tom Horan and Debbie Somers, who will be presenting for us today. And thank you for all being with us, and we welcome you now to your presentations.

>> Thomas Horan:

Yes. Good morning or good afternoon, kind of depending on your time zones. This is Tom Horan here. I don’t know if Eileen and Debbie, are you on the lines?

>> :

Yes, we are.

>> :

I’m here.

>> Thomas Horan:

Okay. Great. So we’re going to give a brief overview really a status update of our work on the Disability Subgroup. And we have a few slides here, which I will just provide the overview on, and then I’ll invite Eileen and Debbie to comment. Next slide, please.

Our objectives were are twofold, and it really emanates from the testimony that several of us were able to provide to the Consumer Empowerment Group and the discussion that occurred thereafter. And these objectives are to first identify PHR issues that are unique and distinctive to the disability community and we’re using “PHR” in this sense as shorthand for, you know, personal health systems that can facilitate consumer empowerment within the disability community. And we’re spending significant time on this issue of “Well, what is really unique in terms of needs of the disability community, and what is distinctive?”, the first one being something that is as the word suggests, is a need that’s within the disability community which may not be shared by other communities but is really a pressing need. The second distinct is a need which is really highlighted within the disability community, and other communities may share this need as well. Our second objective will draw from the first objective, which is to make recommendations to the Consumer Empowerment Committee for consideration in some PHR use within the disability community. Okay, next slide.

In terms of our process, we’ve held three meetings to date and are really making, I think, great progress. We have a matrix that we’re working off of, which we are populating as a way as a decision framework for identifying what is unique and distinctive. And the dimensions that we’ve been focused on are access, security, privacy, interactability, and benefit to services. And within each of these four dimensions, as you can imagine, there’s a number of issues, and we’re talking those out and then identifying some which are, as I said, distinctive or unique.

We’ve had a very robust participation. Listed here are a number of the individuals who have participated in our meetings, several of whom are Consumer Empowerment Committee members and some of whom are on the phone. Others are friends of the Committee and experts in this area. My apologies if anyone was left off. This was from the rosters that we were provided. Next slide, please.

In terms of our first recommendation, and in terms of our first objective and what we have been able to do so far, this chart is really just illustrative of the types of elements that we’re considering and what seems at this point to be bubbling up. So, for example, in terms of access, the issue of access being consistent with 508/504 requirements for access is something that is fairly unique to the disability community. That’s what the “U” stands for. There are authentication challenges in terms of having to go in to authenticate one’s person in order to join into a service. This is something that was brought up within the context of the VA but has broader issues. A third would be coordinated care and emergency need, something that is viewed as very distinctive within the disability community; and then cultural differences and the ability to tailor solutions to account for some of these social, economic, and cultural differences and characteristics within the disability community.

In terms of privacy, a number of privacy issues are being discussed. This includes, as it says here as it relates to the adverse impact of unauthorized release of sensitive disability conditions, which can be quite distinctive of the disability community, particularly if one’s operating or has a disability with an employment circumstance. And then the second aspect of disability of privacy that’s being explored concerns consent for a range of care, particularly given the multitude of care arrangements that need to be arranged for and how can that be streamlined while respecting privacy.

In terms of improbability, one issue that seems to be bubbling up concerns lifelong portability needs within the disability community. That’s really quite distinctive, in that it’s not an episodic type of event but really can be with one for one’s life, and so the portability of being able to take electronic records over time is quite important.

And then, in terms of benefits, it’s as it relates to the use of records, not so much within the clinical context, but within more of the medical evidence context for benefits determination and management processes. This is quite an important financial aspect of disability management, and its use for disability determination within SSA or within workman’s comp or for those types of things is really something that is unique, it appears, to the disability community.

So those are some of the issues that we’ve discussed and we’ll be moving forward on. Why don’t before I go to the next slide, why don’t I just take a moment and see if either of my Co-chairs want to comment on this discussion here?

>> Debbie Somers:

Tom, this is Debbie, and I think you’re doing fine, so (laugh) I have nothing.

>> Thomas Horan

Okay. Keep rolling, huh?

>> Debbie Somers:

Yep.

>> Eileen Elias:

Hi. Eileen. Likewise, as Debbie stated, but I just would want to emphasize, as we’ve heard from the earlier presentations, the interface of your presentation with the challenges that we are identifying for individuals with disabilities. And I think the major factor that needs to be considered and it’s something in light of the electronic personal health record discussion is the challenge that you talked about regarding accessibility. Tom.

>> Thomas Horan:

Thank you, Debbie. Thank you, Eileen.

Moving to the next slide, in terms of our next steps, we will be completing this kind of disaggregated profile of unique and distinctive issues, which will include both kind of barriers to overcoming them as well as enablers. And so what we’re trying to do here is really parse out the subject of disability applications into some identifiable issues and what can be done to address those issues, including, and in particular, those that are unique and distinctive to the disability community. And that really formed the basis of the recommendation.

It is important to say, as the second bullet says, that while we are disaggregating these issues and opportunities, we will also be providing any kind of holistic assessment of needs and opportunities. That is to say, while several dimensions might be distinctive that is, it is true for disability community and true for others for example, caregiver coordination and such one thing that is arising is that when you add it all up in a holistic way, it could very well be that there’s a unique combination of factors that really helps make the case for policy and business model attention to disability community applications. We will deal with this squarely in terms of recommendations for AHIP, and these recommendations will kind of come off of the priorities and will include, in all likelihood, policy issues and recommendations; some use case identification, if not development there’s two that, I think, relate to what we’re talking about in terms of use case discussions so far. Those include the caregiver PHR and disability determination process to areas that seem right for use case delineation. There could be related opportunities for demonstration; for partnerships and partnerships with the disability community organizations as well as public-private partnerships; and an important outreach dimension to engage, in a collaborative fashion, members and representatives from the disability community in crafting solutions.

So that is what our recommendations will cover, and we’ll start dealing with those in our next subgroup meeting. Moving to the next slide, in terms of our timetable, we will be refining the matrix in February, which will carry which will have our identification of key needs. We’ll move from there to outlining recommendations. By March, we should have a summary report for the Consumer Empowerment Workgroup, and that will contain our recommendations and then expect that these will be rolled up with other recommendations to the AHIC meeting in late April.

So with that, I think that is our game plan. And why don’t I first invite the Co-chairs to make any comments that they would wish to make, and then we can certainly open it up to questions or other comments. Debbie, Eileen, does that sound like what we’re doing?

>> Debbie Somers:

Excellent presentation. Thanks, Tom.

>> Thomas Horan:

Okay. And do any of the other Consumer Empowerment Workgroup members who have participated in this subgroup have any comments they’d like to make, or clarifications, or questions?

>> Kim Nazi:

This is Kim. I just would like I think it would be helpful to understand, knowing that the use case was one of the priorities that emerged, although the time frame is later so I just would like to think for a minute about how the work of this Group will connect with that opportunity.

>> Thomas Horan:

Well, I can give what I know of that, and if others on the phone, including ONC, want to comment, that would be terrific too. I had a recent discussion with ONC staff about where things stood, in terms of use case development for 2009, and that those are still being crafted. And as you may recall, this Workgroup had a kind of a use case discussion session, and in that use case discussion session, several possible use cases were identified. Two of those, the caregiver PHR use case and the disability determination use case, were two that, in my notes, were ones that matched well what we were thinking about. And therefore, the subgroup could contribute to advancing the cause on those by kind of flushing them out, pouring that. And my understanding is that ONC is still, you know, in the posture of preceding that.

That’s what I know. I don’t know if others on the phone want to comment on where the use case stands. But the window is still open, so far as I knew.

>> Karen Bell:

Thank you very much, Tom. This is Karen Bell, and I’d like to take the opportunity to respond if I might, Nancy and Rose Marie. Tom is right: There have been a number of use cases that have been advanced for consideration. They are still being looked at, worked on within our office. They will be brought to the American Health Information Community, I believe, at the March meeting for a prior decision process. So at this particular time, there certainly the input from this Workgroup around the use cases that Tom mentioned would be very helpful.

>> Nancy Davenport-Ennis:

Thank you, Karen.

>> Karen Bell:

Thank you.

>> Nancy Davenport-Ennis:

If there are no other questions or comments for Thomas and his team, I would like to recognize Karen Bell again so that Karen can now walk us through the presentation of the PHR paradigm, and we could spend a bit of time discussing that.

>> Karen Bell:

Okay. Thank you very much, Nancy.

I think you all received a series of slides of three slides, which are very much a work in progress. These are designed just to stimulate discussion this afternoon and are no means representation of the way the world actually is at the moment. So let me just start off by laying that groundwork that this is really about a discussion and share with you two things: (1) the derivation of the slides and (2) the work of a contract that we have with the National Association for HIT that’s helping us to really understand what some of these technologies are, how’re they called, and what are similar and which are different.

So with that in mind, on the very first slide, I have to give a tremendous amount of credit to David Lansky, too, because he used something similar to stimulate two very intensive days’ discussions on personal health records PHRs and personal health applications out in La Hoya last month sometime.

And so the real concept here is that right now, there are probably multiple ways of looking at how health information personal health information is created, where it’s stored, how it’s integrated, and ultimately how it can be accessed. So the this particular slide is just one way of describing that. It describes the current creators of health information, and you’ll notice that they can be pharmacies, health plans as well as physicians, hospitals, and other providers. The consumer was not listed there. It doesn’t mean that the consumer the patient is not a creator of health information also, but the thought was is that we would start with the current creators of health information as we know them.

The middle group the middle box actually represents what we were calling health integrators, where all of the data can come together in a longitudinal fashion over the life of the patient from all sources. And this would include not only the current creators of health information but also the consumer and the patient him or herself. That information can be added, as well as any other information that would be relevant. Those particular applications, whether we choose to call them PHRs or integrators or something else, would basically be that composite store of a comprehensive record, which can be accessed by the patient consumer through a number of applications. Clearly, the patient the consumer can access information from their provider if their provider has a portal on an electronic health record that they may have, but it isn’t, again, a comprehensive picture if, in fact, the patient sees multiple providers, and most do.

So the applications that one sees there are just examples of ways that a patient might access that information. There may be, as we heard a little bit earlier, the need to translate it into any one of a number of different languages. There may be the desire to use it for various self-management programs. Or there may be the need to share it with other situations, other patients, other programs where that information may actually lead to more personalized health care or basically to contribute to research, public health, etc. So there are many different ways that that information could be made available and could be shared.

So that would be the very first question I would put before you, then: Is this type of a framework does this framework make sense? Should it have modifications to it? If it should, how would you modify it? So that’s the first set. And I guess I would ask Nancy and Rose Marie whether I should continue now or we should talk about that first slide first. What do you think would be better?

>> Nancy Davenport-Ennis:

I think let’s go to the Group, Karen, and see if we have any questions at this point, and then we’ll go right next to the next one. Rose Marie, do you agree?

>> Rose Marie Robertson:

Yeah. That sounds fine.

>> Karen Bell:

Okay. Thank you.

>> Justine Handelman:

Karen, this is Justine. I just had one question, and I think you said it up front, and maybe I just missed it, but what is this slide going to be used for, or how would it be integrated in? Was it recommendations that’ll be going forward?

>> Karen Bell:

Well, I think what the first part of it is is to get a better understanding of when particularly if we use the term “PHR.” What exactly does that mean? Does it mean an application that allows someone to see their records through a portal of an EHR? I mean, we’ve called that “PHR” in many different circumstances. Is it a composite of information that’s coming from claims and which has the ability to to which information can be added by the patient or by someone else but with which also is essentially owned and operated by another entity? So there are many different, I think, approaches people have had to describing a PHR. So this is a slide that begins to get that discussion going about what really would constitute a PHR.

>> Justine Handelman:

And then can I just ask a follow-up question? Is this tied into I know you mentioned NAHIT. Is this tied into the work that they’re doing to develop definitions? I know they’re working on definitions for “personal health record,” “EHR,” and “EMR.”

>> Karen Bell:

Yes, it is. It is very much tied into that. And so what the thought was is that this particular Workgroup today would be able to provide some input into that process through the Workgroup.

>> Armin Weinberg:

I have (ahem) excuse me. Can you hear me okay?

>> Karen Bell:

Yes.

>> Armin Weinberg:

Okay. This is Armin. I’d just like to make one addition to begin with. When you said the consumer is not in this diagram, it did concern me, because on the one hand, this is the Consumer Empowerment Group to begin with. And I think I would have to say, if the consumer is not a creator of information, it certainly might be that we view it and add another bar that is the owner of the information, in a sense. I mean, I know that’s an oversimplification, but I can’t imagine not having the individual here somehow in this...

>> Karen Bell:

Well, I think that’s really the question I would have of everyone. We had the consumer on the slide a little bit differently, the [unintelligible] question is, where do you think the consumer belongs here? Does it belong in the box of the creators of information? Should it have its own separate box, because it’s creating information outside of the usual standardized ways of doing it? How do you include the consumer information? And that’s really the question I would have.

>> Armin Weinberg:

All right, but if I’m the consumer if I’m the individual I’m going to just put on totally an individual hat and I’ve got my blood work, my blood pressure, my weight, my appetite, my exercise patterns, and my insurance information or lack of it, that’s all there. That’s my data. Okay? And if it is going to be useful to see, I have to see how it interfaces with all these other systems. So I think it I think I would argue that it would be important to have it somehow be an integral part of this illustration.

>> Nancy Davenport-Ennis:

Armin, would you see that more in the creator section of the information? Or in your mind’s eye, would you see “Consumer,” for instance, at the top of this chart with lines then going down to the center red dot over to the left feeding into the creator health information end? Where would you see?

>> Armin Weinberg:

My gut reaction is I’m having a little trouble seeing the image, but my gut reaction would be a bar at the top that is like, you know, the individual consumer or something, and then we could figure out how it interfaces with the others, perhaps.

>> Nancy Davenport-Ennis:

And so from that perspective, you just see that none of these other bars can begin until the consumer has contributed data.

>> Armin Weinberg:

I think that’s where the data’s coming from, unless you’re talking about, like, environmental monitoring, which is then something that gets fed to the consumer in terms of their equation about their health for example, if I was looking at the health in my neighborhood. So I could see where you would have data that comes from not the consumer individual, but I think a lot of people, when you think of personalized health records, again, or if we want to explain the value of these again, you have to put it in terms, you know, that it’s them that we’re interested in.

>> Rose Marie Robertson:

Armin, this is Rose Marie. Is the so there’s information being generated about the patient in many of these other settings obviously some of the medical ones, but pharmacies that you know, medical related as well. And so it’s there ready for use. I suppose until the individual says, “I want a personal health record,” you know, it in a sense, it doesn’t exist. But the fact that, say, in a medical practice, basically you have built a virtual personal health record that’s available to that person as soon as they sign up for it they could start that without really ever inputting anything except a permission.

>> Armin Weinberg:

That’s correct, but it came from them originally.

>> Rose Marie Robertson:

Ah, yes. Okay.

>> Armin Weinberg:

At some point, it’s their data, if you’re asking, you know

>> Rose Marie Robertson:

Absolutely. I see what you mean.

>> Nancy Davenport-Ennis:

Yeah, and Rose Marie, to further your point, and Armin, to further yours Nancy again, but if we look at the fact that we’re having a discussion concerning this chart within the context of a PHR paradigm, I think, Armin, your point is probably very well made that we, as a Consumer Empowerment Working Group, need to give voice to where does the consumer appear on this diagram if the discussion of the use of this diagram is within the larger discussion of a PHR paradigm.

>> Armin Weinberg:

Correct.

>> Myrl Weinberg:

This is Myrl, and if I could I just I feel that we really should, under “Creators of information,” include patients. I think a lot of you know that the work that we’re doing with patient groups and focus groups, etc. is showing that they very much have a vital role to play in how this information is created, what is included, how it’s included and that without their involvement, we’re going to really miss opportunities to have them engage into value the end product. And they have to go back, as I have to say some of the health plans are, after really getting input from actual patient users that what they created left out at least five different items that were critically important to people with chronic diseases and disabilities. So this, to me, unfortunately, on paper, reflects the standard procedure in the health care industry and community, which is, “We’ll do it all, and then we’ll go and offer it to patients and see what they think.” And I would love to push that whole paradigm and in each one of these, at the very first, on the left, have patients as one of those creators of information.

>> Armin Weinberg:

Can I offer a friendly amendment? This is Armin again. I think, you know, a big also challenge is that I see this health information technology not necessarily being used only by a patient, but as a consumer trying to be healthier. So it’s possible they may not be technically a patient sometimes. So I can see where you’re going from, but again, I still think that if we could have the consumer concept at sort of the top and you could have the participant, patient, whatever it may be inappropriate

>> Myrl Weinberg:

Well, you could even have “patient” and “consumer.” I think it’s becoming more and more clear that there is a distinction between people that are more traditionally thought of as patients, where they are constantly in contact with the health care system, who have different needs, have chronic conditions and the sort of more healthy consumer. And they’re you know, different groups represent them and their interests are in fact different, which is what we try to show all the time. So I think it’d be great to have both. It would start to make the point that that they’re not one in the same at all times.

>> Nancy Davenport-Ennis:

Good discussion, Myrl and Armin. Other comments? One thing that I’ve also seen is, when you refer to consumers, that you can refer to them within the context of our discussions as health care consumers.

>> Kim Nazi:

This is Kim Nazi from the VA.

>> Nancy Davenport-Ennis:

Yup.

>> Kim Nazi:

I would just like to, along the same line of thinking, just offer that the informed consumer choice, I think, should be more prominent in this model. I think that’s one of the key pieces of connecting health care consumers to their medical record data. And as it currently appears, I think it seems less prominent.

>> Karen Bell:

Well, let me just Kim, I think you’re right. And let me jump in again, because there are three slides, and I’d like to I think we can have an opportunity to really figure out how to do that when we get to the third one, because I think and I’d like to just sum up I think what I’m hearing is, there’s no question that there is information that is generated by plans, the delivery system, etc., etc., etc. about an individual. There is also a set of information that the individual patient-consumer generates about themselves, which needs a place in this central, longitudinal, comprehensive record as well. And so I think I’m hearing consensus that we need to include “patient/consumer” on either as a separate creator box or somewhere on the creator for the on the creation side to make sure that that’s captured on the creation side rather than the access side.

>> Myrl Weinberg:

Right. I would put them right in the box. I mean, some of it will come directly from them, and some of it they’ll just be part of the development team.

>> Karen Bell:

Okay.

>> Susan McAndrew:

Before we move on this is Sue McAndrew can you just say a little more about the personal health application box and conceptually what that is that uses to which the information may be put? And is I mean, it seems to be a combination of pushing out to third parties, like public health, as well as other providers, as well as some manipulation of the data, as in the translations, to help the consumer, I believe, or used make the information more usable to the recipient.

>> Karen Bell:

Absolutely. I think you put your finger on it, Sue. The applications truly are to make the data as it exists, in whatever place it is, not only accessible but accessible in a form that meets the needs of the individual patient/consumer or maybe even public health or research so that if it needs to be translated, it can be translated. If it needs to be incorporated in some sort of clinical decision support that the patient would benefit from, then it can do that. There we’ve seen lots of applications out there. The market is just teeming with them. It’s very, very exciting. That could certainly anyone could certainly want or may want some of their personal health information to go into those applications and then be used in multiple ways to bring benefits back to the patients. So I think the real purpose of those applications could be just about anything, and as I said before, the market is (inaudible)

>> Armin Weinberg:

You’re cutting out.

>> :

You’re fading.

>> Eileen Elias:

You’re cutting out, Karen.

>> Karen Bell:

Oh, I’m sorry. But they’re all designed to make that information not only accessible, but helpful and usable.

>> Myrl Weinberg:

Okay. Thanks.

>> Eileen Alliance:

Hi, this is Eileen Elias. If I could just add one other question: As I’ve been listening to the discussion and thank you, Karen, for being the catalyst for this one of the issues that we’ve been discussing also within the Disability Committee has been, “How do you move from the electronic health record to the personal health record?” And I know that everyone’s been addressing this issue. And in many ways, as I’ve listened to the paradigm discussion, yes, absolutely, the individual, be it the consumer or patient, needs to be included in the creators of the health information. But I’m also hearing, “But how do you show the transfer of where we are today to where we need to be?”, which is the term “paradigm” is really important. So it’s not just “How do you get the info into the record?” but “How does the person own it? How does it become theirs?” And that, to me, is a challenge of how we also show that major pivotal transition.

>> Karen Bell:

Well, I think there’s that’s a very nice segue into, I think, the next part of my discussion, Eileen. And it comes around where the where it comes to where all the lines are. How do you connect all of these boxes? And we’ll certainly add the one we had ideas of where to put the consumer, but I’d rather that we chose to not put it up on this slide so that you could all share your thoughts on that. But the next question really is, how does everything connect? Where does information flow? How does it flow? If there is a health information exchange in a given area, how does that contribute, and where does that fit in? If we have, finally, the National Health Information Network as a support tool of this, how does that fit in?

Because right now, I mean, there are opportunities, again, for a patient to get a view a portal of their electronic health record that their physician has, and they could even put information in on that as well. But it’s only a piece, and so how do you pull information from multiple sources if you are, in fact, someone who sees eight different physicians? And we all know they’re out there. A lot of folks are in that position. How do you pull all that information into one place? And how does that information flow not only to that place, but how does it flow out back to caregivers, back to providers, back to the patient/consumer, back to their advocate, or out to other sources? And again, that’s where personal health applications come in, or it can go to other sources in other ways. So it’s a very complicated discussion about how the information can flow and under what circumstances it should flow. And so that’s actually the second point of discussion.

But I would like to underline, before we jump into that, with what I could call the third point to this discussion, and that is around the fact that we know that if information is to flow, it needs to be interoperable. So the question around that is, how do we assure that information is created in a way so it is interoperable and can flow? Secondly, if it’s going to flow in an interoperable fashion, we have to make sure it’s secure. How do we do that? And then thirdly, there’s the whole issue of privacy. Security means one thing, but confidentiality/privacy is a third thing. And while I think we all recognize HIPAA is a floor, HIPAA applies right now only to information that’s created in that box that was on the first slide. It doesn’t apply to information that’s created by a patient and then put on the Web somewhere. So as we think through how information should flow, we also should be thinking through those issues of where should it be interoperable; where should we have and how should we assure security; and lastly, what type of privacy protections should be in place.

And I know it’s a very complicated discussion for late in the day. I don’t think we have to absolutely get through it today, but it’s one that I think we have this opportunity to tee off this afternoon. And so I very much wanted to get everyone thinking, get everyone sharing thoughts, and if you have some this afternoon, wonderful. We can continue the discussion online, and we can continue it at the next workgroup meeting. But that’s really the whole background here for where we’re trying to go.

>> Thomas Horan:

Yeah. Hi. Tom Horan here. I’d like to make a couple of brief comments, if I may. First, I like the separation in terms of these different layers, because they are different creators, aggregators, and applications. And you’ve aligned them on an x-axis. I think you know, I think it’s six one, half dozen. Some ways, it could be aligned on a y-axis, because you’ve got you know, you’ve got the creators, and then you’ve got aggregators in some ways on top of that. And then you get these applications, which ride on top of that. And so I do you know, I do see how you kind of separated that out, and it makes sense. I would concur and I’m not sure how you’d position this this is kind of relating to the supply of health infor and personal health information, its aggregation and application. And there’s another dimension in terms of the demand for this information by different types of consumers, some of whom act as patients and some of whom act as in the marketplace. And then there’s demand by public agencies, including for public health and things like that. So I don’t know if we can get that supply/demand dimension onto this, but I think it’s an important aspect of it. And I think as you if one thinks about it, it’s really that pull-down from the demand that’s going to connect with those applications and things like that.

So I like the separating out. Whether it is on an x- or a y-axis is a judgment call, you know. I would kind of think about it in Y, but I can work with X. And then I think, the demand side, in some sense, could be recognized. Those are my comments. Thank you.

>> Nancy Davenport-Ennis:

Thank you, Tom. Are there other comments?

>> Kim Nazi:

Hi. This is Kim Nazi again

>> Nancy Davenport-Ennis:

Hi, Kim.

>> Kim Nazi:

with the VA. I guess part of my comment is also tangentially related to Kathy’s presentation, where she described scenarios where alliances with organizations to accomplish multiple tasks for that are of high value to the consumer or the client end up being those things that are really highly valued. So I just want to comment on the lines that draw these together. I think the issue of access control is going to be quite complex, and I’m wondering how we can, you know, show that complexity. I’m almost wondering if alliances of organizations focused on particular tasks for members that they hold in common, you know, will end up being how we solve this, rather than, you know, trying to do all of it at once. So just a comment and I think focusing on the tasks of most high value so that there is demand for it, I think, will be really important.

>> Nancy Davenport-Ennis:

Thank you, Kim. Other comments and questions?

>> Kathy Ficco:

Yeah. I would just this is Kathy speaking. I would underscore that you are missing some community-based organizations that support vulnerable population groups, so and just kind of echo the last speaker’s comments a little bit in that regard that the enabling of people to utilize the technology.

>> Nancy Davenport-Ennis:

Thank you, Kathy.

>> Kathy Ficco:

You’re welcome.

>> Nancy Davenport-Ennis:

Are there any questions at all to the point that Karen was introducing to the members of the Working Group earlier, about the fact that the information contained in the center box? Currently, we all agree, I think, that it does have to have an interoperability feature and, if it’s going to have that, that there’s got to be some form of secure protection. And there needs to be privacy that is also addressed in that particular center block. I’d be very pleased to hear members of the Consumer Empowerment Working Group address their positions or thoughts around any of those issues that Karen brought up, as it relates to this one section of the diagram, so that at the end of the day, I think, we’re going as a Group, I think, we will have to deal with that issue. And I don’t know if anyone on the phone this afternoon has any thoughts around “Should the information that is contained within this center block should there be a certification process, for instance? Or are there other activities that we could consider that would accrue, for the consumer, assurance of interoperability, security, protection, and some degree of privacy short of certification, or if that might be the best process to follow?”

>> Armin Weinberg:

Nancy, this is Armin. The word that comes to my mind that I was wondering if it had been covered somewhere else is “validation.”

>> :

“Authentication.”

>> Armin Weinberg:

Or “authentication.” (Laugh) Yeah. Thank you.

>> Kat Mahan:

Yeah, no, that was I mean, we’re looking at this is Kat Mahan, and one of the biggest concerns that I have that we see as being a potential provider of pharmacy medication history I’m with SureScripts, and is the issue of authentication. And it definitely prohibits the flow of information and data across this system you know, this ecosystem here, as you see it. I think it’s one of the bigger things that can constrict or enable, in addition to privacy, security, and interoperability standards. So authentication of the consumer; also, you know, protecting the consumer against the consumer against the bad consumer. So that’s certainly a concern for us, and we are, you know

>> Armin Weinberg:

(Ahem)

>> Kat Mahan:

Sorry. I’ll make one other quick comment.

In terms of patient/consumer being centric, I definitely would have to go along with the others who brought that up. I do see the patient/consumer kind of as an interaction into all of these three kind of chunks, if you will, for lack of a better term. On the creator of the health information, we have physicians, hospitals, pharmacies, etc., but there’s an interaction that has to take place with the patient/consumer for some of that health information to be created a PHI you know, there’s a twofold.

The patient also touches this central point. You could like with the Google Health or Adagio or HealthVault, where they interact and log on and say, “Hey, you can get pharmacy and medical information. I’d like that. Why don’t you go get it for me?”

And then the third chunk, to the right, is the health application, where those are actually you know, an ER a PHR is basically an EHR until it goes to the consumer. It’s an EHR when it lives in the clinician’s side, and it’s a PHR when it lives and owned by the consumer. And that’s how I kind of see the patient interaction in all these. And the authentication of “Is Kat really who she says she is? You know, when she’s going into Google asking for Kat’s medical records, is she really Kat, and how do we prove it?”

>> Armin Weinberg:

Yeah. And I think there’s also you know, just on that same thing, there’s a need for some times self-reported data to be checked, you know, or verified or occasionally

>> Kat Mahan:

Verified or (inaudible).

>> Armin Weinberg:

Right. Exactly, just sort of those sorts of things that so that, you know it’s not a matter of lack of trust, but again, I think you said it’s a safety issue as well.

>> Kat Mahan:

Yeah.

>> Justine Handelman:

Yeah. This is Justine Handelman, and I’m on that one point, what I say is, on the information, I think it at least needs to be flagged as self-reported, so the provider knows how you verify everything can become cumbersome. But I agree with what’s been said so far and the need for this to be consumer centric. One thing I just want to point out is, clearly, I know, right now, health plans are certainly can fit in the middle box, because they are offering PHRs and taking data from various sources and putting them together. And I see that missing. But one question I guess I have, too, is that middle box while some may be actual data warehouses, the way they store information and put it out, I know we’ve always viewed it as “We get to the end goal, where we have an interoperable system.” And I know we’re not there yet, but it may be where the data resides with the creator of the information, and it’s just pulled together when the consumer queries for it or the provider queries for it.

So when I look at the center box, it’s just the diagram. I think it’s the visual makes it feel like it may be an actual storage house. And that might not be the case, but if there’s a way, we can make that clear.

>> Armin Weinberg:

Yeah, for example, I mentioned YMCAs or whatever the (inaudible) in my remarks, because I there was a program that’s being launched where the Y’s are going to try and really reach out, you know, to get physical activity and nutrition as a part of the you know, their local communities. So you can imagine they’re going to have some kind of, you know, potential for collecting information that would be part of someone’s personal health record that mo for a lot of other reasons, no one even knows exists until they’ve, you know, sort of integrated in some way, which is the beauty, I think, of some of these opportunities for personalized health records.

>> Kat Mahan:

And I think, you know, I this is Kat again. With the middle box, it may be a split box, and you could call them intermediaries or aggregators. You know, a true aggregate would probably will aggregate the data and store it up. In some of the models that we’re working with a few of these listed here there is no data-centralized storage within the model. It’s basically, you know, a data repository and indicator.
“Have you got data on Kat?” “Yeah, I’ve got data on Kat.” “Okay, well, send it over to this place. I’ve authenticated the user, and they want it sent over to the PHR, not to Google, you know, as an intermediary to yeah, to” oh yeah, you can do the EHR-to-EHR scenario as well. Sure, yeah.

But you know, I’m saying it’s there is a difference here. Some of these may not be, in fact, data warehouses and really just become more a data what’s the word I’m looking for? Not repository, but

>> Armin Weinberg:

(Inaudible)

>> Karen Bell:

Data exchange organization?

>> Kat Mahan:

Exactly. Aggregator where it takes the information and sends it out and puts it back.

>> Karen Bell:

And actually, there was a place up from that we had thought, “Well, you know, there are health information exchanges that function that way in a federated model, and then again, there are things less helpful where all of the data resides in a warehouse.” And so that we’re hoping to create a way of thinking about all of these approaches in such a way that we can assure information flows appropriate, securely, and that privacy is protected. And I think those are the three things that we thought would engender the most it’s happening. Excuse me. I’m about ready to sneeze. (Laugh)

>> Susan McAndrew:

This is Sue McAndrew from OCR. I just wanted to take this opportunity to remind the Workgroup that, you know, the Confidentiality, Privacy, and Security Workgroup has made recommendations to the AHIC concerning the entities that may participate in these information exchanges that aren’t currently HIPAA covered. And their recommendation was that these participants in the network have a significant access to the data, be compliant with privacy and security requirements at least as stringent as HIPAA, and that business associates also have those same requirements so that, you know, that the Privacy Workgroup is on record as at least wanting to bring all of these uncovered entities up to the HIPAA baseline. And they’re now working on recommendations in terms of what in what areas should we be looking for privacy and security requirements that are even more stringent than the current HIPAA requirements.

>> Nancy Davenport-Ennis:

It certainly seems to me from the questions and the comments that I hear, Karen and Rose Marie and members of our committee, that these slides are really stimulating great discussion. And as I look at what our agenda calls for us to be doing next, which is not always an easy job when you’re trying to manage the calls and the clock but it seems to me, Karen, that perhaps what we need to do is take some of the comments that have been made this afternoon and maybe come back to the CE Working Group when we meet again on February the 13th to be able to have a longer discussion about this diagram and to allow members of the Consumer Empowerment Working Group to frame some of their thoughts and recommendations and send those, then, to your office and to us as Co-chairs so that we could have a more robust discussion around, particularly, slide #3 when we meet on February 13. I’d like to know if that recommendation is one that members of the committee as well as Rose Marie and Karen feel it would be a wise for us to do at this point.

>> Rose Marie Robertson:

That makes sense to me, Nancy.

>> Thomas Horan:

Yeah, I think this is a great discussion, and it’s an important topic. We need to make sure we give it sufficient time.

>> Nancy Davenport-Ennis:

Yeah. And I think that just I’ve been making notes as people are making comments. I mean, Kat Mahan has certainly had great observations in this dialogue, as has Armin and Kathy and Kim from the VA. Tom Horan certainly started the discussion Armin and Justine Handelman with Blue Cross Blue Shield. And I want to make certain that every person in the committee has a significant opportunity to evaluate the slide and then to get comments back in to us so that we can have a complete discussion with all stakeholders heard when we meet on February the 13.

And Rose Marie, I would like to ask, in looking at a recap of action items from today this would certainly be one. Armin, I noted that you had cited a particular report and put that, as an action item, you would either try to get the report to us, or you would get for us the source of that report or title of it, and then we will get it from the members of the committee. Are there other action items that member of this committee or Rose Marie, you, as Co-chair, noted as we went throughout the call today?

>> Rose Marie Robertson:

Those were the items I noted as well, Nancy. I think, you know, ongoing thinking about the issues we covered in the initial part of the meeting are going to be important as we configure things as well.

>> Nancy Davenport-Ennis:

I think so. And then Garth, if I may, if you are prepared to proffer perhaps any type of response to the earlier question that we posed to you, around outreach and education and trying to begin to develop very simple educational materials that could be used across the nonprofit sector, around personal health records if you wish to contribute anything on that subject further for the Wednesday, February 13, meeting, we would invite you to notify us and certainly do that. And Karen, are there any recap items that you would like to note at this time?

>> Karen Bell:

Well, I just want to say thank you very much for the discussion that we’ve had, and I absolutely would be very grateful if we could continue it on the 13th meeting. I think we’ll have more information from other sources as well. And this type of, again, discussion has been very helpful, very useful. And hopefully, we’ll be able to have much more clarity about what exactly a PHR is and all of those other sorts of things. So thank you.

>> Nancy Davenport-Ennis:

And Thomas Horan, I’d also like to say to you, it was a privilege to hear your presentation today and to hear you summarize with great fervor, I felt, when you made the comment in one of your latter slides that you would be making squarely addressing holistic assessment of needs and opportunities with the disability community and making recommendations in that regard. Again, we would certainly look forward to hearing from you as we advance, as you continue that holistic assessment so that the Consumer Empowerment Working Group can be sensitive to what those recommendations are. So thank you.

And I would like to thank all of you, and Karen, most especially to you for helping us to get the call coordinated, and to every member of the Consumer Empowerment Working Group. Myrl, it’s always a privilege to have your voice, as it is every person that is on this committee. Thank you for your gift of time and insight as we continue the discussions. And we’ll look forward to being together again Wednesday, February the 13th, 10 o’clock to 4, and the next AHIC meeting will be Tuesday, February the 26th, in Orlando, FL. So thank you so much.

>> Alison Gary:

Would you like to open up for public comments?

>> Nancy Davenport-Ennis:

We absolutely would.

>> Alison Gary:

Okay. For those online, you’ll see a slide on how to call in to comment or ask a question. If you’re already on the phone, just press star-1 on your phone now to comment. Any wrap-up comments while we’re waiting for public input?

>> Nancy Davenport-Ennis:

Hello?

>> Kathy Ficco:

Hi, this is Kathy Ficco. I wanted to just mention a comment I gave some thought to about incentives, perhaps considering incentives for nonprofit organizations working with these vulnerable population groups. I know that HRSA’s put forth a number of HIT grants to consortias and clinics that are allowing them to move forward addressing their core business operations, which are important, but I think those are taking precedence over working with the community directly. So maybe they need some funding opportunities to do it in tandem.

>> Armin Weinberg:

Very good idea.

>> Nancy Davenport-Ennis:

Thank you. Good idea, and thank you for that.

>> Barbara Guest:

Hi, this is Barbara Guest from NCI.

>> Nancy Davenport-Ennis:

Hi, Barbara.

>> Barbara Guest:

Hi, Nancy. I want to thank you very much for inviting me to listen in to this teleconference. It’s been fascinating, and I’ve enjoyed all of the speakers and the questions that have been raised. And I think that many of these issues have such great implication for the cancer advocacy community that I think to include the consumer/patient at the very beginning of discussion of things like EHRs and PHRs is going to be really critical.

The other, I guess, question that I had is if people were thinking about how the introduction of these of this technology will affect health institutions. And it seems to me that it may even increase the need for staffing, with doctors being so busy and on such short time frames that there may need to be additional allied health personnel who can work with patients in the education and interpretation of what patients are able to have themselves. So that was just a question.

>> Nancy Davenport-Ennis:

Thanks. Certainly, it’s a sound question, and it does go straight to the issue of the professional workforce those within the hospital and the clinic and the physician setting. And I don’t know that we have an answer for your question this afternoon, but I think that we should consider the question and then try to get back to you with an answer. I know that at the last AHIC meeting, we actually did have a conversation about the fact that our nation is in desperate need of more people with technological training and skills to work in so many of the health information areas that are now emerging and evolving, and that one of the concerns there were two concerns that were brought up around the work force: #1, the fact that we really do not have a large number of academic centers or institutions of higher learning that have a fully developed curriculum for some of the health information technology areas that are developing that’s #1.

And #2, a similar issue that was cited is the concern that for those entering the health information technology field today in a particular area within a corporation or a foundation, it’s very difficult to define what their future career track opportunities are. And within AHIC, there was a fair amount of discussion that both of these are areas that are going to have to be addressed moving forward as health information technology becomes an integrated feature for our health care delivery system throughout the country. So a solid question, and certainly one that AHIC was looking at the meeting last week.

>> Barbara Guest:

Thank you.

>> Nancy Davenport-Ennis:

You’re welcome.

>> :

Thank you, Barbara.

>> Alison Gary:

Judy, we don’t have any questions from the public.

>> Judy Sparrow:

All right, I think that the meeting is adjourned.

>> :

Good. Thank you so much.

(General thanks)