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Meaningful Use Workgroup

Posted Jan 08 2010 9:40am
The HIT Policy Committee Meaningful Use Workgroup met on Friday, January 8, 2010. Unfortunately, no meeting materials were posted on the ONC website at the time of the meeting. The rough draft transcript of the meeting is below.

Transcript:




> Good morning everybody and thank you for the meaningful useworkgroup, part of the HIT policy committee. This meeting is being conducted in public which means there will be a transcript posted on the track -- website within the week. The public will be invited to make, that the close of the meeting. Just a reminder for everyone to meet your line when you're not in use and please identify yourself or pop -- proper attribution.

David dates? Christina? Neil? Paul Tang? Art Davidson was to mark David Lansky? But can you -- Glenda? Tony Trinkle was to mark --? -- Charlene Underwood? George? Did I leave any workgroup members off that role call? Let me turn the line over to Chris Weaver to talk about the webcast.

Thank you Judy. There could have been a little confusion on the website so if anybody is trying to login, via the linkon the HIT policy page, that link ends in HIT policy. The link for this work group is actually different. If you want to login to the web login as altarum.acrobat.com/mu thank you Judy.

I will turn it over to Dr. Tang. Thank you everyone for participating in this call. I wanted to start out by congratulating both CMS and ONC for tremendous effort. Throughout the past several months and culminating to the almost published, but released NPR M. over the holidays. It certainly kept the office is busy and I think a lot of us have trickle-down effects which kept us busy as well but thank you and congratulations to the team. The other thing I wanted to do is update the schedule, talk with Tony prior to the call, and the e-mail I talked about some of the deliverables as we knew them before. Tony had reviewed them with other CMS offices and came up with a schedule for us. In the end, we would like to have any feedback, formal feedback from our workgroup through the committee by March 1 in order to keep up with their timetable. Working backwards from that, that would mean that by the February meeting, of the full committee, we would want to present our draft recommendations for their review, comments and finalization so that we can turn it around and produce a letter that we can deliver up to CMS. Working back from that, that means that at this meeting next week,

Paul, excuse me. This is Tony. The letter would go to ONC not CMS. The committee is responsible for recommendations to the office of the national coordinator.

Thank you for correcting that.

No problem. Given that means next week, what we would like to do is get the full committee a headset that some of the areas -- and some of the areas that we would like to deliberate more fully and get their initial comments as well. The goal for today would be to come up with, essentially an agitated list and a list of topics that we would like to summarize and put forward to the Main committee. Are focused with the, on the philosophical comment. Three buckets of commentary as one might be the philosophical comment, an example, inequality measures, we had taken an approach, we had a recommended approach, of what we called example are measures. By that, we meant, if you were able to report on and to improve your performance on a given measure, a given exemplar measure, that means that you probably purchased a comprehensive BHR system that had the capabilities to affect your practice, that you probably built and configured it so would be fully effective and you trained and implemented the system, you implemented the system and trained the users to make full use of that system and then provided feedback so that the system could be your group of, whether it is a hospital or physicians or other providers, it would continuously improve their performance. That was the ration are behind the -- rationale behind the exemplar approach. We have formally labeled the other as they and formal misers approach, to have a large set of measures for individual providers could pick and choose. On the spectrum of things, the NPR M. looks more like the 500 measure approach than the exemplar. That is an example of a philosophical difference where we could talk about and discuss more and look at the rationale for picking that approach and see what comments we might have. Another bucket of comments might simply be answered, even in this call, or with follow-up and this might be clarification questions. The statement, the statement was made in the NPR M. that leaves open questions, what is the answer to those questions in that kind of thing can help ONC MCNS find it in the language, so it is clear. A third might be, getting down into the granular items.

It says this and here is another alternative in this is the rationale for considering us other alternative. I think there is going to be other public comments coming in during the public comment period and this workgroup would be best to spending its time on the first category, the philosophical comment. I think through the discussion we can get some clarification out for the second bucket and either as individuals and to the organizations, can provide feedback and the glut -- granular items. How does that sound Tony?

Exactly Paul. That is exactly what we need because obviously we are on a very short timeframe and we would make sure that we utilize the committee to provide us with the best use of that time and we don't want to get tied into a whole lot of granular issues, one, there are some bigger point that would need to be made.

This is Devon. I have a question. To the extent that the stage to criteria, there is quite a bit of time lag as with most need to be set and some of what we might discuss our recommend, for examples of things that we did not get in the first round but we want to see prioritized for stage II, is that on the table?

Good question Devin. We are already on the plan, as you know, to work on stage II and stage III criteria through our series that had -- hearings in our deliberations. Unaffected, I think today's call really deals with the NPRM and it has mainly dealt with stage I and has laid out a philosophy grad or do stage II and three.

That is correct call. On purpose, we did not get into more specifics, on stages two and three, partly because the timing and partly because of the fact there'll be a number of changes over the next several years and we want to ensure that as we prepare for two and three, that we have feedback from how the programs are working and also, some additional changes that might occur as a result of some of the ONC Fendi and other infrastructure building, it may influence with the stage II and three criteria are.

Yes. I don't disagree. I would not want to open up a broad discussion on stage II, the via part of the process of thinking about what we are going to recommend specifically for stage II. To the extent that people may be disappointed or concerned about things that may be CMS thought was premature to do in stage one, I think it would be helpful to put them, on a parking lot list for ourselves about stage II. We would be sending, essentially, signals that we think we are pretty serious and ought to be addressed. On an earlier stage than waiting until we compiled some specific list.

I think it is fine to do that, dad. Obviously they are recommendations and we can take them under consideration. I want to make sure and talking to Paul, that we prioritize what the group is going to be doing because there is such a limited timeframe and we want the group debating certain items into the March timeframe because there is a certain point we are going to move into clearance than anything that the committee sense to us after a certain period of time is going to be too late for us to consider.

Right. I get that. Thanks.

Thank you Devin. I think your comments are perfect. I think what would be most helpful is if we identified a finite and small number of these buckets, as sort of a parking lot, that we can properly triaged the issues to the right bucket. And then, deal with each one of those. One of the buckets you are talking about is something where you would like to make a comment. Feedback on a stage one proposal and also put on things for further discussion in stage II or three. Something like that. How is everybody feeling, with the comfort level of terms of using this approach? We will go through section by section, and will start with the overall general comments and then go through category by category, and sort of put issues and triaged them to one of these buckets to help us with that work plan. Does that seem fair?

Yes. Yes.

Let me open it up for a short period of time. Just for general comments, or general comments about the overall NPRM in their approach.

Paul, it is Christine. I just want to say that, I really want to of pride -- applaud CMS and ONC on the overall approach to the rule, it is very pragmatic and very achievable, by a broad array of healthcare providers and practitioners. I was really pleased to see the approach taken on some of the issues that I know this workgroup talked a lot about and really struggle with how do we establish a payment year versus a calendar year and had we make sure that providers are incentivized early on to adopt it and use it in a meaningful way that give people the time they need to achieve that status so I don't want to say I think it is very positive and very thoughtful rule.

I would agree with that. This is Devon. It seems self-serving sense it was really pretty close to what we would put on the table. Of course, we would say good job. I know what was hard work and I think we may have some issues on some of the details, I think, overall. I certainly was pleased with what I saw.

I will also, do not like a very healthy relationship between the ONC, CMS and the advisory committees to ONC, the policy and standards committee as well as to all the outreaches to the public and private sector. It just felt like a good effort with good results and I think we are in an iteration process where we begin to make some suggestions and the ONC and CMS can make changes before it publishes its final rule. It has been a good iteration to the process and continues to be and I think we will try to get the best possible output, -- constraint.

Right away start moving into the individual categories that we helped define and the first one, just for reference, people have the NPRM in front of you, it starts to talk about the multiple use cry curia on page 48 it looks like. We talk about the improving policies sufficiently and disparity. Images that section, what, the people have awakened sort of triage them.

Start with the most important to give that would be vehicles on local comments.

I won't mention the clinical -- I will mention the clinical quality requirement. Do people want to comment on the any further at this point before moving into that bucket?

It is Christina. I have some comments, I am totally not sure where they should go so are we going into clinical quality reporting next or is that where you think we are now? The rule is so huge I don't know what our span is here.

Good point. The reason I wanted into this category as that's how it fit into the matrix. Her member that we had our objectives and our measures.

Oh yeah.

Clinical quality measures in a section of the matrix.

This is a appropriate time to comment on clinical quality measures.

I think so.

I just say, there is one thing, that is a philosophical approach that we took and I think that is reflected on page 48, which is the importance of disparities reduction but this piece that I think is not present, what it comes down to the practical measures, is the stratification of quality measures, or at least a selected set by race, ethnicity, language or gender.

That is an important point. I didn't see that called out.

It is not mentioned anywhere in the reporting part, it is only mentioned in the election of data.

Right and the data collection provisions are great. It is a multiple places and I think that is fantastic but it is not in the reporting and that is a really important piece.

That is a very good catch.

In general, what they tried to do, where they differed from our matrix, they tried to explain amply fed up.

That was not picked up.

Not that. Good catch. I think you accurately portrayed the workgroup in the committee's interest in that. It is really part of that.

Are talking about the whole quality reporting area Paul question mark

I think so.

One of the things that struck me was, and the big table of all of the different quality reporting measures, that are relevant to different specialties, it seems to me that the burden for different specialties is going to be quite different based upon more upon the end queue at your -- approved measures are the PQR I measures that are available than any sort of rational basis to say we would like to have two or three measures proceed specialty. I am not sure how that is going to play out. I am wondering what other people's thoughts are about that.

Tony, am I correct in, that I think I read the goal was to put out these tables and that through public comment, you would try to get them down to three you would try to get them down to 325 in each of these specialty areas.

Yes. We would certainly try to reduce them as we get the comments back in. The idea was to support out a suite of specialty measures and then invite comment and for that.

How are you going to decide, based upon, are you going to tally up what people think? I mean, I think there are two ways of looking at these. Those that are most readily capture a will. But the other way of looking at it, which are the most important in terms of improving the health of the population, which may not be the ones that are most -- my guess is that people are going to comment are going to say these are the easiest ones to collect. Are those? Is there some basis, some evidence basis to decide on the back of those measures actually are going to be most meaningful, in terms of improving the outcomes and the health of the population? Or, are we just looking at what are the easiest ones to collect an age of specialty? I am not sure that the voting, I am in the voting that the straw poll kind of thing is going to point us towards those that are most significant rather than those that are easiest to collect.

No, we are not going to do a straw poll, based on the numbers of people who have certain common, we are going to be looking at the comments as a whole what they say about the measures and the writing -- readiness and obviously the appropriateness and how they relate to health outcomes. Maybe determination of -- I think the issue with the quality measures, is how they relate to the overall objectives that we are trying to achieve. Of course, that is one aspect. The other is, what are the operational readiness of some of these measures and I think you have to weigh both of them as you look at what we are going to put in for the final publication but obviously, that is something we are going to have to wait and see where different people come in. You're right. A lot of people are going to be looking to say, there are too many measures, we need to eliminate a large number of them because of the fact that we can't make these so there has to be weighed against other factors -- it has to be weighed against other factors. At this point I can't say where we are going to come out. And obviously it is not going to just be me making the decision. We are going to have input from people at HHS and OMB who have their own thoughts on how this is going to, but I think in terms of comments either from a committee or any of you commenting individually, the more you can, Paul, I think he talked about the other day, tying the measures to third -- certain themes. And if you do what type of measure, it may detract from some of the themes that you might have. I think the more you can tie things together, in a certain logical pattern, the more it will make sense to us in terms of, it particularly narrow operationally sound, will make more sense to us in terms of making final termination what we need to move ahead with. I guess is that helpful?

Tony, this is Charlene Underwood. Does that apply to the hospital measures because again, I think we are in a state with those measures and I think the scope of them was really a surprise to a lot of people that they're really not instrumented yeah, a lot of the data is not standardized yet so it is just like it is a steep bar. We will do exactly what you said, we will try to look at the things that might be feasible to do but not correlated to what might be best to do because the scope of what is included in there, does that process you just discussed, I agree with the strategy, also applied to the hospital base.

Yes, and any type of measures and objectives as they were changed or modified, I think one of the things that we need from people commenting, whether it is you commenting as the committee are commenting separately, is as I said, this wasn't just done by CMS, a lot of people have their fingerprints on this and in some cases, it would help in making the final decision, as we hear from you or others that there are certain measures, from a usability standpoint, cannot be done in 2011. I think that that type of argument will carry a lot better sway than someone just coming in and saying this is too much for us to do. We need to back it up with saying this is why we can do these in 2011. I think that will help, in terms of some of the arguments or discussions, rather, that we have internally in CMS were quality folks and also, as we begin to talk with people at the department at OMB they have very specific thoughts on the quality and other measures and objectives in a meaningful use of matrix.

One more comment, I want to follow up a little bit with that, this relates to your theme piece. What is going to be so necessary for the community to be able to respond to these time frames and I know this is going to be jumping the gun a little bit on 2013, we really need guidance on the roadmap in a sequence of these things. We need the guidance that drops out. It looks ahead to 2015 because if we are going to be ready, with the timeline that are so tight, we can't make it. So, as they are looked at, they have to be looked at in both frameworks, in terms of what makes more sense near-term but also with the glidepath looks like.

Right, and I think from a committee, you need to think about that. As well as some of the objectives and -- on the matrix. People are going to be pushing, some of the recommendations that you put in that we have adopted or proposed, I should say, not adopted, but there is obviously going to be people from the provider community and the hospital community are going to give a pretty big pushback so you as a committee need to be prepared also to help defend what you think is necessary in 2011 when you give us recommendations.

When they piggyback on this whole conversation. -- Let me take you back of his conversation and let me address the Charlene's comment on the timeline and the glidepath. I think that is very important. They gave themselves a schedule, a due dateto the subsequent NPRM or 2013 and 2015. As an advisory committee, we sort of moved up our timeline ahead of Ayers so that they can help signal. The whole purpose of signaling is to help with that issue you described, Shirley, both signals to the vendor community so they can start developing these things in their system but also to the provider community so they can start changing the processes to incorporate that thought. That is .1. The other thread of the discussion has been around what are the meaningful quality measures. You just pointed to also mention, the NCHS, one of our sister Proctor group had a hearing on meaningful measures. The goal was, as Tony is talking about, one of the guiding principles we had, as this work group, and putting together both the overall framework for meaningful use criteria as well as the quality measures, was to take this moment of opportunity, with the incentive program, and develop more outcome oriented quality measures versus what we have been constrained to do in the past which is process oriented. Most of us have complained that this is only processed when we are trying to get outcomes and the rationale for that was that is all the data we have in this moment of opportunity where we are trying to accelerate the development and adoption and effective use of these systems, we should have quality measures that track the benefit of doing that. It is probably not using the same old measures that were born out of the claims administrative data. So, one of the reasons we chose the exemplar approach was to say, not only should we look at the whole path that I described before but that also means we should be developing, fast tracking on new quality measures that leveraged this new rich source of clinical information, the HR and PHR's. One of the opportunity cost, I think if we go back to the existing measures, is not to seize the moment. To transform our measurement systems as a necessary path to transform health delivery system. That is wrapped up in the philosophy of the quality reporting and, of what quality measures and the thought would be that we would have an ideal quality measures that new measures designed specifically for the HR -- EHR in the efficiency quality extracting for data reporting. Does that make sense?

This is David and I want to piggyback on that thought. It is very well said a very important for us to raise is a difficulty. In the state. Part of my reaction to Neil's suggestion for criteria in CMS and ONC use and measures, we got into this whole quality measurement business, not primarily at this phase of the evolution of the process, to drive improvement in quality, but to have the eligible providers demonstrate that they are implementing the technology in a way that permits them to drive improvement in quality. So in a sense, I feel that we need to set up tracers or markers in the measurement portfolio. I don't know what they are but maybe a specific departmental or functional data technology based. If I was hitting the deck, on a laundry list of measures that is now listed by specialty are provider type, I would want to pick a small number of measures that reflect competencies or functional capabilities and is going to support content used for clinical decision report are measuring up biometrics that is otherwise not captured to other data systems or capturing of diagnostic and judgment information, that is otherwise not captured through -- greet -- these systems. But somehow, rather than multiplied or decide how many process measures we need, I think we need to encourage CMS to use some kind of a framework that says, have you got at least one measure that is a measure of diagnostic cognitive data question mark have you got at least one measure that is an objective biometric measure? Etc. I don't know what that framework is that we are missing something here trying to drive adoption of a high-performing technology. In terms of these criteria. Like you, I don't want to see 20 process measures for cardiology and 17 process measures for endocrinology. I don't think there are other organizations fighting that battle. What would she be doing is testing whether the technology is going in the right direction.

Paul,

Very well said.

Yeah, I agree with David. We have to be careful. The goal is not quality measurement, the goal is quality. Often when you have concrete call -- quality measures, especially as you said, the old-fashioned one, you can achieve those of different ways. One way to improve quality but another way is to achieve the quality measures, sometimes at the expense of other forms of quality. In general, I would like to see the use of the HR the use of EHR to promote quality practice. One view is quality measurement and that is not the only one. I would hate for the old tire project if you like it is a quality, it is merely an and Q. to talk -- quality measurement project.

Well said. I think there has been excellent, three let me use this opportunity to try to show, this is the kind of discussion that we should have in the future. And then come up with, for example, David just gave a very precise and concrete suggestion, creative type policy for measures. And to modulate with George to set about it, it is not about the measures. We have gotten a better surrogate that we really need to know how to get improved outcomes. That is exactly the kind of discussion we should have an hour and doing calls in the next month before the February meeting. To finish the job for today, we need to pick up these topics and clearly, clinical quality reporting, quality measures and be tied to outcome improvement is one of those big topics. What are some of the other philosophical topics embedded in the changes in the NPRM , the proposal in the NPRM and some of the changes from ourrecommendations..

Our progress notes of this section,

Progress notes are the section, which means it is not in this section.

They are no longer in the section?

They are no longer in the section. You think it is a philosophical?

Yes. I think so.

A lot of us do.

Progress notes as well as the bar for problem list.

Yes.

Do you want some rationale for some of these things?

I think we will say that. I think that the fact that unanimously everybody is missing progress notes, we will certainly discuss that while I come up with a rationale very quickly on that call. It is definitely in that bucket. Another one is somebody raised is problem list.

The barber problem is, especially in hospitals.

I would agree another know which way you're going sterling, but for me, our criteria, what Armitage said, is to maintain an up-to-date problem list, mid-list, analogy list, and the NPRM has none or one or more and it was unclear exactly, that you have to maintain it and keep it up-to-date or if it has to be just present. So one philosophical is, this whole notion of up-to-date maintenance of something versus a one-time act. I think that is a theme that is many of these.

I was talking with our customers on some of these issues and again, I don't know how this falls under the category, but I think everyone gets the attention. It is almost like everyone gets the attention -- and tension about the policy committee wanted to do but the operative they show on operas a shawl is really channeling -- challenging. Because of the time, I am really making good progress, but I don't need all of them and some of the bars are very high. It is just accumulative effect of trying to do all of them anytime one, and the stages, is really a challenge for a lot of our customers and getting absolutely no credit and a coloration of having to be done, any penalties. The whole bucket of stuff, that conversation, and the feedback, we need some more flexibility because we don't want to stop them from doing anything, we want them to make progress, yet the cumulative effect of meeting 80% of a problem within a hospital which is a major problem change, etc. etc. etc. is just a lot.

Can I label that issue as the all or none issue?

Yes actually that was the flexibility issue, that netted it now but the detail behind it, the detail of everyone,

So yes.

I have a question.

Yes please.

This is George. Take progress notes for example, what is the mechanism for us to find out, I guess it is really for Tony. What the thought process, there is no sense in us waxing poetic about any of these issues of the pressure that causes the change are still there and we don't know what they are we still address them.

We can only go so far on that, George. Obviously, the best way, I can't get into too -- who this is their priorities had to the regulation, we can only say here is the regulation, here is how we explain what we did and it by rationale and that is something if you want to question, you can put that into the,, I can't say what the feeling is behind that bar who was behind that, but I think that if we receive comments from the committee and others that question it, as we were just talking about the all or none issue and the flexibility, that is the type of stuff that allows us to rethink it if it is a CMS perspective or if it is someone from the department or OMB. We can go back to them and say, we may need to modify this particular criteria because these are what we are getting into the community and if you looked at our final regulations, and other venues, that is what we try to do, we look at the comments and we have a discussion about the comments and then we come up with what we think is the solution based on what we perceive but beyond that I can't shed additional light behind some of the decisions that were made on what was put into the MPR and because we just can't do that.

All right. Progress notes, George, they did offer rationale, the statement was that it did not impact coordination of care, I am just paraphrasing and I think we could go back and say there is a lot of folks that you think it does and that we would be doing what Tony said which is commenting on the rationale, the written rationale for them dropping it.

And I'm not just saying that we think it doesn't have that wide attacks.

Yes we would offer that but I think there is a specific comment and we can get feedback on a rationale and provide our evidence as well.

I don't want to get into the discussion below me ask a question because it affects several of the areas, is there, because I know where to look this up, for order entry, a doctor has to actually use the system, I believe it says. But for the other areas, you could have it as a meaty area using the computer, is that correct?

What do you mean? For what kind of area?

Entered the problem is very good on paper have your nurse enter it.

The issue with that, and I'm going to answer that question here in the inpatient, 80s to be codified in ICD-9 or snowman. That implies the use of the physician doing that. It won't work for a nurse to do it or it has to be done from your coding system after the fact, which contradicts the timely stuff. Once you link it to the standards, it gets more complex.

I guess my general comment is what I am just thinking right now, after the discussion of quality and progress notes of a problem list is, the issue is to what extent is the doctor using the system versus the intermediary usage and how does it affect the whole thing? For a -- for order entry the doctor has to be using it and I'm not that is true but for everything else, that effects meaningful use is.

Tony, is it exclusive -- explicit that these are Dr. entered? Or whoever is doing the actual? Whoever is responsible for the illegal entry is doing the entry, is that explicit?

I would have to go back and read and see what kind of interpretation it is. Obviously, if somebody is a testing that they did something they would be the people that they thought to be doing the actual activity and whether it is specifically says that in the regulation, I would have to go back and look at what it says. I understand the question. I am struggling with having to go back and read over but once again, this might be a comment, a verification that where it lacks clarity, and you think you can create an impact in terms of meeting the meaningful use or creating a situation where there is an audit I think that is where you need to make it clear in your comments that is something that needs more clarity.

We want to specify, I am not sure what side of this we are on, the Lewin to specify that is not necessarily the position right?

One of the things in the original Maitre, like Percy POE, it has to be entered by AMD but in the objective it was AMD, nurse, licensed practitioner, it was more vague.

The customer rest in -- the customer recommendation, we talked about that, was a licensed professional, we talked about that. Sometimes nurses can't enter that. A nurse cannot you see POE, right? That is not the intention. The recommendation from at least the customers as they we you've licensed professionals are some wording like that would clarify it.

That makes sense. Once again, that would be good for someone.

We will fight noted as a, but there is a lot of confusion because I can get this tempers it with my nursing staff. That is not the intention either.

Right. Exactly.

Tony, you also use the word on the here in the first year, it would be a -- is it your intent that there may be random audits to follow up on me add in stations?

We are still working out the audit protocols but it would certainly be at some level some random on-site audits but we are still working it out internally, how we want to do some of that. We have some ideas but we have not finalized. We say in the regulation that we are going to be doing audit and will begin a more specific as time goes on.

Writer other fellow thought -- correct. All. Local, state

This is Christine. On page 59. But the draft rule, CMS is proposing not to provide patient specific education resources to include that objective. And any philosophical issue, then maybe a granular issue in some people's mind but it -- in my mind there is a philosophical issue which is the assumption for not including that is that you have to have somehow those educational materials built into DEA jar-- built into the EHR and that is not the right assumption. It does not reflect the right understanding. I will let to put that on a list to talk about how we can provide, I think the world is a good for that job of providing access and a copy to information but if there is no contest, the patients are going to be even more confused in the providers will be further burdened by patients calling and saying I don't know what this means, what does this mean? The assumption of a philosophical issue is how we ramp that up in a way that works and is reasonable expectation for the first stage of meaningful use.

This is Neil. I would second that. I also say thatthe requirement that it be integrated into a EHR isn't really what we are interested in. What we are really interested in is using technology to be able to do this for people so people have, people have access to MEDLINE plus through their office desktop computer, and they can print relevant information for people, that is clearly available now to be able to be done. Also, there are many systems in many ways in which these things are actively available within EHR so I think there was some thought there that this stuff is not available at the current time and I don't think that is correct either.

Trek. I agree with you 100%. He philosophical issue is that we can provide multiple ways to achieve this particular objective,which is right, what you have, there is a role for a EHR and it could be the resources are integrated that it doesn't have to be. The role of the EHR , the core is to provide the contextual information that the human can interpret say okay, let me point you to some other electronic education resources so I give you access or copy, you get what I am giving you a that is reasonable , meaningful and actionable.

The other philosophical, as part of the rationale for eliminating it, it would be really hard to account for it everything from language, a literacy it, etc. I think that it's in a perfect being the enemy. We really need to be, there is a lot of things we can get out now so we should start with that.

Writer

And continue to build and perhaps, in the later stages, they will become more meaningful to a broader section of the population. We have set in. Another area is reminders. I think there may have been a misinterpretation here. It sounded like they cut it down to only people over 50 and he would give a generic reminder saying don't forget, health maintenance kinds of things. I believe our intent was that the clinicians, the people using EHR , would be reminded by this system, with patient specific reminders. This patient at this age, with this risk, is a native the following: and it wasn't an electronic postcard, so to speak. I think that is how it read. I may have misinterpreted their interpretation but.

Paul, I am not sure I'm following you. I think this was patient reminders, not reminders to the doctor the patient needs something.

Correct. I guess there is -- I guess those are two sides of the same coin. One of the ways the airline people, you could remind that Dr. germ and the patient. There has been plenty of evidence that if you remind patients, it works even better. But the whole process is, if you give specific reminders that apply to specific patients, in general, it gets are things over 50 and that is how, I am trying to find that I have, that is how it came across to me to just limited to over 50 years old.

It is on page 84 and 85. I agree, but from a women's organization, I have to say that women need a lot more regular ongoing preventive and different kinds of care and this is a big issue for me in terms of limiting any kind of reminders to patients 50+, I think you are right to flag it. I agree. And perhaps we can think through a stronger recommendation will might be that is feasible and not overly burdensome.

Great. Okay. Other global commons.

One of the areas I wanted to bring up was continuity of care kind of fame and the two pieces of that I wanted to bring a. One was, I am sure Tony is going to hear this with confusion about the definition of eligible professionals and the ambulatory environment and do they qualify for the incentive are not. And talking them through, again, that definition isn't exactly clear and there is a lot of debate out on that and maybe Tony can have some clarity but considering the eligibility professionals, for instance, those physicians who are primary care practices, that are affiliated with the hospital, do not qualify and this is flag in the rule as a gap. The issue that comes to the table is not only the funding issue that they can't find them but the bigger issue is that as we look to moving to an integrated model, it really would make more sense to harmonize and balance the uptake of tran4's across those environments and can it have any consistent way, that is one issue and if you have a hybrid model, there is lots of inefficiency and variation, etc. etc. etc. I like to put the issue on the table in terms of the definition of hospital-based eligible professionals get clarity on what that is what the implications are to achieving continuity care. The other piece of that goes, there is a new requirement added to share care summaries on a referral, where before we were kind of, the capability and testing of that, so it seemed to contradict what we were trying to do and are other definitions, which was to make sure that the providers weren't held accountable for making sure they had something to connect to in the early phases and get them ready to do that in the next phase. I think all that links together.

Okay. It looks like we have skipped, have we exhausted the one, the ones to come to mind anyway? For the first category, quality and safety efficiency disparity?

I think that's where the advanced directive pieces though, is that right Paul?

That is correct. You are to raise that, that was eliminated. You want to raise as a discussion point?

I think so, for later because I think it is important, if I had to guess the reasons, given a public debate last summer, I think I probably understand.

[laughs]

Sorry. I think that is the right answer when he talked to Jerry. It is really important and really helpful so I think it is something to keep thinking about.

This is Devon. I read a rationality rule and I get it. It is certainly not one is cutting across all patient populations, and particularly the pediatric context for your talking about how the kids, but I would like to do some more thinking about it too.

Especially, considering this is a Medicare and Medicaid. Clearly all the Medicare should have an ADM likewise, for consistency, so that the pediatric things, which apply to very few people in this target, grew. -- Grew. That would be inconsistent to taking something out because it didn't apply to anybody.

Right away have a reminders that we are are you targeting at age 50+. There is a clue of the signal of the willingness to do this.

Okay. Anything else in the first category?

I have one thing. Which is something to flag and it is definitely philosophical, which is how can, or will, CMS be able to give feedback to physicians and clinicians once they have submitted their quality reports? It would be great if we could see how they compared to their peers and their region are nationally, how are they improving over time? Something that makes it be a two-way street so that clinicians can submit but they can also learn and understand that. Weather data really means.

Okay. -- What the data really means.

Okay. I am assuming that is in the plan. Looking at Hospital compare etc.

Yes.

Let's move onto, and that is not the last thing, to provide the feedback, but let's move on to the patient and family engagement.

One of the things of the whole access to the information and CMS added some parameters, like 96 hours and 48 hours. It might be in the detail, logistical from the providers as well as a system details, 48 hours is not clue weekend, that type of thing. It almost looks like, when you have that kind of timeliness factor in the percent of people who should have access, you are almost, by default, talking about electronic, sort of a web-based access versus these other examples of CB and USB.

Specific?

Yes.

I'm not sure, I think it can be available on USB and patients one a, but the idea was, to try to predict the format, except to say electronic of course, as much as to be flexible for patients, for example, it is probably easier for a patient to take a copy with them to another provider if it is on a USB or a CD versus access to information as I can see and manage my own health for my own purposes on ongoing basis.

We had consider that which is why we put some of those EEGs in there as well. Once you have the timeliness, can you see getting your lab test on a CD to a patient within 48 or 96 hours.

If you could do it electronically on a portal, why can't you just copy it on a CD question mark

By request, you have to mail it to them or they have to be present in the office to get it.

I think that is valid. The other point on Alan, like the measure, and again, I am not quite sure. We'll have a propose alternative, but as you look at the process, how are you going to keep track of, how are you going to get the denominator is a question on that one of you have to have a manual process in place to measure those people or build into the system, that request and, don't get their copy to get my denominator so that was a challenge. That is a burden on the workflow and current offices and hospitals.

What is a good solution? I would rather be in a position of suggesting solutions that raising a problem with it.

Actually, I tell my customers the same thing. We would come back and asked for solutions.

This is Devon. I prefer to sort of look at the timeline to think about a way to work with them. For example, rather than saying that the patient has to get the electronic copy in a certain LA timeframe, they have to be available. Forms within a timeframe that the copy is available and that they can, the provider can make the appropriate arrangements for the patient's preference on how they want to get it. Then, of course, they made automatic download into a PHR, they could check that box off easily. I don't have a good answer for the denominator issue. I think that is a good question.

Let's move into that discussions of the topic is registered and that is the kind of thing, I like the idea of when we do bring it up, as an alternative, we do bring up an issue, a recommendation, have an alternative recommendation and rationale. I think that is the most helpful to CMS. Soon pass this measure is only 10%. Realistic here.

Users have had to percent of what is.

The denominator.

I got that. I got that.

It was the timeliness that is really good, is Devon pointed out. I agree.

Yeah, one of the more exciting things.

Yeah.

I think you wrote remains in confusion between access and copy so I think anything we can do to continue to clarify her interpretation of that because both are very important, would be good.

Exactly. Another area, I think this is something that we did not spend enough time on, we use the term relevant encounters. I do not think that the informal definition, the way we discussed it on our call, is the same, is the same as what is written in the . We need to take the responsibility to be more explicit and what we meant by relevant encounters.

The other thing in this area, that I had, was noting that, for eligible providers, if there is a suggestion to provide clinical summaries to patients free Java's visit, that when you look at them, the corresponding metric in the hospital setting, it is a discharge setting summary upon request. I am not sure I understand the rationale for that.

I think it was upon request, it is almost the patient preference these. Does everyone -- everyone wanted electronically or do they want paper?

Right.

It is also a question of whether or not people should have access, and someone to their record while they are in the hospital.

This is my interpretation, we were trying to deal with the problem, in the early stage, that they might not have a place to send a discharge summary two, likewise, the practice might not have a place to send their referrals. In the meantime, the patient can be the comedy person can be the -- and you will. The intent was like, if that happens, at least in the early phases, we would be able to produce electronic copy of their record to they could carry it to the next place as the age IE started to build up by 2013, we can transfer it and I think the same thing would apply to the clinical summary, what kind of the same intention there. At least I thought that was our intention. He wanted a means to be able to do it to those advanced places could do about at least, the vocal have to have something electronic in that time window.

I think I am saying something even more basic, sterling, it should not mirror the measure was as clinical summaries a discharge summary provided to the patient for at least 80% of all discharges as opposed to summaries provided upon request.

They should or shouldn't?

They should.

I with you.

My question about this, what about access to the information during hospitalization? Right now, people have no access to the frequently one.

I would agree that they frequently wanted. It is by no means widely available in commercial products. We did not include the our criteria. Not that we can't impeach or stages, for example. -- Not that we can't include that in future stages for example.

Okay. Are we ready to move onto the next category?

Paul? This is art. I was trying to make a comment. I was not allowed to speak, I had to call back in. It was only first item, it was around, we had some comments about generic lists of medications that seems to have fallen off the meaningful use criteria. I don't know what happened with that use the generic names.

Good point. That is another one where it is an oversight probably. We didn't point out that that was missing to thank you for bringing that up.

Thank you.

That was one of our efficiency quality cost kind of things.

Right. Right. Thanks.

Thank you.

That reminds event, that means that probably the imaging indication was also dropped.

Was up for 2011?

-- Was that for 2011?

Let me see if I can figure that out.

I have my other piece of paper.

Yes. It was.

Paul, it is David. I'm sorry if I drop off shortly. It does they might be efficiency area is one of deserves to be on our philosophy list. The efficiency measures are approved, maybe 10 again,, they are proved to be difficult to improve mechanically or otherwise, which understand that and try to discuss how to make sure we address that somehow. When forward.

Generic and clarifications for high-cost image you are measures for 2011 so we can get back to it. Some of these, Tony, you might be writing down, that we can get follow-up on rationale. We're available I guess.

I think that is fair.

Okay. Moving on to care coordination. Clue biggest difference here was adding be tested once criteria. What is not clear, maybe this is just as simple as a clarification, tested once at the actual recipient agency that exists or testing or software. For example, testing the communication with the immunization Registry, does the test have to evolve the public immunization Registry and does that exist everywhere? That kind of thing. And reporting of labs and center.

That may be a clarification question. And if not, it may turn into a visibility question.

There is a qualifier about, unless the other public health agencies are capable of receiving at, right?

Yes. You can certainly imagine that a big state like California to be capable, in principle of receiving it but what they want to deal with thousands of practices doing their test?

How are we ever going to get the public health agencies to get a board with this?

Right

When they standers, when they are accessing it through the NHI and. -- End. Without the, however things are going to be moving around, it would be difficult to have all these connections and test.

I see. But, that should be something that ONC considers as it moves forward with the NHIN, how that will impact on our capacity for Jamaica 2011 measures work.

Exactly. If there was one place you could test it, that is fine.

Like, if we had in its infrastructure and to test against that get a check mark, we could do that.

Exactly. That is sort of a software test,

Right. Burkett be the providers it to you but it is something, something like that would help us.

Okay. That is a topic. They did add this new summary care record for transition of record care and referrals.

Paul, before we go there, I am not sure if it is before or after, Kelly Ray something that is on page 95 are just to electronically key a lot -- information. That is, it is a philosophical question, I think this question the infrastructure necessary to develop changes is still being developed I think it is Sam's you need age IE's-- EHR or something like that. And I guess I am philosophically wondering here what about other ways you can exchange key clinical information like secure e-mail are the things. Do we want to be open to that are his only test our connection to an SIE?

I don't think this is specific actually, so it does not rule out what you said.

Right. And that is the case, they could this requirement be more robust than just one?

Which one?

I am on page 95. It is the hospital measure the says to perform at least one test of the HR technology capacity to electronically exchange key clinical information. And it really says the capability to send it should stay to send an receive and the infrastructure is still being developed in a catchphrase makes me think the assumption here is the need a network or sometime bad I'm not sure that e-mail, secure e-mail it to the trickier and 2011 at least the biggest issue that came from on the provider side of the market is there going to be accountable for this one,they would have to know that there are some places, a lot of places were EHR does not exist and practices are not automated so least in 2011, this they are try to get these practices up, we do not to be held to being accountable for something they can't control.

So that was why it was a capability weather was one or several tests I think it can only do the test, but to the exchange of 2011 was a challenge.



We do have this on the discuss list

Paul, this is the other one, I don't know what to talk about the clarification of the outpatient eligible provider piece with this but this is again, the broader context, you could say it is just financial, but it is really continuity of care to.



What is really continuity of care?

What I understand, this is our eligible practitioners, again it is not who is employed in the role, but those who use facilities of the hospital, are excluded from receiving the incentive and the rule really talks about their concern about the outpatient environment. Our customers are concerned to because what that says, they were counting on some of these adding to automated but to just do the impatient without the outpatient, doesn't allow them to grow electronically, consistently across your organization. They feel they will be gaps in quality and continuity.

Can we utilize the stark exception to grant those positions?

Of these hospitals had two nickels to rub together and to give them some money.

That is not right.

This is Devon. It is that the ambulatory doctors, essentially he won't be required to meet any of the meaningful use criteria. Cement that is the other side of it. Now they have a hammer, we will have one anymore. I don't even go there. There are hundreds of these practices out there.

It is very true.

Especially in a primary care world, any of them have sold their practices but are still operating in an ambulatory setting.

Yes.

One of the problems I think we would have though, in many cases, the clinics, or the outpatient departments would probably qualify under Medicaid, probably more than under Medicare while the impatient side I qualify under Medicare. You might end up with some discrepancy there. A lot of the outpatient systems.

At the hospital, they get to dip into the pool.

Rather that they are all professional, it is probably does one or two of the pools, they won't qualify because they are using the hospital facilities. They would have to just be one or the other and they can switch. There is a lot of flexibility in there.

Yes a one-time.

We pursue you can see them getting up and running getting money for Medicare and then switching to care. It is complex but doable.

This is clearly an enormous topic. Tony, was of the impression that the statute required interpretation?

There is a lot of complexities to this and we have certainly heard from 1 million hospital groups. Not one clinic, but many hospital groups. I will put it that way. But, we have been limited, in some ways, by the statute. We have attempted to be as liberal as possible in interpretation, as we say, 90% of substantial, 90% is pretty substantial. And we also point out that a regulation that people have identified themselves in a certain category and have actually received higher payments because they identify themselves in a certain category over the years and now, for the purposes of meaningful use, we want to change themselves to different category. There are also issues that deal with regional or local versus national. What may be an issue in the Bronx may be somewhat different in other parts of the country. We heard from a different groups, we tried to craft as much as possible. Trying to brand the broadest number of, eligible professionals as possible. At the same time, not putting something in that would create bigger operational issues and also create complex with her other programs. What we have done is put out there a proposal and we have asked people to come back and with data and other supporting evidence that will potentially allow us to change the definition, if the rationale is there. It is a very difficult issue, as you can imagine, we have heard from every hospital group in the country about this before it came out. We have certain limitations, some proud -- some programmatic, some statutory. Frankly, there is also in latter years, it is part of meaningful use as the criteria, it there does need to be in integration. There does need to be something that hurts integration donate to come up with something on a national basis that make sense, not something that comes then ask an exception to. We are trying to find a middle ground and to the extent that people can help us do that in the extent that we have changes that we can make that don't undermine other programs, we certainly are open to hearing it but it has very -- it has been a very tough middle of the road approach to try to take. That is why we love the 90%, because 90% is very substantial. And people are utilizing one category to get additional payments under other programs and now they're up want to be something else for this program. It is not an easy answer but

No it isn't.

Tony, would you expect to be participating in a calls over the next six month to iron things out. In particular this to have so much annoying some of the constraints that we can see as helpful as they can to propose some type of alternative to propose a rationale.

I can as much as possible be on the calls and we could certainly have people from our payment policy group also participate as needed. Obviously, there is only so much we can say at this point because we have put out a perception -- position in the rule we are certainly open to hearing solutions that will help promote adoption and meaningful use. We want to take away from it.

Tony, one of the surprises we had, we interpreted from the rule that, therefore in the denominator, this is a positive and a negative actually, we had a big debate on this one, it excludes now, order entry through the emergency department from being counted because it is considered one of these other points of service.

Again, we had the debate from our customers. Some wanted to include about exams the number, the denominator so others do not want to include it so we can see the dilemma that you are in.

Yes we are trying to develop consistency here while trying to, make things as wide open as possible so we can get the largest number of -- out the door. It is a balance. It really is.

I think from this workgroup, and the -- committee's perspective, armed with a focus on the meaningful -- in other words, some of the inadvertent impediments to integrating the data and the care process. I think I'm a perspective that we will try to work on. It is clearly a big deal and I think we should devote a fair amount of time to it. That particular discussion, will easily allow a lot of CMS input. Other constraints that we need to incorporate as well, just like somebody else mentioned, it is for us to come up with a solution that the constraint is not allowed.

Okay. Very good. Other comments in this particular, care coordination and we will move onto the privacy, which has changed fairly substantially.

All one more question on the med rec any care summary. The med rec piece is nothing like interpretation of what is put in the role, followed what we talked about because it seems than 2011 we look at med rec, for instance, at the point of omission or discharge, as we read it now, it could apply every care transition. You would say, okay when I'm transferring you from ICU down to step down, too whatever. I think we are going to need some more, we need to decide if we want to go back to where we were, so I think the translation may not have occurred in the way that we intended it.

You are saying we do not intend to go over what it does do, when you're transferred from one unit to another?

That's what the intention was to do reconciliation in stage one, for instance, when you were admitted or at the point of transfer between physical entities as opposed to ease stage of transfer within a facility.

Okay. I remember us having a little difficulty in trying to separate the two.

I know.

It really raises the bar a lot to go to the whole thing in 2011. That is all.

Relevant encounters as a provider, we should put a more precise definition to what we would -- we did not do that initially.

Okay. We are ready for the privacy piece?

Sure.

[laughs]

Not to call directly on you, dad.

I know. I was pleased to see that a security assessment stayed in there, especially given the testimony that some of us may have heard that the standards committee, they had a daylong committee on security and essentially, based on some surveys that have come out, there is an indication that the health-care sector, in particular, has a vast room for improvement on the security side and this is one of those areas where the technology can actually move you forward through capabilities, can be built directly into the system, so I was glad to see that on there. I think I wondered what the measures should be in terms of the risk assessment, is a just an attestation that you did what? Is an attestation that you did the attestation that was recommended and was alone more unclear have more clarity there are would like to see. On the compliance of the nationwide data sharing Claymore, I think, it is noticeable by its absence, on the one hand. On the other hand, what is in that framework, is a principal level. I think it is very clear for providers to be clear on what they need to provide of something. I think that is really something I principal level and one could argue that if you are in compliance with it though you are in compliance of that framework because there are implements of hit that vision with those principles. -- Hit the

I understand why they didn't make it in. On the privacy rule compliance and sort of not picking up on our wreck of a nation that people who are under an active, formal investigation versus the complaint said, personally disappointed there and now we have a privacy and security workgroup which we do not have a we first came up with this matrix are nowhere going to be discussed in more detail in our call on Monday, and I think I still wonder why, particularly if an entity is the potentially going to be fine, simple -- for a HPPA violation, why would allow money to be going out of the treasury for meaningful use lawyer having a clear problem on the privacy and. I don't know if others feel the same those are my general impressions. Again, this is also common and we have a privacy and security workgroup, we are going to be discussing these, so I guess there are some cross jurisdiction now that we have the workgroup establish.

I think we can certainly invite your new workgroup, particularly with your next call to formulate something to bring back to this workgroup as far as dealing with this category.

We would be happy to adventure on it, Paul, there would be discussions too.

Thank you.

Is that the intent Tony, that if you are in full compliance with HPPA security that you would meet this objective?

I guess it depends on how somebody interpret that but certainly risk assessments are part of that role. I think that you can interpret that. Well, I don't want to make a blanket statement because the only thing that we are requiring is the risk assessment.

A critical part of that security role.

One, based on survey data, a lot of providers, now listed in the requirements, don't get too.

For a large complex medical, and we really carry out the execution well, most medical centers should be fined every year small amounts for things that are going to go wrong that you can't stop.

That is not necessarily.

I can see, my faculty members are in charge of an $8 million corporation. And you just can't stop that 10,000 person from giving away Social Security numbers or something and you act appropriately and he reported to the state prosecutor in the do all those things that is going to happen on a very large thing, a very small section -- I am not sure that the, I don't know we are linked so carefully. It is too difficult things, meaningful used in privacy and security. And mechanisms for both. I've another we should do that. I don't know if we are in compliance for at the. I don't know. I don't want to go that far. I am going to re-with you.

I don't know if I want to go that far either. I think it is important to lead it is workgroup do something. At a minimum, we need to talk about the importance of the security assessment given a wild number of healthcare organizations that don't do the required annual security assessment and let Devon and her group come up with things because you can't be meaningful using any HR if you are not protecting patient information.

We have a good cross section of the book as well in terms of providers being while for -- well were presented. We have a health plan represented on a call so it is not as the there are people that understand that incident happened. Every day. And that you have, we want to craft a solution that would send a message but also be reasonable. And appropriate.

Thank you. That clarified it. Incidents are different than compliance.

Correct.

That is right.

Thank you.

Will he originally wrote it, and the second round, we did clarify it not just to -- but they simply we were convicted. Out of compliance. And that action, in our proposal, would have stopped her payments until that happens. But --

Okay. Moving off of the categories, it looks like the CMS took us up on the adoption year strategy which meant that regardless of how, which came a UU came in and and your verse, except for your current efforts, etc. 2015, your first set of criteria that you held up too, was stage one. And they have a nice table that shows how that works.

One of the implications, and I remember Tony asking this question, actually, is what is happening if you come in at 2015 and what would she be measuring again at 2015 and the implication of our statement was you would still have to be held accountable to the criteria in effect that time. And that is what is on the table. Clearly, that is challenging for folks coming in late. Is that a topic that we would want to discuss?

Wood as the customer's perspective, and we know it is going to take five years to implement these systems, we just don't know how to do it and the second thing is, it puts pressure, right now, to know what is in stage II and stage III breast to get there. They really impacts to things.

This is Neil. I don't know there is a solution to this, but I think this is a real serious problem. It basically, it creates, first of all it creates enormous pressures in the next year, then presumably would drop off somewhat but in the first year, that we are trying to do all the stuff, the direct centers are getting up, that some of these facilitative mechanisms are being put into place to help people implement, at the same time, there's going to be a norm is a flood of activity. I like to see this back on our agenda for discussion. I think if we are really interested in adoption, it has to be something that has a glide path, the same guy path -- glide path, with the start of this year, next year or the following year. You can be, you can't say you have to learn how to fly and when you. If it takes five years to learn how to fly, you have to learn how to fly in five years.

It is definitely worth discussion. This is Christine. Maybe there's something I am complimenting. At that this was better that you adopt me first three years. We adopted an 11 versus 12. I'm talking eligible providers because the hospital, has a trigonometry degree. There are only $5000, either way, we have something -- we have somebody breathing into the phone. It is hard to hear folks.

As a drop-off in 2015, more significantly, but it is is the need to balance, the need to do something that folks have the one he providers to do for a long time, and delivering benefits to patients. A multimillion dollar investment. I thought it was a pretty reasonable approach that I am open to if I miss something here.

We have successfully put on the list.

Sorry.

These are excellent points.

Any other topics?

That the you can't write some in when you think of it later.

From an organizational point of view, you can tell this is going to be several hours of discussion. Our timeline is, we need to be prepared to present, we are going to present top level view of all this, so the committee has a headset that committee members will have a time to comment as we have next week and we will take that next month, let's say three weeks because we need to put in a form that can be presented and adjusted by the committee by the February meeting.

Call, I wonder if it would be, I am worried about the payment you are discussing in the policy committee setting all the oxygen out of the room. And people have a lot of energy around, so I think it would be helpful to start thinking about a way that we could have a dialogue on this, in particular, and maybe it is as simple as two different people sort of layout pros and cons to this approach in there is discussion so we don't have to.

Very good idea. Thank you. That is excellent.

Some of the major topics will set that up. Thank you Christine. So in fact, were you suggesting that for the Main committee or for the work route meeting call?

I was adjusting it for the full committee because I think there is a lot of energy in the full committee. I am thinking about, like folks to Gail and others have made in the past.

I am wondering that may be a strategy for our work group call? For the major topics, like you and Neil, just volunteered yourselves.

Duke it out.

It really helps. Once, things have been said that we don't need to repeat that we have a thoughtful approach.

Very good.

You see this is going to be several hours. I definitely have a two or three hour call that we need to schedule in the three weeks after next week.

Yes. You have a couple already on the books. You have January 28 of February 12. You need a few more I think.

January 28, is only two hours. What is the other one?

February 12.

That is way too close.

I know.

Will have to extend the one we have in a find another one for three hours so that we can try to get.

This clearly was the meat of the committee work in the first months and it is once again, the next few weeks, will have to be the meat of the committee work because it is a good thing. This is an extraordinarily important program. The crux of the HIT incentive program and we need to do the best job we can and I think this group has cruelly been committed throughout this to do that. We have had back and forth and in the next round, it is worth the public support to try to get meaningful comments back. For the next round.

Any other, they were reopened up to the public?

Just a question about whether or not we should try to plan a committee meeting in person. I hate to suggest that but I am wondering. Is that possible?

That is a great idea.

I think it is hard to do some stuff over the phone if we are really going to get down to it, I would like to make a trip and slog through this and try to do this through three conference calls.

I totally agree. First of all a lie too, that this group has been extraordinarily productive or conference calls. That is really an asset. Judy, do you have any thoughts about that -- about why that might not be possible.

I might suggest the day after the policy committee meeting.

What is that date Judy.

January 14.

Those of you that travel will already be here.

What about the day before?

The day before we have to work group meetings are scheduled of the day before, a committee meeting is horrible, to be honest.

Let's do this, Judy, can you organize a pull for us, both for that suggestion it is made as well as other dates that the committee can make for an all-day meeting?

And let's try to get those on the books?

Can we open it up to the public? Any more comments from the work group members? This is an excellent call. Very productive and great suggestions.

Right remind me, I think we open the lineup, but let me say to the public, you are limited to three minutes for your comments please.

Thank you Judy. For anybody who is following along on my, if your art he dialed in, press star and one if you want to me to comment. If you are listing online any wish to make a,, you need to dial in, that number is 877, 705

Thank you Judy. For anybody who is following along on my, if your art he dialed in, press star and one if you want to me to comment. If you are listing online any wish to make a,, you need to dial in, that number is 877, 705-2976. 877 -- 75 -- tonight 76. Impress a star and one going to get dialed in. We have nobody at this very moment. We are going to a couple of minutes for anybody that wants to comment, to get dialed in.

Paul, this is Christine, can I ask Tony a mechanical question? Tony, if you're there, my question is, can you walk us through the mechanics of how the second payment year would occur question mark let's say a meaningful user has, then he meaningful user for a 90 day continuance. In their first payment year and La Scala 2011. They did October through December. The second payment year, when do they have to start meeting the criteria and when do they get a payment?

I can talk you through it at this point because it is a proposed rule.

Right. Can you walk me through the proposed process? And then it is in the rules?

In terms of the second payment here?

I am trying to get a sense of for the requirements in stage II, in stage I of 2011,

Stage to does not begin until 2013.

Okay so they had to just keep doing the same thing in stage one that they were doing for the 90 day period in 2011, for 2012.

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That is what I would -- that is what I needed to know so that gives 2012 to ramp upper stage II.

Is either.

Tony, question in terms of the 90 day period, does that apply for the first year for any stage one? So if I started in 2011 or 2012 or 2013, it is just 90 days per year one?

Yes.

That is what we read.

That is correct. And that is not clear.

It is there.

Charlie?

Customers are jumping up and down.

That is why we have proposed this because of the fact that, you have the stage one requirements, you also have a shorter reporting. And any ramp up this as she moved to stage II.

And in the second payment period, neighbors, even qualify for quarter one, within 90 days. The occasion quarter two, presumably. And 2011, and 2012, two collector second payment, your reporting. Is the entire payment year or in that case?

Yes.

You're still maybe the same criteria, you just never 90 days.

Right. You have to demonstrate over a full year.

People year, let's make you qualified in 2011, and agape, and when you get paid for the second payment year 2012?

The entire year.

The entire 2012.

That is what we propose.

You would get paid in the first quarter of 2013?

Correct. The other is actually made, say we missed the year, we are going 2011, 2012 but we don't stage II, we dismiss that year and we have to do to stage III? Once you start, you start.

Say, if you moved your hospital and somehow you do not move your HR or something,

Right.

The calendar that you started with.

Yes. Once you start, you start have to move up the stages or you just don't get paid.

If I don't make it to stage II, that year, you're three or whatever,

I would have to go back and reread what we've been a propose on that. I am not going to say yes or no.

Those questions will come in.

Is the kind of questions, and we have not been clear about, what might have to add some clarity.

Paul, I would like to repose my original idea, which somehow got turned into a face-off. With Tony are somebody, just explaining what is in the proposed rule because having it be a 90 day thing, it changes a lot. We have been is that the requirements, stage I and stage II, calendar year, payment year, is to understand that, at the policy committee level but also at the workgroup level before we can understand whether the requirements are reasonable, these the payment years.

Will you be admissible to that Tony?

Yes. I think so.

Thank you Tony.

So I think what happens is that will solve some of that confusion but I think it is nice to have the, it is not a face-off but it is a pro, it is an organized way of getting to point out that we can efficiently make a decision. We can identify by e-mail, those areas, as a hospital-based, and adoption your, there'll a handful where we would need that level of perforation.

-- Of perforation.

Do we have anybody to the public on the line Chris?

We have no public comment at this time. Reminder to folks, if you make a comment via the web, in written format, whether it be cut -- public, so the screen, those, do not read aloud but will be delivered to the members of a part of the public record.

Integrate

Once again, I like to thank all the participants. For this very productive call. I look forward to our schedule and are intense time together so we can provide people -- the back of her own CMS. I look forward to seeing you next week.
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