Wednesday, December 12, 2012

#ONC2012 Transcript

The following is the official transcript from #ONC2012 as captured from the webcast page from approximately 10:00 a.m. to the program's conclusion at approximately 5:30 p.m. The beginning was not captured. >> indicates a change of speaker.


(break) IsStarting to exchange data across state lines in California and Oregon, Florida and Alabama, and other states, states have been fantastic partners in this.

Today, in our New York environment we have over 70 percent, almost 80 percent of the hospitals are now connected.

>> Health information exchange as a public good came out in spades in the Sandy storm. The super storm, biggest storm to hit New York City in 120 years in some cases we had to shut down hospitals because of the physical damage. This network was there, this network caught that when you shut down a hospital and closed up its data center, all the data wasn't lost it was in the network.

>> Good morning, good to see you.

>> In health care, anything that influences outcomes in patient care is beneficial to everybody, including the providers, the patient.

>> You saw the cardiologist oh couple of weeks ago, Dr. Ensong, right

>> You don't have to go back for six months.

>> That's wonderful.

>> My information is linked to the hospital and for the practice to practice portal.

>> You seem to be doing well and you are taking the same medication

>> The practice that implements HIE as soon as possible is putting itself at the cutting edge.

>> We want to tike the best practices and lessons that have been learned in states like New York and Kentucky and make them available for everyone. We don't need to recreate the wheel to create great health information exchange.

>> The system is only as good as the number of people in the system, and the more people that join the health information exchange, the stronger we're going to be in terms of being able to provide the most complete care, and most holistic care.

>> These are the kinds of things that are public good, it's a public utility, it's a community benefit. Something that we owe to the population.

>> Ladies and gentlemen, please take your seats, our program is about to resume.

>> Have a seat, have a seat. Hi, everybody. So we're going to talk about one of the most important and critical issues for the success of the move towards using information and the power of data to improve health care, and that is making sure that we keep the health information private and secure.

I want to start off by acknowledging that that's one of the core expectations that patients have of their providers. That as they use their health information to take care of them, to share it responsibly, that they keep it private and secure.

This is going to take an all hands on deck approach. The responsibility clearly involves health care providers, there's also a role, an important role, for patients, protection of their own personal health information. There's more that vendors could do. Vendors of the IT systems, to make sure that their products don't introduce any vulnerabilities as we move towards electronic patient information, that they provide the tools to providers to keep their information private and secure, to comply with the HIPAA requirements. Whether it's around authentication, whether it's around encryption, whether it's around audit logs, our regional extension centers, one of the most important things I believe that we've done is to work with those small practices. To not just make them aware of the requirements and meaningful use that a security assessment be done and that risks be assessed and mitigated, but to actually make that meaningful. We've work with national institute and standards and technology to create tools to figure create the security of those systems and our most important partner and our good friends and colleagues at the Office of Civil rights. And if there's anybody who can deliver the message that health care needs a little bit of a wakeup call, it's le on Rodriguez. Le on. (Applause.)

Le on is a friend, and as you'll see, brings a prosecutor's attitude and a patient advocate's heart to the challenge.

>> Thanks farza. So let me start, and farza did what he was supposed to do, he left me the clicker.

First of all I want to let everybody know that we carefully analyzed all of the confetti, it is free of any protected health information, so thank you. Whoever.

So it's a -- I had a root canal yesterday. And I feel fine, and I'm very pleased to be here. But it underscored that my experience as a patient has really been transformed by my role as the director for the office for civil rights. And some of you are from Washington, many of you are from elsewhere, but here in Washington, just about the first thing that anybody asks you is what do you do. What do you do for a living.

And so when you go to a health care provider as the lead hip

Enforcer for the country, it's always a touchy moment to decide what you're going to say. So for example, when I went to my opt moltion, I was frank with her. I said well, I'm the lead of HIPAA en fors ment. You mean for mayor, no for the United States. For the United States, really? But she shared with me that one of the challenges for health care providers is, well, not surprisingly, mobile devices.

Because patients want to text their doctors, they want to call their doctors on their cell phones, and the security needs have not caught up to the patients' demands to communicate with their doctors in this way.

On the other hand, yesterday when I went for a root canal and I knew that somebody was going to be drilling around my mouth, I simply said that I was an attorney. And I did not -- I did not elaborate. On what my role was.

But all of this points to the two basic roles that we play in the office for civil rights. First, as a 100 percent right improbably first and foremost a patient advocate. And as among other things from the personal experience of finding that so far we are not coordinating care in the way that particularly fits patients needs. Often family members with of varying levels of sophistication varying levels of education varying levels of economic viability are the wounds who find themselves coordinating their family member's care.

And we need to get to a better place.

And so the work that you're doing holds out that promise for America's patients. And my role, my office's role as I've described it before, is very much like the role of the Securities and Exchange Commission for the stock market.

People trust the stock market because they know that there is a watchdog, because they know that there are a set of rules of the road that in most instances ensure the integrity of what goes on in the stock market. So as you're lot on this safety role on which you've embarked it's important that patients have trust in the work that you're doing, and we are looking to be your partner in that role.

Now, high tech has led to a transformation in the way that we enforce the health care privacy laws. Until high tech came along most of our work was what I would call reactive. A patient complaint. A patient said somebody disclosed my information to my ex-husband. I heard somebody gossiping in the waiting room about my health information.

I saw my health information in a dumpster outside my doctor's waiting office.

High tech changed it. High tech changed it because it created a critical mechanism to look behind what the patient sees, to look at the overall picture of what we are doing to make sure that patients' health information is confidential and secure. And so we're doing this in three ways that I'm going to elaborate on in the coming moments. One is to reach notification, in other words requiring health care providers who have had some improper disclosure of health information to report that to their patients, to report it to the office for civil rights, and in certain cases to report it to the media.

We're doing it through audit. In other words Randomly selecting certain entities. And for high clients for privacy of clients, and we're doing it through the oh use of the far more powerful enforcement tools that the high tech statute gave us that we didn't have before.

So let's talk a little bit about breach notification to begin with.

First of all we've been doing this since about 2009, we've received about 500 reports. Significantly for today's discussion, in excess -- nearly 4 million of those individuals affected by theft of laptops or other electronic devices were for mobile devices. So critical for the discussion that we're going to be having today.

Also important to understand as you talk to people about electronic health information, it's not the technology that's failing. It's people that are failing. Okay?

So if you look at the top types of breaches, we're talking about theft, we're talking about unauthorized access and disclosure, we are talking about loss. In other words, things that people either choose to do or they do by neglect.

And so that means that it is not only about building better and stronger technology, but making sure that the people who have protected health information understand and live by the rules of the road, to make sure that that information is safe.

These two charts which are in your materials will give you a good sense of how these issues break down. Significantly, about a quarter of the breaches are actually paper records.

A quarter of the breaches are paper records. Meaning that they are not -- not as completely from the health electronic environment as some would have you believe. And here are some examples of some of the more serious breaches.

So talking now about audits. So the high tech -- high tech statute gave us the authority to conduct audits. This year we are in the middle of a pilot audit that's covering 115 entities. There is a wide variety of entities involved, from small doctors and dentists' offices all the way up to large health care clearinghouses, health plans, large health systems.

And we have made a number -- learned a number of interesting things from this first round of audit activity.

First of all, when we talk about privacy, there is no single type of deficiency that stands out. It runs the gambit.

And so any given provider will have sort of a different menu and range of deficiencies than any other provider.

On the other hand, when we talk about security, and I'm going to forward it over to those issues, we do see particular issues bubbling to the top, and this is actually the first 20, we've now done 115, and so I've learned some interesting additional things.

Certainly, a big issue is monitoring of activity. Okay, looking at what disclosures and uses are being made, and reviewing, at least in some sort of periodic way, what's happening with the health information that's being used as an entity. But probably the single thing that bubbles to the top and you're going to find this interesting when we talk about our enforcement, is risk analysis. The very first thing that you need to do when you're setting up a medical records system from a compliance standpoint, and the thing that we found the greatest -- where we found the most consistent deficiencies, was in the area of risk analysis. In other words, looking at your entire bills process, looking at your entire technology setup, and assessing where the vulnerabilities are, assessing what your resources are to address those vulnerabilities, and then taking the steps to have those vulnerabilities addressed.

And it's not only -- not only the completeness of that risk analysis at any single point in time, but it's also the fact that this is an ongoing exercise. What the HIPAA regulations, what the high tech regulations expect, is that on a periodic basis, a year for example is a good rule of thumb for most types of entities, you are reexamining where you are, you are looking at how you've changed your business process, you're looking at what technology you've added to your business. In order to assess what new steps to ensure the privacy and security of those items need to be taken.

The other issue we saw in a number of cases were issues with policies and procedures. And my favorite one were folks who actually printed policies and procedures off the internet on the day they got the letter from our auditors. And it actually showed the date line from the internet as being when the policies and procedures were issued.

But what's really critical about this is although we encourage encryption, although encryption is clearly, for example, for security purposes, the preferred way to secure health care information, we are really far more concerned about the process. We're really far more concerned about that road map that the HIPAA and high tech rules give you as to what you need to do to assess risk and then to avoid risk. So we're talking about risk analysis, we're talking about training and education of staff, we're talking about disciplinary policies that are actually applied with respect to employees who breach information. We're talking about incident response. When you have a breach, whether it's one that's reportable to OCR or not, that you take steps to analyze that breach, to understand what vulnerabilities led to that breach occurring.

Because as we begin to talk about enforcement, and ume see that enforcement is getting tougher, and tougher as time goes on, what we're looking at less and less is what brought you through the door, what brought you to our attention in the first place. Instead, what we're looking at what was the weakness in your business process that caused a particular issue to occur. That's what we are looking at.

And so you'll see how our -- the various deficiencies that we find in our enforcement cases track the kinds of things that we're finding in the audit process, track the kinds of things that we're learning from our breach cases.

So we are talking about -- we are talking about failure to conduct the risk analysis, we are talking about absence of training, we are talking about failure to have adequate policies and procedures.

We're talking about all those common sense things that we're seeing in audit, that we're seeing in the breach environment.

So one of the lessons of this is that we will be continuing our audit program. And one of the ways that that is funded is in fact from these very recoveries.

So one of the authorities that the hi tech statute provides is to use those recoveries in these cases and to put it right back into enforcement. So that will create our ability no matter what the budget is to do these kinds of cases.

Now, you should take a close look not only at the specific deficiencies that we found, but also at the range of entities that were affected. So uch Phoenix cardiology associates you have a physician practices you have hospitals you have health plans, there is no single kind of entity that has been able to -- that doesn't end up becoming subject those sorts of deficiencies and enforcement.

I also want to call your teengs to the biggest of the cases because it points to another issue that's really important. The biggest case that we did, the one that resulted in the most serious fine, was not about privacy requirements, it was not about security requirements, it was about access requirements. It was a provider who filed to give patients access to their records, and then chose not to cooperate with our investigation.

So that is as much an issue from OCR's perspective as privacy and security. And as I've said before, HIPAA is a valve, not a blockage. It is at the end of the day meant to ensure that what health records are used for is for the benefit of the patient. That means the patient needs to get the records when they need them, it means the patient's other providers need to get them when they need them, it just means they need to be private and secure from anybody who doesn't need them for the health care of the patient or for the health care operations of a particular covered entity.

So the last thing I want to talk about, I think my time is coming to a conclusion, is having said all of that, we want to make sure that the industry has in its hands what it needs to be able to effectively comply. And I will be transparent with you that in both audit and in our overall enforcement work, one of the particular areas of vulnerability that we have found is with smaller providers. It's with that individual doctor's office or with that small medical practice or that small pharmacy. And so we understand that the burden on us is to make sure that we are effectively reaching and educating that part of the industry.

So on the one hand we talk about enforcement, but at the same time we're talking about education.

So here there's ryrchs to some videos that OCR has prepared you're going to see some additional materials that ONC and OCR together have prepared, and there is extensive material on both our website, ONC's website, and other resources available to be able to comply. And we want to continue in a dialogue with you, to make sure that those are the materials that you need.

Because I'd rather go out of business. I'd rather not have to be in this business. And I actually believe that the time will come where this will be so second nature in the industry that we will no longer be talking about million and 2 million dollar recoveries. We'll be talking about a very different environment.

So thank you for your time, it is now my pleasure to introduce Catherine martricini from the office of the national coordinator for health information and technology. I asked her what her title was, and she would not tell me. So I have designated her a title. She is today the guru of health privacy for the office of the national coordinator. So welcome, please, Catherine. (Applause.)

>> Thanks, Leon. Good morning. I'm Catherine martricini as Leon mentioned unfortunately, the privacy officer was unable to be with us so I hope to channel some of her energy this morning.

To continue the discussion as Dr. Mastashari spoke with you earlier everyone has a role to play to help keep patient health information private and secure.

Director Rodriguez talked to you about the role government has in roirt and enforcement around privacy and security of health information. I'll new touch briefly on what the office of the chief privacy officer is doing to help assist stakeholders in understanding their responsibility as well as integrating privacy and security into their culture.

In addition to OCR's efforts, this slide provides some information in a snapshot of some of the privacy and security activities that our office is working on. Due to limited time I'll not be able to dive into these deeply, but we wanted to provide you some visibility into some of the activities that we're doing.

For more information about these initiatives, links to many of these are available on healthIT.gov and I'm happy to answer any question towards the end of the session.

One of the initiatives listed here that I will dive into focuses on mobile devices, those things we can't seem to live without these days.

So just out of curiosity, those in the room and join in by webcast feel free to participate by Twitter how many of you today brought a smartphone, laptop or tablet with you?

How many of you have two? Three? Four? Five? All right, great. Okay.

Next is how many of you have a password set to access that mobile device? How many of you have the automatic log-offset up? Encryption?

Welch like you health care providers and professionals are adopting these devices on the job. We recognize their benefits, their portability their size their convenience in care coordination, as mobile technology holds great promise for health and health care.

However, as you heard from director Rodriguez earlier, the losses of mobile devices are frequent causes of breaches of health information.

So as Leon mentioned we've been working with OCR to develop materials to help health care providers administrators and staff meet their goals in overall privacy and security responsibility.

I'd now ask director Rodriguez to join me te podium to make a big announcement about our efforts around mobile devices.

OCR and ONC work together to develop a new educational initiative and set of online tools to encourage health care providers and professionals to know the risks, take the steps and protect and secure health information.

>> We understand mobile devices are having a huge uptake in the health care industry, and are widely used in health care. We realize providers may be unaware of the privacy and security risks associated with these devices, as I mentioned earlier. That said, we know that health care providers care deeply about patient trust and the importance of keeping that information secure and confidential.

The mobile security device security resource gives health care providers common sense tools to help prevent their patients' health information from falling into the wrong hands.

>> So one of the tools we are excited to show you that we developed with support from the maximus federal service team is a video that is now available through our online resource center. So we'll now watch the video.

[music playing]

>> No go ahead and just get a table I'll be right there I just need to see if my patient's lab results have come in.

(sirens)

>> Sorry we'll do everything in our power to recover your report understand we'll be starting a criminal investigation.

>> I understand what's our next step

>> We'll need as much information as possible about your laptop, make model serial number, what kind of records are on it.? All my patients information.

>> Okay you need to notify your security personnel at your medical group or hospital, patient information may be at risk now.

>> I understand.

>> It's terrible to lose a laptop or to have it stolen if you use your laptop smartphone or tablet to receive access or store patients health information, the steps you take before a love or theft occurs are very important.

The HIPAA privacy and security rules were issued under the health insurance portability and accountability act. These rules set national standards for protecting PHI against unauthorized use or disclosure and safeguards for the confidentiality, integrity and availability of electronic PHI

Health care providers who are HIPAA cost intids must take steps to protect the privacy and security of their patients' PHI. This means you must protect and secure patients' PHI no matter what kind of technology you're using.

It is important to understand and follow your organization's mobile device policies and procedures. You should also know who the office or organization's privacy and security officials are in case your device is loss or stolen. The easiest way to protect and secure health information, don't store it on mobile devices. However, if you store health information on your mobile device, back the data up to a secure server on a regular basis, and delete the data from the device after you review it.

Use encryption so that only you and other authorized people can get to the files stored on the device. Encrypting data makes it unreadable except by those who know how to decrypt it. Protect your mobile device from unauthorized use by enabling the password protection settings. Use a mobile device password that's difficult to guess. You can also install specialized applications on your mobile device. One application is a remote wipe application. It allows you to remotely erase data stored on the mobile device if the device is lost or stolen.

In this case you will need to take action to remotely erase the data.

Another specialized application can automatically block access to your mobile device, or erase the data stored on the mobile device after a number of failed logins, in this case the application itself will lock the device or erase the data.

Sometimes bad things happen when you are using devices that are portable, such as laptops, tablets or smartphones, even when safeguards are in place. You should report the incident immediately to the appropriate person in your office or organization as part of the security incident response and reporting plan.

Once you've established that there's been a loss of health information, follow the office or organization's security incident response and reporting plan, as well as the policies and procedures for determining if there has been a reportable breach. If the office or organization determines there's been a reportable breach, the office or organization will need to take any action necessary under the HITECH breach notification rule. State law may have additional requirements that will also have to be met.

>> I can't believe it. I think I have almost all of our patients' files on there. Yes, I did back it up to our office's secure server this morning.

>> After any loss of health information, it's important for an office or organization to perform a new risk analysis and to make changes to policies and procedures to reduce the risk of any additional loss of health information. It should also provide retraining to all staff on how to protect health information and how to secure mobile devices.

Create a culture of privacy and security awareness that encourages proper handling of health information. By doing this, you can take steps to minimize the loss of health information before a mobile device is lost or stolen.

Watch the other videos in this series to learn more about identifying and implementing mobile device safeguards, to help you protect and secure patients' health information. All providers are different and their privacy and security considerations are different. These five videos are examples of some risks and safeguards. They are not all-inclusive of every risk and every safeguard you should consider. Visit the mobile device privacy and security website to learn more about practical ways to protect and secure patients' health information when using mobile devices.

>> So as an output of the mobile device round table we held this past spring this video you just watched is one of five in a video series along with other educational tools that are now available at www.health IT.gov forward slash mobile devices. Here's an example of how some of the information is organized on the site. We tried our best to present the material in a way that would be helpful to health care providers.

You'll find tips, steps, frequently asked questions, in plain language on how to protect privacy and security of health information, including key points to consider when drafting or reading an organization's mobile device use policy.

>> Our goal in making these tools available is to help raise awareness and increase providers' and professionals' understanding around these areas to help them in our common fwol of protecting and securing health information en trusted to their care.

>> You also find easy downloadable materials and information focusing on mobile device management for organizations, personally owned or bring your own device BYOD, and using a remote device.

>> The steps, tips, frequently asked questions and videos can all be used in combination -- and this is an important word -- to help create a culture of compliance. We're talking about everybody getting it, that this is important. In security awareness within a health care organization, that encourages proper handling and protection of health information.

>> So we invite you to check out our online educational tools available through the resource center, to learn more how to take the steps to protect and secure health information.

>> And with that, we welcome any questions you may have.

Is there questions?

>> Mic?

>> Okay, so there are mics about sort of center room over there, and center room over there.

>> Good morning, shanterrosso American health hospital association. Just wonder if you have any more about your timing of releasing of HIPAA HITECH rules.

>> Good morning, and thank you very much for that very timely question. And I recognize that as we await the release of those rules, you do too.

I am hopeful that you will be seeing them very soon, but can't share a specific timetable. But thank you so much for that question. I'm sorry, did I say thank you for that question? In fact, if I would like to ask that question again, I would welcome that question being asked again.

>> Good morning, Mark Warren Price Waterhouse, apps, tools, mobile devices are coming out rapidly now across the federal health agencies. Including bring your own device, for example, in the VA at least.

How are you coordinating across federal agencies to assure some common approaches to security and privacy in this arena?

>> Well, sir, our role of course is first and foremost with respect to other federal agencies as an enforcer. So in many respects, the actually federal agencies are no differently situated than you are in terms of the compliance requirements.

That said, for example, I know we're going to be talking to the American college of health executives this winter, which are primarily consists of government health care executives, so it will be a great opportunity to talk to them about that sort of consistency.

I don't know if anybody from ONC has any tag on the specific issue of federal government.

>> The only thing I would probably add as you're probably wear the FDA under HHS has a movement around mobile medical apps we did coordinate with four other governmental agencies at the round table this past March but since then Congress has asked FDA and ONC to work together in this area, so we will be coordinating.

>> Thank you.

>> Thank you.

>> Thanks for that question.

>> Good morning, just a question. The Incidents that you all investigated, how many times have you found that the actual health record was the target of the hack or whatever? Do you have any information about that? And if so, what's the motive of these folks that are trying to gain access to these records?

>> Yeah, that's a very good question. In many of the incidents in fact it's our sense that the health care record is not the target of the hack, it's actually the media stolen. The laptop, the mobile device is the target.

There are a certain segment of true hacks and true thefts of mobile devices and they really tend to fall into two categories. Probably the most common is identity theft, in seeking those records, in order to engage in some sort of identity theft.

The second purpose is to cause some embarrassment or exposure to a particular patient or a particular limited group of patients. So for example, our UCLA case involved a celebrity's health records who were publicized

But actually underscore those are a relatively small portion of the records, they tend to be more about getting the stuff, getting the media involved.

Yes, sir.

>> Hi, Leon, this is Steve markel with modern appliance solutions. First of all thank you for releasing the data on the breaches and recoveries you've performed thusfar.

Were any of these entities using the free tools that are available through Health and Human Services like the HSR toolkit or the spreadsheet to conduct their risk analysis?

>> I couldn't specifically tell you. My sense is that some of them were using those tools. And one thing that I want to underscore, just because an entity has been the subject of a breach doesn't mean that that entity was out of compliance. And that's why, for example, you will never hear me, other than in compliance, use the phrase wall of shame that I know has become very popular, because the point of the breach notification exercise first and foremost, the very small number of these, have actually resulted in enforcement is first to have the entity that was subject to the breach to do what the regulations require, which is analyze the breach, figure out what needs to be done to remedy the vulnerabilities that led to the breach.

And we similarly use it on a more global level, to identify the broad categories of issues that seem to underlay particular breaches. So my sense is that probably some of those entities that are reporting are in fact mostly in compliance, mostly doing what they're supposed to do, and probably then using the kinds of tools that we make available to them.

>> Thank you.

>> I gather we're out of time, do we have time for one last question? One last question.

>> Good morning, Charlie judge from calver County Maryland, actually a two part question. Number one, in the BYOD world we read every day about Facebook and other entities taking your data and doing whatever they want with it. So the big issue is as a health care provider, or as a patient, how can you verify that what you're communicating with a portal or whatever is not going to be picked up by the Facebook app that's running in the background.

And number two, I know this is pie in the sky, but the question of getting a uniform standard of some sort of a program which the Feds could certify as secure and compliant and roll that out for all the major devices out there and say look, this is a secure communication platform for iPad or PC, or whatever, just a thought.

>> So let me take your second question first because I actually think it's a very interesting challenge, and a dialogue that we need to have, as to whether in fact there should be certification criteria, should they come from the federal government, should they come from an industry body, should they be the same for everybody, should there be different ones for particular industry segments. That's a discussion that I think we're all going to be having in the months and years to come.

So I can't rule out the idea that we could reach a point where there could be such standards out there. I welcome that discussion, actually.

As to your first question, I think the answer to that question goes to one of the points I made during my presentation, is we are not looking at particular technological decisions that covered entities make. Instead, what we're looking at is a process, is a way of analyzing risk, a way of implementing the results of that risk analysis, responding to incidents, training, disciplinary policies, contingency plans. And so to the extent that a particular technology is exposed in the way that you describe, the question is, was there a thorough risk analysis conducted to minimize or eliminate the kinds of risks involved.

>> Thank you.

>> Thank you for your question.

>> Okay, thank you all, I'll be around for awhile to have an opportunity to meet everybody, and I certainly look forward to our continuing dialogue.

>> Thanks. (Applause.)

>> Thank you, very impressive thanks so much Leon.

Want to thank you all again really appreciate all your effort, and it is important to demonstrate collaboration that occurs between the agencies, but also the collaboration that occurs while the people who are stakeholders in that would be every single soul in the United States so we appreciate that very much.

We're going to transition to the health information exchange discussion, and I would welcome Claudia Williams up here, who is going to be our moderator, I need her as a prop. Let me tell you a little bit about her background and responsibilities right now. She's responsible for the HIE activities, and we only get her part-time because of her talent and capability and dedication. Todd park in the White House has asked her to be on partial assignment, and we appreciate that very much. But she comes to us from the markel foundation where she was the director of health policy and affairs but if you don't mind turning around here now. You've heard the expression about wearing your feelings on your sleeve -- come on you've got to do this better. She's wearing her passion on her back. I don't know if you know Regina holiday -- I don't know if you know Regina holiday she was in the audience yesterday, she was here yesterday, she's not here today, okay.

But she believes in creating wearable patient stories, so farazad is lucky enough to have one of those pieces of art and it really is a testament to the passion that health care and health care IT instills in all of us so we certainly appreciate that and look forward to the panel discussion. Thank you all.

>> Thank you, David. Wow, it's different up here. It's great to see all of you guys up there. And I think we're really looking forward to bringing to life the ideas that we talked about this morning, that Farzad introduced, that we are here because we want to transform health. We are here because we think we only can do that by knowing, and information is how we know, and how we know if we're improving. And we're here because technology can enable the innovation we need to know and improve and learn.

So I think you'll hear from our fabulous panel those themes repeated and personal stories, and stories from people's professional lives, during this 45 minutes.

So I am really delighted to introduce a panel that probably needs very little introduction. Folks that are very familiar to you. On my right John halumka who is the CIO at Beth Israel databank oness medical center and also we're very very gravely co chairs the health IT standards committee.

And in addition serves as the cochair of the Massachusetts state health IT effort so plays a critical national, state and local role.

To his right is Josh shar scene and is director of mental health in Maryland and we reluctantly gave him up as a federal leader to lead the work in that state but he'll be joining to us talk about a state and public health perspective.

To his rate is Justin barnes who also as everyone wearing multiple hats take it which is multiple hats today he's chair and VP, bringing a tech vendor perspective, and finally drug frizzma who is a chief science officer and director of the office of centers of technology here at ONC. So welcome everyone.

So we have not only some great folks here but also a prolific writers and blog gers and tweeters which have been tweeting during this session so you guys will have to do the job, but I think Josh and Justin have written about how using stage 2 is going to enable a giant leap forward in exchange and operability this year and next year Josh will you start off by talking a little bit about that.

>> In stage 1 we had very good chts out of our EHRs but there weren't specific transport standards so you've got summary but how do you get to a patient how do you get it to another provider we didn't have these unambiguous implementation guides that would make that possible. Further we dpbts really have incentives to do it because stage 1, and again best at the time it was good work, but to do a demonstration, because the technology is pretty early in its evolution, stage 2 said you must exchange clinical summaries for 10 percent of all those transactions of patients seen in a reporting period, and oh by the way 5 percent of your access must actually access, view, download transfer their record. Suddenly what you have is the technology standards for transport content vocabulary, plus an incentive. You won't get paid as a doctor or hospital unless they're actually used.

The quick personal story is my mother broke her hip a couple of months ago. I went to the hospital and said I'd like to see her medication list to make sure it's appropriately reconciled. And they said well, we can't give it to you. You can't get access to it. Well, if you get her consent we'll print it out on paper.

This sort of thing should never happen. Again, now with stage 2, it won't.

>> Thanks. Justin, you aren't -- you are dealing with providers across the country who are probably still working on stage 1, but soon will be pivoting to using your product for stage 2. How should providers get ready, and how are you talking to them about how stage 2 will actually help them deliver better care?

>> Sure, I think the bigger -- we lead with kind of a little bit of a picture. Certainly to think of interoperability not only provider to provider, and platform to platform, but also provider to patient, provider to registry potentially even provider to device, to really coordinate that care.

To look at that, look at the future, really to not only further your practice, but really your goals. You look at it from a standpoint of what do you want to achieve over the next year, it's not just meaningful stage 2 serm over the next couple of years but it's about what do you want your practice or hospital to look like, how do you want to advance your goals and how can your patients help do you that, how can you really engage your community of health through interoperability, and also look to educate your patients.

And ensure that they're engaging their health, and they're also beinging more accountable which is critically important in this process. To look at stage two towards provider to provider exchange provider to patient exchange provider to registry and really unleashing this data, creating liquidity that we need in a health care system moving forward.

>> Heard that you really tying that back to the goals that the health care provider may have, and the tools in toolbox for getting there, which is making meaningful use.

>> Right.

>> So Doug, we heard this morning that you all are having lots of meetings over there in S&I land, but really I think the meetings are just a means to the end, which is to speed our progress on standards adoption. And to make it possible to take these leaps forward in stage 2 and then stage 3 that enable better patient care.

So what's that set of progress look like, how have you done it and how have you made it possible to get to standards specification and documents in months rather than in years.

>> Well, I think -- I think meaningful use as you sort of talked about, provides a focus. And sometimes getting that focus and being able to sort of create or identify a very specific problem to solve helps focus those energies, and I think that's an accelerant to be able to do that there's a need to support the policies arrange meaningful use, and all those things serve as drivers. And in fact I only expect it to increase as we start to look at things like accountable care organizations and other things in which interoperability and standards are one of those things that support interoperability will only accelerate.

ONC provides really the convening space, if you will. We become the convener of authority. We can say there are some important problems we need the community to solve, and here are some of the ones that really are important for us to take a look at.

So we can provide an opportunity for, rather than having one group identify the problem and another group kind of create a solution and a third group do the implementation, we can create a forum and a place where all of those folks can come together, and they can feed off of each other to try to make sure we're focused on the right problems.

So do that we provide technology, we provide wiki and is we provide web ex and we provide teleconference, we try to lower the barrier for people to collaborate and to coordinate. And by reducing those barriers we can focus on those things that tend to hold people up.

So let's make sure that people have, you know, that notes are being captured, that we put things out there so that people can comment on. And I think that also helps to accelerate it, as well.

As we talked about this morning, we have 1700 people who have signed up to participate, and some of them just lurk, they just look, but they oftentimes -- and that's okay. That's okay.

>> We see you out there.

>> Because they're tracking what's going on and they will likely learn and bring that back to the organizations in which they work.

Of that, those 600 of them greater than 600 I think it was 617 is what today's total is, participate in regular meetings. And so they represent probably 450 different organizations. There are 35 pilots that have gone on over the course of the last 23 months.

We've resolved 1800 comments that people have said about how to make things better. And the mean interval between meetings is about three and a half hours. So we probably have 2 so far. But it's remarkable, and I think, you know, we -- our job is to serve as a platform for people to be successful in the communities. Because these standards aren't being developed by us, they're being developed by people that are passionate about standards, and the standards development organizations providers that are trying to solve real problems, vendors and others that are trying to provide solutions that can demonstrate that change.

>> Thanks and I didn't get the perspective from all of you sitting there, so can you just put your hands up again if you participated in any of this activity standards work over the last couple of years? So thank you. For that.

So Josh, and put your hand up if you're from -- where's your Maryland team who are the Maryland folks in the house, all of them are great. So Maryland is -- I can't remember if you're the first or the second state. I'll call you the first. To connect every single one of your hospitals to the HIE infrastructure. Delaware there's a little battle between Delaware and Maryland around that, but I'll call you first.

And literally every -- think about that -- every single hospital.

And each of them is feeding at least ADT feeds and much more rich clinical information into this infrastructure.

Josh it would be great if you could share with folks here what are some of the amazing services and values for providers with just that simple ADT feed coming from each and every single hospital? So how can you choose this simple technology for incredible impact in health care system?

>> Sure, thank you. Thank you also Claudia for inviting me to this, this is exciting. When I first got the email from Farzad I thought it said it was for a focus group. But.

>> We can do that later.

>> Is that after?

>> Sure.

>> I --

>> We won't let him (inaudible) anymore

>> There are a lot of people here. (Laughter)

>> We do think big.

>> It's a -- I was going to say I don't believe the 614 people, but I believe the 614 people.

So I'm the secretary of health so I'm maybe a bit of an arm's length from HIE but it is a tremendous asset in Maryland and even the ADT feeds are a terrific asset and I'll give you a couple of examples

One of is for our those payment system, which is one of the rate is the setting in the country one is readmission program so as we think about paying for value instead of paying for volume of services there may be certain readmissions we don't want to pay for well there's a unique identifier and as patients move from hospital to hospital we can track readmissions very closely within the Maryland system and give very specific information to the hospitals.

So that certainly is very important to hospital because that's how they're paid and it's a real value because it allows us to pay on the basis of something that matters.

For primary care doctors, we have -- they have a system which I think is fantastic, (inaudible) a pediatrician when doctors can upload their patients list and be notified realtime when they go to the emergency room or the hospital so it comes right out of the ADT feed and as we're pursuing some pretty interesting medical home initiatives in Maryland, again the payment side comes in because the clinicians get paid more if their health outcomes are better and people are not having to do to the emergency department.

So it's one thing to wait until the end and get the fax, which seems to be the story it's another way to help right away and be able to manage the case and so we're doing that, the third thing which we're really moving forward on and I think the team that works on this, and there are some people, here in Maryland who do terrific work,

And you know the governor lieutenant governor are completely supportive is to use that to develop some maps of where we're seeing particular acute. And even if you're just looking at ER visits it's amazing what you can see on a map and the distribution and what's going on and where there may be poor access to primary care.

And I think as we do have a lot of different clinical information coming in now, over time there's going to be an enormous opportunity between that and the public health side. So it's not just a matter of an individual clinician's encounter with the patient, but are we seeing a particular part where we know there's lower life expectancy where we know there are different problems, what exactly are we seeing in that area, and are there different public health interventions that can be used to address the problems.

>> So in the old days, we'll call them the old days, when we had paper, you dealt with whatever problem came in your door, and you did it as well as you could. But I think all three examples are ways we can think in a population health way. Anticipating problems that are not in front of you yet, and using technology and information to do that, which is amazing.

Well, HITECH is not the only thing that's been going on in the health care system over the last couple of years, even though sometimes I think it feels that way to us. This has been a period of really unprecedented change in the way we're paying for health care, and whether it's Medicare ACOs or medical homes or private sector initiatives, readmissions penalties in Maryland.

One perhaps slightly overoptimistic analyst said one in 10 Americans will be served by ACOs this year, or by accountable kinds of care delivery this year.

So clearly, this provides now an important driver for using health IT, but also for moving health information between providers and exchanging information. Because if I now many paid for providing care to my patient and my patient shows up at your AD and gets admitted to your hospital, I'm going to want to know about that.

>> Claudia can I just jump in for a second

>> Yeah

>> Just on readmission, in Maryland it's not a readmission penalty. Through payment system the hospitals are given essentially a amount of money for the expected amount of readmissions and if they lower that they get to keep a big chunk of the difference, basically. So it really matters to them every single one, not just whether or not they're going to hit a threshold and be penalized. But it is really a very fundamental rethinking of the volume based incentives that exists now in health care.

>> Thanks, that's great.

So John, you are one of the recipients of the pioneer ACO payment model from Medicare.

As you've been thinking about what you're needing to build out and how you need to provide accountable care, what exchange functions are most critical, and what's your health IT strategy going to be?

>> Sure. So weighs talked earlier, about the public HIE about the health IT, there's another incentive that's ACO with global capitated risk, I am penalized when someone goes to your emergency department unappropriately or someone wears an MRI already have a copy of, so what we need is community wide measures we need community wide data exchange so what you see is the rise of private HIEs to try to create registry and is repositories in the interest of keeping people well. Don't want to deliver too much care don't want to deliver too little care, want to reach out into their homes, look at all of the data about their lifetime record, not just an episode, and deliver that appropriate care to them.

So what do we do, we use health care information exchange technology to get summaries of care from each inpatient and outpatient encounter to a common registry, where that is used for ACO quality recording PQRS reporting meaningful use reporting, and importantly, by care managers, who can say oh, well I'm in a diabetic guideline. Who is not getting the foot exam and the eye exam that they should get this. I'll call them up.

So in effect you can't be an ACO unless you have a health information exchange strategy and a care management strategy based on aggregating data across multiple sites of care.

>> And I think what I heard you say too is fine to build that analytic capacity among the folks you're most closely tied to but you also need a way to exchange with a hospital that's across town that you don't necessarily give as pat of your partnership circle.

>> That's exactly right. So a few years ago when I went to the CEO health care system, in Missouri we do have these monolithic health care system in the eastern part of the state and said have I goot a deal for you we'll get rid of those redundant radiology and laboratory tests reducing your profit by 15 percent.

Sort of a hard sell. But today, they say wow, we must share data across competitive organizations, because we're all at -- we all have global capitated risk we can't survive unless we have coarpetition.

>> That's a great way to segue to Justin. We have a great way to say these payment forms are creating a great way for business exchange, and we see evidence of that, in these examples.

But still, when folks are trying to exchange across vendor boundaries or organizational boundaries I think those questions still crop up. Those little niggling worries that maybe this isn't in my business interest and maybe it would be better to just see if I can keep the information myself. How do you see that changing how do you see a database for liquidity secured information exchange shared information, how do you see that emerging from some of these new delivery models and payment systems?

>> 88 think this is actually, this is where it gets -- there's a lot of fun in this for us and for me personally and I'm sure for all of us is to go into these communities, and over the past year engaging numerous communities at different levels, educating them on what care coordination is possible, outside the four walls of your practice or your health system.

It is practice to practice, practice to health system, practice to registry, and then also incorporation of those devices, and then look at not only the interoperability that's before them right now, but if we can create this new community of health, new partnerships, new relationships, new educational opportunities with their patients, what opportunities exists.

Now we still have a lot to do in the payment reform and payment model side so a locality of the of these providers most still work in the fee for service world, but as we see those evolving, educate them on those opportunities how to best position themselves now so they're ready for it so when it hits they're not scrambling and calm years off. We want them ready now and that's again I think it's a lot of fun going in there.

And they're at all different levels we've see great communities or medical villages where they're still in the fee for service model but theeg patient medical home model and it's where it's going and could be going in some communities but they're also focused on patient satisfaction. And they understand the importance. Because having a satisfied patient that's a fundamental business component. However they're going to be paid under that type of model potentially six months to a year, year and a half from now so understand the importance of that

Understand these business drivers today a lot of our practices are seeing a significant decrease in patients because they're creating sticky in these relationships using portal and personal health record and really engaging and empowering the patient. So they're excited about that. Not only are they en dpaijing in business today very successfully but they're very well-positioned for where the future of health care is going, so I think that's exciting navigating all this together.

>> So 6 AM this morning John post add blog that all of you should read, and Justin also had a fabulous exchange blog, and I think it's 605, or 6:10 I tweeted it.

And one of the things that you talked about is the concept that two years from now anybody using 1 HR vendor should be able to exchange using another.

And what gives you such confidence that we'll get there?

>> Well, of course we talk about meaningful use and the various incentives, but I think patients will demand it. So let me give you a personal example.

December of 2011 my wife was diagnosed with breast cancer at a suburban hospital and she went to the medical records department and said I want my XML fully electronic, document transported to the next provider of care, please. And they

>> And they said if you come in well Monday through Friday 8 through 5 we'll reduce the electronic record to paper and you can drive it down the Massachusetts turn pike to the next provider of care.

Well, you imagine the anxiety, discomfort of now having to shuttle paper around. On October 16th of this year, did you val Patrick our governor in fact pushed the button that lit up the health care information exchange across the state of Massachusetts, and actually as a gesture not only did he push his own record from urban to suburban, but my wife's record, fully electronic lifetime continuity of care document went across the institutions that previously had exchanged paper.

So I think what you're seeing, patients demanding it. The infrastructures are being built, it's becoming real. And that was really the purpose of my blog this morning. We as patients never want our wives or our children to experience paper-based transfers ever again.

>> Thank you.

>> Very true. (Applause.)

>> So a lot of the work that we all do is focused on getting better care in a DOC's office and individual encounter but the potential for health IT and HIE to drive population health, whether that's clinician, taking a population health view or literally public health interventions, is kind of remarkable and in some sense we've just begun that journey.

Josh, when you think about the problems like prescription drug deaths or the millions of Americans who have cardiac events that could be prevented with hypertension control or through other ABC kind of efforts, what do you -- what gets you exilted about how health IT and HIE might help you as a public health leader address these issues?

>> Sure, well, on the one hand you have in public health very interested in outcomes and a lot of great people working in public health, and on the other hand you have the clinical community that's very focused on patients and the quality of care delivered to patients, and for many years there's been very little intersection between those two. There have been all these big reports about how public health and health care come together and what's that about, and how can we trigger it. I think this type of technology has incredible potential to bridge the gap, in both directions.

It's not just about health care thinking more about population health, it's about public health community thinking more about health care. And so for prescription drug deaths, which is, you know, a remarkable challenge right now, and we however just reported a small dip in prescription drug death as heroin goes back up. So it remains an enormous challenge in Maryland and across the country.

PDMPs we're a little bit late to the game with PDMPs, prescription monitoring programs where physicians can see the records of other -- the previous pharmacy records but what we're going to do is build it within the HIE, so that it draws people into the HIE it is much more accessible and when we launch it it will be part -- something that is a platform for something that we hope both through individual clinical interactions and the ability to study the data across the population, can lead to interventions. On a one person level as well as across the state and thinking about how to control prescription drug deaths

>> There are other to that if we can pull into the HIE that makes it more useful and accessible to people and that's good but you may also be able to tie that with other clinical information and find opportunities, around a million hearts and the need to address quality you can think about getting data and completely -- I'll end with this, but when we -- we do a lot of performance management in Maryland.

And when we look at public health measures it's typically been a survey that is completed six months before, the data has just come out and the survey reflects 18 months ago. But if you can use data from an HIE to assess interventions and assess the effectiveness of different strategies at different levels, you know, from the previous week or the previous month it is a totally different experience about you know are we getting better, if not what can we do.

So I think there's tremendous potential in getting information out about how health care is delivered and thinking about the population that will transfer not only health care but will transform public health also.

And as an aside, I encourage people if they're interested in finding out what's going on in Maryland to join my mother and three of her friends on Twitter and follow me. (Laughter)

>> Josh@

>>@Dr. Josh S. And I will not comment on whether that's part of my own performance management and plan or not. So.

>> I apologize because I have a little time question, it says 18 minutes left here?

>> -- for Q&A

>> We'll manage that a little fluidly, okay, thank you.

We -- you know, a lot of the meaningful use work is very focused on providers and hospitals across the nation, and the private health care community, but there's been tremendous work in progress among federal partners. Can you talk a little bit about some of the signal achievements and strategies you're seeing across the DADOD, SSA, and others, CMS,

>> shumplt I think it's important to recognize that the federal partners are an important part of the partnership that we have within ONC and, you know, the VA and the DOD and CMS and Cdc, they interact in every community that we've got represented in this room. So that's an important part of success.

I think our federal partners have helped us really to implement and support meaningful use, as it is now. But they've also been developing and piloting and working ahead to try to figure out what the future might hold, and try to help us understand some of that work, as well.

So without going into all of the things, I mean for example now, the VA is the one that initially piloted the blue button, and they thought maybe 250,000 would be a good number to strive for in a year.

Well, they've over 1 million people that have used the blue button. And now we are taking that the next step. The blue button was about access to information, and now what we want to do is create something that takes that information and makes it computable, makes it possible for computers and applications to begin using that information in useful ways to support patients.

The DOD has been supporting the VA efforts and wuned war area for a long time in health information technology, getting that information from the battlefield all the way through is an important aspect of the care that they deliver.

I think the Social Security Administration for example has had tremendous success in doing some of their claims adjudication. So for example, it may take 92 years -- sorry, 92 days, not years, 92 days. (Laughter)

92 days to move one of these things through the process. And that can be significant, both for hospitals, who then have to make decisions what they want to do for those charges, for patients that are getting bills and worried about losing their homes, they've been able to use electronic means of reducing the the time they've decreased it by almost three weeks in terms of what it typically takes.

And in some cases, you know, a small percentage, 3 percent but that's still significant, they can adjudicate these within 48 hours. And that may not seem like a big acceleration, but if you're faced with losing your home or if you're worried about your bills, that can make a substantial difference to patients.

They curnlt have pilots now that are running in over 1200 different institutions, 18 different organizations are represented in those facilities, and 16 different states.

So they're really beginning to expand the work that they do there, and I think they've had tremendous success.

Our federal partners have also done a lot of work in looking towards the future. One of the things they did this summer is the federal, they look what the health IT standards committee does and they said gee wouldn't it be great if we had ways of exchanging information that was different than web services and different than email but kind of based on what we do all the time with the web and interacting there.

So they did a Sears of pilots and series of studies looking at this restful way of exchanging information, which we're using to inform the work that the automated blue button activities are doing.

They've been working on some of the hard problems like theory and response, and how do we do that, and looking ahead to what that looks like. And have been tremendously instrumental in the successful launch of what was the NWHIN but has now become the E-health exchange, and I think that's been a tremendous success to see their partnering with ONC and supporting those activities as we move into the future, as well.

>> Terrific. All right, now we'll open up for questions, comments, ideas, challenges. I will also ask the panel to work into your responses what some of your kind of biggest challenges and biggest opportunities will be this year. As we look to the growth.

So itle it's a little hard to see but I think I see -- so we have mics on either end, and I see Keith boon.

>> Thank you Keith boon from GE health care. So Doug you can't answer this question, this is not a question for you.

This is actually a question for the rest of the panel. I'd like to hear your responses to the idea that we aren't getting to consensus any faster on standards, but what we are doing is getting them implemented faster. And see if that resonates with any of you in terms of S&I framework.

>> Yes, from my perspective Keith what I've seen is people have come together more often, that the lag periods between meetings have been reduced, the barriers to communication have been reduced, people have a much more practical approach. Instead of looking at every edge case they're getting the core functionality done, perfection is seen as the enemy of the good.

So you know I actually think we've got a little to take off time on all aspects of the standards development process. But you are quite right, there's an impatience that has happened because of ONC's leadership, it's leading us to implement even standards that are nascent faster than ever before.

>> Yes, I'll pick up on that and I completely agree. I feel over the last six months we have implemented more direct exchange with other platforms than ever before. More leaders in the industry around the EHRs have come together to have cross-platform exchange. The devices, device interoperability has really risen and the need -- ONC has been a terrific driver in that in certainly the regulations but I also think there's a thirst and a need by our communities for this type of data exchange, so they can achieve their goals.

So as we get more pennant models that encourage that, incentivize this, we will see it only grow much faster. But patients are a critical component, they're getting more educated every single day, they're taking on Morse more costs of their own health care every single day so they are engaging more than ever before they're using new devices protocols and platforms to engage their health care. Those are all drivers so it's drivers from the provider side drivers from the patient side drivers from the regulatory side, I think all of those are come together much more quickly, I think all of those are drivers to move this forward.

>> Thanks.

>> So Keith can I comment, even if I don't answer?

>> Doug, would you like to comment?

>> I think your point is important. I think we need to get a pivot. What needs to start happening is we don't develop standards and then adopt them, we need to start kind of adopting standards first, and get that implementation out in front of that.

If we get into the point where we've got sort of an agile iterative incremental approach I think that's where the sweet spot is. We're not there yet but I think we can see a future that probably includes that.

>> To Doug's point maybe we've had a waterfall approach to date and I think what we see in the industry is we must impart use in exchange do we have a perfect standard yet so let's experiment see how it works in practice and then spread the wealth of our experience so we've got to implementation actually ahead of standards being finalized and within a few months we're able to report back to you how it went.

>> Yeah. Yeah.

>> I don't know if Tye will have a chance to talk about lead startup and how it can be used in health care but this concept of getting as quickly as possible to implementing and evidence creation and then improving as you go is I think a sort of core way in which this work has gone forward.

Yes, I think we have a question at this mic.

>> Hello, Monty Harkins NCQA. I have questions about registries and who is driving what components are going to be in a registry. We see a lot of variation, and I'm not sure if we're developing, you know, standards around that, and who would be carrying that flag.

>> Sure. Well, a couple of thoughts is that if you look at the latest NPRM that came out of ONC they've come up with this expanded sed of coordinated elements and this minimal dataset that will be the necessary data to compute all the quality metrics as part of stage 2. So having that notion of a core dataset and all the CQM actually enumerated as certification criteria specifying data elements you must have is very helpful.

The way we did it in Massachusetts is we did it a couple of years ago, is we effected a poor man's approach to that we said well, what does PCOS require what does ACO requires what does P for P pay for performance, require and we map a schema draft a document and send our raw data from hefrs into that registry so we can compute all the things necessary for our business processes.

I think we're getting to a level of maturity and with ONC's latest ram you're going to see that iteration, that schema set for the country. And then there are others in the standards committee who are looking actually even forward from registries and asking can you use query health or federated data mining models to send questions to the data instead of data to the registry.

And that would be really exciting if we can get that humming for the country.

>> Great. Let's take one more question over there.

>> Yes, reed gall zero provider resources also cochair with evidentiary support work group also have been quite active on the ESMDs, S&I initiative.

One of the things that has been noticeable at least in our work group is we've had wonderful participation from end users of data and from entities that support standards or develop standards or have implemented standards into business products.

But we're not hearing a whole lot from the people who at the end of the day actually have to implement and use these systems in their clinical and business operations. And given the push-back we've seen on 5010 and ICD 10, it would seem like it would be prudent to take a more vigorous effort to blend that into these processes.

In particular there was an RFI earlier this year that was essentially about mandating that all standards had to be tested and proven, actually implementable in the marketplace before they could actually be promulgated through a federal agency. And I think all of us would like to see that sort of intermediate step prevented. But then we also understand that these clinical facilities and these clinicians are hearing this continuing flow of mandates for things that don't necessarily address their business needs.

So how can we bring -- how can we bring that additional player into the loop, do you suppose?

>> John?

>> So the standards committee, next week will actually be addressing this very point. So it's an extraordinary issue for the country to take a set of scripts that have been developed by experts and then ask every provider at every hospital to execute such scripts. We need to test and pilot them first.

Stage 1 was on an extraordinarily accelerated time frame so we didn't have that piloted step and what Wended up with can you prove that you can prescribe a scrub that the FDA banned 10 years ago. Well that's not a great thing we wan to eliminate those sorts of problems so Liz Johnson is going to be reporting on the implementation work groups efrd to pilot test and evaluate every script before it actually goes out into the wild.

So absolutely, that process needs to be essential.

>> I have the honor of closing this session, and was really struck yesterday by a gift that one of our dear colleagues, Ross Martin, gave us at the HIE team day. Ross of course is known for his singing and his putting of meaningful use and other important concepts to song.

Yesterday he shared with us a poem, and I will read you a part of this to remind us why we're here, and keep us grounded in that throughout the day.

So this is a part of his -- and he's blogd it yesterday so it's available also on his blog. And it's man among millions is the name of his poem.

Here I stand, just one example of a man among millions, with a family lost in its maze with a wife who faces cancer number 3 in 30 years, who alone carries the burden of coordinating care among the dozens and dozens of providers who focus on the particular part of her that they understand.

Who alone carries the records from place to place from year to year, from diagnosis to diagnosis, hoping she can keep it all straight. So at the very least, they do no harm.

Here I stand in a room of my heroes, who possess amazing super powers, to bend maze corners and to straight quarters, and change the flow from a trickle to a torrent.

I don't presume to know what drives you, what compels you in the morning, to forgo another 15 minutes of sleep and return to the battle, to do the heavy lifting to add another line of code, to write another line of policy, to sign up one more to join the exchange, to solve one more problem, to make one more connection, to make it flow.

But if you need a story to motivate, to steel your resolve to press on, mine is here, and free for the taking.

Still better, forget my story and tell your own. Shout it from the roof tops, or whisper it only to yourself. But keep that picture sharply focused in your mind, to give you the inspiration to do the work, so we can all be one among the millions whose information flows.

So thank you, Ross, for that gift, this is his last day working for the (inaudible) (Applause.)

So continue a round of applause for our panel as they leave the stage, and I will introduce another. Thank you. (Applause.)

I'm eyeballing our following folks. I am truly delighted to introduce a man who, even more than the prior panel, needs no introduction. Todd park. The nation's chief technology officer.

And he leads our national agenda on technology innovation and entrepreneurship and that means bringing to life the concept as far as I talked about this morning of leveraging innovation and technology and change for huge and massive societal impact.

So please join me in welcoming Todd who will be moderating a panel of stakeholders here today. Thank you. (Applause.)

>> Hello everybody. How's it going? Terrific. Terrific. Well, we have an all star panel for you today, a panel of personal heroes who think a lot of us and kind of open it up with a few words and then actually get into the meat of it.

Innovation is obviously critical to every goal we have as a nation, and nowhere is innovation more important than in health care. Transforming health care, make it more atheable, make it more available make it higher quality, patient-centered is a top priority of the country, a top priority of this President, this administration, a top priority of all of us in this room. And I think we know, all of us in this room maybe better than anyone just how critical HITECH is how central HITECH is to the nation, we all need HITECH is a critical component of the President's health care agenda

I don't need to tell you you can't solve a problem you don't know you have, and maybe what health IT does is most powerful, is it actually enables knowing and learning and changing at a level that heretofore was not possible, it's incredibly powerful stuff.

And if we can actually take a moment to appreciate this as a human level, a doctor can identify all of her patients with the power of health IT with diabetes or hypertension, to see what they need she can evaluate to ehow she's doing how she can get better. As the prior panel talked about can be done electronically as opposed to paper. And if any of these patients have unexpected hospitalization she knows she'll get critical information back.

This is all made possible by HITECH, and by meaningful use. While it may sound basic while it may not be what everybody wants it's a huge step forward an incredible step forward a literal move out of darkness and into light and not light that makes video games more entertaining or pizza less cardboard like but improvement that saves lives in a dramatic fashion.

So I join today with unbelievable appreciation for all the work that you've done and continue to do as the father of a baby who went through open heart surgery who is benefiting from the work that you are doing, and it's progress that is made possible by everybody in this room.

And by so many folks across the ecosystem, by employers, by doctors, nurses, consumer groups, tech companies, hospitals, patients, an all hands on deck approach that is literally making health care better, second by second, minute by minute, day by day.

And we're going to talk about that progress, talk about that innovation, talk about what's next, with an unbelievable, a ridiculously distinguished panel of stakeholders from across the system, and I'd actually first like to introduce each of them and then get into the discussion and open it up for questions from the audience at the end.

So we'll first hear from Dr. Craig sem met who is president and dean of health system one of the largest delivery systems in the meist under dork's leadership it's gone under awesome myself rapid transformation of its business results of better care lower cost as one of our leading examples of accountable

He began har strard community health plan, was on the turn around team at Harvard, CEO Fallon dlink May was appointed to the Medicare payment system, and continues at dean to deliver the best possible care to patients, and it's fantastic to have Dr. Sammet here we also hear from bill wash a senior advisor at Arp in case you don't know who AARP is it's a national nonprofit consumer advocacy organization representing people over the age of 50.

Recognize the power of health information AARP is making sure its members, nearly 40 million folks, 50 years or older have access to personal health records for Bill works with AARP health portfolio whichst setting the agenda, implementation of that agenda, he's involved in program development strategy and planning and before going into AAPR in 2008 he spent years as a journalist, appearing in tim magazine and newspapers around the country guess starring CNN fox, CPR, C-Span recently joined the HIMSS advisory counsel in 2013 will take positions on the editorial board of magazine generations and is appearing here today in his spare time.

The third guest we have is Scott white who is VP of activity at dignity health the third largest hospital system in the country his role includes leading dignity health $150 million investment in position EMRs clinical immigration accountable care organizations health care forum, imaging telemedicine health information exchanges and other unbelievably important thing prior to joining dignity in 2005 he was cre O at children's hospital in Phoenix, consulting with Ernst and young, sea men's, and life sciences companies.

Last but definitely not least we'll hear from David lansky who is not a stranger hopefully to anybody in this room, in case he is a stranger to you he's the president and CEO of the bisque business group on health and one of the most influential voices in health care, he's led PBGH since 2008 and it's 50 large employers and health care professionals representing 3 million Californians he's a nationally recognized expert in quality measurement health IT board members advisor numerous health care programs, leapfrog groups et cetera he serves as purpose representative on health care policy committee. Shares its quality measurement group enjoys long walks on the beach with his wife, and is an amazing human being. It's awesome to have all four of these here today I'd like to cict off with a brief question then we'll open it up to individual questions and broader questions.

Will you briefly describe your organization, I think everyone knows what his organization is, about who you are, and your organization

Actually on the spectrum of issues on your organization in general is grappling with, honestly, how high does health IT rank, and very importantly, why.

So actually just hawm a few bars about your organization, that would be helpful. Let me start with Dr. Sam met

>> Great it's great to be here, dean is what I would describe tas a present day accountable care organization, we're one of those remnants of a provider-sponsored health plan that survived the disintegration of integrated systems in the 90s 2000s I was at Harvard community health program, when we divorced from Harvard, then Fallon link when we divorced from community health plan. Then eI moved to dean we weren't getting a divorce we weren't even in therapy we were an integrated system that really had the three legged stool.

So we've lived in the world of value for at least a decade and long before the ESEA was passed we had made the decision to pursue value at any costs.

And so when you make that decision, you know, especially when we've made that decision all those years ago, it's enabling, you know, it's a new paradigm.

So the story that we have to tell is that we've lived in the value world and we've tried all the things and done all the things that an organization needs to do to maximize value, and it was interesting to hear the panel about exchanges, and even to think about the notion of meaningful use. When you're in the world of value, you don't step incrementally into implementation of EHR, adoption of EHR, meaningful use of EHR, it goes all the way to optimal use. Because in the world of value, you can't just use it piecemeal, you need to use the most capability of technology.

So that's who we are, you know, I can't underscore enough the importance of technology and how that has been transformative for us. And to answer your question, Todd, about, you know, what are the issues we struggle with. You know, our objective is to simultaneously prove to the country that we can be best in the nation in clinical quality, while at the same time being best in the region or the country, for that matter, in patient satisfaction. And at the same time being one of the lowest per member per month cost providers, and in fact, we've gotten there in all three dimensions.

So the thing that we struggle with is how does one simultaneously achieve all of those things all at the same time.

By the way, a fourth primary objective is engaging and satisfying your workforce, which is going through tremendous change. So our objective is to be a nation leader in all four, and I I think that's the issue we struggle with every day, how do we make progress in all dimensions.

And it underscores for us the importance of technology, because technology -- and many will talk about technology, I probably will focus even on data and analytics, because that's where we concentrate a lot of our efforts. Technology and data has been transformative for us.

When I finished my residency I went back to business school. As many of you probably have, I sat and listened to, in business school, case studies of the best companies in the world. And what was remarkable to me is throughout my two years in business school, not once did I hear a case study about a health care company.

And the lesson there is that we as an industry historically have not used all of the necessary strategies to be transformative, like technology, and like the use of data. So we've maximized that as a critical catalyst of transformation of our system.

>> Terrific. Good. So at

>> So at dignity health we're a large health system

We're the fifth largest in the country serving 16 states. We have 56,000 employees, over 10,000 physicians, that are affiliated with us, and over 300 sites of care.

Our primary states in which we serve are California, Arizona, and Nevada. And all three of those states are particularly -- have particularly difficult times in this last recession. And if you consider that, you know, what are the priorities of our organization, it's all about care delivery. And we are concerned about the health of our communities, and many of our communities have poor and underserved folks. We serve in downtown urban Los Angeles, or in rural parts of the state of California.

And with those concerns, how do we measure the quality of our care, and how do we strive to continually improve that care, and demonstrate that we're continually improving that care.

How do we find the resources to make that happen, as a not for profit organization, we can't go to equity markets to find money, so we need to go to our operations, and then the debt markets to fund these complex initiatives.

And it's a time in health care where we are moving of course from a fee for service model of delivery to ultimately a fee for outcome, and with clinical integration, and accountable care, a system where we look at population health.

And one of our values longstanding has been collaboration. And we see that value as absolutely critical at this juncture, this time in health care. And we've seen it all morning here, the theme of working together.

So if you look at the theme of quality of care, and demonstrating and measuring and improving that quality, and if you look at that theme of collaboration, well, information technology is absolutely essential to quality measurement and to collaboration.

So to get to your question of how important is health IT, it's not number one, but it is a critical means of achieving our goals of serving our communities.

>> So a lot of you may know the name AARP, you know, as those guys who sent you that damn letter when you turned 50 welcoming you to the organization.

I apologize for that, that's not my department. But what a lot of people don't know about AARP is that we originally formed over 50 years ago to increase access to quality, affordable health care for retired teachers who simply didn't have anything at the time.

We've grown far beyond that, we have offices in every state and the territories now, we advocate on a whole variety of issues.

But health care is in our DNA and it has been, which is why early on we recognized the power of health information exchange to improve quality outcomes and care coordination and track racial disparities among people over the age of 50. Well, among all people.

We also see it as core to our mission, which is to allow people to live independently on their own terms, and with dignity as they age. Because we believe that these tools hold the promise to allow that to happen.

And so how high a priority is this for us? Well, at the moment we're trying to protect Medicare and Social Security from the folks across town. So that's occupying a great deal of our time. But our second highest priority rate now is implementation of the affordable care act, if anyone remembers that, it seems so -- so last election, I guess.

Making sure that this law actually comes to pass, and especially the health information technology provisions of that law is critical.

So we've charged each of our state offices to oversee implementation from the consumer point of view, to make sure those exchanges comply with the letter of the law.

We also launched our own personal health record, AARP health record, in June of this year, and plan a public media blitz all of next year, we hope to be coordinating with the office of national coordinator on the blue button initiative, sometime next year on that, as well. So we really see HIT as central to our mission.

>> Pacific business group on health is a coalition of about 50 large company as Todd said they're mostly house hold names, Chevron, target, very large companies and if you imagine they have hundreds of thousands of employees scattered all over the country all over the world and they have a common concern about the quality of health care thur employees get the reliability of the health care they get cost of the health care they get the affordability of the health care they get much

So they came together to form this organization 20 some years ago to try to drive improvements in quality and affordability.

At this point, understand the specific question you raised Todd health IT per se what you all do is very very low on their radar almost invisible and they absolutely understand it is foundational to all the things they want to see happen in health care.

So the paradox is this is not -- if you work if you're an executive at Chevron Wal-Mart or whatever, obviously health care, the delivery of health care is not your day-to-day business not what you wake up doing, but of course it's chewing an enormous amount of your bottom line and exposing your employees to enormous risk. So Clarke in store today pick Wal-Mart Safeway target, about a third of their compensation goes to us, health care, not to their and their family and their needs except for their health care needs and that's going up 6, 810 percent a year

So from the point of view of the employee who is having a third of their earnings go into the health care system, and not quite clear what they're getting back, and from the point of view of their employer who can't say to the employee in Wells Fargo, teller in California I can assure you you'll get the same quality of care that you're paying for whichever door you walk into, that's a terrible situation so health IT is the backbone to create reliability affordable coordinated care.

So they care about it loot but it's not something we've much luck to engage in, which is why I try to support some of their interests here.

>> All right, so I'd actually like to start with just a short question for Dr. Salmon you a lot about health care at dean how do you use those to advance your mission.

>> As I mentioned a little bit earlier while technology is important in many respects in our organization it's been a means to an end, that you obviously can't manage what you don't measure, and you can't measure without technologies.

So for us, the end game is developing the analytics. So we're an organization that relies heavily on external benchmarking. So as we set our objective to be best in the country and all the things I mentioned, we started with external validation, where are we versus any information that we can find about our performance.

And so we really started the journey with benchmarking, because we couldn't tell who was best of breed in the country and actually how to top them in their performance and move to the first spot without analyzing the information and comparing it to readily available data.

So we started there and that was the first critical step.

The next step for us has really been reporting. I'm part of a consortium called the group practice improvement network, and we have discussions about how do you lead large integrated systems in multi specialty groups, and I facilitate groups perhaps not this large, but, you know, I ask questions, what are the strategies that are most effective in moving physicians, persuading them to align with the objectives of an organization.

And you know, is it incentives is it vision, is it data. And the collective sense was that the most effective strategy to move physicians is unblinding of data.

So we actually started there, and we started not with nontraditional data we actually started with patient satisfaction scores.

And they were readily available, we measured patient satisfaction, and so back in my Fallon days we measured patient satisfaction and then we unblinded it and rank ordered it and published it on our intranet for all of our physicians and employees to see.

And one of my staff had to start my car for the first few weeks after I did that, because it was a very unpopular decision. But where that has evolved to ever since is the power of analytics and the unblinding of data as a means to persuade physicians to change their behavior and to improve their performance.

Where we've actually stepped next in kind of the third generation, and I never thought that I'd be able to use this word in my career, is profiling. So we're working on gathering claims data, EHR data, with the purpose of analyzing not external performance, but internal comparisons.

So now we use the data to say how is Dr. X different in their practice patterns than Dr. Y versus Dr. Z. And let's show them this information, and say we're confused.

How can three talented physicians for a common diagnosis practice so differently. Can you help us develop a protocol or a guideline to improve that performance.

And it has been transformative for us to do that kind of internal profiling.

And then finally at the end of the day, where the data is actually most critical for us, I'm a big believer in aligning incentives with physicians, have done a lot of physician compensation redesign work, is you can't accurately reward value unless you can measure it and report it.

And so why technology is so important is to produce the data which is a motivator in and of itself, but at the end of the day, if we want to reward value, whether it's commercial plans, whether it's government plans, we need to be able to link incentives to accurate data. Which is in essence what we're doing within our own system, from system to doctor, and from our health plan to our broad network of physicians.

So that's a subset of how we're using data to change our organization.

>> Terrific. Terrific. A question for Bill. So why did AARP decide to roll forward with its own personal health record, and how is that going and what's your strategy to drive adoption?

>> Right, so AARP divided its health work into three pillars, one is around health care security where we advocate on the Hill and the state legislatures for our members.

Another pillar is around long-term care, making sure people have choices when they need long-term care in their community, not just a nursing home, for example.

The other pillar is around health care management. We know that increasingly our people are having to shoulder the burden of managing their own health care, they or their loved ones.

So many of our members are caregivers for somebody else. And so we're providing the tools or trying to provide the tools to help them do that. We've launched 12 different online health tools, and in June we launched the AARP health record in the same spirit.

We know that there are a lot of opportunities for people to sign up for their own health records without AARP, so why do we need to be here? Because trust is a big issue. You know, our surveys told us that even though insurance companies are reaching out to their beneficiaries, encouraging them to sign up with personal health records, a lot of the beneficiaries didn't want to engage with their insurance companies in that way. They were afraid of information falling into the wrong hands, they didn't want a personal health record through their employer.

So we're hoping to lend some of the trust they have in AARP to get them to use the tool, to manage their own or their loved ones' health.

Now, having said all of that, it's been slow going. You know. There are numerous obstacles as we've talked about here this morning.

You know, we did some user testing before we launched the tool, and people said I love it, it has all my information in one place, I can have access to my mother's information, I can check in on that, it's easy to use.

And heck, I can even print out a little card with all my Salient information so I don't have to, you know, fill out a form every time I go to the doctor.

The only problem with this PHR is it's online. We don't like that. And so that's a real obstacle, you know.

And so we're having to negotiate that. And, you know, there's been a lot of talk this morning about concerns about privacy and security. And that's there. That's there, I saw a study this morning that said three quarters of people surveyed were somewhat or very concerned about a data breach, if their information was online.

So that's a real concern.

But I also think that the privacy concerns masks a different obstacle, and that obstacle is around awareness. I don't think, at least among our members, they understand the value of a personal health record, and information sharing, they don't know the -- I mean they'd love to be able to email their doctor at any hour and get an answer. They'd love to be able to look in on their mother's information.

But I don't think they understand that these capabilities are out there yet, and how easy it is potentially to use.

So that's why we're launching next year a multi faceted campaign to raise awareness around the PHRs, and give people some level of confidence that they'll do what they need to have done.

>> Very interesting. Extremely interesting. Scott, so you've been doing a lot of work with meaningful use.

>> Right.

>> How has that journey been, and where sit taking you, and what are your next steps?

>> Right. It's been a good journey and started prior to the term meaningful use. So part of good health was defining requirements, what would computerized physician order entry look like and what would be a safer system of technology and processes that would improve our care.

So that was 10, 15 years ago that we started worked selecting a vendor worked with physicians nurses pharmacists worked with other folks to design a care processes that would be more standardized, and that we could measure.

And along that road we had meaningful use, and I see meaningful use has really been a catalyst, and it has also been, in a sense, almost like an elevator pitch, in a good way, so just the term meaningful use, it resonates with nonIT leaders.

So they want to see not a live date, but they want to see people actually looking the system. And they don't want to just see people using the system, but they want, you know, outcomes. Not acronyms.

So when they -- when a business executive or when a physician executive can say that we're measuring our VTE processes and our stroke processes and ED processes, that's powerful to them. And so I think meaningful use has really helped our executives and others throughout the industry on the provider side to say this is important, we get it, and it makes a difference.

So from that journey 10, 15 years ago to where we are today, we now have 18 hospitals that are live on CPOE, we have 900 physicians, all of our physicians that are either employed or in the foundation with us. All of them are live on very comprehensive ambulatory electronic medical records, we have 31 hospitals on health information exchange with almost 5,000 physicians, so HIE in all three states.

We're working on a patient portal and more patient engagement. And when you think about or ask what needs to happen yet, I think that is one of our big challenges, is how do we better engage with our patients. How do we provide them with the tools, and how do we make it really simple.

There are some other challenges that we continue to face, the last panel was discussing health information exchange. And how do we comprehensively exchange data with the smaller physician groups, with the one and two doctor practices and physicians in rural locations, that don't have IT resources within their group to set up and configure and test and maintain exchanges.

There's continued challenges with provider identification, how do we make sure we know we're sending information to the right doctor, to ethically and legally protect patients' data. How do we identify patients, the patient identification is a challenge, too.

So there are lots of things that we're still working on, but again, share the passion of those in the room to continue to fight the good fight.

>> Terrific. Terrific. David, so I have a couple of quells for you. One you mentioned this very interesting dynamic where employers feel the importance of health IT, but really don't think a lot about it.

Do you think that that's actually okay, as an equilibrium point or do you think there's actually a need to get them kind of closer to what's going on and to kind of unlock more support or mojo to support what's going on. Or it's actually cool like they're beamg enough mojo in the system and they're saying that they want this to work, and that's cool?

>> No, sirly I go to the latter answer. I think that it shouldn't be their job, it should be our job. And I think they're baffled and frustrated to look at their own industries, if you walk into a bank you walk into a travel -- you know go on line for orbitz you go to the grocery store and check stuff out or watch the inventory people do their work, it's you bick Tuesday, and they walk into the health care environment and it's you bick Tuesday in the environment, but it's not in the service of a lot of things we do here, clinical care management. They can't believe this incredibly expensive and extended industry hasn't already adopted the technology that they won't have survived if they hospital 10 and 20 years ago.

So they think it's our job 0 to solve that problem and do iment faster quicker. I think it's one of the frustrations many of us have had I was involved with the California HIE process, and you go to the employers and say why don't you come join the party and help us out this is valuable to you and we're going to help give give better care Scott we had this conversation, they're going to say that's not my job that's your job. We shouldn't be at that table so I think it's going to be a tough sale to get employers engage at the level of this kind of audience works so hard on.

So that said, I think the opportunity going forward is to focus on the information content that can be made available by the great provider organizations, and then to the community, as Bill said, by the work that we're all doing.

So I think from the employer point of view it's about the content it's about the information. As Farzad said this morning, what's really meaningful to the community, and not so much about the infrastructure development that we all have to do hard work on.

>> Got it. Got it. And then so just feeling the path you're talking about stage 2 and stage 3. In your professional opinion what are the most promising aspects and challenging aspects of stage 2, and where do you think we should go in stage 3?

>> So my slant -- I tend to look at this largely through the quality measures apparatus because that's where I give most of my attention. And a frus straition I've had is that it has come to be seen as an imposed burden, the quality measures that are kind of laid on at the end as an accountability task, not as an intrinsic good to the quality improvement and public accountability enterprise. So I think we're making good progress on the quality measures, in stage 2 we've opened the door a little bit for example to patient outcomes reporting and getting the patient in the game of measuring and reporting on their health.

And we've opened it a little bit more towards longitudinal measures of outcome like the blood pressure pracking over time. So these are peaks of where it's going. I think the main thing I want to share from the point of view of people who pay for health care that I work with, the payment system as we've heard from the last panel is going to be changing rapidly and hopefully dramatically, and the reward will be on achieving health outcomes over a period of time whether it's an episode or a lifetime. So managing information across settings across providers, across competitors as John said this morning, that's the challenge.

And I think where we're trying to go with stage 3 is to enable an infrastructure that lets that happen. And it's challenging because it means that the ACO or the provider organization that wants to wrap their arms around the patient and hold them in their embrace financial and clinical, has to open that up and say we are a part of a much longer chain of relationships to manage a person's health. Including their family, their caregivers themselves at home, their pharmacy and so on.

So I think that's the opportunity with stage 3 is begin to put that out there. The quality measures in turn are going to kind of drag us all kicking and screaming into that world. We're going to say you're accountable for measuring reporting and then getting paid on the kinds of things you talked about, the outcomes of care. And that's hard, it's very frustrating epeople say well I can't get the data from the patient, I don't have that patient engagement capability built in yet I can't get across multiple settings when they're capturing from the lab data so that's exactly where we think we have to go.

The payment mod lels do that then the question is can we build an infrastructure rapidly enough to support really rewarding value as it becomes more manifest.

>> Got it. Very exciting. Very exciting.

So what we're going to do now actually is crowd source questions from the room. And we have 22 minutes and 31 seconds of questions. That we'd like to gather, and answers that we'd like to hear.

So I think there are -- yes, there are microphones, and we'll just kind of alternate one and the other. So yes, ma'am.

>> My name is Laura Adams I'm from the rirlz quality institute. My question is for you, Bill. You're intrep edly going where many you are talking about. At the end of the day, nothing can replace the relationship, as you move forward with data analytics and double helix intertwines with the intensely human thing, with the doctor-patient relationship. We can't go fast enough for the patient expectations regarding our use of technology. You know, I've got a couple stories to tell, I shadow our physicians to understand how they are practicing and why they have high patient satisfaction scores and so on and so forth. I was shadowing a urologist and he was seeing a 92-year-old patient with a medical condition. At the end of the visit, the 92 year old took out a jump drive and said, could you please put my medical record on the jump drive so I can take it with me when I travel to Florida. My physician went pale, because we don't do that, but the 92 year old, there is a misconception generationally, the 92 year old wanted us to do that. Likewise, the reality we have is that while much of the world continues to invest capital in buildings, you know, volume-based care, facilities, heads and beds, we've invested capital and infrastructure and our perspective is that the world is going virtual. Our younger generation doesn't want to come in for visits, they want to SKIEPT SKIEPT with us. So any technology and subset of patients want us to embrace it faster. The only problem and I agree completely is how does the physician use the technology effectively in the exam room itself so it does not interfere with the patient-doctor relationship? And we've done extensive amount of evaluation and training to help the physician realize what they are doing in terms of minute-to-minute behavior that interfere with communication style and frankly that is an issue we can address and solve.

>> I agree with you that the tools of technology need to be applied towards the care of the patient and we are way behind other industries in that manner. The data that we collect and the quality improvement processes should not be -- the value of the metric or data that you collect has to have a value to somebody. It could be to the patient, it could be toward the institution, it could be toward the insurance company in terms of financial savings. And it may or may not apply to patient. What hemoglobin (inaudible) valued metric for a patient. The aggregate may be good for population management for the physician to manage the population, but the variable that affect that metric for the physician are sometimes by factors that are not measurable in a metric. Thank you.

>> Mr. Cummings.

>> How we are large system and look at aggregate data, but when it comes down to it, you are right, it hases to be what difference is it making to the patient right then and there. We have worked with our EMR vendor in the hospital for instance, to allow for or really provide concurrent quality review. So we can see those meaningful use metrics and display them right then and there for that patient instead of having to wait and look at those measures after the patient is discharged. It is too late to prescribe that medicine after the patient is discharged and it's too late to find out if you have taken care of the VTE and smoking and stroke measures. So thinking about that individual patient you are right, is critical and considering Director Rodriguez's comments, it is not technology issue, but peep and he will process issues. How do we make sure we train the people who invest in them and do we have the processes surrounding what we are delivering so it makes a difference for each patient.

>> Todd, can I also add, we use quality data a lot down to the individual physician level or at minimum at the Department level and our philosophy, we can't let perfect be enemy of good as pertains to quality measure. The bundle or measures are imperfect, but certainly better than nothing F. Our objective is to move forward toward value and toward quality, waiting until the data is perfect is too late and so we've tested unproven data just as a means of studying variation and taking an incrementalist approach toward where we need to go.

>> Two things. One is I know all of us know this, but sometimes forget because we are busy doing our work, not to romanticize the world we are trying to leave behind. The person to person-doctor relationship unsupported by information flow produced enormously valuable care that we can't be as proud of as we should is be. We forget a lot of the country is still living in that world and we need to reexplain the importance of what we're all about and improving consistency, reliability and evidence base of care.

On the other side of it, the reason we are advocating for more outcome measure and less process measure is this concern that if we try to prescribe a process for every patient walking in the door, it is not going to fit 20% or whatever number F. We say let's focus on on what the care team has done to achieve outcome, that leaves latitude to integrate in what is appropriate for that patient.

>> Very insightful.

>> Hi, Todd and esteemed panel. (Inaudible) aVID tweet under hash tag Larry Len. Question about ubiquity of data. You mentioned that people can go to travel websites and see flights or go to grocery store, do you foresee a car fax of sorts for each of us as patients and as healthy individuals and whether that could be accomplished in ever how many years using the national hint named as e-health exchange? Thanks.

>> Hmm.

>> In other words, the car fax, you buy old car, used fax, show me the car fax and you can see the problems with the car. With a patient you can say, show me the previous problems and not just the person's health condition, but problems that things didn't fix, drug PROSHGS seedures, peep they'll didn't fix it, do you see that data happening in the future?

>> I mean, I would envision, yes. I think it probably is a question that was probably more suited for the information exchange panel, but I think the ultimate objective is for the patient to control their own information. So I don't think anyone will will be able to access a patient's information without their approval, but I think ultimately, a patient is going to want to be able to release the information to any of their caregivers in the future and have a full catalog of information about their past or about their present conditions. I think that would be the ultimate end-stage of not just regional exchange, but national exchanges. I would hope that that's an end state we're striving for.

>> Yeah, I would agree, when I meet with practicing physicians, that's neVA na, they want to know what are all the problems, what are the medications, and we're taking steps, I think as David described, as healthcare delivery will be so informed by healthcare reimbursement and as reimbursement changes we will be driven to wanting a complete record of the patients and patients will be interested in that and I think that demand will pull that and I think you may have an idea for a good start up there.

>> Hi. My name is Sharon Cantor with Chime or Chief Information Officer for Hospitals. I'm going to put on my consumer hat and address Bill's offer for a PHR, sounds like a great idea. The question is how can I be sure that the data is being matched with me, Sharon Canner, or not Canter, or some other spell something by way of background, Federal law prohibits HHS from developing a rule on patient identifier, I certainly think that is off the table, but as we exchange health information across the region, within a city, not within the same system, hopefully across the country, this problem of not being able to accurately identify the patient with his or her data is critical. And so I particularly as consumer issue, particularly those individuals John Halumpka mentioned patient identifier within the hospital, but you can't do that across the region. Some of us have looked to try to get some sort of agreement on on field, can we all use the same fields for matching, I want to throw that out to you, Bill, and perhaps Scott may have some views on that as former CIO.

>> Yeah, I mean it cuts both ways, doesn't it? To get into the ARP health record, you have to enter your Arespect rP number and go to the next hurdle, the Microsoft Health Vault. You put in user name and password there. But those -- we initially set up those hurdles because we wanted to make it difficult for anyone to get into those records who was wasn't AUTH rised. The effect is the uptake of the record has been low because people see as hassle to get into. Right? It is a real conundrum for us, at the same time we want to protect integrity of the information, we want people to use the tool to manage their health. It's tricky.

>> Yeah, it is vitally important and this is one of the biggest challenges I think that we face right now, we've shared dignity health, shared testimony with the ONC about the patient matching issues, we are wrestle WG our own index, this is true for not just patients, but providers. I know states there are pilots as John mentioned that of directory resources, we must put some attention to this. It is challenging just to share records without that and very importantly as we want to respect our patients' privacy. You have to be able to properly identify them, just speaking here in Washington, D.C. a couple weeks ago with a colleague, CIO Bill Spooner. Someone asked him, what is your top wish for 2013? It was identity management. So it is something we in this room need to get done.

>> Yes, sir?

>> Sam SikardFRSHGS North Carolina. In your systems, where you have built extensive data systems for the patient with multiple complex illnesses, are any of you putting together data in a way sort of looking at patient-centeredness, because if you look at -- adhere to multiple guidelines and put the patient on on 80 medicines oftentimes you'll do more harm than good. So are you putting together any algorithms where you weigh out patient-centered outcomes in total health quality of life versus meeting every guideline target?

>> So absolutely in our system, that's one of the desired end states of accountable care to develop patient-centered solutions. So it's more complex than you'd think as cuimagine and that to see the complete view of the patient, we need to collect information from historically data sources. One primary objective is to build a sort of big data claims information system that takes our claims information, EHR information ambulatory and hospital and enable us to paint a complete picture of our polulation first of all and enables us to drill down to the most complex patients. Our ability to model, our ability to define that complex population, so that we can then, that is kind of where the data part stops, though, and then once we know what the population is, we can deploy our care coordination and care management resources to ensure we are looking at everything we need to manage the patient's health and quality and service and cost. So it is one of the end games and it's a critical one because as you know, that subset of the population incurs such tremendous amount of attention of doctors and cost in the system that is absolutely where we want to concentrate resources.

>> Great. And is there any specific tool that you are using to measure quality of life?

>> There are an array of options, that's probably one of the hardest things to get at. I can't recall the exact tool we're using, but we are measuring that as one key component of an outcome that we'd like to see.

>> All right. Thanks.

>> Last question.

>> My name is (inaudible) a practicing physician from the BRONx, I'm medical (inaudible) group practice and also involved with countable health organization health home and level three patient centered medical home and we are in the process of evolution. We all of us in this room have seen paper go to electronic and every year or every month we see new alphabet soup health home, a prescription was great until the next thing came in and the patient portal is the -- and PHR will be the word on on the street next year. Patients don't have much understanding of healthcare system, they really don't. They just have a card and they go to the doctor or the hospital and all they know is that here is a co-pay for you and they get a bill and don't understand that. And it is so important that patients are involved and this is very heartening and everybody is happy to be involved even the patients. However, from the panel, looking at the years of experience and evolution we have gone through, what kind of picture can we paint to a patient? How will they get care delivery in the next five years? Because every year, you know, we look at something else that has evolved and in the next phase of evolution.

>> Happy to start. You know, I guess if I were to paint a picture out into the future, we're going to see much more personalized healthcare. My sense of historically, we've tried to create a one size fits all model for patients because we've had to, we haven't had the resources to determine differences between patients or have personalized or tailored care protocols to individual patients. So I think in the future our objective is to meet the patients needs where they are, so if they have complex illness, they are going to have care that is very focused on a care management protocol F. They are younger generations, they may very well want virtual healthcare and we don't neat facilities or doctor's offices for their care, it's all technologically based. So I think at the end of the day, the benefit to the patient of the transformation toward value is first and foremost we will improve the quality of care, improve the service and lower the cost and reduced waste, but in addition we'll do that in a manner that's specifically addresses their individual needs. That would be my prediction of where we're going and how patient centeredness is very tangible and very achievable in the world of value if you approach it that way.

>> I would add just a couple comments. One is that theme of finding the right location for the care and we oftentimes, too often, deliver care in the most expensive setting, typically the hospital. And so we have in dignity health and across the country, initiatives with telemedicine and ways to wow patients to visit with providers remotely and less expensively, we have home health initiatives and other things that help engage the patient as you describe where they are. In addition to that, I think it's going to require us to deliver patient education because you mentioned all these tools available, but they haven't necessarily engaged and I know Bill touched on that, as well, so we need to be out ourselves adopting some of these tools, as far as Farzad coached his parents on and I think it's going to be person by person and thinking of more and more ways to educate and equip patients to understand, take accountability and start taking advantage of these tools.

>> Slightly different take on it. I think from the consumer point of view, you will never see ARP talking about HIT or other alphabet soup. Our goal is to explain to our people the value of all of this stuff. We don't want to focus on the latest shiny object that folks are talking about, we want to tell our people what's out there and what it means to them in their lives. We know that physicians hate it when patients show up with reams of print outs from Web MD, we tell our people, go do it, inform yourself, that information is out there. Here is trusted places where you can find it. Here are tools you can use to manage your own health, but bring those records to your healthcare provider when you have your next appointment. We want to arm our people with as much information as possible. A lot has to do with messaging, when we survey our members, older demographics are less interested or least interested in personal health record, right? That is partly a generational thing and so a lot of our messaging goes to the caregivers, we think there are better delivery mechanism to those patients, it is a trust factor there, help translate the information and frankly it brings more people into the circle of care. You know the question earlier about will the drive toward health information technology CHAFSHLG the doctor-patient relationship and -- well, yeah, it will, but we think it will make it better, bring more people into the circle of care, more eyes on that care experience and we see that as a good thing.

>> I agree with everything we've said, but add one other dimension to it, which is the patient's ability to make decisions about where to get their care and their responsibility for self-management will change and so part of that, the last associated with cost sharing getting more and more burdensome on people. They are paying a lot of the bill depending what they decide to undergo.

That can dampen necessary care, but keep them from going to care that is not high value. More BLTability, the Federal enterprise PRUZing compare and tools and private sector developers are producing tools of that kind. There has got to be much power and burden in some way, patient having to make decisions based on available data that we produce to enable them to make the decisions. So I think that will be a change in the level of patient engagement in the different sort of way that we'll have to respond to.

>> Please join me in thanking this incredible panel. Thanks so much. (Applause)

>> You guys.

>> Thank you all very much, wonderful interchange. It is one minute away from lunchtime, just want to make sure we talk about logistics. This is a networking opportunity and that is not digital networking, that is human analogue that needs to take place. Up to my right and through those doors are themed lunches, we'll be talking about things like stage 2, stage 3, PC, patient centered medical homes and other topics of interest. I hope you will take advantage of the several facilities that are here in the hotel to provide food. There is a cash bar upstairs and if you are adventuresome, go across the street, there are some alternatives to the hotel food if the lines are too long. I would like to remind you that at 2:00 we're having Senator Warner come to speak, he will appear in person and we will want to try to get back on track. I would ask you to try to return to the auditorium by 1:55, which means we can get started at 2:00 so that he can get back on his schedule, as well. Thank you all very much.

>> Oh. Excuse me. One more reminder, if you have any valuables with you, I suggest you take them with you, we can't be sure that everything will stay secure in here. Thanks. (Music playing)

>> How you manage your health is about to change for the better. Medical breakthroughs help us live healthier and longer. Advancements in technology are giving us the tools and resources to take control of our health. Health information technology or health IT for short is upgrading our healthcare system for the 21st century. Today's technology is freeing us from the confines of a paper world, giving our doctors, nurses and ourselves the flexibility to access and share our health information securely when and where it's needed. It's a big leap, but not a new one. Throughout history technology has changed our lives, getting us where we need to go faster, saving us time, and improving how we communicate. It's time healthcare caught up to the way we live the rest of our lives. The good news is that health IT is reshaping healthcare, creating smarter, more responsive system, reducing paperwork, saving time scheduling doctor's appointments and improving the way prescriptions are filled.

Health IT has potential to bring your health information together for multiple sources so everyone who is caring for you is on the same page, not pages and that's a good thing. As technology advances, you'll be able to securely connect with doctors online to review test results, manage chronic diseases like diabetes and make a shared plan to keep you healthy. Progress means better communication with healthcare providers. Suppose you have a new doctor who needs results of a past checkup or your father forgets which medicine he's supposed to take? Or your child is away at camp and has to go to the ER, having online access to you and your family's medical history can save more than time tcan save lives. Having complete picture of your medical histories vital to managing your health. Health IT gives you, your loved ones and healthcare providers access to the big picture so you can make decisions together that are right for you. Now is the time to take that step into a world of better communication and greater convenience. Having secure electronic access to information at the right time and right place can help everyone get the best care. Health IT, it's good for you more ways than one. To learn more about health IT giving healthcare 21st century upgrade visit healthIT.gov, or ask your healthcare provider how they use health IT.

>> If you are a healthcare provider, here are tips for protecting and securing health information when using a Smartphone, laptop or tablet to access, transmit, receive or store patient health information. The Hippaa privacy and security rules issued under the health insurance portability and accountability act, these rules set national standard for protecting PHI against unauthorized use inTEG rit and he availability of electronic PHI. Healthcare providers who are Hipaa covered entities must take steps to protect the privacy and security of patient PHI. Whether you are a doctor practicing by yourself or in a hospital setting or in a group practice, or you are a healthcare professional such as a nurse or therapist or home health aide or work at a clinic or physician's office or other healthcare facility, you must protect and secure patient's PHI, no matter what kind of technology you're using. Before you use a mobile device to access, transmit, receive or store patient health information, you should educate yourself on the risks of using it and learn about the safeguards you can put in place to minimize risks. Some of the risks you should be aware of when using a mobile device for work are the ease of losing your mobile device, the risk of your mobile device being stolen, viruses or other mal ware you may download to your mobile device. The risk of share MOG bile device with friends, family or coworkers and risks when accessing and using unsecured wifi network. You need to take action to protect and secure health information when using a mobile device. Possible safeguards include setting a strong password, using encryption, using automatic log off requiring unique user ID, enabling remote, locking the device, keeping the device with you, using screen shield, refraining from sharing the mobile device. Registering the mobile device with your healthcare setting, installing firewall using secure wifi connection and researching mobile applications before downloading. You can learn more about these risks and safeguards, as well as other tips and information in this video series and on the mobile device privacy and security website. Ultimately it is your responsibility to follow your office or organization's mobile device policy and procedures.

If you plan well to minimize risk and your mobile device is lost or stolen, you're much less likely to lose health information and with it your patient's trust. Create a KUMENTure of privacy and security awareness, reduce the risk of unauthorized access to your patient's health information, protecting patient confidentiality increasing trust in your care and reduces chance of accidental disclosure of patient health information and your organization's liabilities. Watch the other videos in this series to learn more about identifying and implementing mobile device safeguards, protecting health information against the possibility of devices being stolen using public networks and other tips and information to help you protect and secure patient health information. All providers are different and privacy and security considerations are different. These five videos are examples of some risks and safeguards, they are not all inclusive of every risk and every safeguard you should consider. Visit the mobile device privacy and security website to learn more about practical ways to protect and secure patient health information when using mobile devices. Let us know if you have questions we haven't answered by submitting a comment through mobile device privacy and security website.

>> ONC, the office for technology and OCR, office for civil rights, both in the U.S. department of health and human services want to make sure that healthcare providers who hold protected health information, PHI or use mobile technology to access, receive, transmit or store PHI have reasonable and appropriate privacy and security safeguards in place. This video series offers some important tips and information to help providers and staff keep patient health information private and secure when using mobile devices. Mobile devices, those things we can't live without. Smart phone, tablet PC and laptop computers can be personally owned or provided to you by your office or organization. They are portable, small, easy to use and convenient. We can e-mail, text, fax, transmit test results, even access patient records and reference information at the touch of a finger. Any time protected health information, PHI, is being accessed, received transmitted or stored, healthcare providers need to think about privacy and security. Let's talk about Hippa, the privacy and security rules were issued under the health insurance portability and accountability act. These rules set national standard for protecting PHI against unauthorized use or disclosure and safeguard for confidentiality, integrity and availability of electronic PHI. Healthcare providers who are hippa covered must take steps to protect the patient PHI. This means whether you are a doctor practicing by yourself or in a hospital setting or in a group practice, or you are a healthcare professional such as a nurse or therapist or home health aide or work at a clinic or physician's office or other healthcare facility, you must protect and secure patient PHI no matter what kind of technology you are using. We have a responsibility to work together to protect and secure patient health information F. Patients think they can't trust you to protect their privacy or if they think you are careless with health information, you may lose their trust. There is also the real possibility of damage to your reputation, legal costs and penalties. So how can you protect the privacy and security of patient health information when using a mobile device? By watching these five short videos you will learn more about identifying and implementing mobile device safeguards, protecting health information against the possibility of the device being stolen and using a public network.

We've also gathered tips and examples of measures you can put in place immediately, such as encryption, using a strong password or blocking your screen. Finally, you can find answers to questions about topics such as texting, password management and how to dispose of a mobile device. All providers are different and privacy and security considerations are different. These five videos are examples of some risks and safeguards, they are not all inclusive of every risk and every safeguard you should consider. You can view all these helpful tips and information on the mobile device privacy and security website. Let us know if you have questions we haven't answered by submitting a comment through the mobile device privacy and security website.

>> Hello MRSHGS Jones, how long have you had shortness of breath?

>> It's been since last week. I don't know why, but I can't seem to catch my breath.

>> Let me listen. Deep breath. Again, please. And your pulse? Okay. Wait here, Dr. Anderson will be right in.

>> In this video, we'll focus on one risk, a patient having access to the laptop, the Hippa privacy and security rules were issued under the health insurance affordability and accountability act, the rules set national standard for protecting PHI against disclosure and safeguard for confidentiality integrity and availability of electronic PHI. Healthcare providers who are hippa covered must take steps to protect the privacy and security of patients PHI. This means you must protect and secure patient PHI no matter what kind of technology you are using. Let's review what Dr. Anderson's office might have done to protect and secure the patient's health information? First of all, before any one in Dr. Anderson's office starts using mobile devices, the office should perform risk analysis to identify threats to the privacy and security of health information based on a risk analysis. Dr. Anderson's office should develop a risk management strategy to address the risk of a patient accessing the laptop. To reduce the risk of a patient accessing the office's laptop, Dr. Anderson's office should create and implement mobile device policy and procedures that include safeguards to mitigate identified risks and finally, training for Dr. Anderson's staff is essential to be sure that everyone understands and knows how to follow the office's mobile device policies and procedures.

So let's take a closer look at the safeguards Dr. Anderson's office might have in its mobile device policy and procedures to reduce the risk of a patient accessing information on on a laptop. Some safeguards are to require staff to lock laptop screen when is they step away from them or to keep the laptop with them at all times. Additional safeguards are to require all mobile devices containing health information to automatically log off or screen lock after a short period of inactivity. By requiring log off or screen lock the next person who wants to use the office laptop will have to log in using a unique user ID and strong password. Another safeguard Dr. Anderson's office might implement is to protect the mobile device screen from being viewed by others. Two approaches are to install privacy screen or shield the screen from view. Create a culture of privacy and security awareness that encourages proper handling of health information. By doing so, it should become secretary nature for providers and staff to follow appropriate mobile device policies and procedures. Watch the other videos in this series to learn more about protecting health information against the possibility of devices being stolen using public networks and other tips and information to help you protect and secure patient health information. All providers are different and their privacy and security considerations are different. These five videos are examples of some risks and safeguards, they are not all inclusive of every risk and every safeguard you should consider. The visit the mobile device privacy and security website to learn more about practical ways to protect and secure patient health information when using mobile devices.

>> Go ahead and get a table, I'll be right there, I need to see in my patient's lab results have come in.

>> We'll do everything in our power to recover the --

>> What is the next step?

>> I need as much information about laptop, make, serial number, what kind of records were on on it.

>> My patient information.

>> You need to notify security personnel, patient health information may be at risk.

>> I don't understand how this could happen, it was a few minutes for lunch.

>> It is terrible to lose a laptop or have it stolen. If you use your laptop, smartphone or tab to the transmit, receive, access or store patient health information the steps you take before a loss or theft occurs are very important. The hippa privacy and security rules were issued under the health insurance portability and accountability act. These rules set national standard for protecting PHI against unauthorized use or disclosure and safeguard for confidentiality, inTEG rit and he availability of electronic PHI. Healthcare providers who are hippa covered entities must take steps to protect privacy and security of their patients PHI.

This means you must protect and secure patient PHI no matter what kind of technology you are using. It is important to understand mobile device policies and procedures. You should also know who the office or organization's privacy and security officials are in case your device is lost or stolen.

The easiest way to protect and secure health information, don't store on mobile devices. However, if you store health information on your mobile device, back the data up to a secure server on a regular basis and delete the data from the device after you review it. Use encryption so that only you and other authorized people can get to the files stored on the device. Encrypting data make its unreadable, except by those who know how to decrypt it. Protect probile device from unauthorized use by enabling password protection settings. Use mobile device password that is difficult to guess. You can install specialized applications on your mobile device, one application is a remote white application it allows you to remotely erase data stored on MOT bile device if the device is lost or stolen N. This case, you will need to take action to remotely erase the data.

Another specialized application can automatically block access to your mobile device or erase the data stored on the mobile device after a number of failed log ins N. This case, the application itself will lock the device or erase the data. Sometimes bad things happen when you are using devices that are portable, such as laptops, tablets or phones even when safeguards are in place. Report the incident immediately to the appropriate person in your office or organization as part of the security incident response and reporting plan. Once you've established there has been a loss of health information, follow the office or organization's security incident response and reporting plan, as well as the policies and procedures for determining if there has been a reportable preach F. The office or organization determines there's been a reportable breech the office or organization will need to take any action necessary under the HITECH breech notification rule. State law may have additional requirements that will also have to be met.

QI can't believe that. I think I have almost all our patient files on there. Yes, I did back it up to our office's secure server this morning. After any loss of health information, it's important for an office or organization to perform a new risk analysis and make changes to policies and procedures to reduce the risk of any additional loss of health information. It should also provide retraining to all staff on how to protect health information and how to secure mobile devices. Create a culture of privacy and security awareness that encourages proper handling of health information. By doing this, you can take steps to minimize the loss of health information before a mobile device and lost or stolen. Watch the other videos in this series to learn more about identifying and implementing mobile twice safeguards TOCHLT help you protect and secure patient health information, all providers are different and their privacy and security considerations are different. These five videos are examples of some risks and safeguards. They are not all inclusive of every risk and every safeguard you should consider. Visit mobile device security website to learn more about practical ways to protect and secure patient health information when using mobile devices.

>> Hello? Hey, good morning, I just left my 9:00 appointment. I have the patient records right here. Yeah, I can send them to you before my 11:00. Okay. Let me know if there is any problems. Bye.

>> There you go.

>> Thank you. QDo you have wifi?

>> It's called thebean.

>> Password?

>> No, log on in.

>> Thank you.

>> You are welcome.

>> Mobile devices make our lives so much easier instead of running back and forth to the office, we can enjoy a coffee between appointments and conduct business wirelessly. It is important to be careful when using wifi, particularly in public spaces, such as a coffee shop or in an airport. An unsecured wireless network, such as one in a public space, even if it requires a password to access the network is a risk you need to be aware of when you are dealing with protected health information. Mobile devices like tablets are valuable tools in today's networked world. But healthcare providers must take steps to ensure that protected health information is protected and secured from unauthorized disclosure when using mobile devices. The hippa privacy and security rules issued under health insurance affordability and accountability laws. Protecting PHI and safeguard against integrity and availability of electronic PHI. Healthcare providers who are HIPAA covered entities must take steps to protect privacy and security of their patient's PHI. This means you must protect and secure patient PHI, no matter what kind of technology you are using. If you can get to a wifi network in a public space, so can anyone and without certain precautions just about anyone can navigate to your mobile device when it is on a public wifi, open, view and download information. So how should you access health information using your smartphone, tablet or laptop when you are in a public space? Use a virtual private netore VPN which encrypts information you send or receive so authorized peep KEL see the information. You can also SUZ secure browser connection. You will know if you have secure browser connection if you see HTTPS in the website address. Encrypt your device so authorized people can see the information stored on mobile devices. Use passwords that are difficult to guess COMBCHLT time you are in a public space, you should be aware of someone watching over your shoulder. If you are in a public space, log your screen when you walk away or even better, always keep your laptop, smart phone or tablet with you.

Create a culture of privacy and security awareness that encourages proper handling of health information no matter where the mobile device is used. Watch the other videos in this series to learn more about identifying and implementing mobile device safeguards to help you protect and secure patient health information, all providers are different and their privacy and security considerations are different. These five videos are examples of some risks and safeguards, they are not all inclusive of every risk and every safeguard you should consider. Visit the mobile device privacy and security website to learn more about practical ways to protect and secure patient health information when using mobile devices.

(Music playing)

>> My name is Randy Wanson, born in South Gate, California, I served in the army for eight years. In 1991, I had to have emergency bypass heart surgery.

>> Michelle Straw, I was in the United States Army, I unfortunately came down with gynecological conditions which were very serious.

>> I'm Craig, navy veteran. I contracted very rare disease called (inaudible).

>> I have been in the hospital numerous times. I've had eight heart attacks and it's been hard to get access to my private medical records.

>> I was surprised at what my medical record looked like when it printed out. I got two suitcases full of paper records. I couldn't bring back any of my own personal stuff or clothes because I had had to bring back my medical records.

>> I actually had to make paper copies of the lab tests (inaudible) --

>> For the first time ever, veterans will be able to go to the VA website, click a simple blue button and download or print your personal health records so you have them when you need them and can share with your doctors outside of the VAthat, is happen Thanksgiving fall.

>> We've taken the information that you normally fill out on a clipboard when you went to see the healthcare provider TOCHLT make this information accessible to them and easily read, easily transferred, but secure and private mechanism, they don't have to copy telephone book or encyclopedia, and carry them around from one place to the other.

>> You can click and download allergies, drugs, prescriptions you take, what doctors you take, take to your primary care physician or specialist or emergency room instead of laying there and 0 questions, you can tell them here it is, all here in black and white, it's in order.

>> In 2009, I had to go see a civilian provider, I had some emergency complications from a surgery I had in the army. Because I didn't have the Blue Button available to me at the time, the provider was not able to treat me, they didn't have all my medical history.

>> When in the wheelchair, I (inaudible) --

>> We thought maximum 25,000 individuals who would want to try this new technology. We had 25,000 in less than three months.

>> If I have to have emergency surgery and they don't know that I'm on blood thinners and they start cutting on me, you know, I'm going to bleed out. They need to know that I'm on a particular medication that causes my blood to be thin, having access to my medical records, I can bring this up to them and I think that would eliminate a lot of their risks to the patients to their health. Everybody in the country should have access to electronic health record or download them at any given time.

>> (Speaking in Spanish) --

>> I like health IT because it will improve the quality, safety and care that we as patients deserve, opportunity to improve patient safety for all Americans. It has meant a major change in my life, my professional career and how I can practice medicine.

>> I like health IT because it is what we need to help people all across our state achieve their full potential.

>> Because it can help make the care that all of our patients receive in this country better.

>> Because it is transforming the way we provide health.

>> I like health IT because the difference it can make in the quality of care we provide the people of our country and improving overall health and well being of the American people.

>> I like health IT because it will finally bring innovation to a field where we desperately need it and best of all it will help me play a more active role in taking care of myself and my family.

>> I like health IT because it will improve quality of care, expand access to care and it's going to make care more affordable in Maryland and our country.

>> How you manage health is about to change for the better. Medical breakthroughs help us live healthier and longer. Advancements in technology are giving us tools and resources to take control of our health. Health information technology or health IT for short is upCOMBRADing our system for the 21st century. Today's technology is freeing us from the confines of a paper world, giving our doctors, nurses and ourselves the flexibility to access and share health information securely when and where it is needed. It's a big leap, but not a new one. Throughout history, technology has changed our lives, getting us where we need to go faster. Saving us time. And improving how we communicate, it is time healthcare caught up to the way we live the rest of our lives. The good news is health IT is reshaping healthcare creating smarter, more responsive system, reducing paperwork FSHGS saving time scheduling doctor's appointments and improving the way prescriptions are filled. Health IT has potential to bring health information together for from multiple sources so everyone caring for you is on the same page, not pages and that's a good thing. As technology advances, you'll be able to securely connect with your doctors online to review test results and manage chronic disease like diabetes and make shared plan to keep you healthy prompt aggress like this means better communication with your healthcare providers. Suppose you have a new doctor who needs results of a past checkup or your father forgets which medicine he's supposed to take? Or your child is away at camp and has to go to the ER? Having online access to you and your family's medical history can save more than time, it can save lives.

Having complete picture of medical histories vital to managing your health. Health IT gives you, loved ones and healthcare providers access to the big picture, so cumake decisions together that are right for you. Now is the time to take that step into a world of better communication and greater convenience. Secure electronic access to information at the right time and right place can help everyone get the best care. Health IT, it's good for you more ways than one. To learn more about how health IT can give healthcare 21st century upgrade visit healthIT.gov, or ask your provider how they use health IT.

>> (Music playing)

>> If youar healthcare provider, here are tips for protecting and securing health information when using a smartphone, laptop or tablet to access transmit, receive or store patient health information. The HIPAA privacy and security rules issued under health insurance portability and accountability act. These rules set national standard for protecting PHI against use or disclosure and safe guards for the confidentiality, inTEG rit and he availability of electronic PHI.

Healthcare providers who are HIPAA covered entities must take steps to protect privacy and security of patient PHI. This means whether you are a DRA practicing by yourself or in a hospital setting or in a group practice, or you are a healthcare professional such as a nurse or therapist or a home health aide or work at a clinic or physician's office or other healthcare facility, you must protect and secure patient PHI, no matter what kind of technology you are using. Before you use a mobile device to access, transmit, receive or store patient information, you should educate yourself on the risks of using it and learn about the safeguards cuput in place to minimize risks. Some of the risks you should be aware of when using a mobile device for work are the ease of losing your mobile device, the risk of your mobile device being stolen, viruses or other malware you may download to your mobile device. The risk of sharing your mobile device with friends, family or co-workers and risks when accessing and using unsecured wifi network. You need to take action to protect and secure health information when using a mobile device. Possible safeguards include setting a strong password, using encryption, using automobile log-off, requiring unique user ID, enabling remote wipe, locking the device, keeping the device with you, using a screen shield, refraining from sharing MOT bile device, registering the mobile device with your healthcare setting, installing a firewall using a secure wifi connection and researching mobile applications before downloading. You can learn more about these risks and safeguards, as well as other tips and information in this video series and on the mobile device privacy and security website. Ultimately it is your responsibility to follow your office or organization's mobile device policies and procedures. If you plan well to minimize risk and your mobile device is lost or stolen, you are much less likely to lose health information and with it your patient's trust. Create a culture of privacy and security awareness. Reduce the risk of unauthorized access to your patient's health information prompt TEKTing patient confidentiality increases trust in your care and reduces the chance of accidental disclosure of patient health information and your organization's liabilities. Watch the other videos in this series to learn more about identifying mobile device safeguard prompt TEKTing health information against the possibility of devices being stolen using public networks and other tips and information to help you protect and secure patient health information all providers are different and privacy and security considerations are different. These five videos are examples of some risques and safeguards. They are not all inclusive of every risk and every safeguard you should consider. Visit the mobile device privacy and security website to learn about practical ways to protect and secure patient health information when using mobile devices. Let us know if you have questions we haven't answered by submitting a comment through MOT bile device privacy and security website.

>> ONC the Office of national coordinator for health information technology and OCR, office for civil rights which are both in the U.S. department of health and human services want to make sure that healthcare providers who hold protected health information, PHI or use mobile technology to access, receive transmit or store PHI have reasonable and appropriate privacy and safeguards in place.

This video series offers important tips and information to help providers and staff keep patient health information private and secure when using mobile devices.

Mobile devices, those things we can't live without, smartphones, tablet PCs and laptop computers, they can be personally owned or provided by an office or organization. They are portable, small, easy to use and convenient. We can e-mail, text, fax, transmit test results, access patient records and reference information at the touch of a finger COMBCHLT time protected health information, PHR is being accessed, received, transmitted or stored, healthcare providers need to think about privacy and security. Let's talk about HIPAA. The HIPAA privacy and security rules were issued under the health insurance portability and accountability act, these rules set national standard for protecting PHI against unauthorized use or Kis closure -- protect privacy and security of patient's PHI. This means whether you are a doctor practicing by yourself, or in a hospital setting or in a group practice or you are a healthcare professional such as a nurse or therapist or a home health aide or you work at a clinic or physician's office or other healthcare facility, you must protect and secure patient PHI no matter what kind of technology you are using. We have a responsibility to work together to protect and secure patient health information you may lose their trust, there is possibility of damage to your reputation, legal costs and penalties. So how can you protect the privacy and security of patient health information when using a mobile device? By watching these five short videos, you will learn more about identifying and implementing mobile device safeguards, protecting health information against the possibility of the device be being stolen and using a public network.

We've also gathered tips and examples of measures you can put in place immediately such as encryption, using a strong password or locking your screen. Finally, cufind answers to questions about topics such as texting, password management and how to dispose of a mobile device. All providers are different and privacy and security considerations are different. These five videos are examples of some risks and safeguards, they are not all inclusive of every risk and every safeguard you should consider. You can view all these helpful tips and information on the mobile device privacy and security website. Let us know if you have questions we haven't answered by submitting a comment through the mobile device privacy and security website.

>> Hello, Mr. Jones, how long have you had shortness of breath?

>> Since last week. I don't know why, but I can't seem to catch my breath now.

>> Let me listen. Deep breath. Again, please. And your pulse? Okay. Wait here, Dr. Anderson will be right in.

>> In this video, we're going to focus on one risk, a patient having access to the laptop. The HIPAA security rules issued under health issue affordability and accountability act, set standards for protecting PHI against unauthorized use or disclosure and safeguard for confidentiality integrity and availability of electronic PHI. Healthcare providers who are HIPAA covered entities must take steps to protect privacy and security of their patient's PHI. This means you must protect and secure patient PHI no matter what kind of technology you're using. Let's review what Dr. Anderson's office might have done to protect and secure the patient's health information. First of all, before anyone in Dr. Anderson's office starts use MOG bile devices, the office should perform a risk analysis to identify threats to the privacy and security of health information based on a risk analysis. Dr. Anderson's office should develop a risk management strategy to address the risk of a patient accessing the laptop. To reduce the risk of a patient accessing the office's laptop, Dr. Anderson's office should create and implement mobile device policies and procedures that include safeguards to mitigate identified risks and finally training for Dr. Anderson's staff is essential to be sure that everyone understands and knows how to follow the office's mobile device policies and procedures. So let's take a closer look at the safeguards Dr. Anderson's office might have at mobile device policy and procedure to reduce the risk of a patient accessing information on a laptop SMCHLT safeguards require staff to lock laptop screen when is they step away from them or to keep the laptop with them at all times. Additional safeguards require all mobile devices containing health information to automatically log off or screen block after a short period of inactivity. By requiring automatic log off or screen lock, the next person who wants to use the office laptop will have to log in using unique user ID and strong password. Another safeguard Dr. Anderson's office might implement is to protect the mobile device screen from are being viewed by others. Two approaches are to install a privacy screen or shield the screen from view. Create a culture of privacy and security awareness that encourages proper handling of health information by doing so it should become second nature for providers and staff to follow appropriate mobile device policies and procedures. Watch the other videos in this series to learn more about protecting health information against the possibility of devices being stolen using public networks and other tips and information to help you protect and secure patient health information. All providers are different and their privacy and security considerations are different. These five videos are examples of some risks and safeguards. They are not all inclusive of every risk and every safeguard you should consider, visit the mobile device privacy and security website to learn more about practical ways to protect and secure patient health information when using mobile devices.

>> Go ahead and get a table, I need to see if my patient's lab results have come in.

(music playing)

>> Take your seats, we have special guest here, Senator Warner has been a true champion for the use of technology and innovation to solve our nation's toughest problems. He's been entrepreneur, co-founder of telecommunication firm Nextel, and early investor in scores of early start-ups that have really transformed how business operates and so many different fields. Following that, he of course applied his considerable executive powers as Governor of the state of Virginia, one of the best run States when he was there, and then took his passion and talent to the United States Senate. What I can tell you about the Senator is that when we talk about health IT like no other legislator I have ever met with, he gets it and he gets it at a level of depth, of clarity, of questioning that is truly remarkable and I think you will see that on full display here. Ladies and gentlemen, Senator Warner.

(applause)

>> Senator Warner: Thank you for that very generous introduction and thank you for all the good work that ONC is doing and this opportunity to bring folks from around the country to talk about the challenges and opportunities around health IT.

I know many of you are just trickling back from lunch, so layout two thoughts perfect we get -- I get into my presentation. My background before I was in politics, I was a cell phone guy, co-founder of Nextel, I am the only speaker and I guarantee you the only politician around that says even when I'm speaking, leave your cell phones on. (Laughter)

You know, you hear an annoying sound, I hear chaching. Leave it on. I've been in the Senate for three years now, 3-1/2 years, I guess, usual introduction is and Mark Warner has been a bipartisan guy dealing with debt and deficit, I can assure you while I am happy to be here, I would much rather be in that room with the President and Speaker making sure we don't go over the fiscal cliff. This shouldn't be as hard as it is playing out to be, but that issue, which dominates the news at this point, will clearly have ramifications, not only on the issue we're talking about today, but whether our economy is able to kind of move forward in the way that I hope it will.

Again, I PDP the opportunity to speak to you. I know that everyone in this room believes that health information technology can help us improve patient care, increase coordination amongst providers, hospitals and most importantly, start to reduce healthcare cost, not to diverge back to fiscal cliff issues, but as somebody who believes strongly that Medicare is one of our very important safety net providers, we just got to recognize a system right now where you pay in 114,000 of Medicare taxes over your lifetime of employ SXMENT get out $319,000 in healthcare services, that imbalance, which is going to continue to grow as we have an aging population and more and more people on entitlement and less and less folks in the work force paying in, mean that we can do all the age adjustment possible, but until we drive down the overall cost of health DLT care and make the delta smaller, we're not going to get things done.

I think the question is going to be and the question you have to address and I as a policy maker have to nudge you along on is whether we have the personal and political well to take this enormously powerful tool of healthcare IT and really allow it to be transformative. Whether we're going to be able to continue to push on Meaningful Use, which I will come back to in a while, not some mystical point in the future, but right now and one of the most important points I'm going to try to come back to today time and again is Meaningful Use is great, but without interoperability, you know, you really are not kind of creating the kind of comprehensive promise that healthcare IT indirectly providers and even more indirectly, consumers have been promised and the high-tech act is part of the stimulus, when we thought it was going to be 27 billion dollars in healthcare IT, now since those Meaningful Use payments may tick up toward north of 30 billion, that is some serious dough. The fact that we've spent out $10 billion THAF so far means we've got more to come, but it does mean that here we are four years after the stimulus and while progress has been made I think we have to put our foot on the accelerator even more and we have to recognize that it is going to require all of us to get into a little bit of discomfort zone if we're going to get this done. I think there are three critical steps that we have to grapple with. First, we need clear interoperability requirements amongst electronic medical record systems. And farzad, pitched me on what is going to happen in stage 2, I think that is a step forward, stage 2, but we've got to have an audit trail and be able to figure out and not just have this be an aspirational goal, but something that we can make sure is accomplishd and measured. Second, we need to accelerate Meaningful Use. Not step away from that, but that Meaningful Use has to be tied in to clear interoperability standards. And third, we need to establish long-term strategy for health IT, which means how do we have to align incentive inside the healthcare system to make sure health IT really works, right now and approximate I'll come to more of this in a moment, I don't think the economic incentives are truly aligned for health IT to work. As I mentioned, I'm a telecom guy, somebody that was in the wireless field, and I know analogizing wireless to health IT, we get into some problems. They are definitely not -- they are apples and oranges, but they are lessons we can learn. I recall when I first got in the wireless industry back in the early '80s, the projections were that at the end of 35 years, not 10, not 20, but 35 years, a full 1% of Americans would have cell phones. (Laughter)

Here we are about literally about about 30 years end and north of 300 million cell phones in the world and over 6 billion -- 300 million cell phones in America and 6 billion cell phones across the world. I would argue, one reason why that explosion took place was that before we -- before we built out all of the cool apps, the FCC did something that was very hard, they set very strict standards for interoperability so that all the systems that developed could all talk to each other, otherwise we could have ended up in the wireless world not unlike where we at least are in the healthcare IT world with lots of cool apps and lots of cool stand alone systems, but the ability to really exchange data information and communicate would have been seriously retarded. So first and foremost, interoperability, now let me acknowledge that there are four areas where my analogy breaks down and there are four areas that I think are clearly challenging if we're going to get interoperability right. First, because we department set interoperability standards first and because healthcare IT has been around for 30 plus years, we have enormous number of legacy healthcare systems. Second, and what is different in healthcare than almost any other area is that HIPAA requirements while terribly important make this exchange extra ordinary important information about patients that providers, patients and others in the network need more difficult because very appropriate privacy concerns. Third, even if we can get around the HIPAA challenges, we have I think enormous lack of economic incentives for those who are currently collecting the data to actually take what they view as proprietary and share it. And fourth, we have to recognize that unlike cell phone data or unlike internet use of almost any other information system, there is nothing as rapidly changing as both medical technology, medical procedures and connected to that, all of the complexity that goes along with billing. Let me come back to each of these and touch on them for a moment. We actually in the phone world and in the computer networking world, let me acknowledge that there was a great deal of disagreement at the outset about how you could set common standards, one area, we got it right on overall cell phone systems, one reason why now only 30 years later or 25 years later from kind of the idea of common in building communications and wifi systems, that has been slower to adapt, we never got the equipment vendors to actually agree in that space on interoperability. But around EMRs, we've conseKWENTly had the fact that we've got these -- we've got this lack of compatibility, we need crystal clear front end requirements for systems. It is not enough to be simply able to send secure e-mails. We need to figure out in the next two year -- year or two, not the next five or 10, how to get equipment made by different vendors to allow for searches, transactions and for exchange of information between different vendors. June 2012 New England Journal of medicine article found part THF problem again is of course our legacy systems. The authors argued that the first electronic health record systems were created in 1966 in "most EHR vendors not only have failed to innovate, but don't even embrace existing modular architecture with interfaces that allow extension of product capabilities inadvertent uses of data and interoperability with other software." So when we got the New England journal of medicine acknowledging those have been in the market place for some time are not aligned at all, we are going to have to at some is point and again stage 2 is a step in the right direction, we need clear, clear interoperability standards. Second, unlike credit cards, where we've again got some analogy or mobile technologies, where it is easier for financial companies or mobile companies to aggregate consume SXER transactional data, significant and important restrictions and protections placed on access to patient data. As you all know, HIPAA restricts access to patient information, which is an important privacy safeguard. However, the law also restricts some potentially useful uses of patient data, which may help to improve healthcare outcomes and lower the cost of treatment. One of the things I should have told my staff was to print this speech in a little bigger font, as I go through here for a moment. Yes, we got to protect patient personal data, but we have to look at where I know this is enormous can of worms, where some slight switches in HIPAA might take place because HIPAA I think does restrict patients from use Thanksgiving information that can drive down better healthcare outcomes and better cost containment. Third, even if we could reach consensus how to best protect patient privacy, the healthcare sector currently has no economic incentives to share data. On the contrary, business models are centered around proprietary data. There are a lot of hospital systems here and providers, this gets into uncomfortable space, that you have created I think some of this, hospital systems in Virginia, where I've had brilliant presentations made because I am a bit of a telecom, and little bit 've of a tech geek, which is fairly low bar when you are in politics to get over. I like to say I was very current circa 2000, which still puts me a decade ahead of most of my colleagues, but, you know, I remember hearing a major healthcare system they just invested 120 million dollars in a remarkable -- a remarkable electronic health record patient record EHR system and then I made the mistake of asking, gosh, if you have a patient from a competing healthcare system or one of your patients goes to a competing healthcare hospital not in your network, can you share any of that information? I got this, you know, horrid look on his face saying, my gosh that, might mean that patient could become a customer of another system. So into the day, we have to recognize that CMS has to actually accelerate its work to incorporate how we share reimbursements, how we allow and get the incentives right and this is one of the ones as a policymaker, I would like your ideas on how we get this circumstance right. Then finally, the dynamic nature of healthcare, one of the great secrets and I think you've seen in cell phones, that you have seen in credit cards, all goes back to the razor theory, you know, the razor business got ahead of this a long time ago. They exactly out with a fancy doodad razor that has all bells and whistles and sell it off at incredibly cheap price even today, they make their money is selling very expensive razor blades that go into the raisar. We've seen the same thing to a certain degree in cell phones, the same thing in credit cards, the same thing in computer technology, we're going to give you a whiz bang initial device and then we're going to make the money on your usage, updates and billing. You know, that is challenging in each of those fields, but exponentially more challenging in a field like healthcare, where the constant transformation of healthcare procedures, the constant transformation on billing procedures, on coding procedures means we're going to sell you an electronic health record system low price of $50,000, but where we make the money is on updates and monthly billing and accessories. We have to recognize that again is a challenge to having a truly robust interoperability system. So my first and major point on this and I'm already getting cue cards here to wrap it up is that I absolutely believe that interoperability has to be the standard. We're 10 billion into this roughly 30 billion Federal investment, stage 2 is important. Recognizing here around interoperability that perfect is good and let me also acknowledge tis easier to get Republicans and Democrats to agree than it is to get software engineers to agree. (Laughter)

You know, on a common system. At some point, somebody's got to come in and say enough debate, the perfect is good, this is the standard and those of us from the policy standpoint have to back you up when everybody who invested in legacy system that aren't going to meet the new interoperability can't make the grade. Second thing we need to continue to do is accelerated time frame for Meaningful Use. Again, we can't, we need to accelerate Meaningful Use, there are some in the house who are saying my gosh, we have not seen this transformation take place, let's cut this off. We're about 10 billion out in terms of Meaningful Use payments, we have 2 billion out in terms of healthcare systems that are talking about accountable care organization and interoperability, I believe we need to continue to put the pedal to the metal on Meaningful Use, but I fundamentally believe again in this area that in many ways what is pushing forward Meaningful Use more than anything and I've got great statistics on how much the Meaningful Use has increased here, but I can't read them with the type font, but we have seen it go up, but we've also saw and I think all of us who want you to be successful had a little bit of a chill when we read the New York Times story this past June that actually said healthcare IT was one of the biggest drivers of Medicare costs without the kind of ancillary and corollary benefits. So we got to get our data sets together. We got to have real numbers that show that just having Meaningful Use in legacy systems is not enough and frankly I believe that end of the day time is our best allie here as more and more people even doctors become competent on if not a computer, at least an iPhone, the value of being able to exchange patient data in a meaningful way and utilize that becomes a much less scary item and will become more and more the norm. So I support what fazad and the team are doing in terms of increasing Meaningful Use, but we have to do it again with this interoperability component in place.

Finally, we've got to think about a long-term strategy here. The long-term strategy is we think about new areas MOSHGS bile apps, we think about the area I saw a friend of mine last night who has a new Nike wrist band that is kind of 21st century pedometers which I think will become all the rage in this holiday season. We've seen the new Fibitz that go on your waist and measure activity. You know this, fits in healthcare IT. This is fwe're not careful, how we sync up all these systems in a patient friendly, user friendly way is part of the challenge in front of you. I still fundamentally believe this -- the tool here that we are developing can be one of the most important in improving patient behavior, improving patient personal patient healthcare themselves and driving down costs. We also have to acknowledge that healthcare IT is a means to an end. It is not an end in itself. All the bells and whistles of individual systems, I saw the vendors out here, it is great, what are our in? We want a healthier America, an America that is more fit and understands what we all have to do with individual responsibility. We want an America that better utilizes whether it's pharmaceutical drugs or whether it is medical devices in a way where they can measure their output. We need a provider system that can help monitor and then encourage patient participation. We need to make sure that we've got an ability to link so that we avoid the kind of duplication and mistake s that none of us like to acknowledge, but take place each and every day in our doctor's offices, in our hospitals, all powerful tool and we have to then find a way through health IT to build this out and charge for this in an efficient and effective manner that is appropriate. We don't get there and I say this again with respect when people simply say am, Meaningful Use, I can simply use cloning technique to get increase reimbursement rates. Nothing will do more to not only get the house, but frankly even your allies in the Senate, heads explode if we continue to see those kind of activities. We need an audit trail and a policing mechanism since end of the day, like it or not, increasing number of dollars are going to come from the Federal taxpayer to reimburse to get this right. So I remain excited about the opportunity. I have a really exciting well thought through conclusion, three paragraphs here that I will put up at some point for those who want to read the speech online.

So instead I'll just say, hang in there, stay at it. Closing messages, perfect is the enemy of the good. We have to have interoperability sooner rather than later. We cannot retreat from Meaningful Use goals, but simply paying you for Meaningful Use without interoperability all it does is create a lot more legacy systems and third, I ask you to still dream big, dream big about how these tools get out of the doc's office, get out of the hospital and get on to the patient in a way that actually improves the quality and cost effectiveness of our healthcare system F. We do that, all of the potential that we thought about in healthcare IT, all of us who stood up during or argued quietly and publicly, yeah, we got to put real resources behind this, even in something as controversial as stimulus bill, we will see dramatic dramatic returns, but the ball is in your court. I and others are here to help. And I want to be supportive, but quoting that FAMGS American, Ronald Reagan, I would simply say around healthcare IT and its potential, trust but verify. So with that farzad, thanks for having me, I look forward to continuing to work with you for many months to come.

(applause)

>> That is awesome. You know --

>> Read the formal comments, I will leave it here. Thank you all.

>> I think the most impressive part of that was that he obviously didn't do it off his notes.

>> Thank you all, good luck, everybody.

>> Thank you. Very nice. The next group we're going to bring up will be headed by Jodi Daniel and the nice thing, it is J.D., a lawyer with wonderful experiences who, actually started in the Office of General Counsel and helped give birth to some of the regulations and some is activities. We are very thankful for her being a thought leader in this area. She has seven plus years within the ONC rank, so I think you are our most tenured individual, which we certainly PDP. (Applause)

If you don't mind, a little hand for the starter. I will let you kick it off. Thanks.

>> Jodi Daniel: Thank you very much. Is this working? Okay. It's really a privilege to moderate this panel patient engagement or rather rephrase it as consumer engagement, we're talking more broadly than interaction that people have with healthcare system, but more broadly about how they manage their own health and healthcare, including interaction with the healthcare system. We are going to pick up where Senator Warner left off, talking about the patient and how to use tools to engage patients in their own health and care. I would like to introduce the panelists, we have Dr. Daniel Craft, Dr. Craft has 20 years experience in clinical practice, biomedical research and healthcare innovation. Daniel chairs singularity University and executive director for Future Med, a program which explores convergent exponentially diverging technology and biomedicine in healthcare. Dr. Craft went to Stanford and board certified in internal medicine and pediatrics program at Mass General and Boston Children Hospital. He completed hematology and oncology and bone marrow transplantation and did research in stem cell biology and regen rative medicine. Dr. Craft recently founded intelemedicine, focusod enabling connected data driven and personalized medicine and is also inventor of the marrow minor, FDA approved device for harvest of bone marrow. And he founded region med system, company developing technology to enable adult stem cell based regen rative therapy F. That wasn't enough, Daniel is an avid pilot and serves in the international guard as officer and flight surgeon with f-16 fire squadron, conducted research on aerospace medicine published with NASA and was finalist for astronaut selection. We are thrilled to have Dr. Craft here to join us. -- is a colleague of mine, I'm thrilled to share the stage with her. She leads our consumer health program at ONC and responsible for developing and implementing ONC national strategy to engage consumers in health and healthcare using information technology. Prior to joining ONC in 2011, she had a private consulting practice focused on consumer health and previously director in the health program at the Markel foundation, policy advisor for the chairman of the Federal communication commission, content manager at dot-com and research associate at HarVA rd business school, earned degree from harVA rd. We have two very exciting panelists to talk about patient and consumer engagement.

We're looking forward to an exciting discussion by Daniel and upon can Lygeia Ricciardi. Let's cue the video.

>> Video: Manage your health about to change for the better. Medical breakthroughs are helping us live healthier and longer. Advance NMENT technology are giving us the tools and resources to take control of our health. Health information technology or health IT for short is upgrading healthcare system for the 21st century. Today's technology is freeing us from the confine of the paper world giving doctors, nurses and ourselves the flexibility to access and share health information securely when and where it is needed. It's a big leap, but not a new one. Throughout history, technology changed our lives, getting us where we need to go faster, saving us time and improving how we communicate. It's time healthcare caught up to the way we live the rest of our lives. The good news is that health IT is reshaping healthcare, creating a smarter, more responsive system, reducing paperwork, saving time scheduling doctor's appointments, and improving the way prescriptions are filled. Health IT has potential to bring your health information together for multiple sources so everyone who is caring for you is on the same page, not pages, and that's a good thing. As technology advances, you will be able to securely connect with your doctors online to review test results, manage chronic diseases like diabetes. And make a shared plan to keep you healthy. Progress like this means better communication with your healthcare providers. Suppose you have a new doctor who needs results of a past checkup or your father forgets which medicine he's supposed to take, or your child is away at camp and has to go to the ER. Having online access to you and your family's medical history can save more than time, it can save lives. Having the complete picture of your medical histories vital to managing your health. Health IT gives you, loved ones and healthcare providers access to the big picture so you can make decisions together that are right for you.

Now is the time to take that step into a world of better communication and greater convenience. Having secure electronic access to information at the right time and right place can help everyone get the best care. Health IT, it's good for you in more ways than one. To learn more about health IT and 21st century upgrade visit healthIT.gov, or ask your healthcare provider how they use health IT.

(ark MRAUZ)

>> Isn't that great, not your typical healthcare pamphlet. This was really designed to appeal to lay audiences who are curious about how to improve health, but not really focus on health IT. It was developed by ONC, it was something that Lygeia Ricciardi's brain child, so kudos to her and it was really trying to explain the benefit of health IT in an entertaining way. You can find our video on our website and we encourage folks to use this video, you can embed it on your own website. So take it, use it, it's for everyone to use to communicate to your constituents and your audiences.

So I'm just going to start with a couple brief remarks and give policy context for consumer engagement, kind of where we started and where we are and where we are headd and turn over to Lygeia Ricciardi to talk about consumer health program and Daniel to talk about some new tools and things that are we should see coming down the pike, some exciting technologies come approximating our way and that are already here. I started as David said, seven and a half years ago at ONC and folks were talking about patient-centered care back then and I remember asking what they were talking about because they weren't really talking about patients at all, they were talking about making sure doctors have information about patient, more information, more complete information and nobody -- [audio difficulty] -- part WHAF we talk about when we're talking about health information technology and improving healthcare and health outcome and not just something we put in a paper because it sounds good, it should be patient centered. We I want to begin with the policy framework and I'm looking at the Federal government's role on consumer health and engage NMENT three phases. The first phase, which is where we spent considerable amount of time is focusing on access to information and having the information that is held by clinicians or health plans, the accessible and available and acessed by patients, by consumers. We focused on this Meaningful Use program. We have patient and family engagement provisions in Meaningful Use focusing on download and transmit data and also now in stage two hold providers accountable for patients actually accessing their information, not just having the capability, but for helping to encourage patients to do so and access information.

We've been working on Blue Button, which Lygeia Ricciardi will talk about to liberate the data and make it easy for patients to access information electronically. We put together notice to help patients understand in an easy way some of the data practice, privacy and security of personal health service organizations so they understand how their information will or will not be used by the organizations. And all of that is kind FOF cusod access. We've made progress thanks to consumery health program and Meaningful Use program in that space. The next thing once we liberate the data, how do we both help patients and individuals create data and send data back into the system. How do we empower patients to do that either through devices and remote monitoring, helping patients to better express preferences or their observations of daily living or symptoms. That is something we are just starting to really kind of focus on a little bit more intently as we look down the pike at Meaningful Use stage 3.

Third and where we are headed in the future and there is going to be, we'll see the power of this information is how we include information with combined data with other sources to support patient centered outcome research, wellness tool, leveraging social media and network to support health and healthcare.

So the other thing that underlays this, with health reform effort and change fog cus on paying for outcome and having be accountable for patient health, we will see greater push and focus on consumer empower SXMENT using tools and harnessing tools and information to empower consumers to be more active participants in their health. So with that, I will turn over to Lygeia Ricciardi to talk about consumery health program and immediately following Daniel will start his presentation to show us some of the cool consumery health tools that we will see coming down the road. Lygeia Ricciardi.

>> Lygeia Ricciardi: All right. As JODimentioned we have relatively new consumer e-health office which is really exciting because it signals real commitment on the part of ONC to engage consumer and patients on everything and that goal was articulated in our strategic plan, one of the five goals for the organization was to engage patients and families and so having real program committed to that helps make it so, but it's a small program and is it is one whose walls are permeable. We work really closely with the other programs within ONC, such as Beacon and HIE program and RECs, we work a lot with folks on the outside, people who may be in other agencies within the Federal government and folks in the private sector, whether consumer organizations or provider groups or others. And we really view our role as being conveners and catalysts and setters and learn from other people out there and try and push this movement forward. We really believe it is being fuelled by combination of things, including policy and outside changes, such as the changes we all witness totally outside of healthcare in everyday lives with the way technology has become such a big part of our everyday existence, social media, the internet, mobile devices and some cooler whiz bang things Daniel will tell us about in a moment.

So the way our group thinks about engaging folks in the broader community and pushing forward is organized around what we call three A's strategy. You can see on the slide on the board access, attitude and action.

That is how we characterize and begin to make sense of the many diverse things that need to occur if we engage consumers and health IT. Access is very simply about giving consumers and patients and those who care for them easy electronic access to information in a way they can use it and reuse it, however they see fit. Action is more about building ecosystem of tools and devices such that once you have this liberated data, you can take action with it, do something, track your care, understand what is good and bad about it, how to improve behavior, etcetera. The third A, recognition, attitudes, recognition that consumer engagement really isn't just a technology challenge or policy challenge, it's really about mindsets and changing traditional role of consumers and providers to think about building toward more of a partnership. We need all three things to happen. Those are areas we work in and that we want to increasingly work with all of you in. So with that, shall we move to Daniel and hear where the future is headed?

>> Daniel: Thanks. So I'm going to try to cover briefly a bit of excitement if I can have my first set of slides up, where technology is heading and how that can empower the consumer, help connect the patient and caregiver ares and change the face of medicine, actually, so I'll start before we go into the future with a look back a little bit, back to the future. About a year ago I returned to Mass General Hospital, was intern with Farzad, I think he was missing from that picture, he was fixing his bow tie. We had a nice reunion a year ago, a reunion of the house staff. We had to walk uphill both ways in the snow, it was Boston. I found myself one of the famous healthcare history, you might recognize the eTHER dome, in 1846 this lucky gentlemen was first guy to get general anesthesia with surgery, the first definition of Meaningful Use, right?

That happened a long time ago, it is frozen in time, memory of medical history, you can still see the sponge, special grand rounds there. I wonder about four minutes away, to the ward where I spent my first months as an intern.

That had not changed at all. Some of the same alarms are beeping, being ignored, some same patients and nurses. Only different the intern was pushing around a cart with old computer, had to do MRI and put in the paper tray. Great institution, not taking anything away from them. My realization, medicine has been done and very siloed departmentalized and we have an opportunity, you know, waiting rooms haven't changed much in 100 years, to rethink healthcare. We are not a bunch of body parts, we are in the molecular age, being connected in new ways and need to use technology as ONC and many in the room are doing to address the major challenges, including 40 million uncovered Americans and not enough primary care physicians, for example. Big data being generated is a challenge to interpret and make use of, plus RETH RETH and reimbursement pieces. Lots of opportunity as we move shift the curve to the left to incent vise keeping folks healthy. A lot of patient engagement can make people mindful of health and keep them from moving up to the right where we spend healthcare dollars today. The Senator mentioned we are using technology to keep people out of the hospital, spot checks in clinic, ICU, and to the home and our bodies more engageed with our health and beyond. If you think back in the last decade or so since Farzad and I completed residency training, a lot riding the exPO NENTial wave. Moore's law, the smartphones in your pocket have billion times the price of speed performance of super computers of the '70s and that rate where things double like 30 linear steps, 30 exPO NENTial steps I'd be around the planet, a billion steps. We often don't PDP, those are coming together in many fields to enable consumer centric and connected health, not just IT but sensor and big data and you have seen that on the internet in the last decade, starting to see reinvention of things not in healthcare, but reinvented how we read. Amazon self destructed itself, selling more e-books than hard books. Instagram is more than Kodak. We reinvent fields. One fast-moving area becoming consumerized is genomics, the price dropped twice the rate of Moore's law, I had my exome done for a thousand dollars. Leading consumer genetic companies lowered price from $300 to $90 to have million snips done, not a full sequence, you can get insight into your genetics and share with your clinician, not just genetics, environmental data, clinical imagery, gut biome. Accessible by spitting in a tube or sending a drop of blood through mail. We can see our own data, using faster computing to enable surgeons to see data or understand our own neuroanatomy and beyond. It is disrupting fields, clinical fields. So for cardiologist used to doing cardiogram, those are cloud based. Fast CT scan sent to the cloud can enable analysis of the coronary artery, is that patient going to benefit from stint or not, we can look at that computation and share that directly with the patient and the physician almost in realtime whether they need a stint or not. How we treat heart failure and can be replaceed with quick MRI instead of ultrasound. Enabling clinician and patient to access that from their home and personal health record. The smartphone we heard from the Senator that was ramping up faster than we expected. There are more smart phones than toothbrushes on the planet and we are in the iPad and other erA. Every medical student gets iPad that, is changing how they interact with health DAT A. I am holding a $35 tablet built in India, being sold for $35. Huge implication for both education, healthcare as you can give away a tablet for less than the price of most prescriptions today. Huge opportunity on those. These are becoming dashboard for individuals for consumers and patients to see their data, diabetic glucose numbers or optimized and you have insight and share that information and one small study showed we can lower hemoglobin using connected smartphones. Yesterday was published a study using smartphone for diet. MOT bile group seeing diet was better than the standard REJ mine. Mobile is getting more important. We will start prescribing apps to our patients. Other apps to make sure you are doing the right thing at the right time. Gaming is changing how we interact with medications from the Stanford, we have kids shooting their tumors and staying engaged in oncology. We are using device to make physical therapy more interactive and fun and engaging and adherence driven. A lot of those are moving to the home using low cost technology. An era of digital healthcare moving beyond the electronic health record we'll touch more on. To smart phone. You can have a phone that use camera to analyze skin lesion, or diagnose your eyes or I'm holding an app that was iPhone case approved by the FDA last week. You can see in realtime how nervous I am. My EKG on my phone. This will be sold to physicians next month and to be over the counter next year. This is my live EKG, 150, wow. The cardiologist, that is one example of something coming to you driven by the techno geek in the Bay Area quantify movement. There is proliferation and other devices to measure what used to be steps and activity and health related data. I'm wearing new phone, the band which measures heart rate and motion. My father may have hypertension, I connected a blood pressure cup, we can see the data. I get an e-mail and we can use, one in three Americans have hypertension, half uncontrolled. These empower and engage consumers and maybe physicians will start prescribing these, these are getting smaller and eventually tattoo version of these in point of care diagnostics, not just for pregnancy test, but home tests and the ability for consumer to buy those and sometimes print those at home will open huge opportunity as we merge with telemedicine. The app, we can do facetime visit with clinician in real time. Those things are emerging quickly. The challenge are layering up on each other, we are not necessarily using these effectively, even our implanted defibalators have IP addresses, have opportunities and challenges for data. This is hugo, a friend of mine, the company who owns it won't give him hisidate A. What if other patients could share it and we could crowd source that in a sense. For poor clinicians overwhelmed by patients, we can be overwhelmed, how do we leverage the great healthcare IT and Meaningful Use happen nothing smart ways? One way is artificial intelligence. How many of you saw WATson beat the pants off Jeopardy? I call it intelligence augmentation, that is where it is heading, better diagnostics and clinical decision and sporting family and patient at home. We'll see that spread throughout healthcare, by best analogy, the onstar system in many cars, the sensors, you don't care except when check engine light comes on. On-star body sensors, you want to sign up and help information get integrated. Where is this head something any Star Trek fans here? Remember the medical triquarter? That is not so far away. We have versioned with low cost diagnastic scans -- would better than panel of board certified physicians, debate what school they came from. Over 258 teams have entered this competition to build a smart home based thing. All we have is what? Digital thermometers today. One company built a video to show where this can go.

>> Technology has given us window into the human body. On the day-to-day basis, we're still in the dark about our own health. We are changing that.

>> You okay?

>> Do you feel okay?

>> What if instead of fearing the worst when you notice something out of the ordinary, you could identify the condition yourself? Getting the right diagnosis would save you worry.

>> Says roseola.

>> Unnecessary doctor's visit.

>> Rest, it's okay.

>> Instead of hear burglar viral outbreak on the news, imagine you got an alert that was tailored to your family's needs. It would also give you advice about what to do next. What if you had a way to identify what was wrong right away?

>> 103.8.

>> Way to get all of the information you need to understand the situation. And in serious cases, you would know when and where to seek help.

>> It recommends taking further steps.

>> We're building a way for people to check their bodies as often as they check their e-mail. It's all possible. And it is only the beginning.

>> Some check in too often and that is a problem. A company is actually building one of these. Here is a prototype in my pocket, one of the five in the world that is a medical triquarter. I will try a live demo. This is what the data will look like, it is scanning in real time, getting my heart rate, relative blood pressure and pulse and can communicate that to the phone, it just popped up. Heart rate 95, better. So that is an example of where things are and they plan to ship to consumers in about a year. We can debate the FDA implications. These are coming together in smart ways. Connecting health, patients and family to clinicians and recognizing social network is incredibly important and several new startups and companies are putting those together and recognizing our behavior is more responsible than our genetics for example amada out of San Francisco is leveraging years of data to make systems that kind of social network basis of prediabetics it can precht them from get be prediabetes or using tools bake August lent meanted reality, healthy you if you stay on track unhealthy you that can change our plineds in certain ways I download an app and see myself now and if I gain 50 pounds. So smart tools to leverage phyurl change because we know it's really hard right. We're starting to enable the disabled to be more connected and engaged in their world there's now the world of exoskeletons to enable the disabled to walk. Of course we wan to leverage the world of STEM cells which I've been in the Stanford world the last 15 or so years and the guy won a Nobel prize connecting genetic med inspinal cord, world of 3D printing in a world consumers are inincreaseingly able to do at home not just a strad various but surgery, prosthetics that match a missing leg and we're merching that increasingly with tissue injury where we're starting to print complex organs into the future. All these technologies are great but I think one of the themes is unless we reinvent how we pay for things it's a challenge. As our friend says we don't practice -- we practice reimbursement base medicine, many of you in the room setting those polls which is incredibly important.

How do we put this together in smart ways for consumers and beyond I'm a pediatric oncologist but I'm measuring a new track called sing yoularitys aimed at silicon valley where we cross-train folks in robotics nano and beyond to think where is it going, how do we leverage impacts to challenges like health and beyond, some solutions are coming out low cost UAVs not to just deliver tacos but deliver drugs and vaccines it could be in rural America or Africa.

Or someone built a glove for doing telepreference in exams. A few ideas where that's going put together a program called future medwe across clinical spectrums, to look where health care can go into the future.

So one of the interesting things that happened and especially in the bay area and being foster by HHC and ONC is bringing new players into health care for all these different fields, blue button initiative health data.gov there was action challenges there was here in D.C. this summer, bringing beginners mind into health care to reinvent medicine in some ways even designers getting involved because as we've heard I think from others this morning it's not just the technology it's connecting it if I want to fly to San Francisco put wings on my car I want to have a jet fighter or jet, a whole system needs to be plate it's not technology it's everything around it as mentioned in the introduction I've been a pilot for since college, learning how to fly on the college ground, the landing wasn't as good as the takeoff, and then as a resident at maess general I joined the guard I've been a fledgling a decade or so, you get to fly jets which is fun but the way aviation and military is done is lessons for health care whether it's consumers patients the phol system some of you are aware of checklists, they've made a huge difference in the operating room, and that's being applied to the home environment as well, those are being amplified increasingly not just for emergencies but again for pregnancy and post ops and gond we'll begin to see apps and ITs personalized to the individual, for example in simulation, so our surgeons and our medical students can train like the pilots do on simulators and do it in safer ways we have an incredible sim lab at Stanford where the theme will be instead of see one do one teach 1 which is my area, same one same one, they also simulate by patient encounters and we communicate with families when things go right or go wrong. Other elements apply particularly to the consumer would be that of the cockpit we've gone from this analog world to digital world and the challenge is how do we funnel that data make it smart this heads up display we use in the fighter pilot world will give Tuesday right data whether it's landing in the dark or in a dog fight you need information. Words come at us if I hit a mountain, it reminds you to pull up how do we pull all this big data from our EMRs PHRs and make sense of that, like we do in the car with feedback loops if you're driving tooffles or get your gas mileage you you can use feedback loops and pulling that into health care. GPSs what if you know the right pangt pamgh to take for your prevention diagnosis or therapy obviously you want the right information but not too much information or we get after overwhelmed. Last example from aif vaition would be how we see things, people working on fancy contact lengss that import to your eyeball we don't have to wait for that Google glass we'll start seeing augmented reality for the patient and physician a little heads up display there are going to be interesting apps for that when you're out on a date you can download the wigman app. But there's implications for this technology, Google glass will be released within the year or so, right? How can we use this that in health care, right? You might be a doctor looking at health care data in realtime as you move around in ER you might be an individual consumer trying to stem an obesedy epidemic you see your breakfast this way then you see it this way maybe you're going to get a warning before you dig in, you know.

>> Pull up. Pull up.

Pull up pull up.

>> Finally I think particularly in the health care IT world the real opportunity of a meaningful data stream is this idea of radar seeing the world and systems around us not just our siloed EHR in our hospital but those around us other patients like us, patients like me for example where you see other patients with trajectories like us see where the thorms are or driving apps like waves the drivers don't know it but they're sharing their data anonymously but building a map of Rome in realtime, you can see the road blocks right route to work what if we pull all this data today in a HIPAA compliance anonymized way to make health care more connected and enabling. In closing there are a lot of opportunities happening today on trajectory to improve health care our own understanding and empowering patients and families, we're in this era where Google searches you cap look at flu trends and understand if your particular community has a flu outbreak for example you can mine your social network and see some depth into that you'll have maybe certain warnings that day about whou should shake hands with that day or not based on that data. This is available now not science fiction, finally we'll have dashboards into our own health for ourselves for our families for our physicians. So as we move into the future I think it's going to be integrated con tect walized layers on AI, design thinking and takes from where we are today where we're episodic and reactive with our data and health care is to one continuous and proactive. Not found at -- found at stage 34 not zero or 1.

Ideally shift our thinking from being organ donors to being data donors so we can make this happen in smart new ways and enable new fields like personalized oncology, where we can sequence it, crowd source it look at other findings in our route and paths and get us into the right routes and paths. I hope you look at exponential technologies, use those to fly higher and faster as we reinvent patient engagement and human health care as Gibson once said the future is already here not just eernl distributed those in the room have the opportunity to actually predict and create that future we have to believe and have the vision to drive it forward. So with that I'll say thanks a lot. (Applause.)

>> Thank you so much that was a really exciting presentation. We're going to have a discussion up here I'll open it up for a couple audience questions at the very end. So Daniel you talked about a lot of different technologies and tools that are emerging or that already exists.

Are there particular ones that you're most excited about or do you see you have the most potential to improve health.

>> We had Dr. Marty Cohen who has been head of Watson group. It's been fun in the last year Watson has gone to medical school and we're very biased as clinicians based on who we've trained papers we've read there's a true power of AI, series moved to the smartphone can do basic smart things when you leverage that with tablets prescribing with tablets with apps for example to help manage their disease I think they can be more connected have better patient doctor relationship because you're not scribbling down blood pressure numbers. And layering that with this AI element. So we have a sliding scale for glucose how do we tune your meds.

I think convergence of a new fields mobile connected data smart things that you can measure glucose on your phone, with AI, is going to super-enhance and hopefully improve outcomes at lower cost.

>> Great. So Daniel talked about all these consumer facing tools, and at least some of them are premised on people have access to their own health information, that is held by others as well as being able to match it up with other data and their own eat. Can you talk more about ONC's efforts to promote access to information, the blue button initiative, and how this all fits into ONC's consumer strategy?

>> Yeah, absolutely. Access is one of the most important pieces of our strategy, as I mentioned it's one of our three As, and certainly one of the greatest tools that we have is one that many of you are very familiar with, meaningful use.

And in particular, in stage 2, we really, really enable patient access to data through the requirements that patients must be able to view, download and transmit their data from an EHR. This is a big deal, because we go from, oh, log on to a portal and just see your medical record, to be able to download it and do whatever you want with it.

Maybe you just want to read through it, directly, and see if there are things in it that you don't understand, maybe you want to share it with someone else, maybe you want to plug it into an app or a tool. But the point is it's yours, you can do with it what you wish.

In addition, though, beyond meaningful use, the blue button program, and our work in that area, really reaches folks who are not meaningful use eligible, including payers and others, and takes this idea of patient access to data a step further.

So you heard Farzad talk about blue button and how he's even more of a believer after his Thanksgiving vacation and using it with his parents, but we're working, we're lucky to be working with the VA and also with the White House to really propel blue button forward. It's something that started at the VA, as many of you know, and it now has had over a million users, and we're really trying to take it at HHS and at ONC nation-wide. vr

And part of how we're doing that is trying to enhance its functionality, so we have an amazing team of blue button fellows presentation fellows some of who may be here, who are helping us to build ways that we can have that information be automated so that you can update it automatically. You can set it and forget it.

Truly what's important, though, I think is not just liberating this data but it's the opportunity to match it up with the kinds of data Daniel was talking about. That's where it gets cool. Just your health data? Sort of interesting. But match it up with a, you know, data about your genetics, your environment, other kinds of stuff, and now we're really talking.

>> Great, thanks lejia, and I have to admit I followed Farzad's lead in this pass weekend, I blue buttoned my dad's Medicare data and used the app that was one of our challenge winners and was able to get information and help him look through his data, fortunately we didn't get to use it the next day, like Farzad did.

So Daniel your presentation is so positive, exciting and encouraging. There are of course many challenges that lie ahead and seeing the reality and vision that you set forward. Can you talk about what some of the challenges are that we need to overcome?

>> Well, I think here in the U.S. we don't have a health care system, we have systems, and the incentives different if you're a Kaiser or a VA or fee for service.

So some of the challenges are clearly reimbursement. We're wondering who is going to pay for these apps. But I think the first couple trials are showing they get dramatic results with diabetes or blood pressure and almost be free but somebody still has to build those and encourage the innovators and build the platforms some big payers are buying into it now, so I think they're catching into that but there's still the challenge of who pays for it as we move to value based compare ACO model it becomes easier there is a lot of questions about how apps are going to be regulated the FDA is working on that, they're working with the X price team to figure out how to enable these tricorder devices to come to market in smart ways

There's a lot of regulatory uncertainty which sometimes drives innovation offshore. Others are sometimes the -- a bit of the belief system that I don't -- certain generations aren't so familiar with tracking their data or sharing it, and I think just as our parents and even grandparents generation have gotten on Facebook people can start trying these and they can start fimpl with a fit bit or something similar and move into other tools that will give them more insight and connectivity.

>> Great, thank you. So leji, I'm going to try to bring it back from this vision of an interconnected data-driven future to where we are today.

What are some examples with scaorms use of technology to engage in their care today without access to all of these fancy tools?

>> Yeah I mean in a very simplest sense you don't need anything really complex to begin that mind set of engaging in your care. There's tons of information online, 80 percent of internet users are already searching for health information. Begin conversations with your provider, ask questions when you don't understand, share information.

But you know, tools aside, particularly when you are able to download your data through blue button, you can do simple things, but that are really, really essential. For example, you can essentially be the health information exchange of one. You can be that coordinator among your various providers who makes sure they're all on the same page, even if they're not already sharing with another, with each other, or especially if they're not.

You can also, with access to your information, look at it and make sure that there aren't any errors or omissions. Which can be huge, because you're basically -- you're another source of information about you. You can fact-check and you can also bring in perspectives that your provider may not have.

They don't know that, you know, you have three long haired dogs that might be responsible for the fact that you're sneezing all the time or what other things are particular to your life so you really need to bring in your own information and share that with your doctor and use technology to do it.

Again a lot of those things will be enhanced as we connect all these worlds together, but there are some really simple ways that you can start right now and just being a partner in your health.

>> Thank you, ijia. So Daniel this is for you. So a lot of these tools are things that provide information to patients that today, or in the past, have only been able to be provided to the patient through their physician.

How do you see physicians reacting to this shift and this vision for a future of tools and apps and consumers taking more control over their own health?

>> I think not speaking for all clinicians but I think many feel empowered or disempowered by it, so depends where the incentives are. So for example, I train in pediatrics as well as internal medicine you get a lot of ear infections

So it takes three hours a day half a day off work now there's a little connection, a case for the smartphone, uses the camera to look in the ear and send a picture of the eardrum to your pediatrician, potentially maybe the app can do the diagnosis. Maybe they can use it, but if they can bill for that maybe they'll start to use it.

Maybe email enough clinical settings in many perfect rftion clinicians dpont get -- don't get paid to do it. I think as physicians start to get rewarded keeping their patient panels with low blood pressure overally higher compliance less err visits 3 in the morning that aren't necessary they're going to start diagnosing or prescribing some of these set of tools for them and using that to connect in smarter way toss provide better prevention and follow-up.

>> Great, thank you. So sticking with providers, ijia, can you talk about resources that ONC may have that can support providers who want to better engage with their patients, to engage their patients in their care?

>> Sure. One we just showed you which was that animation you saw a little while ago again it's free it's on our website, download it take it. Along with that we have a lot of other videos that were crowd sourced, created by members of the public in response to various challenges and contests that are focused on health information and its application in certain settion, like being a caregiver, for example, or managing cancer, and so if those -- there are some very funny, witty, and really entertaining videos, that again I'd encourage you guys to look at the winning ones. And again repurpose them, them, they're out in the public domain.

We also have a lot of stories on healthIT.gov, fact sheets, and this is about comupghing with your patients. In addition, though, there are tools you can use, or encourage why are patients to use.

I do want to point out that we have several winners of our blue button match-up challenge, I think Farzad mentioned one this morning, but there's instant PHR, ID blue button and I blue bunt main apps in our lounge area so check them out first hand you can encourage your patients to use those.

I think another major resource for providers certainly, although also for other groups, is our pledge program. Which is a -- an organization that allows us, or a program, that allows us to work with diverse stakeholder groups including dataholders such as providers and payers and a lot of other kinds of organizations as well, consumer organizations.

If you join that, you get to be generally in contact with us and we share information about things that are coming up. We also really take the opportunity when possible to highlight successes of others, as well as to enable people to have opportunities to network off of happy hours and such. So I would totally encourage to you join that.

>> Great. So one more question for you, Daniel. You touched on this a little bit about how some folks may be more accepting or resistant of this technology. Do you see these tools as supporting different types of consumers or individuals with different interests, different abilities to use technology? And how do you see this working for all types of consumers and not -- and how do we avoid creating a digital divide?

>> I think we're in this era now, the E patient the en fwaijd patient some of which create their own platforms for croens disease or ALS, so there are some different buckets, actually needs are for certain chronic or acute disease conditions that create some powerful platforms.

I missed the second part of your question, but I think the challenge is not to make anything one size fits all whether that's for an EMR or PHR part of it can be based on our personality type for doing incentiviation with gaming and points. Not everyone wants badges or points they need some other carrot or stick. And I think carrots often work better. Organizations are going into employers and setting up, you know, employee health systems and a lot of that is instigated by teams getting together and making sure they all beat their calorie or step dpol for the day.

So I think trying to not build siloed one size fits all systems that are flexible and can meet the needs of individual mind sets and groups is important.

One other element is that with technology moving so quickly it should be somewhat modular if you can swap out a pad or a camera or those things are going to be different in two or three years you want to build a system that costs tens of millions of dollars, that needs to be replaced two years later, so thinking modularly as well.

>> So there are lots of folks out in the addence that are lots of questions for our panelists, we have lots of mics in the room if folks can line up we can take a few questions from the audience.

Please go ahead.

Q. So Keith boon, with community health care. I've got the fip pit I've got the I health I've got health apps on my phone I have 23 and Me, and what we've done with all of this stuff now, is what we've done to the patient, is we've brought the data silos to them.

I can't take my blood pressure data and my weight data and my activity data and my genetic data and pull it all together.

So to Daniel the question I have for you is, you know, where do you see the technology going, where we might be able to resolve that problem, and to the ONC folks, what might we do to enable patients to cut through those silos.

>> Right, so to your point you may not know what to do with every heartbeat blood pressure genetic piece to be integrated and the example I gave of the car, where your check engine light goes on is probably the easiest way to say that. Some of these devices now have open APIs so you can mine into them. Many of you might have seen the website mint.com it pulls all your financial data together gives you your bottom line tells you what you might invest in next et cetera. Some of those elements will come together and there's going to be coordination and open sourcing and sharing, and unsiloing of this data to make the most sense of it. Like we're learning with genomics, the number of sequencing have gone from hundreds to tens of thousands we pull that data together we can start to see trends so we can look at traffic and suggest pathways so I think it's the match again it's not one data silo and again most consumers or patients don't want to look at every data stream they want the equivalent lent of a check engine light or GPS so we need to encourage to pull those things together.

>> Keith I know you're a great contributor to the world of standards and obviously we need standards and more standards work as they different areas converge. As you know, we have begun to do some work in the consumer e-health area and standards on specifically blue button through the standards and interoperability framework which is great, vo east which has 60 different folks including you involved. Hopefully on an ongoing basis the federal government can do more in the standards area particularly in the consumer space particularly with the convergence of different industries.

>> We have a question over here.

>> I'm Tom common from Pennsylvania and I'm in charge of a continuing care community of over 300 residents. The blue button, does Medicare have a program to go out to educate and train my residents on how to access that?

>> That is an excellent question. Medicare certainly employs the blue button and I don't think they're yet at a point of having a real robust program to train people, but I think it's an excellent suggestion and one that we can certainly bring back to them and maybe work with them to build such a program.

Are there other questions? All right. Well, please join me in thanking our panelists for a great and exciting discussion. (Applause.)

We would like to next introduce the ONC 2012 annual meeting video challenge winners. So I think you can put the slide up.

Great, thanks. So far I've asked people from around the country to Smith their stories about adoption of meaningful use health IT, electronic -- exchange of electronic health information, engaging consumers in privacy and security. Nothing fancy, just flip phones and personal experiences.

We had about 25 videos submitted and we want to thank everyone who took the time to turn in their story, and here are the winners. So next slide.

Dr. Around Berlin from Cornell university. Next.

Cass County health system, Atlantic, Iowa. Next.

Okay, I don't have this one on my list. River falls Ellsworth spring valley medical clinics. Next.

Isaac dapkins from brawns 11 worth health center in New York City. Next.

And let's all congratulate the winners of the video challenge. Thank you all for contributing. (Applause.)

So we are about to take a break, and I'm just going to give a couple of announcements. Please go and check out the exhibits in the registration area, especially our consumer focus blue button match-up challenge winners, that lejia mentioned they're all out there you can check out them for yourselves.

Please, as David munlts has said a couple of times take this opportunity to network together I think one of the things I find incredible about this forum is the conversations and the diversity of stakeholders and perspectives that we have in this space, so please use this opportunity. A reminder don't leave anything valuable in the room. And please be -- sit 4 o'clock? Please be back at your seats by 4 o'clock, to be sure you hear from Congressman Phil vencary. Thank you very much.

>> Hello, my name is Dr. Arnold Berlin and I'm clinical professor of medicine at wild Cornell medical college, and I also am an internist at a inner city federally qualified health center where I've been using an electronic health record or EHR for more than four years.

Meaningful use of EHR has afforded me the opportunity to better document, store and retrieve personal health information. More important than these meaningful use tasks is the power of meaningful reuse. If meaningful use functionality is the backbone, then meaningful reuse is the brains of an electronic health record.

Reuse is data mining or searching the electronic health record by providers of public health officials. Reuse is transfer of information to third parties. Reuse is 24/7 availability, transparency and interoperability shs with health information exchanges or directly with other facilities or EHR systems.

My first experience with meaningful reuse was an urgent call from the OR on a weekend morning at 6:00 a.m.

The nurse in the OR advised me there was an emergency need for a recent EKG on my patient who was now in the OR.

I advised her that I could fulfill her request, and two minutes later she had the EKG in her hand. I was able to log on to my EHR from my smartphone, and fax the EKG using the embedded fax technology in the EHR.

The OR nurse found this a jaw-dropping feat for an early weekend morning.

Last year I received an urgent FDA email regarding increased mortality for a drug used for atrial fibrillation. This advised this drug should be discontinued in a subset of users. A registry search of our EHR system was completed in less than two minutes, and five patients who have been identified who matched criteria to discontinue this medication.

All five of these patients were contacted within five minutes, and referred to their doctors or advised to stop the medication. This rapid response and resolution would not have been possible with paper charts.

Just two weeks ago, superst storm Sandi devastated the rockaway section of New York City near my home. Most upsetting was the loss of electricity and flooding of area nursing homes. Hundreds of nursing home residents were transferred in the dark to area hospital emergency rooms.

Unfortunately when these elderly infirm hurricane victims arrived at the ERs the doctors were also figuratively in the dark also. No medical records were available to advise of diagnoses, allergies, or current medications. If these victims were part of an EHR, at least their personal health information would have been available through offsite redundant storage or personal health records or a patient portal. The morbidity due to loss of emedical records in this tragedy could have been minimized.

Thank you for your efforts to use and reuse health information technology.

>> Hi I'm here today with Steve stark from Cass health system. Steve could you at the time us a little bit about yourself?

>> Sure my name is Steve stark I'm the chief information officer at Cass County health system in Atlantic Iowa. Cass coypt health system is a 25 bed critical access hospital we're located just in the southwest corner of Iowa, we're somewhat unique in that we have two major health systems, in Omaha and Des Moines Iowa that we see patients from and sends to.

And we have went through a journey to become a meaningful user of certified EHR technology.

>> You mentioned medication error rates as one of your barriers, how did you overcome that barrier?

>> Well, the main thing that we've done and really that our certified electronic health records enable us to do is we now capture nearly every order electronically. So when we have an issue, or we have a success, we have realtime gratification, we can let a physician know that they're doing something right, right away, and we can also assist those providers or those clinical nurses that are having issues putting in orders.

>> Tell us what kinds of results have you achieved now?

>> Prior to going live with our electronic health record system we were hitting about 8.3 errors of medication errors per 10,000 doses, and today we've been live for a little over six months and we're hitting about 4.0. So we've seen a 50 percent reduction in our medication error rates. And that really improves the safety of our patients.

>> Did you represent any outside organizations that assisted you in reaching your outcome of meaningful use?

>> We did we partnered early with our regional in Iowa which is intelligent we began with everything they offered from our hospital side from from our eligible providers they helped us in this journey really from start to finish I don't think we could have done it without them.

They helped us tremendously with work flow that's probably the most valuable component of their service offering that we utilized. And it really helped us learn the ways to do things in a meaningful way and that was evidence based.

>> And can you tell us who your EHR vendor is?

A. We had been on medicheck on a magic platform for about 16 years so we decided through a lengthy process with the help of Intel I gen that we would stay with intelitech well upgraded to version 6.owe and that's our system we have through the hospital today

>> Thank you Steve for sharing your story with us.

>> Thank you, it's been my pleasure.

>> I'm Julie operations manager for the river false Ellsworth and spring -- for patients.

We see our clinic much in the same way, a lay person may view a team sport such as basketball.

Dr. Tashen is our point guard and team captain.

>> I'm proud to share that all of our physicians achieve meaningful use in 2011. We had two physicians in the first 33 in the nation to test including myself.

Achieving meaningful use helped us utilize functionality or our electronic medical record and positively impacted our patients by providing relevant and convenient services such as e-prescribing.

>> I'm Dr. Goldberg and I play center for our team. In 2012 we implemented a portal to give patients access to the the health record and a vehicle to communicate electronically with our clinics.

Some of my patients are snow birds, and winter in warmer climates. They love this technology because it enables them to share their current health information with their Florida or Arizona physicians.

>> I'm Gordy the IT director, guard. And my role is to ensure patients' information is secure and private. This is taken seriously by our entire staff.

In addition to our security measures we perform annual IT risk assessment to help us identify areas of improvement, to update standards, and train employees.

>> Rose and I are the forwards, of care coordinators using the EMR we run reports for each hairg provider on a monthly basis measuring our progress towards quality standards. We work together to better manage care for patients with chronic diseases.

>> And our quality results for IBD, diabetes and hypertension have continued to improve each year because of the access to data, that EMR allows.

>> It's clear it's a team.

>> My name is ice ac dap kins and I'm the medical director of ambulatory care at Bronx Lebanon. For a long time there's been a problem in health care, and that problem is a breakdown in communication between provider and patient.

Meaningful use brings electronic medical records and health infrastructure, health IT infrastructure, into places that ordinarily wouldn't be inclined to do so.

When we were rolling out our electronic medical record, we discovered that more than half of consultations for specialty care went unscheduled.

What this means is if you have diabetes, which many people in the Bronx do, if your provider asks you to see an eye doctor, about half of the time when you walk out of the office you don't know that they want you to get that done.

Using an electronic medical record and our IT infrastructure, we've been able to work out solutions to educate patients in the form of a visit summary, and reconciliation of medications with orders, as well as integrating population management of referrals, and referral tracking and closing the loop on referral requests.

As a result, our diabetic patients have had their eyes checked more this year than last. I think that's a great example of how meaningful use has brought meaningful change to our practice in the south central Bronx.

>> Our practice is a family practice in a rural town in lower Alabama, Jackson Alabama. We have about 6,000 people in the town, and we serve the surrounding areas.

But we knew we had gotten to the stage we had to make a change. We had no room to put paper charts, charts were everywhere and we were continuously losing charts.

>> As an implementation specialist I helped providers in Alabama adopt electronic health records and achieve meaningful use, this is extremely challenging for them, and so we really try to keep that in mind when we go through the whole process.

>> lu sell is almost like she was an employee here at the office in a good way. I mean she was here when we needed her, we could call her whenever we had a question or any concern.

She wasn't overbearing she was there as kind of a coach and also a cheerleader and also an area of expertise also. So it was a real symbiotic relationship which we both worked well together.

>> OBGYN is a 8 person practice, specializing in ob stetics gynecology we have about 50,000 patients on our rolls and deliver about 1400 babies a year.

Before doing electronic medical records we were dictating all our charts and we had been doing it for quite awhile and like anything you do for a long time we were good at it, efficient at it, and we felt like it was -- I felt like it was a good thing to be doing it that way, and was not really excited about the fact we were going to electronic medical records.

What happened is six months into it I realized I was getting out of work an hour, maybe two hours earlier than I was when I was dictating. That at the end of every patient encounter all of my documentation was done, all of my prescriptions were done.

>> My name is ites, awad I'm HIT services. Here we're focusing on managing panel sper vengz within the hive world and setting so the purpose of setting is be able to take some things out of the clinician visit. Allow for other members of the team such as the end and nurses to remind the patient and bring them into their care and empower the team as well as the patients to make sure it's really a patient centered medical home model.

>> I'm paying attention, I want to be more involved, and try to encourage the patient to kind of be involved, as well. Like kind of be a team, and for them to kind of self-manage some of these things, and the reason why they're having the tests, I get the opportunity to explain to them certain tests and why they're having them. As opposed to here's a lab sheet go and have these labs then we'll check back in with you.

>> Some of the tools we're using to do this are registry reports which show you all of the health maintenance activities, visits, needs of the patients at one time, so you're managing the entire panel not just one patient as well as a decision support tool which is a flag in our system for the MAs and the clinician to say these are the interventions that we need to take right now, so they map all through the practice.

The pilot program here at ACMC we are currently using one clinician, and one panel of patients. But plan in the future to roll this out to the entire clinic.

>> I love the panel management but of course there are challenges. The biggest one is when you predict, which is time. You need time to meet with Monica, to go over the registry and go over our summary reports, and that is not always obvious in the day where to do that.

Second thing is that she's helping me bring in people who have been lost and who are sick, there are people who have been lost to care. I find that my days are longer and sadder, because I'm spending time with people around what's hard for them.

But then the third challenge is that there's all this exciting stuff that I get to do for people that's really about wellness, not about the sickness of HIV but about what they need to do to stay well, and just kind of marrying those two pieces together excitement about talking to hem how to relevant from getting pneumonia and going to the dentist things like this that marrying with that ask still talk about what they need to do with their HIV.

For the time thing the solution is either to book an appointment to do that, to not see a patient in one session. Or to find time in a no-show slot or find time at the end of clifeng, those are the only solutions we come up. With

For the sicker patients it's really about teamwork and bringing in our psychologist, bringing in our social worker, because those folks we're bringing back in care they have big social problems in addition to their medical problems, so I need to rely on my team, my colleagues to help with that.

In terms of the marrying with prevention and the HIV disease care, it's, you know, it is a challenge, but it doesn't need a solution. It's a happy thing, going forward. And it's really me just thinking about it differently about how to talk to my patients and how to work on those two things simultaneously.

>> Some of the solutions I feel that panel management can offer is first of all working together as a team with the patient, and I feel like once the patient feels like they have this great team and this support, that they want to be more involved. They know why they're having certain tests, they know why they're taking certain medications now.

They know why it's important for them to do these things.

>> So the exciting thing about scaling up from project, a pilot project, to everybody doing it, to me is the sustainability piece. Then I think our quality numbers are going to go through the roof. Patients are going to get used to it and I think they're really going to like it. And we're going to then be able to make it something that is normal life in our clinic.

(Break.)

>> You have a mic on?

>> Good afternoon.

>> Good afternoon, I think it's time for us to get started with the afternoon session, so if you don't mind having a seat. You'll get a chance to hear from representative Gingrey. Thank you.

>> Thank you so much. We have another special guest with us today, and unfortunately our guest Congressman Phil Gingrey Georgia 11th district does have a vote to run to, so left us without too much of an overlong instruction, if everyone could take your seats and get started Congressman Gingrey is a member of the energy commerce meet, over activities we have here at ONC and also as a physician, OB-GYN who trained at memorial hospital, did residency at medical college of Georgia, he also has been a major driver and chair of the GOP doctors caucus, and provides that clinical perspective to the health policy discussions and activities that have been going on.

And I want to thank Congressman Gingrey for being with us today, and turn it over to the Congressman. Thank you. (Applause.)

>> Well, thank you. Thank you very much for that. It's certainly an honor to be asked to speak, to say a few words and to be introduced by the national coordinator of ONCHIT. I'm always a little hesitant to use that acronym because with the least bit of speech impediment God knows how that comes out.

But we had a little side bar conversation as I was coming in. I have been a supporter of electronic medical records for a long time. I spent 26 years in the private practice of medicine, the specialty of obstetrics and gynecology in my congressional district, the 11th of Georgia, northwest Georgia, the County could beb the town Marietta and I know all about shuffling papers, and charts of patients, looking for a report, not being able to find it, when the patient had their last PAP smear.

So clearly I do understand and support. In the interest of full disclosure, although you probably already know, as a Republican member I was not very supportive of patient protection and affordable care act, and I was not very supportive, you could either support it or not support, so yea or nay on the stimulus bill.

But definitely, this aspect of ARRA, American recovery reinvestment act of was it what, February of 2009, I believe, it just struck my eye immediately as something that I thought had the potential and has the potential to get this effort toward a fully integrated electronic medical record system adopted nationwide to every single office of every physician in this country all, what, 850 to 900,000 physicians in the United States.

It is just hugely important, and bottom line of course is that we're talking about not just saving money, and I feel like that if this had been the only thing that we did and accomplished to its full conclusion, and not 1.7 trillion dollars on other things, it would have gone a long way -- and it will go a long way, toward bringing down the cost of health care.

But as I say more important, the ability to save lives, and not make mistakes, and errors.

And I think ultimately, too, I think it will result in in poybl better physician provider reimbursement. In fact the numbers to date so far bear that out.

The part of the American recovery and reinvestment act, the stimulus act, of course that I'm talking about, is the HITECH provision. And this idea of trying to incentivize providers, whether it's a hospital or as a designee the professional provider, the doctors, to do that through this incentivize them for meaningful use of electronic medical records.

It really doesn't do a whole lot of good, does it, as all of you know, those of you, many of you I'm sure are vendors, for physician practices to purchase hardware and software and long-term contracts for maintenance and upgrades, and to be able to maybe get rid of the charts in their own offices and have that electronic, but not have the ability to communicate once that patient leaves the office. And maybe even goes to a provider, another provider, another specialist in the same town. But how about if they go across the country or across the pond? That's why ultimately this is so important, and why I continue to be a very, very strong supporter.

Now, saying that, obviously we've got a lot of work to do. And when I'm home in my district and meeting with physicians that are maybe not just constituents who support me with their vote, but constituents who support me financially, and yes indeed there are some doctors that do that, although they're not the easiest nuts to crack from that perspective, you all know that too.

But the last time I was meeting with a group, and I thought it was going to be a kind of a social meet and grate and kind of have a good time enjoy a drink, holiday season -- boy, I got blasted, I really got blasted. And these were maybe 15, 20 of my best friends.

A lot of the doctors that I had actually practiced with, although it's been 10 years now since I was in clinical practice. And they -- there were even some comments to the effect that we don't even want this. We wish it would go away, you know, it's more trouble to us than it's worth.

And clearly, they just need to be more patient. They need to understand that the bottom line of course we all understand, that you maybe take two steps backwards and then hopefully eventually four forward. But the initial investment, the cost of, I don't know, 35, 40, $50,000 per provider, that might not be so difficult if you're talking about a big hospital system that can absorb that kind of investment, but for a small single specialty group practice of two or three in rural America, it's very, very difficult. And then to have a learning curve of six months or so, where your productivity is decreased because you're looking at that computer screen and you're trying to figure out what the right inputs are, and you ultimately hope that you have some time to turn around and look at the patient and examining the patient.

These are some of the concerns that I hear as a former doctor, and now of course as a member of Congress.

My position currently in the Congress, on the House side, is on the energy and commerce committee, one of what's considered exclusive House committees, there are four or five of those, and we're only permitted to be on the one committee because the workload is so heavy.

On energy and commerce, one of my assignments is to the health subcommittee, and along with the ways and means committee. That's where the authorization, we have health information technology is one of the many things that we oversee, on energy and commerce, of course, it's the Medicare part B, all of Medicaid, the SCHIP program.

And there is, you know, a little bit of concern. And I think you all are aware that recently there was a letter sent to secretary Sebelius from both energy and commerce committee and ways and means signed by the chairman of the two committees as well as the chair persons of the two health subcommittees, saying look, you're not -- you're not really progressing rapidly enough through the stages of meaningful use, and maybe you should just suspend the program. Even though I think some seven or $8 billion has already been spent in regard to incentivizing doctors and hospitals to adopt meaningful use.

I have some statistics here somewhere, if I can pull those up. Well, let's see. Between the start of the payments in the spring of 2011 and September of 2012, just over a year, over $7 billion have been paid to providers. In 2012, 72 percent of office-based physicians used electronic health records, which is up from only 48 percent in 2009.

That doesn't mean that they have even reached stage 1, however, of meaningful use.

More than 120,000 eligible health care professionals and more than 3,300 hospitals have qualified to participate in the program.

But as I say, there is this concern, and when you get a letter from the chairman of ways and means and chairman of energy and commerce, saying maybe you should suspend the program for awhile until you get it right, that is a little scary. I mean, it's pretty serious, and it scares me, and I did take the opportunity to read that letter, although I was not part of the discussions and the decision to send such a letter, but it was based on -- and I have these reports with me, obviously not time to go into them in any depth, but I was reading these at 5:30 this morning, I want you to know.

But one from the office of inspector general of the Department of Health and Human Services, and it's titled early assessment finds that CMS faces obstacles in overseeing the Medicare electronic health record incentive program. This is one report that I think the letter was based on.

The other is a government accountability, GAO report, even thicker, titled electronic health records, first year of CMS's incentive programs shows opportunities to improve processes, to verify providers met requirements.

This is all about -- well, was the $7 billion that was spent, has been spent, in the first 14 months of the program, was it taxpayer money well spent. Were these providers eligible, and were they supplying the data that they were required to supply, to the department and to CMS, that would justify giving them the incentive under phase 1 or phase 2. I don't guess the final rule on phase 3 is here yet, but, you know, it brings up some real serious questions. That there is more work to be done, and there are challenges. And, you know, the political landscape, you have to deal with opposition from, say, folks like me to what -- and I don't say this pejoratively, because he has embraced the term, Obamacare or back in 2009 the opposition from the minority, of which I was a part, to spending $850 billion to stimulate the economy and the concerns that, you know, that that wasn't successful.

But I don't want to see any of that opposition destroy something as important as electronic medical records and the universal adoption of that and the interoperability of it, and the security of it. I'm still, as I stand here today -- and again, I thank you for giving the opportunity, I know you've heard from senator Warren on a lot of other great experts in the field, in the space.

And my knowledge is just, you know, maybe a mile wide and an inch deep, that's one of the reasons why I'm not taking any questions. Thank God I've got votes to get me off the hook.

But you know, I think about stage 3, where patients have the ability, maybe, to share with their providers information in their records, or maybe they have the opportunity to directly access those records, and to know what's in their medical records.

I think that's a good thing. It certainly reminds me, though, of the Seinfeld episode when Elaine went to the dermatologist with a rash, and she looked over the receptionist's shoulder at her chart and found out that she was a, difficult patient. You all remember that episode? I am an absolute fanatic over Seinfeld, I think I've seen every episode at least five times.

But and then finally in that episode, you know, she actually grabbed her medical records and went running out of the office with them tucked under her arm, and they caught her at the elevator.

Well, I guess once we get to phase 3 that will no longer be necessary, that people will have access to their medical records. And again, I think bottom line is it's all about saving lives and saving money. And right now we're still struggling with saving money. We have, I think, the greatest health care system in the world, I'm extremely proud of having chosen medicine as my profession and having been 31 years since medical school and practicing all those years and delivering lots of babies, and I miss it very, very much.

And I do empathize with the providers now who are facing all of these burdens and rules and regulations and, you know, whether we're talking about the meeting these requirements and hoping to get a little plus up in their reimbursement on either the Medicare or Medicaid program. You can understand. I think you do understand. And maybe more attention needs to be directed. You're so busy developing hardware and software and making things better and quicker and smaller, and all of the wonderful things that the people in this room do from the industry perspective, but, you know, if you don't have someone to purchase and you're not going to be successful if it's just a few huge hospital systems across the country, you need to sell it to every nook and cranny, every practice across this country.

So that's what it's all about, and I think that gives me a little bit different perspective, and I wanted to come today and share that with you.

Thank you very much for the opportunity, I appreciate it.

(Applause.)

>> Thank you so much.

>> Great to be with you.

>> Appreciate the need to go for your vote.

>> Absolutely.

>> Thank you.

>> All right, this will be the last conversation, or the last presentation for the day, but I hope it's not the last of the conversations today.

And by the way, we have not talked about the people who are out there in cyberspace but I do want to point out that after looking at the screen, it is clear that the video adds 10 years and 15 pounds to all of the speakers, so just want to make sure you at home know that.

The next talk we're going to have really does wrap up the day very nicely, and it's a conversation about the importance of the three part aim, which is nice unifying way to talk about what it is that we need to do in the United States system, and then the support that health IT gives to that.

And the person who is going to lead this is Judy Murphy. And if you know Judy, there's only two degrees of separation between Judy and anybody else in this industry. She had served on the health information technology standards council, she's been doing this work for 25 years, I don't know anybody who is more enthusiastic about the work that she does. She has responsibility for the programs and the policy, which is a significant amount of work.

And when I talk about Judy I usually mention certain elements. There's earth, wind, fire, water, and Judy. She is a force of nature. So I'd ask her to come up and finish out the day. Thank you. (Applause.)

>> Well, good afternoon. I'm lucky enough to be able to lead this last, and I will assert to all of you it's actually the best part of the day. Where we actually take all this health information technology stuff that we've been doing and bring it into real practical use.

Several times during the day it's been mentioned health information technology is the means to an end, not an end unto itself. I know that I'm dealing with a lot of folks who have done implementation out there. I myself before coming to ONC a year ago had done implementation for 25 years. Started when I was three or four.

And it's hard. And what happens as a result of it being so hard is that you get to the end of it and you actually think you're sort of done. You know, it's like feels pretty good because you got it in.

But I think you all know getting it in is like maybe the end of the beginning. But it is certainly not even the beginning of the end. And so the idea that we have to take the systems that we install and care and feed them and optimize them, if we're actually going to drive the the kinds of changes that we're talking about with health care transformation.

And that's what we're here to talk about is health care transformation in this last session of the day.

Now, remember, Farzad set out a cup of assertions this morning, because he's my boss and I'm a smart person, do what your boss tells you. In truth, though, they were really, really good things.

We believe that health care can be better. We believe in the power of information, and we believe in the power of health information technology to improve care.

And that's what we're really here to talk about some very practical examples of folks who have done that, who have taken health information technology and made a difference in the way they deliver care, and the way they pay for care in their settings, their organizations.

So let me introduce our three panelists here. And we're going to start with your left, my right. In terms of a small presentation, they're going to give a little bit of background and talk about this whole idea of the three part aim. And by the way just to remind everybody, better health care, better health, and lower cost.

And those three items are also what comprise our national quality strategy, and so they're really important when we think about keeping in mind why we're doing what we're doing. And we'll ask each one of them to address that from their setting.

And then again we're going to open it up just like we have in some of the other sessions for Q&A, what's going to be different is I'm not going to ask any questions, they're going to ask questions of each other and I'm going to give you all the time in the Q&A session to queue up at those microphones and ask your questions as related to your own experiences and what you're interested in hearing about.

Okay, so let me start the introductions. Dr. David wenn berg is CEO of the northern New England accountable care collaborative by Dr. Hitchcock health care systems and Maine health. The collaborative creates financing and accountable models and provides a common infrastructure to support the delivery of value based accountable care.

Dr. wenn berg also serves as chief scientist at the high value collaborative at Dartmouth institute. Prior to his work here, Dr. wenn berg cofounded dialogue and analytics solutions and serfds as their chief science officer.

Dr. wenN berg received his feckd agree from McGill university and masters in public health from the Harvard school of public health. He is an internationally recognized authority on the root causes of unwarranted variation.

His work has been published in many peer reviewed medical journals.

Our next presenter, and panelists, is Dr. Karen desalvo. Dr. Desalvo is health commissioner for the city of New Orleans, and serves as senior health policy provider to mayor Mitch lan drew he helps direct the health department whose mission is to protect and promote the health of new or leanians, that was hard to say did I say that right? Pretty good. And also serves Mayor lan drew on local state and federal state health policy matters she's undertaken a major effort to transform and modernize the city health department into one that is more efficient and capable of improving the public's health.

Dr. Desalvo brought to the room more than 20 years experience medical practice research and policy improving access to quality affordable community health for all.

She en vitioned and led the effort to create the innovative and nationally recognized model of neighborhood-based medical homes for low income, uninsured and other vulnerable populations in New Orleans following hurricane Katrina,

To move innovative health care coverage forward in Louisiana. She received her medical doctorate Attu lane university a masters in clinical epidemiology from the Harvard school of public health, and her bachelor's from Suffolk university.

And our third and final panelist is George hall vor son, he's chairman and scroe CEO of Kaiser Permanente headquartered in California. Kaiser is the largest health plan and hospital system serving more than 9 million members and generating nearly $50 billion in annual revenue. George hall vor son has won several awards for his commitment to health IT and for his leadership and vawfflet in advancing health care quality.

The development, implementation and maintenance of Kaiser Permanente's information technology infrastructure represented a multi billion strategic investment that provides comprehensive care coordination and continually improving quality of care and service to its members.

He is the author of five comprehensive books on the U.S. health care system, including his most recent one, health care will not reform itself. A users guide to refocusing and reforming American health care.

Prior to joining Kaiser, Mr. Hallvor son was president and CEO of health partners which was headquartered in Minneapolis for three years please join me in welcoming our panelists

To start do you want to do some introductory marks.

>> Thank you Judy this is a world of small separation I don't know if it's 2 degrees always but you have known George for quite awhile because my previous job Kaiser was one of my clients, and my anecdote which I'll tell which is appropriate for this audience is one time I was going to Kaiser in Oakland and I got in the cab and we were driving in the cab and the cabdriver leaned over to me and said you must work for epic. I said why would I work for epic? Because we just keep taking people up there and back there all the time.

But it's great. And then Karen and I actually had the honor -- I had the honor of working with Karen after Katrina, and have known -- and she's a dine a mo, so really for me it's very humbling to be on this panel.

So the northern health care collaborative it was just started officially started in March we've been working at it for about 18 months, since after the affordable care act had been passed but before NAVCO regulations have been -- had been written.

And it was started, like many of these sort of collaboratives have started in a very grassroots way it happened in '02 of the CEOs of the health care systems in New England and directly and through reputation, the other two entities.

And co-s, we had talked I had been individually talking with them about getting ready for accountable care, whatever it was going to be like.

And I had the benefit of being in northern New England where the relative patterns of care are quite conservative, and so they had been looking for new opportunities to move away from the fee for service environment.

And so these four streams had been going on between the four systems, and actually Dartmouth college which is the other entity that's part of our group.

And I got tired of both driving across north New England and secondly talking about the same thing, and I said look you guys are all talking about the same thing. I had this sort of crazy idea that instead of you each building your own infrastructure of building accountable care what if you came together, the reason we were successful in bringing those two groups thog is they were only moderately competitive they were more cooperative in terms of how they delivered care across the state. But they also had this understanding that if they did things together it would accomplish two things. One it would probably lower the cost of ownership of building an infrastructure, but more importantly, and I think this is a really part which is a really interesting aspect of the technology, is that if they did things together and actually learned from each other they would actually accelerate their movement into this new world.

In a way -- and sort of this is the underpinnings of our group is that technology is necessary, but it's clearly not sufficient to get to where we need to get to.

So what are we? We have -- we're really a product and a services entity. We're a shared services organization that support these four entities as they're moving into accountable care, and actually we'll be supporting many more as we grow.

And our mission -- and I didn't ask to be on this panel for the mission, I don't think or wasn't asked to be on the mission, but it actually is to deliver products and services to support providers as they migrate from fee for service is, production oriented care, into care that's paid for by capitation and other end global budgets. While delivering efficient and high quality care, aligned with the triple aim. So the triple aim is actually the ending of our mission statement.

The products we're developing is really an integrated information system. We take data from a whole variety of sources, from epic, concerner and sen tristy, from a whole core of lab entities including quest and labcore.

We get information from the Lowell HIE we get ATD information as well as from that lab entity. And we haven't started yet but we'll be getting patient reported measures in the second quarter of next year.

And we also have claims data. The data is integrated into a patient centric longitudinal record, and it becomes a sole source of truth for the applications that sit on top of that. And as we all know, there is no such thing as truth in health care data. But there is an agreed-upon standard that we can have in terms of what we agree to call truth.

And what we're trying to do by having a single source of truth essentially is to keep everybody on the same page from an information standpoint, so that we can argue about the care we deliver but not about the data and how it's aggregated and organized.

Once the data are in we do a whole variety of product models triggers and alerts and create essentially a population management health management system or as we call it health population one person at a time. And on top of that application care coordinators for physicians and administrators who are looking for the contract performance, if you will.

And again all built onto the same information technology.

We've tried to do some things which are a little bit difficult in terms of having the full nuanced value of a data warehouse with near realtime information and the way we've done that is really through our selective and practical applications of realtime data. And a perfect example of that is our connections with the health info net which is the HIE E in Maine we get HL 7 ADT messages from them essentially in realtime. And those ADT messages are parsed into the critical aspects for managing populations which are transitions from management, ER free standing facilities and that data bypasses the EMR and shows up at the care physicians and care coordinators so they actually know within minutes somebody has been discharged from an emergency room for example.

The application suite we started building in July our first application is rolled out the care coordinator application on Monday, so this is going to be a long weekend.

The physician application is the next, and then the administrator application is the third. We've done something which is a little bit tricky from those of you in the vendor world out there, which is our investors, founders, owners, or also our clients, and that is always a double edged sword but they're actually building the product, we're building a product with them and for them. So that's actually been very fun for me to do that.

And our aggressive timeline is to have the last two applications out before the end -- before July 1st. And the reason we're actually able to do that is we've taken, again, a very practical approach which is we don't want to have it perfect, we'd rather get it out, used, feedback, and then iteratively build that on top of that.

Our goal from an information standpoint is to have not just a regional population based using it systems hospitals and health care providers, but actually reach out across the country. And our goal there is that we have a very intensive benchmarking data in terms of best practices along the triple aim, and the more systems that are involved with that and the more variation, which there's tons of variation, is there, can inform us as we move forward.

I'll stop with the technology and then add the last piece before I turn it over to Karen, which is we're also realize that the information is just as necessary as I said before, but insufficient. So we actually have collaborations around the technology, and we're trying to create a word that in my old age is hard for me to say but I'm getting used to it an ecosystem if you will of users of the information.

So our first one is the new care models so each of these organizations are either pioneer ACOs, or shared saving program -- MSSP ACOs. Three of the four already have commercial ACO contracts, which I didn't talk before but we're actually having Medicare data as well as Medicaid data all into the same information system.

Our first model is the new care model. They all have patient centered medical homes but as you know a patient centered medical home varies dramatically from area to area, and we're starting to get enough data now that we can actually see insights from the way they're constructed, the patient medical home in terms of how they're doing in terms of getting patients actively involved in shared decision-making, improving the care, and reducing the cost.

And that ecosystem, if you will, of data feedback not only is great for product improvement standpoint, but it's really going to be the critical aspect for what we're trying to accomplish here in the end, which is really care associated with the triple aims.

I could go on, but I won't.

>> We'll give you some more time later.

>> That was probably 10 minutes that is impressive

>> Thank you. I wasn't even watching the clock.

>> So David was a knight on a Whitehorse and came down to Louisiana when we were still in a debris field to help us rethink how we would build our health care system in a better frame I'm going to get to that but I also want to publicly thank Kaiser Permanente because also immediately after the storm but consistently year after year, your employees volunteer to come to the gulf coast and help our communities continue to rebuild. So we really appreciate that spirit of volunteerism and it's always joyous for them you can tell they love it, we really appreciate that. (Applause.)

So the story that I want to share with you is about the transformation of our health, the care culture, towards reform, and how IT has fit into that, and talk a bit about how the triple aim mirrors that and where we're going for us, really health is the place we are right now with the triple aim, we're beginning to think about how IT forms it.

For Louisiana, we have unfortunately been consistently at the bottom of the pile with respect to care indicators, high costs, poor quality irrespective of payer, and unfortunately have a black box of some 20 percent of our population for whom we really don't know anything about the kinds of care that they're receiving, or the cost of that care, that's our uninsured population.

And for add nults that age window of 19 to 64 it's upwards to a third of the population.

And that is unlikely to change, in the near future, but we have found some good end rounds that help us understand. What we did do is we said given that the flood waters of hurricane Katrina closed all of our hospitals essentially and created an opportunity for us to work together in a different way, what would we build.

And we pulled together key stakeholders be it hospital association, physicians, nurses, nursing homes, legislature, academics, and rag tag other people like myself and created a charter with a set of values and a goal that called for everyone to have access to an affordable health insurance product to use health information technology to improve care, to found the new system on primary care and prevention, and to create a culture of quality in a place where we could sit and talk about quality. So it was really four big items for us.

Statewide we've had a lovely reresurgence in united care and although in the health ranktion we, in Orleans we're in the top 10 percent in primary care providers per capita and that is a deliberate policy action taken after the storm to create a great work environment for primary care, use incentives to recruit and retain providers, and the great environment really was not only the medical home but the opportunity to use data to make decision at a population level so that was using electronic health records primary care structure, Louisiana in particular New Orleans was a place that had relied on the hospital health care system for generations so we did not have health care for insured we have done successly, greater 20 percent of the population uses medical homes and some 100 points of care that range from federally qualified health centers that offer robusts services from dental and medical health specialty care, and just a few mobile units hanging on at some of our harder hit areas like some of the lower parishes

That means that now the uninsured in particular have access to great quality care which we know because their NCQA recognized and/or are a part of a network that uses quality based care, and are part of a collaborative which has formed which I'll get to a little bit later, but we are now it's not just -- it's care but it's good care so we have been able to define that, and define that as a state and as a community, that this is what we should expect for our population.

The quality piece was that we decided we wanted to create a safe place where data could be shared and conversations could be had about health care quality. We established the Louisiana health care quality forum, which carried forward a lot of this blueprint in four areas and continues to this day. The forum became the recipient of a multi payer data base that hebd dialogue, helped to us create. It has now undergone additional iteration and is ready for analytics, I have to tell you after all these many years we're finally getting there.

And has been the leader for two of our ONC grants, the health information exchange, which has been a successful statewide endeavor that has touched the majority of the parishes, counties and states, and has enrolled over 40 hospitals already, and nursing and ambulances and home health agencies thinking about linking together a broader system of care, a recent extension grantee has exceeded the goal in enrolling providers, primary care now specialty care having people obtain meaningful use to the Congressman's point earlier.

The third area that we wanted to look at was health information technology, and how that would enable better care, not just at the point of care, but really thinking at the population level. So for us, this means that when we had this experience that the city flooded and we were shut down for 30 days, under mandatory evacuation, and people were scattered all across the nation, I suspect people in this room sheltered and took care of people.

Those folks left with pieces of paper describing their medications, it was a very unsafe situation particularly for people on chemotherapy regimens or on on anticoagulants so there was a very acute sense for doctors in the community as well as the systems, that we needed to fix that because in times of disaster we need to be more prepared to help people maintain their care, whether that was for, you know, HIV or TB or chemotherapy for cancer.

We also needed to do a better job every day. And the fact that we were building from the ground up, especially the primary care infrastructure, was a tremendous opportunity. We had no legacy systems to move out of, we started by and large from scratch in electronic health records, and many providers, I've seen some of them are here in the community, they can tell you they've already been through a second iteration, a stepping up to a more sophisticated software system, because it really they realize that they wanted to be able to do more for their patients than what the original systems, or they've got en the system to modify. And we've moved in a direction of having the majority of the providers and ie the patients in this community in the New Orleans area be have access to their health information, on electronic health record that is not only relational database but web based and that means if they have to evacuate et cetera we can find that information for those patients, and that's always important.

But it also means that we're able to do a lot more with respect to population management, in the clinics this is so critical when you have limited resources and you want to know exactly, try to understand who you're taking care of and are you doing a good enough job.

I want to get back into that when I get into payment and the last part of the system. But before I get away from HIT I want to tell you a cultural success and then a real success, to the Congressman's point about doctors not wanting to move into health information technology, I say all that like we just implemented electronic health records and now we have an exchange as though it was just as easy as pie.

And of course, it wasn't. But it was easier than I think you could imagine for a variety of reasons. However, one of the memories that I'll Alaska hold is that our state medical society when they had to sign the charter indicating all the things that we believed in for our future of health care in Louisiana was that they needed to change the policy in the state medical society ootion manual that said they oppose the use of computers in medicine.

(Laughter)

This was the spring of 2006. And they were so excited to be a part of this movement and know now what they do and even though they were craimpgy about the challenges they have really been a champion in our state, the physicians as well as many other organizations, to understand how important this is for quality and safety and for cost reduction. So that is an example of how we have really made institutional change.

We are a recipient of a third ONC grant which is a Beacon -- crescent city Beacon grant part of the Beacon grant that's a chance to take all the pieces we had great primary care electronic health records increasing cultural of quality, and put that together in an effort to linked with hospitals and somewhat specialty care and got us to focus on population level indicators and turn our attention towards cardiovascular disease and diabetes something David encouraged me to do seven years ago but it's hard to herd cats.

The institution has done great job to pull community members to get everyone to agree on a set of standards to define what we need when we say our population, 29 diabetes you all know this better than I but it's been a tremendous exercise to get us all focused on what really matters with respect to the population's health, and now the information is live going into an information exchange for our community, I believe there's 170,000 lives in there right now, and there's notification for ER visits.

It's a really tremendous additional tool for providers, and for the clinics to be able to understand how they can do a better job of improving care.

The last piece is about the cost of care and -- well not the last piece, I have one more and I'll be quick. The cost of care is something we have been experimenting with in Louisiana. I mentioned that we talked about having access to affordable health insurance for everyone as part of our charter. We haven't achieved that, but we have worked on some end-arounds to create a financing mechanism at a minimum for the primary care portion of what we have done that has strung together.

And in so doing for the New Orleans area have learned that capitation based is a great way to pay for primary care it encouraged a development of teams and forward approach to thinking of peoples work encouraged providers to work together even though they were competing they were thinking they are stronger together we are now under 1115 waiver which is different than the original grant we have, we've modified that with the help of the state and CMS into a place that will fit in Medicaid it's not exactly where we want it to be with respect to population management but what we were able to do which we could not do under the last grant is actually use the data of Beacon to understand who we care for, what are our quality indicators and how are we showing improvement in that.

So the bonus system isn't about the structure oh you're a medical home it's actually you're making exrofflets in the population health so it's a great step forward for those providers, where some of them see they're going as creating NACO type model so they can use in a for value based contracting as the state moves forward

I want to say a word about health because I'm a health commissioner and I think about it every day, which is my job, so it's a really -- public health is -- has a paucity of actionable data so the information that I work from is often two, three, four years old.

And it's very difficult for me to know if there are hotspots, where there's asthma, that maybe there's a housing issue that I could work with our housing authority on, or where people who are ability challenges live that might need additional emergency services like in flood or power outage one of the many opportunities I see that we have built as a foundation from the data is to have access to that for public policy decision-making. For making policy but also for really helping the community in a crisis situation like disaster.

We just had Isaac in advance of what happened to the east coast with Sandi and the experiences were similar with respect to the power outage and the challenge for some of the elderly and those who are I am mobile, and I think (immobile and I think having the data that is more realtime and more claims data is a tremendous opportunity within Beacon, because it's clinical, right, it's not a stale.

What we're looking at in New Orleans now, though, thinking about health is having all the social determinants. How can we understand who is not using the system, who else is in my community how do I find them and get that information into that multi data pair payer base, much looser idea than just who is using the system. We have gone from zero to within 00 but we know we have a long way to go.

We have a lot to do to understand about our cost equation and how we pay for it better but I think I'm really proud of the progress that we've made. Thank you.

>> Thank you. George?

>> Very impressive. A couple comments by Kaiser Permanente. We are blessed with being a vertically integrated care system, and we have 9 million members. So we have hospitals, clinics, pharmacies, labs, the entire infrastructure of care within Kaiser Permanente, and we take care of an entire population, and we do it for prepayment.

Which means we're not fee driven, we don't have to do pieces of care, and bill for pieces of care. We get a cash flow from the members, and with that cash flow we deliver care. And we care inside that organization

And it basically is a macro model, and until relatively recently when we were forced to do it for external reasons, we didn't even have a price internally for something like a CT scan for an MRI, because there was no internal structure that involved pricing anything.

Everything was based on costs and budgets and appropriate care.

So we have this vertically integrated system, a population we're accountable for, and we concluded quite awhile ago that the very best way of taking advantage of that organizational model and taking care of that population would be to have sufficient data about the people that we're taking care of, so that we knew what the care needs were, we could track care, follow care, track outcomes. So we decided to go electronic, and we made a commitment to have zero paper inside Kaiser Permanente. We wanted to have paperless clinics, paperless hospitals, pharmacies. We wanted all of our imaging to flow electronically, so we wanted to be filmless imaging.

And we set that model up and have been working on it, and we have pretty much achieved that model. We are basically a paperless care system, and our goal is to have all of the information about all of the patients available all of the time to caregivers at the point of care.

So we set that as a goal. All, all, all. As an agenda, and then designed our rollout of our care systems, and our systems around that.

And it's actually a really good model, it works incredibly well. We've managed to follow up on patient care, focused on patient care. We've cut the death rate for stroke by 40 percent, we've cut the number of broken bones by a third, we've basically our HIV patient death rate is half the national average, we've got one of the lowest dengt rates for HIV patients. Because we've put together a total paj of care, care plans, track patients communicate with the patients, and we put together an agenda that uses the data in systematic targeted ways to follow up on care.

We just put a new system in place that goes into the database and identifies -- we call it the outpatient safety net. The outpatient safety net scans through the database to identify whether or not there were pieces of care that maybe we should have delivered, or reminders that we should have sent out or patients not refilling prescriptions that they should have refilled, and created a scan and identified last year across the care system actually two million opportunities to do interventions, to send somebody a notice out to invite somebody to an appointment or follow up care and we can do that because we have the database and because we have the cash flow model we have.

And when we do something like cut the number of broken bones by a third it doesn't hurt us financially, because we're prepaid and we're not based on those admissions. So that actually saves us about $250 million a year in hospital admissions that we don't have, because we don't have broken bones.

For just about anybody else on the planet that would ab lost revenue. So that's a good model. We strongly recommend it, and we believe that we -- we believe to a passion and meaningful use, we really think if you put data on a computer and don't use it in a meaningful way, that's a waste of money. But if you put data on a computer and then actually use it in a meaningful way that's ain credably powerful and important thing to do and patient care is better as a result of that.

So that's one comment. The second comment I'd like to make is as we look into the future what we believe to be true is that the future is going to have care delivered on four care sites. And the four care sites, the first care site is going to be hospitals, hospital equivalents, nursing homes, places where patients are in bed, and are taken care of over time, and in that setting we need the very best and the very safest care.

We need the lowest infection rates best data flow we need those patients to be taken care of, and we think that inpatient setting is going to be taken equipped with increasingly good electronic, technical equipment. That the inpatient setting is going to get better and better relative to monitoring, tracking, follow-up. So we think that's going to be an improving care site.

We think the second site of care is going to be face-to-face encounters with the patient in the care system, in places where the patient actually goes somewhere to get to the care site. The clinic, the medical office, and we think there's going to be a distribution -- and we think that's going to go to two extremes. One extreme is going to be the mega clinic, the macro clinic, where everything exists, the patients go there and they have one site delivers all care and we're building some of those and we're very happy with them. And the other end of the continuum face-to-face care is going to be the care kiosk, it's going to be the little outpost, the place that sits in the pharmacy or sits in some other care settings or sits in a school or work site, where the patient goes in, has an encounter with maybe a nurse who is connected in an ideal setting upstream with a complete infrastructure of care.

So all the intelligentsia of care is upstream and connected to that patient through the care site, but that care site is going to be very important for a certain number of patients.

So we think that's going to be the second site of care and again that's going to be increasingly supported by really great technology. Computer technology that's getting better every day.

Third site of care, we think this is going to be equally important, is going to be the home. There's a certain number of patients who really need care in their home, will benefit from care in their home, and if we deliver in-home care with the right technology, the right support, the right interaction, the right communications, the right follow-up, we think in-home care is going to replace both of the first two sites of care for many patients, the care is going to be better for those people, it's going to be more proactive, it's going to be -- the interventions are going to be good and the ability right now in the home to have a face-to-face electronic encounter with your doctor or your nurse is getting better every day.

And that whole world of having the home be a site of care, I just heard about this isn't one of us but I just heard about someone who is bringing basically little trailer houses, in the people's back yards and they call them something like grandma -- have you heard of this?

>> Yes

>> What do they call them grandma sites or something? They're basically bringing them to peoples homes hook willing them up it's a living quarters but it's got great technologies you're doing blood pressure, doing EKGs doing all this on this site, which is in home care, but the future of in home care we think is very, very robust, and it's going to be well equipped

And then the fourth site of care, we believe is going to be the internet. And the internet is going to make the world flat for much care. It's going to be able -- people will be able to get diagnoses over the internet, follow-up care, monitoring of their care, tracking of their care, care plans, care strategies, second opinions.

There's going to be a very rich set of apps that are internet-based apps that will help people, and interestingly, the fourth site of care is going to be a place where a lot of the placement interventions are going to take place, where people are reminded about decisions that need to be active or reminded about decisions to eat well, and that's sort of a place for coaching and nurturing and even some serious counseling, patient-specific.

And the fourth site of care is going to be operating at the level, one level it's going to be very patient -- specific, where it's part of an overall care team, and another level where it's completely disintermediate 88 ing the care system because it's available as was one site very cheap way to purchase for particular pieces of care in a way that's much less expensive than it is at other sites.

So as we look into the future we actually believe that the future of care is going to be supported by technology, in all four sites of care. And that if we do this really well, care will be less expensive, more consistent, and better. Significantly more convenient. And that the care outcomes are going to be better. So we're really optimistic about the future of care, and everything that we're seeing from computerizing the pieces of care and the sites of care that we're working with, causes us to feel like this is the right path. This is the right direction.

And we need to make sure we get this right, because there is no -- there's really no -- I'll end with that, there really is no good alternative to reengineering care. You've got two R words at play. You can either ration care, and there are people who believe this country should end up rationing care, and I think that would be just criminal. And there's the opportunity to reengineer care, make it more affordable. And if we reengineer care more appropriately we can make it more affordable and the rationing question never needs to come up.

So the path that we need to go down, and we need to do it across the country, is the path of reengineering care. So end I'll end with that.

>> Well, I'm liking the trailer idea because I live here in D.C. and my husband and I share 700 square feet, and he doesn't need any care but I like that trailer. (Laughter)

For him, not for me.

>> Husband trailer.

>> Yeah, you know.

>> That would work.

>> Let's go ahead and queue everybody up at the microphones, I'm sure you've got just all sorts of questions. Anybody want to start? I can barely see the microphones.

Is this like the end of day sort of lull thing?

>> Who drank coffee?

>> Yeah.

>> Over here, okay, good. Thank you.

>> Hi. We actually asked this question a lot tweeter space as well from Kaiser Permanente TCL George if the Kaiser model is so successful why is it not being deployed in many states? Apparently Kaiser plants are only allowed in a few states in the union right now.

>> I'd say allowed is the wrong term.

>> Just don't go to Georgia.

>> Right, there are basically 2.8 trillion reasons why a Kaiser Permanente is not all over the country, and that is the current model of care does extremely well as a business model for the people who are practicing in that model of care.

And the hospitals have rich cash flow, care providers in this country make more money than care providers in any other country. The pharmacy industry makes more money. (Indiscernible) technology makes more money. So the business model of care works extremely well for the business units of care.

And so Kaiser Permanente has a different model but there hasn't been a perceived need for the model in most of the country because the current model works so well that the status quo has great political power and great market power. And I think what's true of the future is people will be looking at the things we're doing, the things we're achieving and basically saying we can't afford that old model they've got is 2.72.8 trillion and we now need to look at alternative models and there's going to be a lot --

I know for a dct CO is basically modeled afterous the so-called medical home our care coordination, the country is evolving to look like us out of necessity.

So that's the first part of the answer. And the second answer is we're not for profit. And we have absolutely no stockholders. Which means if you're a for profit company you have to grow to say stay in business and if you're the CEO of a for profit company you're required by law to maximize your shareholders value. I'm a CEO of a not for profit company and I have a mission accountability to maximize the care for the people that we cover. But I don't have any financial reason or market pressure to grow.

So we don't need to go to the next state. There's no reason -- California is huge, Colorado is a great state, we're in some very -- Hawaii is a lovely, lovely place.

We're in good places, and we're doing well in the good places. So we haven't had a reason, market pressure, to expand, and the rest of health care has had a rich enough cash flow that there's been no reason to transplant the model until now.

>> Also if you look at this is preGeorge also. Kaiser tried to spread quite aggressively in the old model and there was a huge culture clash I think mission clash culture clash. goy agree with George I think the reason, in many ways they were ahead of their time and I think the issue now is that the financial crisis is going to drive more towards capitated type payment models.

And then it will be -- there are a lot of people that will be running as fast as they can to understand how to be like Kaiser and I think that's -- I do sense that's an area -- I mean I'm talking now to places in Mississippi, and in Iowa, as well as northern New England, who are all moving towards some version of a capitated model. And the reason is they can't -- the business as usual is no longer acceptable.

And I think what's also changed differently now is that for many of the providers, they actually don't like what they're doing very much either under the current model.

>> Yes.

>> So under a model where the only way you can quote unquote control costs is by reducing the procedure price, the providers do something naturally, which is they do more procedures.

At some point that running gets too hard. And then I think actually makes people think differently about this concept of a capitated type model.

Whether it's -- even people are using the word now which they weren't allowed to years ago.

>> Right.

>> Exactly. And a quick comment on that. When you prepaid as we are and get the money up front then you can reengineer care and you can do things that make sense. When you're paired entirely by the piece when you live off the fee schedule then the only thing you can do is on that fee schedule. So they're prapd providers are trapped in the fee schedule it's a rigid fee schedule medical homes make a difference in the world bus you can reengineer care in a medical home because they liberate the nurse from the fee schedule and they let the nurse get on the phone to make a call, that would be fraud that would be literally criminal fraud if that was done in a setting outside the medical home.

So we've criminalized certainly leftion of innovation under the fee schedule model, and so we've trapped the current care system, who lives in that cash flow, in that model.

But we're liberating it. So the ACOs and medical homes are now moving more toward by the care package and not by the piece and that's incredibly liberating and providers can provide care and pieces of care when you have that kind of cash flow.

>> Our experience, when we built from the street up of care, was that that medical home type team based model is what grows in the wild. The preference for providers is to work in teams, the preference is to work at the top if you're licensed to think population based, and we had the luxury of it because we were not trapped in the fee schedule based upon either, you know, the resources were philanthropy and then $100 million grant that didn't have the strings attached.

When the waiver came into being which had the fee schedule associated, it was palpable, the changes in the medical home infrastructure, and a refocus on volume based, production based care for those providers, so they can make ends meet. And the innovation began to change.

Our Beacon project might be able to talk about it, but that happened in the middle of Beacon and the reinnovation and care for that Beacon to be successful start to shrink once they started the payment they began to come back to the table

>> Fee schedules stifle any kind of enhancement because they starve it. Yeah.

>> So we got through this prepayment idea and went through fee for service. Talked about capitated models would you describe the types you're seeing because not all I'm guessing are pay for value am I correct?

>> I think now, in my mind -- not my mind my opinion I'll say I think we're at the very beginning of pay for value from that standpoint, but I do think that what are different about the new models are that there are some fairly strong focus on the other two legs of the triple aim, from the older versions of capitated models. And I'm distinguishing that, I mean that's a distinguishing from Kaiser model. Which has been very focused on health from the beginning.

But if you look at the 90s version of capitation, it was very much about managing cost. And very rude amount ri aspects of health.

>> Yes.

>> I think the part that makes me worry right now honestly is that the ACO models that are currently involved are really very baby steps towards prepayment type models, and value based models. And so they're still paid -- physicians are still paid under fee for service, and then there's a shared savings at the end if you do well.

I actually did on purpose I called -- the real world is tragedy of the commons it's actually tragedy of the greens when I think about it the question is do you want to eat and kill what you have now or do you want to be conservative hope you have something at the end I think you have a focused organization who is willing to do the right thing under even the ACO model because there's still temptation to do more under the current payment model.

>> And the other thing about the ACO model, Medicare advantage is a prepayment model. And you can do all kinds of great things with that prepayment model. And one of the things that was fascinating, when the five star program went into place, we loved the 5 stars by the way because we do really well. But the thing that's really interesting with the five stars is NCQA had the greatest improvement in the quality of care in the history of NCQA.

And lives are being saved, when they put the five stars in, care improved across the spectrum.

>> It's a rising tide.

>> It's the only country in the world that actually paid more for quality and actually mesh raably got better quality. It's an amazing approach.

>> Did we answer your question, Larry?

>> Yes.

>> All right. Oh, he's tweeting as we speak. Over here.

>> Hi, I'm nor a super from ONC I'm not sure I'm allowed to ask a question but I'm going to.

>> I don't know, guys, do we want to vote?

>> Go ahead.

>> Thank you. I really more wanted to -- I'm a New Orleans native so I wanted to thank you Dr. Desalvo for all your hard work on behalf of my city.

And also just was struck by my dad was actually the chief of psychiatry at charity hospital for 30 years, so I follow with a lot ofgraphy and anxiety what's happened to the mental health world down in Louisiana. And as you all were speaking I just asked the panel -- and I think about the underserved populations in health IT and patients and, you know, often we're asked that at ONC, what about people who don't have resources, if they don't have computers, do you still work in AARP, we talked about older consumers, they don't know how to use this technology

So I have my answers to that but I wonder how you all respond to those issues as people that, you know, think a lot about the vision and the future of this field, and how we engage some of our most vulnerable populations.

>> Mental health is absolutely a challenge for us, and we have had a real dramatic change in the kind of infrastructure that's available to the population who is served -- who was served by what we call the third floor at charity hospital.

Honestly, much of the change has been really progressive and good in the state. It's been a movement towards community based services, that can help even the most marginalized populations, those with mental health issues, who touch the criminal justice system.

We have gaps in a number of areas, particularly for kids and for folks who are dually diagnosed with mental health and substance abuse I could spend an hour talking bit but I won't. But I will say vis-a-vis this conference is, and my remarks, when I talked about primary care development, I was cheating just a little, because those points of care actually include mental health, as well.

And in fact, if you ask all the providers the type of care that they provide, mental health is the most common type of care provided in the primary care and mental health infrastructure that has evolved since the last seven years.

We have done quite a bit with integrating mental health services into the primary care setting, is is what I'm saying. And we were able to innovate and do that when we were paid without being tied to the fee schedule. That has now changed, since we have been tied.

So we are using special funds that we received because of the recent tragedy the BP oil spill as well as om is other funds we're using that as a community to ri to reinstitute mental health embedded care that's part of the continuum it's such a critical part of great care to be able to. What we had done in many of the clinics including my own was there was an automatic screen, when you hit the door, how old are you your two item screen are you impressed or PTSD it was so prevalent.

Lower level item if you were flagged and then embedded this N the clinic and a warm handoff available for the social workers and other psychologists who could do real therapy or real assessment. And in fact, in our medical homes we had a medpsych duly trained providers as a part of the mental health team who were doing both primary care and mental health setting to be able to do both sides so we have some real nice models in that community but it is inhibit whd you get to payment. Using mass health screen.

Medical health advisers have been twansed in using mental health records those systems are not terrific and they don't always work great because of privilege east issues so there are some really relevant challenges that we have to sort out.

And every community has been working on that. So we are trying to not only make sure we recognize it when it's not known, but in the system that takes care of those with severe mental illness, specifically what's happened is that our new managed behavioral health provider has a platform of data that they're encouraging all their providers to use so they can be a single point of entry for data.

That's going to communicate with our Beacon locally and it's talking statewide with our health information exchange so all that information will come in in protected fashion so we can follow people through the system.

But for me, as health commissioner, it's pretty critical obviously because not only are we missing mental health in primary care but as you all know folks with severe mental illness are less likely to get primary care more likely to die as a result of it so we don't want to miss that, those missed opportunities for care in that population.

>> I think the imperic evidence of this new model we're going to is fairly weak but we actually wrote a paper early in the fall that looked at the physician group practice demonstration project and we looked at sort of where was the care improved and where was the inappropriate care reduced.

The health improves excuse me and inappropriate care reduced the big point in that story was the biggest yar where there was most improvement was in the duly eligible population and this was the area the population people were quite worried about this new model what would happen to that group.

I'm also very optimistic from the standpoint of again payment models are not sufficient, but they are definitely necessary for moving to this more innovative model. And the nice part about these new models is that all of a sudden you are accountable for all the care of the population, and so the dichotomy that has occurred for a whole variety of reasons between the mental health care system and the nonmental health care system doesn't make business sense anymore.

>> Exactly exactly.

>> People are starting to innovate in a much more aggressive way and try to address that. It wouldn't mean there wornt still be gaps we've been a bad place for a long time it's going to take a long time to get there but I'm very optimistic helping to address that pushing people to innovate around that area.

>> This is just a really important point when we think about this illness model that we've had for so many years, and going to what I'll call more of a wellness model where you actually are a partner with your provider, and it's about what you can do together to make sure that your life is good.

Rather than thinking about those sick times, and going to visit somebody during those sick times. And it's a culture change. And the payment model is just helping us get where we know we need to go. So those were really good comments.

Okay, over here.

>> Hi, I'm Steven Palmer I'm the state health IT coordinator in Texas. I really appreciate your comments on the movement toward accountable care and the miscellaneous variations thereof and particularly kind of fully capitate, and so on.

But I wonder a little bit about how generalizeable each of your stories is to the broader world, where the rest of us are having to deal with those 2.ail trillion reasons why it's hard to do.

You know, we heard about a situation with pretty cooperative -- or providers with a history of cooperation, not that much direct competition, and kind of a Greenfield opportunity where the local health care economy was wiped out, and then an organization with a 65, 70 year history of evolving into this space.

But the rest of Russ competing against this en sconsed set of economic dynamics and I'd be interested to hear your thoughts how we get from here to there.

>> Okay, next question. (Laughter)

No this is tough right

>> The answer is I think in lots of failed expermentss, and some successful experiments. I think that the issue here is that it is a huge economy built -- and people are optimized under that economy.

But it's an economy that I mean who knows -- whether we fall off the fiscal cliff or we glide into one and then are resurrected back, I mean no matter which way you cut it business as usual is not going to continue. Either from a funding standpoint, from the public sector, and quite honest Leal from a private sector it's clear if you listen to the CEOs and they're talking about the issues and now they're actually saying it's okay to raise taxes a little bit right underneath that they talk about our biggest worse are health care costs and the infrastructure we need to be able to make this a viable economy.

And they say we want to stop talking about taxes and get to where we need from the other side. I actually think coming back to this issue that dollars are not sufficient, but they are definitely necessary.

And out of the crisis that we're facing, just like New Orleans got to reinvent themselves from a health care environment after Katrina, which I'm not saying we shouffled Katrina across the country but we're going to have a Katrina like event from the financial standpoint I'm coming back to this point we're optimistic old world values old en sconsed traditions change when it's necessary, and it won't all be successful, and there will be failures, but I think out of this will come a much better environment for us to live and be people.

>> And the magic is to buy care by the package, and not by the piece. If you want to escape the piece work, total dismen tifs and dysfunction a letter you really need caregivers who can sell care by the package. When heart transplants flipped from being a pile of pieces to being a package, the price went from about 300,000 down to about 150,000. And the caregivers actually made money at 150,000, because it reengineered every piece of care. They stopped duplicate tests stopped unnecessary admissions.

They went through a complete reengineering because the care was purchased as a package. And care sites all over the country can do that kind of reengineering as soon as they're paid by the package, and they could count on that package as their cash flow, and it has to be a dependable cash flow, bass you can't reengineer around something you can't count on.

But if you can count on it then you can reengineer around it and you can make huge improvements and care delivery, and the caregivers of this country have more than enough creativity to nail that entirely.

Eye surgery, LASIK eye surgery went from $3,000 an eye down to 2,000 down to 1,000, and they reengineered the process, the care got better, because it was sold as a package and not by the piece.

So we need to get there. And ideally, a package pays you for taking care of a population, so you can take the entire population and figure out how much mental health do they need here, what do they need for nursing care. If you can manage the care around the total nealds of the patient you can do some really smart things in reengineering.

So it is essential to change the cash flow and to get the cash flow into various kinds of package purchasing and I think we were experimenting with various approaches, and I think that's not a bad idea to do the experimentation. But I think we need to understand that we can't get there unless we do that.

>> And it actually does sound like a combination, you know, the changes in the way we're paid will drive the way we deliver care. But we've got to change the way we deliver care in order to get paid differently, too. It's a chicken and egg, if you will.

>> We do about 12 million needs at Kaiser Permanente where it's complete doctor visits done electronically that would have been in the doctors office.

Totally in the year. And if we would have lost fees for you will of those we would have been less like three do it.

>> Can I ask.

>> Go ahead

Q. Reask the gentleman from Texas's question being from his neighborhood Louisiana, and perhaps I may not have understood entirely my version of that would be what have you learned that we should just skip right over, as we move to being where you are. Because clearly there have been some failures all over the country, and if we could sort that out, you know, it would be really helpful.

>> Yeah. That would be a long talk, Karen.

>> All right.

>> But I do think

>> Later on.

>> Integrated models are going to come in, and so I think vertical and horizontal integration is a key aspect of success.

Both because you need to innovate together but also because you need a stable base from a financing standpoint to do that.

I think the quid pro quo is people are worried about price competition if you do that, and I'll say it here and I guess wherever else, I mean, I think you can't have your cake and eat it too and everything, so if you do want to move towards vertical integration you also have to be willing to have that hard conversation about wlas the right -- how much are we going to spend on health care what's the regulatory environment to keep us in the environment -- I mean in line with that.

There are areas that are going to have a hard time, though, in this area. I mean, I am my father's son. Mississippi and northern New England some areas of California are going to have a much easier time than are mi am I, New York, and other areas which have built an incredible infrastructure and they've invest add lot of money on fee for service.

And that everything from the bonds that they're paying under the predicate that they're going to continue under that business model to the way the physicians are organized, it's going to be -- it is going to be --

>> Challenging.

>> Ugly.

>> I think, David, there is somebody over there, who was waiting longer because this is our last question, sorry guys.

>> They can both ask and --

>> Quick, go.

>> nainks Judy David low couple with southern Piedmont Beacon community as well as practice endocrine ol gee at duke university. I'm very intrigued about the concept of different sites for delivery care and it's what I see on the landscape in the future. I guess questions are when will we be into that new model with different sites. I know we are in part. And what percentage of care will be at the different sites.

And then the real question I have is are we missing the opportunity of stating where the puck is going to be by spending all these resources on systems, technology systems that support hospitals and clinics, when the majority of the care may be happening elsewhere. And I'm just wondering what your thoughts are on how we're investing in technology, and where we might need to be looking with technology in the future. As having -- a I'm a six month meaningful user of a system at duke but does do one thing really well but incredibly inflexible on types of care I'd like to hear your thoughts on where we're headed.

>> I think that's to you with site of cares, I think we went unfoofour numbers site 1 with 1 percent site 2 -- I'm just teasing

>> Yeah quick answer. The four sites of care are going to happen whether we want them to happen or not. I think there's just a natural evolution t toolkit is so good for home connectivity, the internet access so rich and growth so quickly we're going to see those sites of care.

The challenge is going to be can we optimize them can we use them in ways that really work for patient care or is it just another level -- electronic silos are just as dysfunctional as paper silos, and physical silos. And so what we need is actually coordinated care that's patient focused and we need to focus care delivery system and the cash flow for care around the patient, not around the pieces of care.

And having said that I think the answer is well, where do you invest and what part will evolve from that. And can't be answered today. But I think the distributed model of care is definitely going to come and you should be thinking about that as you make your investment decisions.

>> It just seems our current technology is very centered on the hospital and the clinic.

>> Totally

>> And not very flexible for anything else

>> There's a device right now costs $40 that you can attach to your iPhone and does a really good EKG and you can do it anywhere, I've held it watched it done, 40 bucks. And that's going to make EKGs available anywhere.

There are other monitoring devices just like that that are going to be available all over the -- in your home and other sites.

So the technology is changing very quickly. And things that used to cost us $100,000 or millions are now being done as apps. Stunning.

>> All right, I hope you agree that we didn't disappoint here in this last panel, and please join me in thinking them for this fabulous discussion. Thank you.

(Applause.)

>> What a day. What a day we've had. What a day we've had.

Well, it's sad, but another annual conference has come to a close. It's been incredibly invigorating for us all at ONC to connect with you again. I hope you had an opportunity to connect to each other, to be inspired, to be motivated to be reenergizeed, to learn, to teach. And we got a lot of work ahead of us, but what we're doing really matters.

And let's hold on to our beliefs, let's hold on to our dreams, and let's show, continue to show, that grit and perseverance. Because it really is about being able to deliver for the country the foundation for achieving the three part aims that we just heard about.

I want to thank you, I want to thank the ONC staff who helped put this together. I want to thank David maintenance, I want to help no ra sooper Mac Kendall gnat Ellington Judy Murphy and so many others who helped put this event together, and we'll see you back next year.

(Applause.)

(meeting concluded)

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