Coordinator: Welcome, and thank you for standing by. At this time all participants are in a listen-only mode until the question and answer session of today's call. At that time if you would like to ask a question, please press star one. Today's conference is being recorded. If you have any objections, please disconnect at this time. I would now like to turn the meeting over to your host, Mr. (Larry A. Green). You may begin.
(Larry Green): Well let's get going. I want to welcome everyone to this splendid event on a beautiful May day, at least in the Rocky Mountains. It's nice to have people scattered all over the country participating in this full NCVHS meeting. All we need to do next is do a roll call and then we'll turn this over to (Walter Suarez).
Marietta Squire: Okay, great. I'm going to call the name of the member and – one by one please respond. (Lynn Blewett). For some reason the mute's hit. Operator, can you open up the line for (Lynn Blewett)? She's on the call but she's muted.
(Lynn Blewett): Can you hear me now?
(Lynn Blewett): Yes, so I just have – I'm here but I have to leave for half an hour from 2 to 2:30, but I'll be back on. That's 3 to 3:30 your time I think.
Marietta Squire: Okay, (John Burke).
(John Burke): Present, no conflicts.
(Leslie Francis): Present, no conflicts.
(Alix Goss): Present, no conflicts.
(Larry Green): Present, no conflicts.
(Linda Kloss): Present, no conflicts.
Marietta Squire: Is (Vickie Mays) now on the call? Operator, you'll also need to open up the line for (Vickie Mays).
Coordinator: Excuse me, this is the operator. At this time (Miss Mays) is not dialed into the call.
(Sally Milam): Present, no conflicts.
(Bill Stead): Present, no conflicts.
Ob Soonthornsima: Present, no conflicts.
Marietta Squire: And (Walter Suarez). Is (Walter Suarez) on the call?
Coordinator: (Mr. Suarez), your line is now open.
Walter Suarez): Thank you, yes. I am present, and I don't have any conflicts.
Woman: Okay, also on the phone are (Jim Scanlon), (Debbie Jackson), (Katherine Jones), (Terri Deutsch), (Justine Carr), (Michelle Williamson), (Nicole Cooper), and (John White).
(Larry Green): Are we ready to proceed?
Marietta Squire: Yes, and (Hetty Khan) is also on the call. So you can proceed now.
(Larry Green): Thank you. (Walter) and (Ob), shall we start with the ICD10 letter?
(Walter Suarez): Yes, so (Larry), I don't know if you want to say anything about the logistics or Marietta or (Debbie), about the process we're going to follow.
(Debbie): Yes, this is (Debbie). Can you hear me?
(Debbie): First of all, the agenda was included on the home page, the Web site, that we would begin deliberations on three letters for the national committee on vital and health statistics. We'll start with the ICD10 – is that the ICD you're starting with?
(Debbie): Okay, correct. And the order of business will be to deliberate and discuss and for those who are on the call as the operator indicated at the time when the chairman indicates, then we'll have time for public comment and then determine next steps, whether or not we're going to take action or what as far as for each letter. We're going to do that step by step for each letter. So now this is the discussion time for the ICD10 delay. Thank you.
(Walter Suarez): Great, okay. So we'll just start with the ICD10 letter. Hopefully everybody got a chance to see it from the NCHS Web site, and basically it's – it has been noted in the letter itself, the main purpose of this letter was to restate our NCVHS longstanding position with respect to ICD10. We did not want to express any harder details or great discussions about any other points about the ICD10 but primarily it was a way to communicate to the secretary our longstanding and ongoing position with respect to that.
We held, as you all know, a hearing in February that included the topic of ICD10 and we are including a – also portion of our June hearing, we're devoting that to discuss ICD10 as well, and so the intent is to after the June hearing, formulate or include or draft a letter that will incorporate additional small detailed messages with respect to ICD10, particularly as we look at the new delay and what to focus on, if you will, on the period of this new delay. But in this case in this particular letter the main thing we wanted to state was our ongoing position.
So the letter, very, very briefly starts with the introduction, the sort of background about the various moments when NCVHS had discussion and sort of a history of evolution of the ICD10 review, discussion, adoption, and then the final recommendation. So that's sort of a recap of the first few paragraphs. And we're not really going to read the entire letter itself, but that's what the first couple of paragraphs talked about.
And then sort of a little bit of a recap of the process, since the adoption of ICD10 was officialized in regulation and then the part of the delay that we experienced from October 1, 2013 to October 1, 2014, and then our statement basically on Page 2, the second paragraph, that with this letter, we want – NCVHS wants to express our clear and unequivocal position, a view that it is still in the best interest of the US to adopt and implement ICD10.
And we conclude with a couple of paragraphs. We applaud their recent announcement via CMS. This was an announcement, not yet of course an official ruling per se, but the announcement of the intent by CMS to release an interim final ruling in the near future will require HIPAA (unintelligible) entities to begin using ICD10 by October 1st, 2015 and continue to use ICD9 through September 30th, 2015.
So it's really just simply stating that we applaud that direction of defining the next set line. So that's the fact of the letter. I'll stop there. (Bob), I don't know if you want to say anything about the letter itself or anything else.
(Bob): No, no (unintelligible) other than it's the fact that it's very timely that the interim final rule came out, so simply I think that's probably a key paragraph that really says that we not only applaud but we got to stick to the deadline this time. The point there was that it should be the last and final stage for the healthcare industry. So I think that's the strongest part of our letter. Thank you.
(Walter Suarez): Well, (Larry), just before we turn it to you for any additional comments, I wanted to mention we did not get any partners comments from community members, and we did not get any further comments in the public review process of the letter as we posted them on the Web site. So I'll turn it to you for discussion and the final action.
(Larry Green): Thank you, (Walter). Let me ask a clarifying question. At this point are we positioned to invite public comment, or are we going to leave public comments to later?
Woman: That's kind of your call. As you can see because we have to go back and forth so much and – before these three letters, it might be easier for the committee to just – to do all of this discussion, and maybe even before the action is going to be taken to see if there's any public comment.
(Larry Green): Okay, that's all we'll do so committee members, do you have any further actions or clarifications or concerns?
(Vickie Mays): This is (Vickie Mays). I'm fine.
(Larry Green): Good to hear your voice, (Vickie).
(Larry Green): It's my belief that the committee is in one accord here and that there's been substantial discussion and conversation amongst the committee members leading up to this moment, and I'm not surprised that there are no additional comments. I think they've been accommodated that if there's any committee member that disagrees with that, this would be the right time to speak up.
Woman: Otherwise, since we're in this venue of a conference call we'll have to take silence as consent as we proceed along with this, and I appreciate your clarification, (Walter), about not receiving any comments, any written comments, about this letter.
(Larry Green): So what we will do if (Debbie) concurs is we're going to assume that this – there's no further input to this letter from the committee, that we have no public input at this point in time. We'll reserve time later on in the call to invite public comment about any other work, and we will then take absolutely final action on these after that public comment. Is that okay?
(Larry Green): Let's go to findings from the February 2014 hearing, (Walter).
(Walter Suarez): Right, okay. So this is a letter that of course that you all have received as well, this letter summarizes findings and provides recommendations on the hearing that we had in June 10. The copy that you received and where the action was posted on the Web site is basically the draft that we wanted to start with, and I'm actually trying to open that letter as we speak here.
So and then I want to point out that there were just a couple of additional brief comments that we will go through and important I guess comments and minor typos are still on this draft letter. So basically the letter covers several items, and we'll go section by section and then highlight again, starting from the letter that is on the Web site on the public Web site, and we'll just highlight a couple of the additional comments as we go along.
So in the first page of the letter, there is the introduction about our role as always and then the introduction of the hearing that we held in February. That's the second paragraph, and then on the third paragraph there is a statement there that talks about a sort of additional information really about the background on this letter.
One typo there as some of you noted is that we have 2 on the third line of that last paragraph on Page 1, there is to implementation of, so the third line reads as specifically with regard to implementation of implementation of the first set of standards. So we're – with that one specific edit of course that we're doing is eliminating the second implementation of.
It's just a typo there. And then we get into the first section of the letter that deals with prescriber prior authorization for the pharmacy benefit. So the introduction – we spent a few paragraphs basically framing this topic, you know, the background about it in terms of NCPDP, the national council for prescription drug programs back in 2004, organizing this multi-industry, multi-standard development organization task group to evaluate the concept of prior authorization standards.
Currently the standard that is named in HIPAA is the X12 N278 standard, and this has some – this was found out to be adequate to support the prescriber portion of the prior authorization of the medication, prescriber authorization. And so in this paragraph actually there is a couple of minor points that were provided to us actually through the industry input of this letter. So I'm going to review them in here in this draft – in this particular paragraph.
So in the statement that reads investigators – this is like the third – fifth line on the letter that starts with investigators found that the HIPAA named PA standard, and then the – parentheses and name was not adequate to support medication PA because it was best designed for procedures/services or durable medical equipment prior authorization. And then we say on – it did not have a mechanism for providers to provide relevant information.
It was recommended by the industry to include a – in that sentence before we say it did not have a mechanism for providers to provide relevant information, to include the following short additional statement: "did not accommodate the information necessary to facilitate prior authorization". So that's basically it.
And then we start the next sentence with, "It also did not have the mechanism for provider to provide relevant information. So it just adds that additional statement and continues after the period with the original last statement that we had there. That's the additional change there, and then the paragraph continues with consequently the NCPDP developed and through its vetting process received industry approval for e-prescribing a prior authorization transaction.
And actually said for any prescribing or prior authorization transaction, and the recommendation was to change that to instead of defining it as a single transaction, it's really taking out the a, A-N, before e-prescribing prior authorization, and adding an S to the word transactions. So it would read, "So consequently the NCPDP developed and through its vetting process received industry approval for e-prescribing authorization transactions, plural.
That's basically it and then there's just down a little bit farther in this same sentence where it says, "Which enables the health care industry to exchange prescriber initiated prior authorization requests for prescribed medications." The recommendation was to add e-prescribe, basically the letter E dash, before prescribed medications suggests – emphasize you know, that this is e-prescribed medications, electronically prescribed medications as part of that provider patient – so there's a minor typo there on the word patient.
So those were the changes recommended in this particular section, and then the rest of the paragraphs before the recommendation, they are additional background paragraphs about the transactions that we are – and the standard that we are discussing with – about the e-prescribing or the prescriber prior authorization. And then we get in Page 3 to the actual recommendations. We have two recommendations.
Recommendation one is for HHS, that HHS should name the NCPDP script standard version 2013101 prior authorization transaction as the adopted standard for the exchange of prior authorization information between prescribers and processors for the pharmacy benefits.
And then recommendation 2, HHS should adopt recommendation 1 (unintelligible) sections and processes that would enable some industry interpretation at the earliest possible implementation time. That's the first part of the – of this letter. I – let me see.
(Larry Green): (Walter)? Real quick.
(Walter Suarez): Yes, go ahead.
(Larry Green): So those changes on Page 2 did not have any real context change other than help clarify those comments around the e-prescribing transactions, you know, all those verbiage changes that you mentioned.
(Walter Suarez): Yes, exactly. Yes.
(Walter Suarez): It did not change any context. It did not change any direction or anything significant about it. It just failed to clarify exactly.
(Larry Green): Right, thank you.
(Allison): (Walter), this is (Allison). From the – I believe NCPDP was part of the changes on Page 2 to the prescriber prior auth, the pharmacy benefits section, and I want to make sure I tracked with you correctly that what we do to sync up the requests for e-prescribed medications is that we were – I wasn't sure if you said we were adding or removing the E dash from prescribed and medication.
(Terri): (Walter), it's (Terri). It's you take it away.
(Walter Suarez): I'm sorry. I guess I'm looking at the red line and the red line shows that the E was being added rather than taken away. It is taking it away.
(Terri): Good, and that we also caught the typo in patchent to become patient.
(Allison): Thank you. I'm with you now. Appreciate it.
(Walter Suarez): Thanks for that clarification.
(Larry Green): (Walter), (Larry). Do you have any other comments to report about the two recommendations?
(Walter Suarez): There were no comments about changes to the recommendation and I'm going to ask (Terri) if – because I can't seem to find but I believe there was a suggestion about this recommendation, (Terri). Is that…?
(Terri): If we're just talking about the prior authorization, that was the only edits that were done. There are a few more edits later on in the document.
(Walter Suarez): Okay, yes. That's it, basically for this.
(Larry Green): Okay, let's keep going.
(Walter Suarez): All right. So then the second section of the this letter, the health plan identifier section, so in here we recount on the bottom of Page 3 the testimony that we received during this portion of the hearing, the – some of the issues regarding clarification, concerns about the use of the health plan ID, the understanding of who needs to be enumerated and who can and who cannot, and the location of the use of it.
And you know, the difference between really the health plan ID and the payer ID and that the health plan ID is not intended to replace the payer ID, and so there were a number of comments regarding this and some questions and you know, ongoing – the need for some more clarification.
So on Page 4, recommendation 3, basically points out that to mitigate the confusion about the HPID among the health industry, HHS should, and then we have several bullets there, provide more guidance on the health plan ID or HPID/OEID, the other entity identifier, specifically clarifying when an HPID should be requested by the entity that needs to enumerate.
Clarify the definition of health plan, DHP, or the controlling health plan and ASHP, self-health plan. Define how health plans determine whether they have CHPs or HH (unintelligible) HPs, identify whether HPID which is not intended to replace the payer ID should be used for payer identification, explain the applicability of HPID to self-insured and fully insured it should say actually there.
It should be a correction of that typo, fully insured, it's an I instead of an E. Group health plans, specifically, the extent to which all self-insured plans are required to obtain a HPID. Where the HPID is to be used in the transaction and when a third party administrator is the entity processing the plan – the transactions on behalf of the self-insured plan.
Then another bullet, define the purpose of the OEID, provide educational outreach to explain the use of the requirement of the HPID/OEID, and provide guidance on benefits and value of the HPID for health plans and providers, and administrators specification requirements. So those were the recommendations. We did not receive any specific comments to change this – those recommendations.
We did receive a suggestion about adding a possible third bullet under this section that points, or that – I guess requests that HHS or CMS or HHS consider obtaining industry input on the need to access the HPID/OEID database and so we – this is the one additional recommendation I guess or suggestion received from public comment.
The point about that suggestion I guess is that we did include that in our letter back in our recommendation when the regulations were being drafted, and you know, when we had and we held previous HPID hearings. The recommendations are – well, I guess the rule is now final with respect to the adoption of the HPID. We are in this set of recommendations not certainly recommending anything to be changed in the rule, but basically to HHS to provide clarification and additional guidance.
So and in the rule there was a – some statements that pointed to the limitations that the health plan ID database would have with respect to being accessible. So you know, I guess the feeling is that we might not be you know, need to include this particular additional bullet because it has been already I guess addressed with respect to what can be or cannot be shared with respect to the database, has been addressed in this final rule.
But we wanted to bring it up to the committee to speak, you know – hear about the recommendation and make a decision as to whether we would want to include it in this bullet.
(Larry Green): Well, let me just start this off by asking the committee, if you would like – having heard what you just head, would you speak to wanting to include the recommended inclusion, speak to that now.
Coordinator: And excuse me. If speakers could announce their names before they speak. Thank you.
(Larry Green): This is (Larry). I was asking the committee members to speak to – in support of the public recommendation to add that – an additional bullet recommendation three, if they so wish. And this way, if you do – if you don't speak up we will assume that you are not in favor of that.
(Alix): This is (Alix), and if we're talking about the – obtaining industry input on the database I am supportive of that.
(Larry Green): Others? Let me ask you, (Walter), could you read what the additional would be, that (Alix) is suggesting?
(Walter Suarez): Well the request from the public was really a request that CMS or HHS request industry comment on access to the HPID/OEID database. So that is the specific recommendation. One possible compromise might be – because the issue is really how does the process for requesting input or comment on the access of HPID would work, you know, whether it would be a regulation that would – or some sort of a public, you know, regulation or public request for comment or something like that.
But rather perhaps what can be added as a bullet is provide clarification with respect to access to the HPID/OEID database. And maybe that is what is needed in terms of what can be and what cannot be shared.
(Linda Kloss): (Walter), this is (Linda Kloss), and I think on last – there's a statement of the process of that access, and I would prefer the way you restated it than to come out strongly in support of access without clarifying to what ends.
(Alix): Hi, this is (Alix) and I totally agree with (Linda).
(Walter Suarez): So just to summarize, an extra bullet would be basically provide clarification with respect to access to the HPID/OEID database.
(Larry Green): Let me rephrase my question now to the members would – if you would like to oppose that addition as (Linda) and (Alix) have explained and (Walter) has formatted, would you speak that opposition now? Going twice. Let's keep going, (Walter).
(Walter Suarez): Okay. All right, thank you. As – on the bottom of Page 4 is the third section which deals with electronic fund transfer and electronic remittance advice. So we heard actually two very significant messages here. One was – this is really very important. It's one of the most important transactions in terms of the efficiency and ultimately the goals of administrative clarification.
This is truly a transaction that provides concrete benefits, a measurable element. I mean, so this is you know, (unintelligible) with respect to administrative simplification. So the other thing that we heard were concerns about the emerging issue of the virtual cards and credit cards used by health plans to pay and transfer funds to providers.
So we articulate that in Page 5 in the second, third, and fourth paragraph basically where we describe the issue about virtual credit cards and try to simplify the understanding of the issue. So we start with – I'm going to go over it, because there were a few comments about this that are important to add here, so I'll go with – start with the paragraph that start with the concerns and since this concerns where it spreads by many testifiers with a new emerging issue, they show virtual credit cards.
So that one, there was no comments on that one. And the next one, virtual cards are generally 16-digit credit card numbers without the plastic card sent to a payer, sent by a payer to a provider to pay for services. Providers then enter the virtual card number in the regular payment system, and here is an addition. To authorize the payment, comma, and subsequently receive the payment, and then another addition, via ACH in their merchant bank account.
(Linda Kloss): This is (Linda Kloss).
(Linda Kloss): Should we spell out that ACH?
(Walter Suarez): Oh, great point. That's very important, so we'll spell out the ACH.
(Linda Kloss): Automated Clearing House.
(Walter Suarez): I'm sorry, that's good. Thank you for that. Automated clearing house.
(Walter Suarez): Thank you, that's great. So we'll put via automated clearing house and then in parentheses ACH in the merchant bank account. Then the next paragraph starts with issues raised by testifiers included the additional fees charge for each, and then here is an insertion, virtual card authorization transaction. So it's a – three words are added there, virtual card authorization transaction, and then as much as 5% of the payment, and then we have a series of additional points.
There's no other comments on this until the end of this paragraph. So I'll start with you know, ¾ – I guess 2/3 down, the line that starts with excessive fees to conduct standard transactions, period. However some testifiers describe advantages to using the virtual card indicating that large numbers of providers currently accept credit cards, comma, as well as ACH, semicolon. Provider enrollment is not necessary, semicolon.
(Larry Green): (Walter), (Larry) again. Let's pause here and ask some members if they want to express any concerns or clarifying questions before we move to the recommendation. Okay, let's do the recommendation.
(Walter Suarez): Well, there's one more addition in this same paragraph before we get to the recommendation, so – but that's all right. It sounds like we already are okay with the previous minor edits. This one is adding a new statement, so let me read it.
So you know, right toward the end before the recommendation, toward the end of that previous paragraph, five lines before the end, the statement starts with use of the trade number, and then in parentheses that is, comma, reassociation of payment and remittance advice, close parentheses, is seen as the key to improving efficiency and then the following is added.
For providers with the health care EFT standard, period. Unfortunately the trace number, and then in parentheses, TRN, cannot be used with the virtual cards, the HIPAA compliant X12835 version, 5010. ERA, or electronic remittance advice cannot be created to support a credit card payment. So that's an additional statement. I'll read it again.
So it reads use of the trade number, and that is the reassociation of payment and the remittance advice, is seen as the key to improving efficiency, and then the following insertion, for providers with the health care EFT standard, period. Unfortunately the trace number, TRN, cannot be used with the virtual card as the HIPAA compliant X12835 version, 5010. ERA cannot be created to support a credit card payment. Period. (Unintelligible).
(Bob): I think that's really to – this is (Bob). I think that's really to clarify but I'm not sure whether we want to use the word unfortunately, because we're not advocating one way or another. I'm sorry, we're advocating the use of HIPAA, but if you're in the use non-standards, you know, the pay – using credit cards or virtual cards, of course there's no standard to support that today.
(Larry Green): I agree with (Bob), (Walter). I don't think we should put the word unfortunately in there.
(Walter Suarez): So I would say it is – we can replace it with it is important to note that the trace number cannot be used.
(Larry Green): Yes, we can just say – yes, the trace – why not just take the word unfortunately out and say the trace number cannot be used.
Man: Agreed, I think that clarifies it.
(Walter Suarez): Okay, that will be fine.
(Larry Green): Anyone opposed to that addition with that adjustment?
(Linda Kloss): I would – this is (Linda), and I would just use the parameter trace number the first time the trace number appears in the previous sentence.
(Walter Suarez): Yes, we – oh.
(Walter Suarez): Yes, we'll make sure to use – to do the trace number and then in parentheses in the first time it appears. Yes.
(Larry Green): Okay, let's go to the recommendation.
(Walter Suarez): All right, the recommendation for – to address the concerns raised by the health care industry regarding the use of credit cards, including virtual cards, for electronic contractor transactions, HHS should explore the use of virtual credit card payments to determine if its use is compliant with the AFT standard and if providers are afforded the opportunity to use the HIPAA AFT standard rather than the virtual credit card, work with the health industry to be aware of the practices that exist to encourage the use of the standard for the AFT instead of the virtual credit cards, and work with the health care industry to ensure greater transparency.
And then recommendation five is HHS should assure that all HIPAA COBRA entities comply with the adopted AFT standard. Specifically entities should correctly format the TRN segment in the addendum portion of the CCD plus to assure that providers are able to match an EFT to its associated ERA, and there's a typo in the word, and, it says and with a D at the end, so we'll type – we'll correct that.
Second, use the standard description required by the national rules so that the health care EFT is easily recognizable by someone reading an account statement, and third bullet is use the X12835 version, 5010 PRE3 report in place of the version 46 for the TRN reassociation trade number. So those were the two recommendations. We did not make any public corrections or comments or additions to the recommendations.
(Larry Green): Committee members have concerns about these recommendations? (Bob), is there anything you want to clarify?
(Larry Green): (Walter), shall we wrap this letter up?
(Walter Suarez): Yes, so the last section is about the operating rules for the remaining transactions, so during the hearing we heard about the status and progress made towards the development of the rules. We did not have any concrete recommendation about this at this point. In fact, we basically mentioned that in Page 7, but just to comment on this, there were no comments on the – from the public with respect to this particular section.
And again, the section primarily highlights the progress being made, the – you know, sort of specific elements that have come out in previous hearings about a very particular transaction that has been transacted as one of the standard transactions that are – that need to have development on the operating rules side, and then we as I said state right before closing that NCHS does not have any recommendation regarding this topic at this time.
Rather we will continue to work with the operating rules operating entity to monitor the development of operating rules for the remaining transactions and receive the recommendation operating rules later this year. NCVHS anticipates that recommendation will be provided to the secretary after the operating rules have been developed and submitted to NCVHS for evaluation, so that's our closing statement about the operating rules section.
(Larry Green): And the closing comments? Anything else there?
(Larry Green): I have a non-serious comment about the closing comments. I think that closing paragraph commits you and (Bob) to continuing this work forever.
(Walter Suarez): Well this is sort of a journey, right?
(Larry Green): So committee members, now that you've seen the whole letter, thought it through again, any issues you would like to surface? (Walter) and (Bob), with your permission I will make an attempt to summarize what we've done here with this before we go on here. But in the material related to recommendations one and two in this letter we fixed some typos and added the phrase about the prior authorization standard did not accommodate the information necessary to facilitate prior authorization.
Under recommendation 3 we provided – added a bullet about provide clarification with respect to access to the HPID and OEID database. In recommendation 4 in the run-up explanation said that we clarified the adoption – oh gosh, what is it? The adoption to concretely – we recommended to concretely clarify how providers use the virtual credit cards. I don't remember the exact language.
There were some minor clarifications about the virtual automated clearing house, and we – let's see, there was something else, wasn't there? Yes, we changed that last sentence about for providers with health care ESP standards. Unfortunately, the trace – no, we took the word unfortunately out of that sentence about the trace number card not being used. And then there was a typo in recommendation four and five.
(Larry Green): Committee members, did I – did you hear something else or did – are you comfortable with that?
(Vickie Mays): Yes, well done. This is (Vickie).
(Walter Suarez): Well, we have a third letter.
(Larry Green): Yes, that's right, but I think we're – well, we're scattered all across the country. It's 54 minutes after whatever hour you're in, and we've got – used just a little shy of half of our time. I feel like we're making good progress here, but nonetheless I suggest that if you are sitting, that you stand up and count to ten and sit back down, and if you're standing that you sit down for 10 seconds and stand back up. And we'll just take a moment's break to get our heads clear before we start this third one, about 10 or 15 seconds here.
(Linda Kloss): Oh, good idea.
Woman: And is it at this point we can make an announcement about the Center for Medicare – the CMS directorship? We've – there's been a change in the director. (Terri) sent us some information, and I'm trying to find that. (Mary), we're going to let folks know about that before we go into – with all the work that's been done with CMS, it's an amazing amount of work. Is this a good time to mention that or do you want to do that later?
(Larry Green): No, sure, that's a good time to do it.
(Terri): Absolutely. What – and I don't know, (Walter), if you got this as well but we wanted to make sure that the committee was aware of the fact that (Rob) has gone to work at the front office of OEM. He's going to work on special projects, and in his place we have an acting director of (Todd Lawson).
And he – (Todd) has a lot of experience in CMS and particularly in OEM, the office of electronic management and having to do with enterprise initiatives, and so he's going to be our acting director. At the same time (Denise Fleming) went to work at actually core, and in her place (Matthew Albright) is going to be the acting deputy director. So I don't know if (Todd) is on the phone now. I believe he joined us earlier, but I'm hoping he's on the phone so that he can say hello to everybody.
(Larry Green): (Todd), are you there? Operator, is (Todd) there?
Woman: He may not have been – his line might still be muted. He wasn't on the original list, so it may take a little while.
Woman: I sent (Todd) the correct phone number and password.
Coordinator: (Todd), if you are on the line, can you please press star zero?
Coordinator: It looks like (Todd) hung up.
(Terri): Okay, he did – he was not able to stay the whole time and he had indicated that he could not do that, but I will convey to him that we did introduce him and I'll convey to him that the committee said welcoming comments about him if that's okay with everyone.
(Bob): (Terri), this is (Bob). I just want to say that both (Rob) and (Denise) will be dearly missed, but I'm glad – I don't know (Todd) but I'd be glad to hear that (Matthew) is stepping up.
(Terri): And I will convey that information as well.
Woman: When we're updating the June agenda I'll check in with you tomorrow, (Terri), to see if we can change that CMS update from TBD to an actual name, so thank you.
(Terri): I'll talk to you tomorrow about that.
(Larry Green): I think (Bob) speaks for all of us on the committee of these messages to these folks that are moving on. They have been simply spectacular to work with.
(Larry Green): But well, ladies and gentlemen, let's go to the electronic standards for public health information exchange letter.
(Walter Suarez): Okay. All right, we're – letter #3, the third letter is about the public health hearing that the national committee, basically the standards subcommittee joined me with the population health and the security – private and security subcommittees held back in November.
This was one of the very first national hearings on the topic of public health data standards and public health information systems, and we were very excited about – we had an incredible amount of input received from many different organizations, all of them really applauded the effort of the national committee to convene this.
And as I think we mentioned this in the hearing as well as in our earlier reports to the national committee, this really is – we see it as sort of a starting point of – a series of future activities focusing in this area as well, so this is truly one of our core areas of activity and roles that the national committee on vital health statistics, ultimately, and so we're delighted to be able to directly engage in this discussion and provide feedback to the secretary around these large issues.
And so as we started with this we really thought about you know, standards, and public health standards, and just like with HIPAA, you know, when you start talking about standards you tend to be very focused on very specific transaction types and things like that, and even you know, very technical elements.
What we heard actually was a much higher level perspective around public health information systems and public health informatics standards, a whole host of very important issues that really weren't that specific at the level of we need this standard for this specific message in public health exchanges, but again much higher discussions and at a much letter holistic view of the public health information systems in the US.
So the letter really tries to highlight the key points that came through in this hearing. Again in the first space we provide an introduction to the letter and to the hearing itself. In the second and then in the third paragraph we actually with input from the national committee members, we actually brought up in a big simple summary way the recommendations.
So we give the recommendations up front in terms of bullets, and then we really dive into the specific recommendations. So that's what the third paragraph says, an overview of our recommendation follows and then detailed descriptions for each recommendation is down there. And so my suggestion is rather than reading these bullets, we'll be able to get to the recommendations as we move along.
(Larry Green): Good idea, let's go to the background.
(Walter Suarez): Yes. One minor element on the sort of last bullet before the background on Page 2, one suggestion I guess that came out was – and it was a clarification. It really – when we say HHS in partnership with national public health professional associations such as this and it might be best to avoid naming specific ones, but just simply say something like HHS and this is in partnership with national public health collaboration organizations and professional associations should develop a new strategy.
And so it would not specifically name one or two or more because there is many that we would want to probably name, so rather than naming them we just bring them as a category of organizations. So that's one relatively minor edit there. In the background basically we highlight again the – some very important points.
There's been significant advances in the convergence of electronic standards within and across health care industries – in health care industry, and there's been some significant gains in public health reporting and data exchange. This hearing was really a way of gathering where we are with some of those. We – you know, we use terms like informatics standards, public health, population health. So we added a footnote that helps put all these terms in context.
And then we on Page 3 we really dive into the context around the general public health informatics standards, information systems development, and all the various issues around this including of course the – you know, issues around resources, around capabilities in the public health sector. There are challenges and limitations, so that's what we do in this Page 3 and really parts of Page 4, the way we highlight the overarching themes of the hearing.
And then we tried to really present a larger view, because really we didn't hear very specific elements around or issues around the technical standards of a specific transaction or anything like that.
(Larry Green): Well, first, I apologize, but if you'll allow, let – can I just interrupt for a minute and invite the committee members to at this point before we leap into the recommendations, have any of you developed any concerns about the key overarching themes, these six bullets? Is there anything that you want to call out at this point?
(Larry Green): Okay, that sounds like we've got good agreement here. (Walter), were there any public comments about these themes?
(Walter Suarez): No, there were none and one point that we should make at this point and it's not really a major issue, it's – some of the organizations that we are – you know, certainly that we are testifying and that we invited to participate and that we will be working with very closely into the future, are sort of the public health professional associations that you know, of course have their process to go through when it comes to commenting on something.
And since we've posted the letter on the Web site about seven days or so ago, probably a little more I guess, but it was several – around seven days, I'd say, that time frame didn't necessarily gave enough time to some of these associations to go back to their boards and to get them together to talk about this and get us more direct feedback. Having said that, they actually – a couple of them actually sent us a nice note saying you know, we appreciate this.
We want to clarify very briefly here a couple of things which we were going to as we talked about this in the recommendations and they just pointed to that reality, that we did not have enough time to really get a more formal review process of the letter.
So I don't – I wouldn't take that necessarily as a negative fact or a concern about the letter itself. I just wanted to highlight it here as a process element, but we did not get any comments on these overarching themes or – and I will be highlighting some of the comments we received on the recommendations.
(Bruce Cohen): First, (Walter), can you hear me? This is (Bruce Cohen).
(Walter Suarez): Yes, (Bruce Cohen), yes we can.
(Walter Suarez): Yes, yes, Page 2, the last bullet that says (unintelligible) partnership, yes.
(Bruce Cohen): I like the – I actually like the idea of giving examples of public health informatics groups because this is a new and emerging, you know, for folks like me who are on the other side of the public health house, I think it's nice to call out specifically informatics focused organizations, so I like your idea of keeping it general, but the such as really provides specific direction about the kinds of organizations that we're talking about here. So I actually prefer the existing language to removing specific examples.
(Walter Suarez): Great. Great point, (Bruce Cohen), and here's my suggestion there. From the – going back to that bullet, it would read as follows. HHS combined partnership with national public health collaboration organizations and professional associations, comma, including (Unintelligible) and its members, and AMIA and others, (unintelligible) and its member, AMIA, and others, and the reason I frame it this way is because (Unintelligible) is not an association.
It's a national public health collaboration organization, and so that was one of the elements. But I totally agree. I think we can include those examples if that's okay with the rest of the group.
(Larry Green): (Bruce Cohen), I thought that we had – I think we went – as we went by this, I took two ideas out. One is we wanted to avoid naming particular organizations. We did want to state categories, and I think you're suggesting that we have a category called public health informatics?
(Bruce Cohen): I'm comfortable with either suggestion, but that focus needs to be there since this is a particular subgroup of all public health associations and collaborators.
(Larry Green): So (Walter), let's make sure we have that phrase in as a category of organization, and then let's stick with what we had with the consensus of not naming a particular organization and just name categories.
(Larry Green): Yes, yes, that sounds right to me.
(Larry Green): Would committee members speak up if I'm leading us astray from where we were?
(Debbie): This is (Debbie). I think that's a great direction. This letter in comparison to the others, it's really a combination or coalescing of so many of the other – of the various subcommittees, so I'm so glad you've chimed in, (Bruce Cohen), and if you need – and you might need more time to just have some of this settle in, and we can work on that later. But so far the discussion has been great and we're looking forward to public comment when that's open.
(Larry Green): Okay, we've got that addition, (Bruce Cohen). Thank you very much. I'm sorry that you just got unmuted.
(Walter Suarez): Okay, so we'll jump to Page 5, recommendations. And so recommendation 1, HHS should pursue the enactment of a health specific systems improvement act to advance and bring to par public health information systems with the electronic health record systems including (unintelligible) for public health informatics work force development.
And then recommendation 1.1, HHS should establish a public health information infrastructure trust fund as a component of the health statistics and the word systems has been inserted here, so as a component of the health statistics systems improvement act to be jointly governed by CDC and an organization representing the state and local public practice communities.
This fund would serve as a dedicated funding source to improve the information infrastructure needed to support all public health functions. The public health information infrastructure trust fund would – and then we have a series of bullets, fund a specific new and improved information infrastructure capability for state and local public health agencies, support the public health informatics, public health systems, and system research communities in assessing current levels of standards adoption and identify where the barriers and gaps exist, conduct analysis of public health program areas within which a clear value proposition for a standard may exist but has not yet been acted upon by the community, engage standards experts and make them available to public health programs to support establishing standards based on defined business needs.
I believe there's an extra P in there somehow, but then another bullet provides cost effective training both in informatics and in the standards development of the public health practice community, and support the collaborative development of an overall roadmap that lays out a path for how public health can transition towards a modular reusable shareable services space and standard base design of information systems.
So that's recommendation 1.1, and let me read recommendation 1.2 and then we can stop there and recommendation 1.2, the HHS should also leverage this public health information infrastructure trust fund to provide sustained funding for continuous quality improvement to support public health information systems, promoting development and sustaining public health information management skills thus increasing workforce capacity and standards development as an option with a broad engagement strategy and collaboration that includes state and local public health. So those are the recommendations for this part of the letter. (Larry), do you want to stop here and…?
(Larry Green): Yes, yes. So were there any public comments about this, (Walter)?
(Walter Suarez): No, there were no public comments or recommendations or changes or additions to these recommendations.
(Larry Green): Let's hear from the committee members.
(Jim Scanlon): (Larry), this is (Jim Scanlon). Can I discuss some friendly amendments maybe? I think the – and (Bruce Cohen) can weigh in. I don't think the (unintelligible) it's fine to suggest that HHS seek the enactment. We don't enact ourselves, but I don't think the health statistics improvement act I think would mean something different to our agencies and probably some other public health folks than the standards and informatics directions that are included in the specifics.
And I think they're fine. And in fact there was – you'll remember there was a section of the early versions of the ACA that were called health statistics improvement, and it had entirely to do with surveys. So I'm just wondering if there – if we're not wedded to the idea, I think the details of the recommendation and the basic trust to your standards, infrastructure, interoperability, interchange are not necessarily what we would – certainly what our agencies would view as statistics, so I – maybe there's another word or maybe there's another way of – it's really standards and infrastructure, it sounds like, public health standards and infrastructure. (Bruce Cohen), do you…?
(Bruce Cohen Cohen): Yes, I – you know, you stole my comments. We're reading from the same cue cards.
(Bruce Cohen): Because you're a member of the statistics – I think in terms of statistics improvement it would be something entirely different than this, so I wonder if there are some other alternatives for the name of – and then by the way I view this as directional, not specific, so the idea of the creation of such an initiative, you know, is what the real goal is.
But I think it would be – I think our statistics agencies and units throughout the country would be scratching their head about the content – the specifics of the idea because – and it's just not what they would think is meant. So I would just thing there's a different title for example that would work better.
(Bruce Cohen): Otherwise if you really want to talk about health statistics improvement this is not – this is – I don't think anybody would think that's what this says.
(Walter Suarez): So what if we were – this is (Walter) – what if we were to add the word information, and I'm at the top of the recommendation #1, the title I guess. What if we were to insert the word information before systems? So it would be the health statistics information systems improvement act, which is really what this is about. I totally agree. I think it's not the – what people usually would perceive as a health statistics systems. That seems to cover a lot more than information systems.
Man: Well, (Walter), I think it's still – I don't know that we're going to be able to resolve this today, but I think you run into the same situation when you start with health statistics improvement act, when those words are in the title, it implies a much broader context of all the statistical agencies, the content of the data, the methodology, something much larger than the focus of what is covered here in recommendations 1.1 and 1.2.
I think (Denise Love) talked, you know, about this in some of her comments at one of our meetings, and there's been a literature promulgated not only by this committee historically about others, about a much broader more expansive notion of health statistics improvement, so I think these are hot button words when put together and adding more words doesn't clarify of this issue when these recommendations I think are solid, but just need to be renamed more specifically and explicitly to deal with what you're talking about.
(Walter Suarez): And I understand that, (Bruce Cohen). I think – and not trying to resolve it in this call, but at least trying to move it forward, I do believe that we can for example with simple changes clarify this. So I understand that the key button words are health statistic systems, and what we're really talking about instead of health statistics systems is public health information systems.
Public health information systems have been the – you know, information system infrastructure of public health agencies that are not exclusive to health statistics, actually are inclusive of all the functions of public health agencies. So for example again, what if we were to adjust the title to be, say, public health information systems improvement act? That takes away the health statistic systems element of it.
(Bob): This is (Bob). I think to (Walter)'s point, if I may make sure that I understand this, the issue is so much that there – it's really around it's not so much statistics but how we collect the information through these applications and systems. Is that correct, (Walter)? That's what we heard.
(Walter Suarez): Have you thought about just health statistics as in you know, the traditional health statistics?
(Bob): Right, but the way the data is collected through all these different applications and such.
(Walter Suarez): Different health programs, etcetera.
(Walter Suarez): Would something like health informatics infrastructure improvement work?
(Jim Scanlon): How about public health? But I think you need to have standards there and throughout. The last thing we want to do is fund a lot of public health information systems the way they are now. The whole idea here is this standardization and interoperability and integration with health care. Otherwise we're continuing the numerous and diverse various reporting systems that aren't integrated and probably wouldn't be.
So I think that you have to emphasize to (Rob) that this is based on standards, interoperability, that kind of functionality, integration with other systems – with health care. But again it's not statistics. I wouldn't even mention the word statistics other than it would be a byproduct or a secondary, you know, result, and then – I mean, I think that's the main point. I think it would confuse our – certainly our statistics folks.
(Walter Suarez): Yes, (Jim), we took away the word statistics.
(Walter Suarez): The wording basically – I know that we call it an act and we want it to I think based on the discussions in the hearing, we really want it to coalesce towards the establishment of a formal congressional act that would pursue the enhancement – I mean some people even call it a modernization of public health information systems. The word statistics is not there but it's just purely the public health information systems around the country.
Man: (Jim), this would be a strategic initiative under HHS.
(Jim Scanlon): Yes, well, that would help and if an act is needed then you know, then that certainly – then that would be the way as well. But again I think – so we're agreeing on the statistics part of it, I think, which I think the committee may want to look at separately in terms of health statistics improvements, but these are standards and infrastructure and informatics, which I think are good recommendations, yes.
(Larry Green): (Jim) and (Bruce Cohen), do either of you have a specific recommendation at this point?
(Bruce Cohen): No. I don't. I think this – I think you know, (Bob) and (Walter) can talk with me and (Jim) to craft the language. I like the strategic initiative and the focus on information standards and system development.
(Bruce Cohen): I think that language is more appropriate to the content of the recommendations.
(Jim Scanlon): Yes, yes, I – we could send some red line edits I think, but I don't have the – quite the right wording down.
(Jim Scanlon): But I agree completely with you know, the detail of the recommendation stuff, you know, in terms of the – except to emphasize interoperability and standards and integration.
(Larry Green): So we're down to our last 12 minutes.
(Larry Green): And we're going to have to move along here. I want to insert here, I am quite confident as one member of the committee that the committee overall, the committee's intent, discussions, and review of this letter to this moment in time really emphasizes a bolder, more comprehensive attention to this. That's the – it's not just about standards. It's not just about statistics. It's about getting going in the new data world on behalf of proper product health.
And I think I've probably heard at least ¾ of the committee members voice support for a fairly aggressive recommendation here. So as you start thinking about your red line edition, I just want you to remember that one man's view is that there's a lot of interest across the committee, and this being a relatively bold recommendation and not just another recommendation from NCVHS.
(Linda Kloss): This is (Linda Kloss) and I would echo that, and I think in some ways we use the act – the word act as a bold statement, not necessarily that specific action, but it was for that reason and something that was more than a series of projects.
(Larry Green): Okay, (Walter). Let's go to the next recommendation.
(Walter Suarez): Okay, recommendation two, that's a minor edit in the previous paragraph, the introductive paragraph, so I won't – given the time I won't get into it. It's a very typo thing, but recommendation 2, the HHS should work with the public health community represented by national public health and professional associations to establish a national public health informatics standards collaboration initiative to accelerate the adoption and implementation of standards in public health programs.
At the state and local levels, the initiative needs to be a part of a broader prioritization with public health serving in leadership roles. The roles and responsibilities of this entity will be to work towards the harmonization of demographics in all public health databases, establish (unintelligible) that clearly document and demonstrate the importance of bidirectional information exchanges between public health and clinical care, support the core group of public health professionals to actively participate in standard development, expand the effort to bring public health, population health, community health, and clinical care closer, create opportunities for advancing population health management tools and resources, and make the case for a standard base approach for public health case reporting. That's recommendation 2.
(Larry Green): Any public comments?
(Vickie Mays): This is (Vickie Mays). I had a question.
(Vickie Mays): (Walter), on the harmonization issue, are you thinking – it's great to harmonize the data, but are you thinking anything about the linkage of the data? Is that implied anywhere in here?
(Walter Suarez): No, it wasn't implied and this was primarily harmonization. We didn't really – even though the testimony talked about not just harmonizing the data, but linkages, we did not mention it here. We can add it. The harmonization and linkages of demographics in all public health databases.
(Vickie Mays): I mean, I think that's probably one of the most critical things, because we could even use statistical techniques to try and – you know, by using standardized estimates as something to make the data the same, but it's when you can't link it that it's very frustrating. So if that's not going to be a big change that anybody has an objection to, it would be great if we could include it.
(Bruce Cohen): (Vickie), my only concern – this is (Bruce Cohen) – is if we include linkage, will that particularly at the individual level, will that bring up a variety of privacy and security related issues?
(Vickie Mays): Well I guess I was thinking that when we were talking about the public health data that it is – that what we're talking about is de-identified data that would be subjected anyway before any public health entity would give it to you in a way in which even with the linkages you should be able to protect the data.
(Lynn Blewette): So I think that that's – and I think you know, the trying to harmonize all public health data I think is probably – we've spent almost 10 years now trying to harmonize the national health interview survey, so I think maybe it's – I would be more comfortable if this was more in kind of pilot and work toward demonstration of successful both harmonization and data linkage projects to promote public health standards and approaches or whatever, have it more – because I think it's almost too – two pilots, I don't think we could harmonize all demographics in all public health databases.
But I think it's important to start and move towards that objective and it's part of the standards, you know, that's part of why you're doing standards, so you don't have to go back and harmonize data that's already been collected that you can't compare or contrast because the definitions are so different.
(Walter Suarez): Great, so yes, so what if we modified this quote with work towards the harmonization and data linkages of demographics in public health databases, so we take out the word all and we add the data linkages concept?
(Lynn Blewett): That would be fine with me.
Woman: (Bruce Cohen), are you okay with that?
(Bruce Cohen): Sure, I just don't want it – yes, no, that's fine.
(Vickie Mays): Yes, I mean, I agree with you. I don't want privacy – for this to be seen as if we're not thinking seriously about privacy, and that becomes something that is a barrier to this moving along.
(Michelle): (Vickie), this is (Michelle). One comment, just at the very end of Page 7, top of Page 8, (Walter) hasn't gotten to yet makes a reference to the fact that we are planning to have subsequent hearings to provide more feedback on privacy and population concerns.
Woman: We could for now include appropriate linkages.
(Vickie Mays): Oh, that would get us out of any criticisms that might slow it down.
(Vickie Mays): Very good, thank you.
(Larry Green): Do the members like that revision of recommendation 2? If not, speak up. I would just also add, (Walter), after pilots, I would add pilot programs rather than just pilots.
(Walter Suarez): On the second bullet.
(Walter Suarez): Yes, yes, added that. Establish pilot programs, yes.
(Larry Green): Any other suggestions? (Walter), let's keep going.
(Walter Suarez): So, and maybe before we finish up, one point before we go to recommendations 3 and 4, very briefly if – with this letter is clearly going to go through additional revision before it's – our review meeting, so the good thing is we will have another round between now and June to review it and go over it. And so I think that's – that that will be great, actually.
So since we're going to be modifying the language at the top before it gets formally approved by the committee. So expect that we will be bringing this letter back and depending on how we decide on the other two letters, so we can talk about that, too.
But all right, recommendation 3, HHS should leverage several different policy programs and initiatives including the affordable care act and the EHR meaningful use incentives program too, align incentives for key components of public health reporting to factor – to foster collaboration between the public health – the public and private sectors, and to stimulate vendor engagement in adopting and using public health data standards.
So there's another and here. So we'll take the first and out, and then just last one, and to ensure public health data requirements are incorporated into clinical systems. And then the second bullet, develop a new component of the value proposition for the public health agenda that includes identification of use cases and the benefits and significance of adopting and using public health standards.
(Walter Suarez): Public health informatics organizations, comma, and public health professional associations, and we take out the such as, should develop a new national strategy for public health informatics capacity building to increase the number of skilled workers in the public health workforce needed to address the new and emerging advances in health informatics technology – information technology, electronic standards, and information infrastructure. So those are recommendations three and four.
(Larry Green): Comments or concerns? Surely someone has one.
(Bill Stead): This is (Bill Stead). I'll try to put in the thing I was trying to say a bit earlier. I think what you're describing as you go through this makes sense. I think you're really talking about public health information infrastructure. You're broader than – you're not statistics, you're broader than systems and you're broader than standards.
(Larry Green): Yes, that is correct. Any other comments? Thank you, (Bill). Well, I agree with (Walter). I think we're not going to be taking action on this letter at this meeting. I want to again intend to very quickly just the highlights here about the changes we just I think have a pretty good consensus about. In the upfront summary and also later on in the actual recommendations we're going to drop naming particular organizations and just say categories of organizations and that recommendation is three and four.
Recommendation one's going back for revision, recommendation two we want to get the idea of linkage in there and work towards harmonization and appropriate linkage of demographics and public health databases.
And we want to not just do pilots but we want to establish pilot programs, and then we left otherwise recommendation 3 and 4 pretty much alone and (Bill) basically summarized (Jim)'s and (Bruce Cohen)'s earlier comments about the recommendation one work, that this whole letter is really broader than standards or statistics.
It's about infrastructure. It's about building the infrastructure. So anyone want to edit that or disagree with that in the – so that the committee can feel like that they've got good direction from us?
Man: And we'll get some suggestions for recommendation one, you know, moving towards more of a strategic direction step by (unintelligible) as opposed to an act, to clarify that.
Man: Yes, we'll send you some friendly edits or amendments I think.
(Larry Green): (Jim Scanlon), are you okay with this?
(Jim Scanlon): Yes, yes, yes, yes, yes, I'm fine. Again, the only thing is I will edit suggested red lines to stress standards and interoperability and you know, at various points, but other than that, I – it's a great letter and I think all of the specifics are quite good.
(Larry Green): Okay well thank you all very, very much for the good work here. I suggest if (Debbie), if it's okay, that we ask the operator to invite public comments for what has been discussed here about these three documents.
Coordinator: Okay, thank you, and we will now begin the question and answer session. If you would like to ask a question, please press star one and record your first and last name clearly when prompted. Your name is required to introduce your question. To withdraw your question, you may press star two. Once again if you would like to ask a question, please press star one. One moment please for our first question. And we do have our first question from (Lynn Gilbertson). Your line is open.
(Lynn Gilbertson):Hi, there, I just had notified (Terri) that (Tony) and I had a conflict for the first minutes of the call, so I just wondered if you had any questions about the prior authorization letter modifications that we submitted or anything I needed to help you with since we couldn't be on the start of the call.
(Walter Suarez): (Lynn), this is (Walter) and if I may answer very briefly, no, we did incorporate all your changes so thank you for submitting those comments and clarifications.
(Lynn Gilbertson): Okay, thank you. I just wanted to be available if you had any questions. Thank you.
Coordinator: And there are no other questions in queue.
(Larry Green): Oh, okay, then let's take action here.
(Walter Suarez): If I may – (Larry), this is (Walter), if I may. One additional clarification I forgot to mention, really, not clarification or but just a comment from the public during our public comment process of the letters, this is the February 2014 hearing and this is about the attachments section, and the recommendation was considered additional – an additional recommendation really that adds to the direction of the attachments, specifically the attachments standards.
The reason, and I'm not going to – I will just mention that the reason we did not really incorporate that recommendation or additional recommendation was because we are going to have an additional hearing in June regarding attachments specifically, and so this information is going to be included in that discussion and so we didn't feel the need to add that to this specific letter, but rather bring it in as a discussion point to our hearing in June. So I just wanted to mention that point specifically.
(Larry Green): That sounds responsive to me and I appreciate it, and any other public comments that we need to hear?
(Walter Suarez): Those – and I apologize again for not bringing that up earlier, but that – those were the only ones that we received.
(Larry Green): Okay, well – unless someone speaks up, I'm going to assume you're ready to take action on the two letters. I suggest we take them one at a time. I would entertain a motion to – for approval of the ICD10 delay letter.
(Larry Green): Can someone – did you get the names?
(Jack Burke): (Jack Burke), I moved.
(Vicki Mays): (Vickie Mays), second.
(Larry Green): Is there any further discussion? We will try to simplify this, all opposed say your name.
Man: So we can mute you.
(Larry Green): Say your name if you're opposed. Okay, hearing none we will assume that that letter is unanimously approved.
Woman: And I will – I would do a call so that in case anyone had to leave their phones and that'll be on the record.
Woman: That means the approval would be for – just indicate you're present. (Lynn Blewett).
(Lynn Blewett): Yes, I'm here.
Woman: (Larry Green), yes. (Linda Kloss).
Woman: We've got everybody on a verbal agreement that the – to take that vote and the action as already submitted and that means approved. All in favor, that was all in favor and everyone was accounted for. Does that work well for you, Marietta? Marietta might be on mute, but I wanted to make sure we had everyone on the record. Thank you.
(Larry Green): Okay, I will entertain a motion to approve the findings from the February 2014 hearing letter.
(Bruce Cohen): This is (Bruce Cohen), I move approval.
(Larry Green): Any further discussion from someone, if someone just had a brilliant insight that can be inserted at – just in the nick of time? So my efforts to simplify this have been a total failure, so now (Debbie)'s going to call the roll again.
(Leslie Francis): Yes, sorry I had to get off mute.
Woman: Yes, we got them. And anything from the operator as far as anyone trying to do a star one for any of this?
Coordinator: And there are no questions in queue.
(Larry Green): Thank you very much. (Debbie), let's go to you and to review the plans for the June 11-12 meeting.
(Debbie): What will happen for June, I do have a mock-up. I sent to the executive subcommittee the mock-up for the June meeting which essentially is what we're going to wind up doing. We had time on the June meeting to discuss the process for this May conference call.
It's the first time we've done something like this. I felt that we just needed to have a little space to have any reactions in case you got email messages or something, some constituents and stakeholders, just to have a little time on the agenda to review how this worked. In addition we have time on the agenda to cover any overfill which we find up having.
The public health information exchange letter would be the additional action item on the June agenda. At one point the original was – do I have the right letter? Yes, the original was the HIPAA report as the only action so we will add this letter to the June agenda for action and we have the space for that.
And this has been my ideal all along that this letter is actually a platform for the entire full committee to grapple with a lot of these issues that are embedded. So this discussion has been wonderful as a start, and then we'll get the updated – a draft from there and then have that in June with the HIPAA report.
(Debbie): Great. That she would like, I'm going to check with (Damon) to see if you two can do this presentation and update and briefing like together, that 10:30 as just part of the working group and data-palooza, because that will have already occurred early June, and that will be a nice segue to if we can get the – any comments from the new ONC director. I've been in contact with her office, (Dr. Karen DeSalvo).
We're trying to get her on for that midmorning Thursday the second day the full committee, as well as get some updates from NCHS, (Charlie Roswell). So we've got a great lineup for the entire meeting, and going then onto the afternoon for the working groups, everyone already has – there will be an agenda that's already been developed in the working groups. That'll be included and incorporated for the June agenda.
So we're shaping up very nicely. I'd like to get this out to the full committee membership once I get the chair and others to – and maybe the co-chair to take a quick look at it. I'll get that out maybe tonight if I can or first thing tomorrow, but with those two action items and these great updates, we should have a great June meeting.
(Vickie Mays): (Debbie), this is (Vickie), or (Jim) maybe can answer this. Do you know if we're going to have an NIH replacement for (Bob) there yet?
(Debbie): We're looking at that. It happened – things happened very quickly and at this point I don't have him on the agenda and with the action item – I mean, of course he's at ours. I don't have a replacement or anything, but with the action item that we've got, we might just need to stick with the four that we've got.
Man: You mean as the liaison.
Man: Yes, NIH asked that I go to the director, the director's office. They usually designate the liaison. So I've done that. I have to wait for them to come back.
(Bruce Cohen Cohen): (Debbie), this is (Bruce Cohen). One – I'm sorry, I don't have the draft agenda in front of me. When is the population block scheduled for?
(Debbie): That is the second day because we know that you come in on that second day.
(Debbie): And then the subcommittee really has kind of sketched out what they want to include in the block, but I'd like to get just a basic framework of this agenda out to everyone and then we'll incorporate the subcommittee block information in the next iteration, but I just wanted you to get an overview of what'll be covered. The populations are the second day. We did a switch-up so that standard would be meeting the first afternoon.
(Bruce Cohen Cohen): Thank you.
(Walter Suarez): This is (Walter), (Debbie). Two or three points, very briefly. One is did you mention that and I missed it, I apologize, the HIPAA report to Congress as an action item?
(Debbie): Yes, at one – this was the only action item on the original agenda, and now it'll be – the other, this letter, the public health information letter will be included, so that's why we'll have two action items on the agenda.
(Walter Suarez): Oh, okay. Perfect, yes, and thank you, and for the full committee, just a reminder about the HIPAA report. You know, this – it will be distributed and your feedback would be greatly appreciated. The other comment is we do have a hearing the day before we have the full committee meeting, so June 10 is a full day.
The way we call it is the seven topic in seven hours hearing of the standards subcommittee, and I understand there's also a working group or workshop or a round table meeting, you know, on Friday after the full committee meets on population and health, is that correct?
(Debbie): Mostly, that's June the 13th, the final day of NCVHS week at HHS will be the populations framework group that will be working through its several of (unintelligible) with various – kind of strategizing and organizing the material in preparation for future work and hearings and workshops in the fall.
(Vickie Mays): Are we getting the draft agenda of that when you send this stuff out?
(Debbie): That, we're still working on. So what I'll be getting out to the full committee is the full committee agenda, and then the rest, we'll follow up next week. Were you planning – you weren't planning on – what is your plan on that? Is that something you were doing, (Vickie)?
(Vickie Mays): Well that's what I was trying to decide, whether you know, I could stay for a little bit in the morning because I have to get back to go to graduation.
(Bill Stead): This is (Bill). I'll be glad to send you the current draft of the agenda if that would help you.
(Vickie Mays): Yes, it will, and then I can see whether it's part for me to stay or to just go back.
(Bill Stead): We're hoping to have the full set of pre-reads put together – we've got a draft of it, so we're hoping to get all that out, but I can just send you the current draft of the work plan.
(Debbie): And this is a strategic group. It's not like it's – we're trying to have any broadcasting or any of that. It'll be there at HHS, people or invited or it's open meetings, but at this point it's not – I don't think it's being broadcast, but the plan is more strategic and planning and boots on the ground to do some brainstorming in preparation for the fall.
(Debbie): Yes, it's a full day.
(Larry Green): That's a half a day for where I work. No, that's – yes, that's half a day.
(Debbie): Great, great. I mean, we've gone after the previous three full days of NCVHS. We're glad to get the folks who are committed and are considering to come on and join us, because it should be – it's going to be a great time. Thanks for bringing that up, (Walter).
Woman: I hear you calling it NCVHS week.
(Debbie): That's what we feel like we're doing.
Woman: Spilling over on both ends.
(Debbie): That's right, and thanks to (Jim) and his staff for helping to support that, because we would not be able to do that without all the special – talk about infrastructure, to get through the security mechanisms and all, so thank you.
(Jim Scanlon): We'd like to have you here in the Humphrey building.
Woman: I second the motion.
(Larry Green): Well, (Debbie), or anything else, or are we ready to adjourn?
(Debbie): I'm shocked and pleased and thrilled thank to all that so much has been done on this call. This is the first time we've done something like this. Marietta has been an absolute wonder and a whiz to pull these lines and things together. I (unintelligible) and folks on the call have no idea what it takes to set this stuff up. Think of this as the wave of the future. We know this is a time period between the February and June. We wanted to be as productive as possible, and we got it done, so thanks to all.
(Walter Suarez): (Larry), if I may just jump in and say this is (Walter) again, I'm just amazed that according to Marietta's statistics we have just over 100 people on the call today, so just a quick statistic about this call.
(Larry Green): Yes, well I want to thank everyone – the committee members, you all individual really helped get this work done in this manner, and I wish to express my appreciation for your help and add to what (Debbie) was just saying. We really have some outstanding staff work, I mean really outstanding staff work on the letters and this call. And we really want to applaud that. (Jim), we want to thank you for your support of the staff and I want to suggest that all of you email (Debbie) any suggestions you have about transacting business this way, having a virtual meeting of the committee. Any observations you have, any suggestions, any concerns, please do so. If you haven't read the HIPAA report, you are really missing a copyrightable all-star ready to be put into a movie report, and you will miss an incredible opportunity.
(Larry Green): Make sure you read this before you show up in June, okay?
Man: (Larry), I had one comment. Is the version that we've received the latest draft, or has there been more work?
(Walter Suarez): You will be – I'm trying to – with (Terri), you might want to jump in, but I think we are going to be – I'm trying to think about it. We will send you in the coming days a final draft copy, clean copy, with all the comments that we receive. I think at this point in the review process we're waiting for comment from the executive committee before he gets in like next week to the full committee. And then the full committee will have until the end of the month to submit comments, so the agenda you receive from the – as an executive committee member is the latest version.
(Terri): (Walter), that's exactly where we're at.
(Larry Green): (Walter), do we have outtakes? Okay, guys and gals, thank you so very much. I think we're adjourned.
Man: Bye, everybody. Thank you.
Coordinator: This now concludes today's conference. All lines may disconnect at this time.


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Coop's former chain manager, Patrik Wirlén, returns to the grocery business by opening an independent grocery store for Matrebellerna – in the former Coop Extra store in Katrineholm.
When Apotek Hjärtat will supplement the ICA in the sign, eight pharmacies located in competitor City Gross stores are excluded. "We will not change the signs on them," says Ola Fernvall, Ica.
The battle about C4 Shopping in Kristianstad will continue, Land and Environment Court considers that Fastighetsägarna Syd are entitled to have their appeal heard by the County Board.
Citygross opened its 38th store on Wednesday and beat its previous opening records. At the same time, it was the start of a new retail park in Linköping.
Coop's bonusprogram is the most beneficial among Swedish food chains. This according to a research that Testfakta has made – on Coops behalf.
Sales rose by 5,9 percent within the Bergendahl Group during the second quarter (Like-for-like 3,4 percent).


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Hale Charter Academy and Gifted STEAM Magnet
California Distinguished School
HCA Charter Renewal Petition 2016 - 2021
HCA Approved Board Agenda Charter Information
HCA Pertinent Section of Affiliated Charter
HCA Affiliated Charter Welcome Notice
STEAM Magnet
Visual and Performing Arts Academy (VAPA)
Grading Periods
Graduation Policy
Links to Homework
2019 - 2020 Important Dates
Culmination 2020 requirements
Elective description 2020
Smarter Balanced Practice Test
W.E.B. (Where Everyone Belongs)
Common Sense Media for Parents
Suicide Prevention, Intervention, & Postvention
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Tech Office
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HCA STEAM
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Cool AVID gear
Counseling/ Guidance » Links
Show links in topic: 1. Do you have a concern or question and don't know what to do? Click here. 2. Counseling and Family Help and Mentoring 3. Homework Help and More 4. Parents/Guardians having difficulty with your middle schooler? 5. Where is a safe place to go after school? Internet Safety 6. Let's Go to College 7. Find your dream job and career. 8. Summer Fun and Enriching Programs AVID website Title IX
Are you dealing with issues regarding gender? Here's a resource to help. For gay, lesbian, bisexual and transgender people the coming out process can be both difficult and liberating. Our members -- parents, family members, friends and members of the gay, lesbian, bisexual and transgender community -- understand the coming out journey and we offer our support and unconditional love to people at any point in their journey.
Drug Awareness and Help This site is a rest stop for like minded individuals who believe in being 100% Naturally High and rejecting drugs and alcohol. We are committed to helping you explore Natural Highs and proclaim your own! Check out our "what's your natural high?"
The It Gets Better Project's mission is to communicate to lesbian, gay, bisexual and transgender youth around the world that it gets better, and to create and inspire the changes needed to make it better for them.
While many of these teens couldn't see a positive future for themselves, we can. The It Gets Better Project was created to show young LGBT people the levels of happiness, potential, and positivity their lives will reach – if they can just get through their teen years. The It Gets Better Project wants to remind teenagers in the LGBT community that they are not alone — and it WILL get better.
It's My Life...Surviving Middle School What Is "It's My Life"?
It's My Life deals with (you guessed it!) life and the stuff that we deal with every day. Whatever problem you're dealing with, believe it or not, other kids and teens have gone through the same thing. Here at It's My Life, you can read informative articles, share your stories, play games and activities, take quizzes and polls, watch video clips of other kids talking about their feelings and experiences, get advice from older kids and experts, and contribute your own comments and questions. It's My Life also features interviews with celebrities about stuff they had to go through when they were kids.
No Haters Here: Let's Stop Prejudice, Racism, Homophobia, Sexism The Los Angeles County Commission on Human Relations has been in existence for over 60 years working to improve the way different groups of people get along in L.A. County . We believe young people possess the keys to unlock a future free from hate and discrimination and we want YOU to get involved!
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redpajama_set_name: RedPajamaCommonCrawl


An experiment in concertgoing, this thrilling collection of music will only be revealed at the performance. We have a few hints, though: a surprise (and surprising) opener by up-and-comer Ted Hearne, a favorite piano concerto with Margaryta Golovko (winner of UNI's Midwest International Piano Competition), and an orchestral classic chosen by our April 2014 audience based on teasers from Tchaikovsky 6, Firebird, Shostakovich 10 and Sheherazade. We think you'll be pleasantly surprised!
There are no program notes for this concert due to the fact that all three works will be revealed from the stage at the concert. We hope you enjoy the surprise!
Margaryta Golovko is the winner of the 2014 Midwest International Piano Competition in Cedar Falls (* more information below). Her performance with wcfsymphony on November 1 is presented in conjunction with the MIPC.
Margaryta was born in Kamenez-Podolsky, Ukraine, and started her piano studies there at the age of five. In 1997 she entered to the Kiev Special Music School and continued her studies with Boris Fedorov at the National Music Academy of Ukraine P. I. Tchaikovsky. Starting in 2011 she pursued additional studies at the International Piano Academy 'Incontri col Maestri' in Imola, Italy with Piero Rattalino.
Margaryta has enjoyed outstanding success in international piano competitions: In 2006 she won third prize at 'Citta di Marsala' in Marsala, Italy; at the 2012 International Smetana Piano Competition in Pilsen in Czech Republic she was awarded first prize and the EMCY Prize; the same year Margaryta received the third prize and the Bacau Orchestra prize at 'Citta di Acquaviva delle Fonti' in Italy; and in June 2014 she won first prize at the Midwest International Piano Competition in Cedar Falls.
She has performed as both soloist and ensemble player in concert halls in Ukraine and abroad in France, Germany, Italy and Russia. Earlier this year Margaryta gave a solo recital at Mozart Hall at the Philharmonic Academy of Bologna (Italy), and in September 2014 she took part in the 8th MITO Settembre Musica in Milan and Turin, Italy where performed recitals featuring the piano music of Brahms.
Margaryta has performed concerts with the Kiev State Symphony Orchestra, the Bacau Philharmonic Orchestra, Pilsen Philharmonic and Helycon Symphony Orchestra. Margaryta's November 1 performance with wcfsymphony marks her US orchestra debut.
*The University of Northern Iowa School of Music recently hosted the first annual Midwest International Piano Competition. This biennial, global piano competition and festival located in the heartland of the United States featured outstanding youth and professional performing pianists and all rounds were open to public audiences.


A New York Xeljanz infection lawyer notes that, according to the results of a study involving more than 3,000 rheumatoid arthritis patients, the prescription drug Xeljanz poses health risks for patients who take it. Those involved in the study express renewed concerns about the drug's link to liver damage and increased cancer rates. Affected patients and their families may be able to file a lawsuit and recover compensation with the help of a Xeljanz lawsuit attorney.
For more information, contact the Attorney Group for New York today. We offer free, no obligation consultations. We can answer your questions, and if you choose to pursue a claim we connect you with an affiliated New York Xeljanz infection lawyer who can assist you throughout the legal process.
After reviewing the results of five human studies involving 3,300 patients, the Committee for Medicinal Products for Human Use (CHMP) concluded that the popular arthritis drug Xeljanz is not fit for the treatment of rheumatoid arthritis. According to Medical News Today, the drug, which is intended to help reduce inflammation and other symptoms of rheumatoid arthritis, is typically prescribed to patients who are unable to tolerate alternative treatment methods.
After studying how Xeljanz affected thousands of patients suffering from rheumatoid arthritis, CHMP determined that the drug's risk-to-benefit ratio did not favor patients enough for it to be considered a safe method of reducing disease symptoms. In addition to raising new questions about the drug's overall efficacy, the study results suggested a link between use of the drug and the development of serious infections. Furthermore, those involved with the study did not feel that physicians would be able to effectively and successfully manage the many side effects attributed to the drug, among them an increased incidence of some cancers and liver damage.


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Russell Brand: The Emperor's New Clothes
Note: This review is from 2015
Movie review by Jay Richardson
Russell Brand opens his new film, The Emperor's New Clothes, reading Hans Christian Andersen's short story across footage of The Lord Mayor's Show in London, with all its ridiculous pomp and regressive ceremony.
Last night, following the premiere of the inequality-focused documentary, he concluded a live question and answer session, babbling meaningless nonsense at Brian May.
Glibly concluding 'another one bites the dust', after the Queen guitarist surprisingly took the mic to ask for concrete solutions to problems highlighted in the film, the comic gave him nothing for his pains.
As an encapsulation of the appeal and maddening irritation of Brand, it was perfect.
Under the guidance of director Michael Winterbottom, the comedian-turned-activist confirms himself as a compelling documentary-maker, his common touch eliciting moving testimony from victims of austerity, while his willingness to cock a snook at the Establishment presents a clear-eyed, compassionate and comprehensive articulation of the widening gap between rich and poor since 2008's financial crash.
Throughout the film, his egotistical prancing and faux-Dickensian verbosity is kept to a minimum. And for those of a certain political persuasion, it really stokes fury at a financial system gamed towards the 1 per cent.
Sadly, then came the Q & A, broadcast live to 200 cinemas from the Hackney Picturehouse. Here Brand was revealed as the Emperor and May, inadvertently, as the little boy who emboldens everyone else to see the lack of substance. A series of questions from within the East London cinema and from Twitter found the comic reclining louchely in his seat, head lolling in a look of disengagement, promising a series of initiatives that were never expanded upon to members of organisations like Oxfam, the Fire Brigades Union and NHS. They had to content themselves with publicising their causes, because he had nothing useful to impart.
Despite this urgent, topical film being scrambled together shortly before the General Election, jamming in updates to bankers' bonuses since the initial footage was shot, he sidestepped a predictable question about his much-publicised unwillingness to vote by saying that Winterbottom's views run contrary to his own non-engagement.
As he lapsed into a familiar pattern of vague, quasi-mystical Utopianism and soundbite, only narrowly avoiding his usual refrain of 'paradigm shift', the contrast with his direct, concise address in the film was horribly marked. And I can't have been alone in wanting to hear more from the more measured, thoughtful Winterbottom at his side.
But it was May's intervention that truly threw a spanner in the Revolution. A patently decent man, promoting his Common Decency project to clean up politics, the rock star reckons he might be able to change Brand's mind about voting.
For now though, he wants leadership, imploring the extoller of Guevara and Gandhi: 'If you really don't want to vote and you don't want us to vote, what do you want us to do to achieve the things that we know we need to do because we just watched your film. What do you want us to do?'
To which Brand replied: 'Did you put Freddie Mercury under this kind of fucking pressure? It's a long-term strategy of the re-centralisation of the power under the co-ordination of vital institutions and vital services fully autonomous collectives that collaborate to preserve the rights of the individual and the rights to pursue spiritually whatever direction we want to with the prioritisation of the ecological preservation of the planet. It's going to take a while for it to get on the ballot box but I don't know if that is necessarily the right way to go about it but I support you, what I support most of all is people becoming fully activated and I'd be very, very happy to talk to you and Anita Dobson in your caravan.'
The awkwardness of May's rictus grin as he grasped the vacuity of Brand's rhetoric was painful to watch. Nevertheless, he persisted. 'But what do we do Russell?'
To which Brand responded: 'I mean, look, you know me, help me out. In that film that we grafted over there are loads and loads of ideas. You're saying how do we get that shit to happen. I mean don't make me say something mad on the telly. I believe in creating different relationships with powerful institutions which operate on behalf of the powerful, bringing them on to our side. I don't agree with remaining within the parameters that have been set for us. I don't believe in that in any level, I believe in real change. Like if an election is us the people we can have one whenever we fucking want, we can do whatever we like. I have some ideas, I have some strategies but I also have really serious limitations. I'm here to amplify the issues for the people in this room to help people in any way I can'.
To claim that this was a let-down after an excellent film is something of an understatement.
Revisiting his hometown of Grays in Essex repeatedly during the film, Brand lays the blame for its decline squarely at the feet of Thatcher, Reagan and their free market fundamentalism.
He spoke to those struggling with the bedroom tax, students saddled with debt, tenants facing eviction and cleaners scraping by on pittance wages, contrasting their experiences with the bank bosses and CEOs hiding behind security in their gleaming towers of steel and glass in London and New York. The comic mischievously scales the scaffolding of non-dom Daily Mail owner Lord Rothermere's residence to erect a poster demanding the press baron pay his taxes, as Winterbottom adroitly balances journalism with Brand's frivolity.
A series of economics, tax and banking experts armed with persuasive metaphors and damning statistics add authority. But credit has to go to Brand for distilling so many difficult and potentially boring issues into an easy-to-follow feature. As he says himself at the top of the film, we already know all this. But it's still an achievement to join up all the symptoms of inequality in such an accessible package.
Even as one of the self-acknowledged rich, his desire for change is beyond reproach, as the now celibate lothario declares: 'If you aren't angry enough to kick a pig into a ditch, you've not been listening'.
Unfortunately, while he's accomplished at highlighting the problems, his performance in the question and answer session makes you seriously question if he has any answers at all.
Review date: 22 Apr 2015
Reviewed by: Steve Bennett
GameFace Series 2
Michelle Collins: Strong Monster
Katherine Ryan: Glitter Room on Netflix
Supper With A Side Of Humour
Adam Hess, Fern Brady, Lou Sanders, Phil Ellis
Angelos Epithemiou, Gary Delaney, Alex Boardman
York Great Yorkshire Fringe
Friday 19th Jul from 21:00 - 22:30Book now
Cheltenham Town Hall and Pillar Room
Thursday 25th Jul from 20:00
Stewart Lee: Snowflake Tornado
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Friday 29th Nov from 20:45Book now
"Comedy is simply a funny way of being serious."
– Peter Ustinov