Geographies Meeting 2010-07-07

Notes from Implementation Geographies Workgroup
Date: July 7, 2010
Time: 12pm-1pm
Attendees: Richard Elmore, Sandra Sarnoff, Chris Voigt, Didi Davis, Andy Heeren, David Kibbe, Douglas Arnold, John Moehrke, Noam H. Arzt, Matt Koehler, Leroy Jones, Arien Malec, Uvinie Hettiaratchy, John Hall, Gary Christensen, Brett Peterson, Don Jorgenson, Brian Behlendorf
Actions for this Week

#	Date	Action	Status	Owner	Due Date
22	7/7/10	Edit template to include HISP detail and key success metrics.	Open	Brett Peterson	7/14/10
23	7/7/10	Write-up on process for and description of existing pilots	Open	Brett Peterson	7/14/10
24	7/7/10	Fill out briefing template	Open	WG	7/14/10

Agenda
· Review the template for a pilot project brief created by Gary Christensen.
· Review the first pilot project briefing document submitted by Gary Christensen of the Rhode Island Quality Institute.
· Discussion of process: How do we advertise the pilot project briefing template? Are there deadlines?
· Revisit and discuss Rich Elmore's suggestion about how we ensure clear success and measurable outcomes. Can we spread our focus across multiple initiatives and still achieve externally recognized success? If so, how many initiatives can we support in such a manner?
Notes
Brett Peterson

• Doug Arnold put up second pilot briefing project to review on the wiki page.
• Gary created a template for describing potential pilot projects. The reason for doing that is to advertise that information.

Round the Room –Feedback on what might be added to template and process on how to utilize this.

Rich Elmore	Good work was done on drafting initial operational plan. It seems to me to make sense to use that as a reference for how we’re going to build out this template. There is a lot of good information we can bring from there. Would like to add expected success metrics. It’s necessary to have a target for each of the pilots. Brett Peterson Should that be added as additional fields or sections? Certainly profile information and success metrics. Some information on what the pilot is striving to achieve. Focused targets will be useful.
Sandra Sarnoff	Just joined as of this week. Not much to add at this point.
Chris Voigt	I agree with earlier speaker. Missing some details on what might help us understand what we’re trying to accomplish.
Andy Heeren	Similar comments. Template is a great start. Only suggestion is an additional statement that says we’ll know we’re successful when…. Specific to Gary’s brief, question around HIE, are they signing up with HIE specifically? Gary Christensen Yes, they are participating in current care.
David Kibbe	Strongly recommend we follow Rich’s advice to add metrics to the template. Assumptions around resources available.
Doug Arnold	Agree with Rich Elmore. Important having participated in Reference Implementation call yesterday to make sure we’re in sync so we’re not out of phase. Happy to discuss this further.
John Moehrke	Agree with everything said. As much as I’d like to see more detail, we shouldn’t over-engineer the template. Expect it to evolve.
Noam Arzt	Nothing to add. I didn’t get the email.
Matt Koehler	Nothing to add.
Leroy Jones	Clarification question, is this a declaration of intent? Brett Peterson Something maintained over time and altered as well as a declaration of intent. It is a declaration of what some groups plan to do.
John Hall	I would echo what everyone said. Emphasize what Dr. Kibbe said. If this is a declaration of intent, we should keep it straightforward but leave room for measurable goals as project proceeds.
Gary Christensen	Obviously the usage of the document is what drives the format of the document. I was not trying to precede operational plan. The format was to communicate here’s the idea.
Don Jorgenson	No comment.
Didi Davis	No comment.
Brian Behlendorf	No comment.
Arien Malec	The one thing I’d like to see in operational plan and brief is to scan and see who the HISP is. That’s a missing element and that’s the only new comment. Agree with rest of comments.

Doug Arnold

• Connecticut is proposing MedPlus Quest.

Brett Peterson

• I heard there was some desire to fold operational plan document into briefing document with desire to keep it simple so we can debate whether idea fits. Rather than going over the current briefing document I would like to flip around the agenda to a discussion of process. If we understand how these processes work, we can see how the document can support them.
• There was a debate last week looking for how we ensure clear success and measurable outcomes. What do we intend to do with briefings that come in?
• I am not going to suggest a solution to that, I think I would like Arien and Brian to comment from an ONC perspective, what role these pilots would play.

Arien Malec

• There’s a limited role that ONC can directly play with respect to governance and organization of piloting. There is a current legislative mandate for ONC to provide governance for NHIN locally. Because ONC is formal part of federal government, any kind of governance activity has a set of responsibilities to call for a formal rulemaking process. This process takes a lot of time and effort and is not feasible in our timeframe. For many reasons, it’s much better if this group takes primary responsibility voluntarily organizing and managing pilot activities.

Brett Peterson

• Does that give us authority to say as a group that this particular initiative or pilot does not fall in the realm of where we want it to go? There was some concern that if a large number of these come up, it will difficult to track them and offer support. It’s a question of what authority this group has. A group that is organized that asks for a report each week on progress?

David Kibbe

• I think this is a very important question. I’ve spent some time talking to three different physician membership organizations about NHIN Direct at the leadership level. I think it’s clear that there’s very little understanding about what NHIN Direct is and what it’s not.
• In particular, I think they don’t yet understand how NHIN Direct would help physicians in medical practices to qualify for meaningful use.
• I see our major issue is to demonstrate as quickly as possible how real doctors are benefiting from NHIN Direct under this framework.
• I think this group needs a consensus around whether the NHIN Direct protocol actually works. If it actually offers additional help to practices hoping to qualify for MU in the context of health reform. There’s no question that there’s an information gap and closing that needs results from real people from real world.

Brett Peterson

• I think we want to continue bottom up approach. I suggest a 2 step process – we don’t make briefing document more complicated, and get many people to fill it out. Second step, for those who do fill it out, suggest they fill out operational plan.
• The role of this group would be to obtain a weekly status from those groups to see how it’s going and what the issues are. I’m going to suggest this as a role and process. Still allows organic approach.

Round the Room Feedback on this Charter

Rich Elmore	Pass
Sandra Sarnoff	That’s fine.
Chris Voigt	No comment.
Andy Heeren	Decent proposal.
David Kibbe	Fine with this. Just want to make sure we don’t lose Rich Elmore’s point. I think the template can be improved dramatically by adding metrics of success. Arien’s point of making it more transparent and saying who HISP is would also be better
Doug Arnold	Agree with David. Also would like to bring up point about HISPs – I think it’d be valuable if all the organizations who are prepared to be either national or regional organizations identify themselves.
John Moehrke	Favor of iterative approach
Noam Arzt	Fine with this. Maybe we need a template for HISPs as well.
Matt Koehler	This is fine.
Leroy Jones	Generally supportive. Whatever we do, we should be definitive. I think the declaration of HISPs was done in one of these meetings. Similarly with this template, it’d be good to put our stake in the ground and say this is it so we don’t have to keep repeating work. With that said, I’d be in favor of filling out form of what’s been published and catalogue things.
John Hall	Supportive.
Gary Christensen	One of the things we can do is indicate on the template which ones we think have gaps and what our overall pilot program is trying to accomplish. Perhaps recruit someone to fill in gaps if necessary.
Don Jorgenson	Fine with this.
Didi Davis	Support the idea.
Brian Behlendorf	Fine with this.
Arien Malec	I would like this group to have a strong role with respect to oversight of pilot operations and as David Kibbe said, making sure we’re getting the right outcomes and designing pilots that demonstrate value. In a future meeting, I’d like to discuss that the HIT policy committee and tiger team is likely to get out a policy framework and I think this group can play a role there. We can ask that organizations involved in pilot activities also conform to policy framework.

Brett Peterson

• If I can summarize what I think I heard, I agree with Arien about taking a strong role. I think the role of this group as more pilots are described is to ask hard questions about operational details and policy details, which is Rich’s point. To make sure that groups do come forward and fulfill goals. I like Gary’s idea of filling in which use cases we’re fulfilling.
• I think we should have a participant section. I could add an item so that people name a HISP or that it’s not yet known. I think I heard that while we don’t want all the details of operational plan, we should include some metrics for success. I will make those two changes.
• I will ask that people who have submitted templates so far make those changes as well. I think it would be worthwhile to give some time for the people who have submitted each of the two briefings.

Gary Christensen

• HIEs all over the country are concerned about NHIN Direct. I think NHIN Direct is an opportunity to get vendors to want to build capability of aggregating data in EHRs.
• To take advantage of Beacon Community work would also be useful.

Doug Arnold

• Question for Gary – In your write up, you referenced the Beacon Community grants. I know you got one. I think given that asset, there should be some spillover for any kind of NHIN project which would be advantageous. The converse is that it leaves pilots who are less financially advantageous in lower position.

Gary Christensen

• It’s an asset we can bring to table.

Doug Arnold

• Feasibility of using NHIN Direct protocols to share clinical information amongst diverse group of physicians in small practices as well as hospital and lab providers in support of MU. We’d like to address first 5 NHIN Direct user stories. 75% of physicians are in practices of 5 or less. Our practices have a heterogeneous set of HIT tools from Web Access to fully functional EHRs. We have fair amount of interconnectivity established amongst Quest, DocSite, eClinicalWorks.
• Hoping to build off current established relationships and try to work to implement NHIN Direct protocols across a set of physicians who haven’t moved to EHRs. This reflects more closely state of affairs of physician groups in country. We want to see if this can lower cost and see if they can get MU.
• Our brief was put on the wiki page a few minutes before the call.

Noam Arzt

• What part of country?

Doug Arnold

• Connecticut.

Noam

• Can you talk about relationship with HIE activity in CN?

Doug Arnold

• HIE activities are just starting. On board of REC for Connecticut, and we’re discussing HIE activities with Department of Public Health which is the lead for HIE. One of the participants, DocSite, has substantial HIE experience.
• I think there’s some fear from HIE participants about NHIN Direct. I think there needs to be some assuaging of concerns and understanding of how they can complement each other.

David Kibbe

• Focus on accountable care organization so not just about MU.

Doug Arnold

• Whole HIT activity is nervous system of accountable care organization especially in ambulatory area that can share information that can drive value for public and private payers. It’s impossible to do that unless optimization of sharing of clinical information happens. We’re doing that already, but long way to go and I think NHIN Direct can really help with this process.

Brett Peterson

• Thanks for the overview. I’d like to see if we could go round the room if anyone has further questions.
• Call for questions for Gary and Doug about overview of document – anything to ask or challenge.

Rich Elmore

• Both of programs are thoughtfully laid out and focus on demonstrating some important elements for what NHIN Direct will be used for. Question, how could we as a group help? What should we bring to table to help you succeed?

Gary Christensen

• There are some things I need to get people on my side to play. Someone needs to say we’ll be a HISP for you if you don’t want to build that capability. I’d also like to give vendors the reference code and specifications. That’s the short term I need help with.
• Overall, having a place to ask help for problem solving. Also, if we’re successful, see how we can extend to other places. If there are others who want to try back and forth with them, a place to reach out to them for that.

Doug Arnold

• We’ve addressed the first 5 of NHIN Direct uses cases. Need help with participation of patients. I know other workgroups and organizations who have access to patients. If any organizations are interested in joining up on our team, would love to work with you to get as many use cases covered as possible.

Sandra Sarnoff

• No comment

Chris Voigt

• No comment

Didi Davis

• No comment. In the two proposals on the table, is there any initial discussion on policies? Is there any feedback for any others who are considering this?

Gary Christensen

• We’ll treat these as data sharing partners. Trying to do this as vanilla as possible. We’ll hopefully fit with all policy frameworks that exist.

Andy Heeren

• No futher questions.

David Kibbe

• Gary’s point of using NHIN Direct to facilitate EHR to EHR exchange is important. I think that’s great. Gary, can you elaborate on why your HIE does not want to be a HISP? Who do you think should be? Matter of money?

Gary Christensen

• It’s not in our business plan. The hard part is not the technology for being a HISP. By being a HISP, you’re going to need service responsibilities, billing, etc. There are all sorts of infrastructural and operational aspects of being a HISP which is not what we’re about.

David Kibbe

• Do you think other HIEs will feel it’s not in their business model?

Gary Christensen

• No, I think it’s possible for others to have this in their business model. I feel like this should ultimately feel like a utility. I remember a couple of folks who said they would be willing to. It doesn’t matter that much in terms of business terms, I just need one.

John Moerhke

• No further comment.

Noam Arzt

• No comment.

Matt Koehler

• No comment.

Leroy Jones

• No comment.

John Hall

• No comment.

Gary Christensen

• No further comment.

Don Jorgenson

• No comment.

Brian Behlendorf

• No comment.

Arien Malec

• I see ECW prominently in the Connecticut example. I wonder if we should be including or how we’re going to include ECW in this brief and in pre-planning discussion. I believe also presence in Rhode Island. Wondering how to get more ECW pre-planning.

Doug Arnold

• I’ll get back to you about this.

Gary Christensen

• If ECW part of the mix, would be beneficial.

Brett Peterson

• Going to change current briefing document to address Arien’s question of who’s a HISP.
• I will also add a metrics for success section. I will also try to minimally change briefing document to see what information belongs in the briefing document. Advantage of keeping it simple. We can discuss next week.
• I will also write a little bit of the process about what these people do and also about those who have already volunteered as pilots.
• Arien will advertise how this will work on Tuesday in larger group.
• Start next week to see how each pilot project is coming along.