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There are three things we'd like to talk about. There was a handful of wordsmithing and editing that needs to be done, but basically three things that we want to report. The first is the need to look at our target of three months to iterate two or three more times. We'd like to get more input than just the five of us. The editor will take this draft, add our edits, and send out to you by email for your input. We'd like to see that happen three times in the next couple of months. The things with bullets are what needs to be in there. We haven't been as careful about the words "must" and "should". In parallel with that, we're looking for inhouse counsel that won't cost us anything to get a legal review. If you have an inhouse counsel that you can ask to review this, we'd like that to happen along with the editorial review. We'd like written feedback from that. We've had commentary about that but we'd like to get expert opinion on it.

At the end of the two months we would put version 1.0 out on the wiki for all the participants of the alliance and after we get comments back from that we'll send it out beyond that. We should not just send it with a cover letter, we should take it and talk to people about it. We should be ambassadors. Maybe the messaging group could create a letter of transmittal.

We believe strongly that some compromise between a highly centralized controlled document and a completely evolving document is the way to go. There needs to be a .pdf document out there that can't be edited as well as one that can be edited. We need to be flexible and open, but there needs to be periodic approval and publishing of the current version.

We have presumed that organizations that promote specialties need to provide an appendix to this document that puts in some details with some narrower domain of practice. We need to have a couple organizations to volunteer to do that so others can see what that would look like. It'll be easier to give an example to make this happen in the future. We need long lists of organizations to sign up on these three boards.

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We took a real shot with coming up with expectations. We put it in the first person: what I want from my doctors and their practices. [click here to download the document]

In terms of medical skills and knowledge, it was pretty condensed. I'll read some of the list that we came up with. When it comes to the care, I may not want all family members to help and that should be a clear option. We have listed the kinds of things we want in terms of communication and care. We also have the involvement of caregivers in decision-making.

In terms of access and availability, we have requirements for office visits and responses to calls and getting test results. We also talked about ethical integrity. There were other issues such as the right to privacy and good referrals.

We also had an excellent opening paragraph. Question: What about a second paragraph about what the patient will pledge, such as "I will show up on time for my appointments, etc."?  We thought about putting this document in a rights and responsibilities form but we focused on what would be expected from the physician. This is not a contract. This is a covenant of the physician to the public.

I would request a few more bullet points that I can send you.

Q: What about patients who don't want to be involved?
A: We can make the language be inclusive of that. This is a rough draft and we welcome all input.

Resources

• Bendapudi - Patients Perspectives on Ideal Phys Behaviors.pdf
• Populus_What_patients_really_want.pdf
• Setting_Standards_Final.pdf
• Get better care from your doctor - Consumer Reports

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We looked at the communication plan that was done yesterday. We spent time elaborating on the stakeholder groups. The first phase is the going-to group, such as the house of medicine, and groups that are working on parallel documents, such as patient standards. The second phase would be taking it to the practitioner. Phase three would be to the public at large. Before that happens we'd want to talk to Don's group and make sure the document answered the questions: what, when, why and where. Most of our time was generating the questions people would ask out there. We also got into some more specific ones, such as payment and liability. Out of that, we spent some time coming up with core messages.

These messages would be used for the transmittal letter and to you as ambassadors. There will be specific messages for each stakeholder group as well. We want also to have the 'so what' question answered as well. We came up with a goal statement. We feel it's important to say that this is created by a coalition and not an organization. It's built on existing work that's out there already. The GMP is the first product and is a work in progress. It's important to make it clear that this is better for physicians

Someone pointed out that we don't have the word 'efficient' in there and we had a lot of pushback on that. We didn't solve that issue. We had two people raise the question of trusted agent because it got a lot of pushback from the AMA and our group decided not to take that on right now.

Comment: Another word can be used for efficient which is appropriate. Organizations have come together to improve conditions for physicians, but I do think there is something in this room that hasn't been spoken about yet. There are many groups in this room that haven't talked together before and now they're in deep conversation. That needs to be noted.

Comment: There are potholes in the road with our misunderstandings. We see that about the trusted agent and the alliance. A uniform message coming out of this is one of the most important things we can do.

Q: What about a uniform messenger?
A: I don't know about that, but we should identify people who can respond to questions.

Q: Why 'good' medical practice as opposed to 'excellent' medical practice?

It's about creating a common language. The process outlined yesterday included the idea of focus groups.

Resources

• Static copy of Communications plan summary Alliance.doc

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Some of the programs we know a lot about. There seems to be no incongruence in the process that certifies residencies or in the board certification exams That's all covered. Maybe there are different ways to blueprint, but it's mostly covered.

Some of the pilot and practice work is also allowed for. There is nothing prescriptive about the applications, certification or re-certification.

There are some programs that we don't know enough about. There are some proprietary tools that are used to satisfy RRC requirements that may be unique. We just don't know enough.

There may be some incongruency in the relicensure requirements. We just don' t know.

There probably is an incongruency with a free standing CME program. There are some pilots that can be used, other than trusted agent. It would be interesting to take a larger medical plan, such as Kaiser that could be retrofit to the GMP and see how it fits. There would be an opportunity to look at the USMLE strategic review process.

Comment: I heard there is a broad coalition in pediatrics that is looking at graduate education and see if they would analyze it through the GMP.

Michael: I could take this document to the pediatrics residency redesign session that's happening in two weeks. If no one is opposed to it, I'll bring it there.

Group response: Sounds good.

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The real question is what international students have prior to receiving GME education? The question will really be about when we go public with the document? When the USMLE is modified by the GMP then they will be tested for that and that will be the measure of the entry into the system. There will be a whole series of information that will be available. We could help them generate portfolios. There is an enculturation program that is in progress. The idea is to help them with mundane things, but we also want to include the health care system.

There was a lot of discussion about whether we could take GMP and impose that on international schools. It's probably impossible. This puts a significant burden on GME in this country.

Q: Is your vision that all of graduate medical schools will go through an enculturation process?
A: I don't think that's possible, but that would be a great idea.

Q: There is a movement underway to standardize the international medical education. If that continues, would it be appropriate to move GMP to that arena?
A: That would be the right idea.

Comment: There is existing use of portfolios.

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We looked for areas in which we could work more closely together. We asked whether the medical examiners would like to rely on the specialty boards. My board doesn't have any capacity to generate anything like this, so we rely on the specialty boards. There are some issues about how we get along.

One of the things that stuck out is that to be certified, you need an unrestricted license but to be licensed you need to be board certified. This needs to be ironed out.

We have issues with the specialty boards thinking they haven't done their job because they don't know the specialty enough. There is some talk about getting specialists involved in having influence on the decisions.

Our board would like to make it known to the public who is board certified. Right now we take the physicians word for it because there is no mechanism that is cost effective to find out that information. If we used board certification as a MoC, there are problems in the calendar. Boards license every two years. We would have to come up with a benchmark that could be used for relicensure. What happens to the person who isn't board eligible? How do we deal with people who come back into the profession and show their competence for another time? There is plenty of room for more discussion between the organizations.

We need to set a future meeting. We'd like to have a satellite meeting of the alliance. The ABIM foundation has offered to provide support for that meeting. We would talk about the interfaces for licensure. We would then add another group into that and we'd come together to talk about the non-certified physicians. We would want to have that happen in 6 months.

Q: Is the recommendation to retain license in a state, would you need to be board certified?
A: We made no recommendations. Some states would like to use that credential as part of their process. There are issues of communication and transmittal.

Q: Did you deal with physicians who have a practice that is outside of their specialty?
A: No.

Resources

• 121507 Opportunities for Licensing and Certifying Boards_SAS.ppt

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There is an existing pilot going on with the trusted agent by the FSMB. We're trying to put together an electronic system and three states have agreed to do this. We had to get these states to use a single form which was a bit of a challenge. There is a state specific addendum that still doesn't fit.

The way it works is that there is a series of repositories. We're only accessing two of them. They're accessed by a hub, which is a smart piece of software with a series of business rules. We called it a trusted agent but that's not quite right. The information is only released with permission. It can go out and get pieces of data from each of the repositories. That name could change.

We have an application written in XML which allows the systems to talk to each other even if they're not the same. The user checks the information and if they say yes, it goes to the state medical board. It sounds complicated but to the user it's transparent. You could also have other users in this system. This is the system that is being built.

There are 67 other jurisdictions which may want to use this system. There are other credentialing applications that could also be used in this. Nothing particularly concrete with ABIM has been used, but there is interest. It would be a much more difficult thing to work out. One of the things we're thinking about is working with these four organizations and finding out what the state of the art is. The data needs to be transportable. We need school systems and residency systems that talk to each other.

The operational costs are being funded by the FSMB and the National Board. This is not a recipe for success in the long term. We need to maybe levy an additional transaction fee on the individual. This would allow us to do ongoing operations. We could also charge new users.

One suggestion for a new name is PGOP: Physician Generated and Owned Portfolio.

Q: The portfolio does not exist, right?
A: Right. The record remains in its original location and a copy is made for the purpose needed and then the copy vanishes.

Comment: You could call it the Physician Data Security System.

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There is already some language around this. We need to understand all the different kinds of teams. There will be differences and we need to know how to work with the differences. Physicians have to communicate effectively on a team both as a leader and a member. The assessment of team functioning will be elaborated, but it will be measured by the effectiveness.

The team assessment criteria had to do with patient outcomes, diversity of the team and respect for the roles they do. There needs to be included the satisfaction of the family. The team goal needs to be included. The efficiency of care is important. Whether or not a team is productive and accountable are both very important as well.

We did make a list of the professions that are involved. The patient we put at the top of the list though we didn't think about it until later. There is a group that will be convened in February. We have to ask how we effectively integrate this into the training and practice of medicine? We have to work on the concept of shared competence.

We have to expand on the possible assessments in terms of how we assess the teams.

We put some qualities together of what makes a team successful.

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The first issue we had was about the word itself. No one liked the word 'non-competent' but no one came up with a better word. We looked at what qualities the competent physician should have and then matched it against a threshold of the competencies. We don't know exactly where that threshold is.

You don't want to generalize a physician is non-competent if there is really only one area that doesn't meet the threshold, but use it only for egregious problems. We tried to come up with some areas of measures that we would consider in determining whether someone is non-competent.

We made a laundry list of what we do now. Generally we felt the remedies would be the same, but we would have a lot more options for assessment tools. We have a lack of sufficient remediation and re-entry programs right now. These would be developed as we bring this on.

Comment: Raising the bar higher seems almost the opposite of what some other groups are doing, such as putting NP out in the field.

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We mapped out as much as we could capture on this timeline. [click here to see the timeline as a .ppt] As you see the next 6-8 months are pretty intense. The emphasis is on getting the first draft of the GMP completed and disseminated for comment and input by mid-April.

We want to explore working with groups like Blue Cross/Blue Shield and Kaiser in pilot projects involving the GMP. We also want to solicit input about the GMP from three to five new groups who have not been participating directly in this dialogue.

We captured the planning meeting for a portfolio conference, which should occur somewhere between February and March. The portfolio conference would take place later in the year, perhaps as part of the next summit.  

We talked about the plan for Summit V and whether we should push that out to January of '08 or, if it was held sooner, structuring it in a way that's very different from what we're doing now. We got feedback from people that the momentum could drop if we wait too long to meet, so we agreed that it made more sense to meet in October and have three work groups parallel processing with more focused objectives, such as the portfolio, organization, GMP adoption and implementation. These groups could work in the same place at the same time so that there could be expansion of the base but still get things done.

It will be important to have the learning expedition on chaordic and self-learning organizations prior to Summit V, sometime between June and August.  We're not sure who would be involved in that.

It is important to get the communication tools done as quickly as possible so everyone is conveying the same messages and using the same reference materials.  We also need to be clear what we're asking our organizations to commit to when we talk with them – commitments like stay engaged, feedback on the GMP, possibly continued financial support.

Q: When are we going to involve medical students and residents?
A: These would be groups we reach out to early on, particularly about the GMP.

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[click here to see the timeline as a .ppt]

Report Out

You're going to finish our work for us. Not enough of you came through to give us feedback, so we want to get all your feedback here. If we would have had time, we would say that it's not just about the people and other groups, but what kind of technology do we need to have.

If you're engaged in the alliance as of right now, you're an influencer. Who is outside the room that can help us further our work? We did a little clumping of the choices, but we want you to rank order for us who we need to go after to include in this process.

Let's vote! Please vote for your top three choices.

Here is the result. (click on the image below to see a larger version of the results)

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Closing Comments

Someone has to represent us and I vote for Jim Thompson. We need someone who can speak to the big picture.

We've approached this up this point as a coalition. I think we should also include a group of people with Jim. As the demand for information increases, we need to all say the same thing.

It's often much easier to bring someone in from the outside.

Michael: Should we have a sign up for these things? Sign up on the back board for either being an ambassador or being part of the team. (see results of sign up below)

I thought about how it was that I got here. I knew when I showed up Sunday night that there would be no people of color in this room. We have to think about this and do something. We have an awful disconnect in looking at who is here, who is offering the care in the world and who is receiving the care in the world. Given that I sat here through Martin Luther King, Jr. day here, I couldn't go without saying something about this. (applause)

I'd like to acknowledge on behalf of the veterans of this process the newcomers and how quickly you came up to speed.

I'd also like to offer a big thanks to Carol Clothier and Frances Cain for all their work in putting this together.

Michael: Great! Thanks again for all your work. We'll see you next time.

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