Interoperability for Texas Powering Health 2016...HHS Transformation, as directed by S.B. 200, 84th Legislature, Regular Session, 2015, provides many opportunities for targeting improvements

Interoperability for Texas: Powering

Health 2016

As Required By

H.B. 2641, 84th Legislature, Regular Session, 2015

Health and Human Services Commission

December 2016

Interoperability for Texas: Powering Health 2016 A Texas Health and Human Services System Report

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Table of Contents EXECUTIVE SUMMARY .......................................................................................................................1

INTRODUCTION .................................................................................................................................3

BACKGROUND ON INTEROPERABILITY ................................................................................................3 THE NATIONAL STORY OF INTEROPERABILITY ..................................................................................................... 3 THE TEXAS STORY OF INTEROPERABILITY ........................................................................................................... 6 ONGOING EFFORTS TO PROMOTE INTEROPERABILITY .......................................................................................... 7

OVERVIEW OF TEXAS HHS AGENCIES AND SYSTEM ........................................................................... 10 TEXAS HEALTH AND HUMAN SERVICES COMMISSION (HHSC) ............................................................................ 10 TEXAS DEPARTMENT OF AGING AND DISABILITY SERVICES (DADS) ..................................................................... 11 TEXAS DEPARTMENT OF FAMILY AND PROTECTIVE SERVICES (DFPS) ................................................................... 11 TEXAS DEPARTMENT OF STATE HEALTH SERVICES (DSHS) ................................................................................. 12 TEXAS DEPARTMENT OF ASSISTIVE AND REHABILITATIVE SERVICES (DARS) .......................................................... 12

HHS SYSTEM STRATEGIC GOALS RELATING TO THE EXCHANGE OF HEALTH INFORMATION ................. 12 DATA NEEDS .............................................................................................................................................. 14 SECURITY, CONFIDENTIALITY, AND PATIENT PRIVACY ......................................................................................... 15

STATUS OF INTEROPERABILITY WITHIN HHS SYSTEM AGENCIES ........................................................ 16 HHS STRUCTURAL SUPPORTS FOR INTEROPERABILITY ........................................................................................ 17

HHS Office of eHealth Coordination (OeHC) ....................................................................................... 17 Medicaid Health Informatics Services and Quality ............................................................................. 17 HHSC IT ............................................................................................................................................... 17 HHSC Office of the Chief Data Officer (OCDO).................................................................................... 18 DSHS Center for Health Policy and Performance (CHPP) .................................................................... 18 Electronic Health Information Exchange Advisory Committee (EHIEAC) ........................................... 18 HHSC eHealth Advisory Committee (eHAC) ........................................................................................ 18 Privacy and Security ........................................................................................................................... 18

SHARED RESOURCES AND TOOLS ................................................................................................................... 19 Data Asset Repository ........................................................................................................................ 19 Identity Resolution Services ................................................................................................................ 20 Public Health Gateway ....................................................................................................................... 20

INTEROPERABILITY GOVERNANCE AT HHS AGENCIES ......................................................................................... 20 HHS System Health Information Executive Steering Committee (HIESC) ........................................... 21 Data Governance ................................................................................................................................ 21

SELECT PROGRAMS CURRENTLY USING STANDARDS-BASED INTEROPERABILITY ................................ 22 SELECT PROGRAMS AND SYSTEMS AT HHSC .................................................................................................... 22

Medicaid Systems-General ................................................................................................................. 22 Pharmacy Claims ................................................................................................................................ 23 E-Prescribing ....................................................................................................................................... 23 Client Admission and Registration System (CARE) ............................................................................. 24 Clinical Management for Behavioral Health Services (CMBHS) ......................................................... 24

SELECT PROGRAMS AND SYSTEMS AT DADS .................................................................................................... 26 SELECT PROGRAMS AND SYSTEMS AT DFPS ..................................................................................................... 26 SELECT PROGRAMS AND SYSTEMS AT DSHS .................................................................................................... 26


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Public Health Information Systems .................................................................................................... 26

INTEROPERABILITY SUPPORTS IN TEXAS OUTSIDE OF HHS AGENCIES................................................. 29 THSA ....................................................................................................................................................... 29 LOCAL HIES ............................................................................................................................................... 31 REGIONAL EXTENSION CENTERS ..................................................................................................................... 31 PROVIDER AND INDUSTRY ASSOCIATIONS ........................................................................................................ 31

STANDARDS AND STANDARDS DEVELOPMENT ................................................................................. 32 OPEN VS. CLOSED STANDARDS ...................................................................................................................... 34 STANDARDS DEVELOPMENT ORGANIZATIONS .................................................................................................. 34

Sample Standards Development Organizations involved in Health Care ........................................... 35 EXAMPLES OF STANDARDS ............................................................................................................................ 37

HL7 ...................................................................................................................................................... 37 FHIR .................................................................................................................................................... 37 DICOM ................................................................................................................................................ 37 North American Association of Central Cancer Registries (NAACCR) Version 15 ............................... 37

STATUS OF INTEROPERABILITY WITHIN HHS AGENCIES AND BETWEEN HHS AND OTHER HEALTHCARE ENTITIES .......................................................................................................................................... 37

THE IMPACT OF TRANSFORMATION ON INTEROPERABILITY ................................................................................. 38 NEW SYSTEMS IN HHS AGENCIES THAT EXCHANGE PROTECTED HEALTH INFORMATION AND HAVE BEEN PLANNED OR PROCURED SINCE SEPTEMBER 1, 2015 ........................................................................................................... 38 INTEROPERABILITY PROGRESS ........................................................................................................................ 41

Information Management .................................................................................................................. 41 Exchange of Encounter Data for Medicaid Claims ............................................................................. 41 Syndromic Surveillance ....................................................................................................................... 41 Psychiatric Hospital Clinical Data Exchange Enhancements .............................................................. 42 Clinical Management for Behavioral Health Services ........................................................................ 42 Advancing Interoperability through HIEs ........................................................................................... 42

HHS AGENCIES INTEROPERABILITY PLANNING FRAMEWORK, 2017-2022 ........................................... 44

CONCLUSION ................................................................................................................................... 52

REFERENCES .................................................................................................................................... 54

LIST OF ACRONYMS .......................................................................................................................... 60

APPENDICES .................................................................................................................................... 63 APPENDIX A - TEXAS HEALTH AND HUMAN SERVICES’ HEALTH INFORMATION TECHNOLOGY ROADMAP .................... 64 APPENDIX B - SELECT STATE LEGISLATION RELATED TO HIT AND INTEROPERABILITY ............................................... 67 APPENDIX C - HHS CIRCULAR C-009 ............................................................................................................. 69 APPENDIX D -HHS CIRCULAR C-010 .............................................................................................................. 71 APPENDIX E - HHS CIRCULAR C-032 ............................................................................................................. 75 APPENDIX F - HHS CIRCULAR C-049 .............................................................................................................. 79 APPENDIX G - STANDARDS-BASED ELECTRONIC TRANSACTIONS USED AT TEXAS MEDICAID ..................................... 83


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Interoperability for Texas: Powering Health 2016 Executive Summary

Interoperability is defined as the ability of two or more systems to exchange and use electronic health information from other systems without special effort on the part of the user. It enables entities involved in health care, including providers, payers, and public health, to efficiently interact with each other to provide improved health care services, improve the patient experience, better manage costs, facilitate research and protect the public from health risks. Texas’ Health and Human Services (HHS) agencies have long been engaged in implementing a variety of technologies in its efforts to achieve and advance interoperability.

This is the first biennial report to the Legislative Budget Board (LBB) and the Governor regarding HHS agencies’ progress on interoperability regarding its information systems that exchange protected health information (PHI) within and across HHS agencies and between HHS agencies and healthcare providers.

The report provides an overview of work on the federal and state levels to advance the interoperability of health information systems, an update on HHS agencies’ progress on interoperability, and examples of HHS agencies’ information systems and programs that are currently using standards-based transactions to achieve interoperability.

As required under House Bill (H.B.) 2641, 84th Legislature, Regular Session, 2015, HHS identified information systems planned or procured on or after September 1, 2015. A status update is provided on the capability of those systems to send or receive information in accordance with applicable data exchange standards.

The report provides an update on areas for advancement of interoperability and provides a framework for 2017 – 2021 to implement a plan for interoperability. The framework, aligned with the HHS 2017 – 2021 Strategic Plan, centers around five domains:

Infrastructure Governance Business/technical operations Policy and practice Communications

Each of these domains includes current or ongoing activities that will advance interoperability, and identifies potential new activities. HHS agencies will collaborate with each other as well as their stakeholders to further develop the interoperability plan, implement planned activities, and realize the plan’s goals.

The use of standards is essential in exchanging information, and the use of national standards impacts the efficiency and costs of advancing interoperability. Standards development and


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adoption processes that are being used to implement more seamless communications between information systems, the role of accreditation organizations, competing standards, and the current limits of standards are described in the report. The report also provides a background on the progress the public and private sectors have made in the United States as a context for how Texas and, in particular, HHS agencies have used standards in the exchange of PHI with external entities.

Collaboration within the HHS system and particularly with stakeholders is important to support interoperability including standards development and adoption, establishing connections between trading partners, ensuring privacy and confidentiality, and addressing information security.

Existing HHS supports, governance, and standards are leveraged to support interoperability. HHS stays s aligned with advances in the use of interoperability standards to support more meaningful information exchange through the adaption of existing technology and, where necessary, new information systems.

HHS Transformation, as directed by S.B. 200, 84th Legislature, Regular Session, 2015, provides many opportunities for targeting improvements and changes that will improve how HHS agencies communicate and exchange information with the healthcare community. HHS is adapting its resources and building a framework that supports an increasingly interoperable posture with its stakeholders including individuals, providers, other governmental entities, and payers. Improved interoperability, communication, and collaboration will enable an increased quality of health care, better management of health care costs, and improved health.


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Introduction This is the first biennial report to the Legislative Budget Board and the Governor on the HHS agencies regarding the interoperability of HHS’ information systems and the use of applicable standards in new information systems planned or procured after September 2015 that are used by HHSC or other State of Texas health and human services agencies to send or receive protected health information (PHI) to/from health care providers use applicable standards and are interoperable with each other.

H.B. 2641 requires HHS agencies to develop interoperability plans and for the HHSC Executive Commissioner to report on progress. This report includes a consolidated, integrated interoperability planning framework and progress report. The approach used in establishing a planning framework for interoperability and reporting progress is similar to that used in the development of past Consolidated Strategic Plans for the Texas HHS system and reflects the HHS transformed organizational structure. The integrated approach to planning and reporting will help facilitate collaboration and interoperability within and across agencies, assist in the alignment of resources and methodologies, and facilitate consistent practices when exchanging data with external trading partners.

The focus of this report is the interoperability between HHS' information systems and between HHS’ and healthcare providers' systems. This report includes an assessment of the progress made in achieving Commission goals related to the exchange of health information including facilitating care coordination among the agencies, ensuring quality improvement, and realizing cost savings. It recognizes the importance of ongoing collaboration between business and technology areas within HHS and between HHS agencies and stakeholders in identifying how interoperability may affect the delivery of health care services, manage costs, and improve health through the use of applicable standards and continuing to expand the capacity of HHS’ information systems to utilize interoperability to meet the health needs of Texans.

Background on Interoperability The National Story of Interoperability In the 2004 State of the Union Address, President George W. Bush introduced his Health Information Technology Plan to the nation, stating “[B]y computerizing health records, we can avoid dangerous medical mistakes, reduce costs, and improve care.”1 President Bush thought by putting everyone's health information into an electronic health record (EHR), health care delivery could be improved by eliminating the problems of records being scattered and

1 Promoting Innovation and Competitiveness: President Bush's Technology Agenda - A New Generation of American Innovation.

https://georgewbush-whitehouse.archives.gov/infocus/technology/economic_policy200404/chap3.html#. Accessed September 9, 2016.

https://georgewbush-whitehouse.archives.gov/infocus/technology/economic_policy200404/chap3.html


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inaccessible to a patient, physician or caregiver. He set a 10 year goal for technology systems to be “designed to share privately and securely a patient’s records across providers.”2 President Bush also created the National Health Information Technology Coordinator, housed within the newly-established Office of the National Coordinator (ONC) for Health Information Technology at the Department of Health and Human Services and proposed $100 million be allocated for related demonstration projects.

To enable interoperability, the ONC began to plan a new National Health Information Network (NHIN), a nationwide system to allow for the secure exchange of information across entities. The ONC made grants to establish exchange standards through the Health Information Technology Standards Panel, address privacy and security through the Information Security and Privacy Collaborative and, through a newly-formed Certification Commission for Health Information Technology, create a certification program for electronic medical records, all key components in advancing interoperability.3 The work of the newly formed groups required collaboration across the affected stakeholders involved in health care including health care providers, payers, technologists, and policy-makers.

The passage of the Health Information Technology for Economic and Clinical Health (HITECH) Act in 2009 revamped activities at the national level, establishing two federal advisory committees charged with making recommendations to the ONC. These committees had a particular focus on new EHR Incentive Payment Programs (EHR Incentive Programs), intended to incentivize the adoption of Health Information Technology (HIT) by Medicaid and Medicare providers.

2 Ibid. 3 Gur-Arie M. The History of Healthcare Interoperability. http://hitconsultant.net/2013/04/11/history-of-healthcare-

interoperability. Accessed September 24, 2016.

Interoperability Defined

It is essential to understand the difference between “exchange” and “interoperability.” “Exchange” has historically been defined as the ability to pass information from one place to another, and is a prerequisite for interoperability. In the context of health information, the ability to exchange information is the ability for one system to pass information to another, distinct system. It is focused on the delivery, but not the understanding, of the message. Exchange allows information to be collected in a single place or to be accessible from a single location. This is not as advantageous as having systems that are interoperable, where interoperability is defined as “the ability of two or more systems to exchange and use electronic health information from other systems without special effort on the part of the user." 1

1 - Office of the National Coordinator for Health Information Technology. Shared Nationwide Interoperability Roadmap version 1.0. https://www.healthit.gov/policy-researchers-implementers/interoperability. Accessed September 15, 2016.

http://hitconsultant.net/2013/04/11/history-of-healthcare-interoperability/



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HITECH drove significant technology infrastructure changes as well as established the HIT Policy and the HIT Standards committees.4 NHIN Direct was developed to facilitate exchange through a system resembling email. After some successes, the name was changed to Direct and is currently being used at both the national and local levels. NHIN itself went through a similar name change, emerging as the Nationwide Health Information Exchange (NHIE). It then transitioned to eHealth Exchange, and is now managed by the Sequoia Project. The ONC has prioritized utilization of the Direct protocol, convincing many HIT vendors to include support for the Direct protocol in their products to facilitate exchange. The ONC also established the Standards and Interoperability (S&I) Framework, which has undertaken numerous projects and continues to establish collaborative workgroups to advance interoperability by providing an open forum for organizations that share common challenges to work together to create common solutions and works to ensure alignment with Meaningful Use requirements.5

It is now ten years since President Bush’s charge and considerable work remains. A 2015 survey of U.S. physicians conducted by the Centers for Disease Control and Prevention (CDC) reported an 86.9 percent EHR adoption rate across the nation and a 93.1 percent adoption rate in Texas. A recent Medscape™ EHR 2016 survey indicates nationwide EHR users have converted 83 percent of their paper patient records to electronic format.6 The position of National Coordinator is now legislatively mandated.7

The goal of achieving full, comprehensive interoperability between and across the healthcare landscape remains a challenge. The Stage 2 Final Rule for the Centers for Medicare and Medicaid Services (CMS) Incentive Payment Programs expanded upon the Stage 1 criteria, including the exchange of information.8 The migration of medical records from file cabinets to EHR systems has often resulted in a transformation from paper silos to electronic ones, except in instances where providers are using the same company's EHR software. EHR vendors have built private health information exchanges (HIEs) to support actionable data exchanges and interoperability amongst their EHR purchasers (e.g., hospitals, physicians, labs), with the top

4 New Health Information Technology advisory committee members to advise National Coordinator. http://www.hhs.gov/about/news/2013/03/01/new-health-information-technology-advisory-committee-members-advise-national-coordinator.html. Accessed September 25, 2016.

5 Office of the National Coordinator for Health Information Technology. Standards and Interoperability Framework. https://www.healthit.gov/sites/default/files/pdf/fact-sheets/standards-and-interoperability-framework.pdf. Accessed September 25, 2016.

6 Peckham C, Kane L dir, Rosensteel S, ed. Medscape EHR Report 2016: Physicians Rate Top EHRs. Medscape Business of Medicine. http://www.medscape.com/features/slideshow/public/ehr2016. Accessed August 25, 2016.

7 Health Information Technology for Economic and Clinical Health Act (HITECH Act) of 2009. 8 Centers for Medicare and Medicaid Services. Electronic Health Records (EHR) Incentive Programs.

https://www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/index.html?redirect=/ehrincentiveprograms. Accessed September 9, 2016.

http://healthewayinc.org/index.php/exchange

https://www.healthit.gov/sites/default/files/pdf/fact-sheets/standards-and-interoperability-framework.pdf

https://www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/index.html?redirect=/ehrincentiveprograms



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five EHR vendors dominating more than 50 percent of the physician markets and 68 percent of the hospital or health system markets, further strengthening an interoperability barrier. 9,10,11

There are significant efforts taking place across Texas and the United States in both technology and policy arenas to close the gaps hampering health systems’ ability to exchange health information to improve patient care and safety and lower costs. Efforts include partnerships within and among private and public sector entities as well as a shift to accountable care and pay for performance implementations which changes incentives from business volume to care coordination.

The Texas Story of Interoperability Texas government has also taken action to advance interoperability. In 2005, the Legislature created a multi-agency Texas Health Care Policy Council (Council) which had, as one of its charges, the promotion of the use of technology in healthcare to decrease administrative costs and to increase and improve the quality of health care."12 The Council subsequently formed the Texas Health Information Technology Advisory Committee (HITAC), composed of experts from the public and private sectors, which published the Roadmap for the Mobilization of Electronic Healthcare Information in Texas in 2006. This report made clear that implementing EHRs before interoperability standards were defined was a concern among doctors and hospitals.13 The HITAC report also identified the need for governance to define the coordination for sharing health information within an applicable context.14

In 2006, Governor Rick Perry established the Texas Health Care System Integrity Partnership which recommended mechanisms for operationalizing the state-level recommendations of the HITAC. This contributed to the creation of the Texas Health Services Authority (THSA), a

9 Office of the National Coordinator for Health Information Technology. Certified Health IT Vendors and Editions Reported by

Hospitals Participating in the Medicare EHR Incentive Program. Health IT Quick-Stat #29. dashboard.healthit.gov/quickstats/pages/FIG-Vendors-of-EHRs-to-Participating-Hospitals.php. July 2016. Accessed September 12, 2016.

10 Office of the National Coordinator for Health Information Technology. Certified Health IT Vendors and Editions Reported by Health Care Professionals Participating in the Medicare EHR Incentive Program. Health IT Quick-Stat #30. dashboard.healthit.gov/quickstats/pages/FIG-Vendors-of-EHRs-to-Participating-Professionals.php. July 2016. Accessed September 12, 2016.

11 Peckham C. Kane L dir. Rosensteel S ed. Medscape EHR Report 2016: Physicians Rate Top EHRs Medscape Business of Medicine. August 25, 2016.

12 Texas Legislature. House Bill 916, 79th Legislature, Regular Session. 2005. 13 Texas Health Information Technology Advisory Committee. Roadmap for the Mobilization of Electronic Healthcare

Information in Texas, Final Report of the Texas Health Information Technology Advisory Committee. Version 1.1, September 29, 2006 - Foundation for eHealth Initiative. p 39.

14 Ibid. page 68.


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legislatively-created public-private partnership established to play a leading role in advancing health information exchange in Texas.15,16 The road to comprehensive interoperability is difficult. There were many factors that hampered the interoperability of EHRs during their initial move into the marketplace including: Technology challenges regarding patient matching; Multiple, differing standards used by vendors for storing health information; Healthcare economics; EHR design; and Difficulties in establishing trust across and among healthcare entities. In addition, in 2009 a major focus in Stage 1 of the EHR Incentive Programs “[E]stablished requirements for the electronic capture of clinical data, including providing patients with electronic copies of health information.”17 The EHR Incentive Programs offered limited immediate requirements for demonstrating interoperability between healthcare providers other than with pharmacies; however they did require engaging with public health entities regarding exchange.18

Ongoing Efforts to Promote Interoperability National efforts to promote interoperability have continued, with the Medicare EHR Incentive Payment Program evolving into components of the federal Medicare Access & CHIP Reauthorization Act of 2015 through the Merit-Based Incentive Payment System and new Advanced Alternative Payment Models (APMs).19 Collaborative entities like the S&I Framework, Health Level Seven (HL7), the Sequoia Project, and CommonWell, several of which will be described later, are now serving leading roles in the development of interoperability tools and standards.

15 H.B. 1066, 80th Legislature, Regular Session, 2007. 16 Texas Health Services Authority Staff. The State of Health IT in Texas: Staff Report to the Texas Health Services Authority,

March 2009, http://hietexas.org/component/docman/doc_download/40-state-of-health-it-in-texas?, retrieved September 20, 2016.

17 Centers for Medicare and Medicaid Services. Electronic Health Records (EHR) Incentive Programs. https://www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/index.html?redirect=/ehrincentiveprograms. Accessed September 9, 2016.

18 Centers for Medicare and Medicaid Services. Medicare & Medicaid EHR Incentive Program- Meaningful Use Stage 1 Requirements Overview. https://www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/Downloads/MU_Stage1_ReqOverview.pdf. Accessed September 9 2016.

19 Centers for Medicare and Medicaid Services. MACRA- Delivery System Reform, Medicare Payment Reform. https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Value-Based-Programs/MACRA-MIPS-and-APMs/MACRA-MIPS-and-APMs.html. Accessed September 24 2016.



https://www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/Downloads/MU_Stage1_ReqOverview.pdf



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At the March 2016 Health Information Management System Society annual conference, the Secretary of the United States Department of Health and Human Services, Sylvia Burwell, issued a charge to the health IT industry to improve interoperability and eliminate information blocking. She also announced an agreement between several major health IT providers, including Epic and Cerner, “[T]o work together on interoperability and standards initiatives.”20

ONC reports on the implementation of interoperability standards for the healthcare industry yearly. The Interoperability Standards Advisory (ISA) provides a single list "catalog” of standards that can be used by the healthcare industry to execute clinical health information interoperability processes.21 The ONC recently provided its draft 2017 ISA for public comment in an online, interactive format.

The ONC also published its 2017 interoperability roadmap, Connecting Health and Care for the Nation: A Shared Nationwide Interoperability Roadmap.22 The Roadmap sets the 2015 – 2024 goals for all of the stakeholders in the healthcare community and maps each to a comprehensive call to action. The driver of the roadmap is "[T]he payment and regulatory environment" and focuses on how interoperability will facilitate the move from fee-for-service to accountable care. The policy and technical components are the interoperability mechanics needed to make improvements in the availability of health information to everyone. Lastly, the outcomes define the measures that will be used to determine the progress made.

20 Sutner S. At HIMSS 2016, HHS Chief Burwell Blasts Information Blocking.

http://searchhealthit.techtarget.com/news/4500277764/At-HIMSS-2016-HHS-chief-Burwell-blasts-information-blocking. Accessed September 15 2016.

21 Miliard M. ONC's Draft 2017 Interoperability Standards Advisory Posted for Public Comment. August 23, 2016 http://www.healthcareitnews.com/news/oncs-draft-2017-interoperability-standards-advisory-posted-public-comment. Accessed September 15 2016.

22 Office of the National Coordinator for Health Information Technology. Connecting Health and Care for the Nation: A Shared Nationwide Interoperability Roadmap Final Version 1.0. The Office of the National Coordinator for Health Information Technology. https://www.healthit.gov/sites/default/files/hie-interoperability/nationwide-interoperability-roadmap-final-version-1.0.pdf. Accessed September 15 2016.

http://searchhealthit.techtarget.com/news/4500277764/At-HIMSS-2016-HHS-chief-Burwell-blasts-information-blocking

http://www.healthcareitnews.com/news/oncs-draft-2017-interoperability-standards-advisory-posted-public-comment


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The Government Accountability Office (GAO) issued a report to Congress in 2015 on 18 initiatives that represented a cross-section of private and public sector entities working on a variety of approaches to achieving interoperability. 23 Many of these initiatives are in process and outcomes will not be known until later in 2016.

One of the initiatives reviewed by the GAO, Carequality, a project under Sequoia, is a public-private partnership that includes several of the top ten EHR vendors, as well as Surescripts© and the THSA. Carequality announced in August 2016 their initial success at implementing an interoperability framework that enables the exchange of clinical care data between different EHR vendor platforms.24

CommonWell Health Alliance is a not-for-profit trade association whose goal is to use standards to develop an interoperable national infrastructure that is vendor-neutral. They promote making the right information available at the right time for a reasonable cost to providers and patients. In August 2016 CommonWell announced its plans for a patient portal, providing patients and/or their caregivers with access to their records held in the Alliance's EHRs to be available by the end of the year.25

Another initiative cited for its progress is the Blue Button Connector Project initiated by the ONC which enables patients to pull together their health records from different EHR platforms, 23 Electronic Health Records - Nonfederal Efforts to Help Achieve Health Information Interoperability. September 2015. United

States Government Accountability Office. 15-817. http://gao.gov/assets/680/672585.pdf. Accessed September 17, 2016. 24 Goedert J. New Health Information Exchange Service Goes Live. Health Data Management. August 17, 2016.

http://www.healthdatamanagement.com/news/new-health-information-exchange-service-goes-live. Accessed September 3, 2016.

25 Commonwell Alliance. CommonWell Members Enable Patient Access to Their Health Data. http://www.commonwellalliance.org/news/commonwell-members-enable-patient-access-health-data. Accessed September 3, 2016.

Four of the main challenges interoperability initiatives are addressing include:

Implementing standards using methods that enable interoperability - This is being approached through a variety of methods including the use of technical system modifications, agreement on semantic normalizations, and adoption of specific standard implementations.

Handling the variation in state privacy laws - Recommendations include enabling patient consent for personal health information components, enabling providers to share limited segments of patient data, or ensuring providers are fully educated in the privacy laws of their state.

Patient matching - The challenge is with the different algorithms being used to define identities across EHR systems. Recommendations include standardizing the collection of patient demographics to allowing patients to pull information from different EHRs into a patient health record and correct any erroneous records

Interoperability Costs - Interoperability can be implemented at a cost which all of the initiatives attempted to minimize or eliminate through several approaches. One approach was to develop standard EHR customizations across systems, another was standardizing the interfaces for specific information sets (application program interfaces (APIs) and a third was making EHR interfaces engines available at little or no cost.


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similar to one of the initiatives in the GAO report. The ONC-sponsored solution is an open data source solution that has been evolving since 2014; its goal is to provide patients "a one-stop shop to aggregate their data in a useful format."26

The ONC's standards and technology work includes the “Interoperability proving ground”27 website enabling active and completed projects across the nation to display how the ISA standards are being used. Stakeholders implementing clinical health IT projects self-report updates on their initiatives and the standards being integrated within their solutions. Some of the gauges the ONC uses regarding the adoption rates of specific standards across the nation include feedback, usage, longevity of usage and public comment. Overview of Texas HHS Agencies and System28 In September 2016, as directed by S.B. 200, 84th Legislature, Regular Session, 2015, and based on recommendations from the Texas Sunset Advisory Commission,29 Texas launched its transformed approach for delivering health and human services to qualified Texans through a reorganization of state agencies responsible for providing services. The new, restructured HHS system will make it easier for people to find out about the services or benefits for which they may qualify, better integrate programs by removing bureaucratic silos and grouping similar programs and services together, create clear lines of accountability within the organization, and develop well-defined and objective performance metrics for all organizational areas.30 The business units listed below may engage in the exchange of PHI to deliver, manage, and coordinate services. For more information on agency transformation activities, including a link to the final transition plan, please see the following website: https://hhs.texas.gov/about-hhs/hhs-transformation.

Texas Health and Human Services Commission (HHSC) Experienced HHSC employees deliver eligibility determinations, benefits, and services for Texans, including:

Medicaid for families and children

26 Slabodkin S. Task Force Recommends Improvements for Blue Button Connector. Health Data Management.

http://www.healthdatamanagement.com/news/task-force-recommends-improvements-for-blue-button-connector. Accessed September 16, 2016.

27 Office of the National Coordinator for Health Information Technology. Interoperability Proving Ground. https://www.healthit.gov/techlab/ipg. Accessed September 9, 2016.

28 Texas Health and Human Services Commission. Agencies & Departments. https://hhs.texas.gov/about-hhs/agencies-departments. Accessed September 21, 2016.

29 Texas Sunset Commission. Sunset Advisory Commission Staff Report, Health and Human Services Commission and System Issues. December 2014. https://www.sunset.texas.gov/public/uploads/files/reports/HHSC%20and%20System%20Issues%20DM.pdf. Accessed September 9, 2016.

30 Texas Legislature. Senate Bill 200, 84th Legislature, Regular Session. 2015.

https://hhs.texas.gov/about-hhs/hhs-transformation

http://www.healthdatamanagement.com/news/task-force-recommends-improvements-for-blue-button-connector


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Children's Health Insurance Program Long-term care for people who are older or who have disabilities Supplemental Nutrition Assistance Program (SNAP) food benefits and Temporary Assistance

for Needy Families (TANF) cash assistance for families Outpatient behavioral health services Services to help keep people who are older or who have disabilities in their homes and

communities Services for women, children and other people with special health needs such as those with

Autism, visual impairments, or for those who are deaf or hard of hearing Services to promote independence at home and in the community for those with significant

disabilities Disability determination Early Childhood Intervention

HHSC also includes an Internal Audit Division (IAD) and the Inspector General (IG) which serve the HHS System in its entirety. The IAD provides independent, objective assurance and consulting services that add value and improve operations. The IG ensures that more of every tax dollar appropriated for the delivery of health and human services in Texas actually is spent on those services.

Texas Department of Aging and Disability Services (DADS) Many of DADS programs and services transferred to HHS in September 2016; the remainder will do so in September 2017. The agency's areas of responsibility in fiscal year 2017 are:

Trust fund monitoring Educational services for regulatory programs State long-term care ombudsman Regulatory services for long-term care providers State supported living centers (SSLCs) Office of the independent ombudsman for SSLCs Consumer Rights and Services complaint intake

Texas Department of Family and Protective Services (DFPS) DFPS employees do their best to ensure children and older adults live free of abuse, neglect and exploitation. They do this by focusing on these areas:

Investigating abuse, neglect, and exploitation of older adults and people with disabilities Investigating abuse and neglect of children Placing children in foster care and helping foster children transition to adulthood

https://oig.hhsc.texas.gov/

http://www.dads.state.tx.us/


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Seeing that eligible children are adopted Licensing child care operations and investigating complaints Promoting programs that prevent abuse, neglect, and juvenile delinquency Receiving statewide reports of abuse, neglect, and exploitation

Texas Department of State Health Services (DSHS) Many of the direct client services that were performed by DSHS, such as primary health care services and services for people with special health care needs, were transferred to HHSC in September 2016. DSHS now focuses on providing these functions:

Maintaining vital statistics, such as birth, death, marriage, and divorce records Compiling and disseminating health data on more than 25 topics Chronic and infectious disease prevention and laboratory testing Licensing and regulating facilities on topics from handling potentially harmful substances

including asbestos to mobile food establishments to youth camps Operation of the state psychiatric hospitals Improving health through prevention and population health strategies

Texas Department of Assistive and Rehabilitative Services (DARS) The 84th Texas Legislature abolished the agency, effective September 1, 2016. DARS services were transferred either to HHSC or, for vocational rehabilitation and related programs, to the Texas Workforce Commission.

HHS System Strategic Goals Relating to the Exchange of Health Information The exchange of PHI is a critical activity in supporting the goals outlined in the 2017-2021 HHS Strategic Plan, and advances the five themes that are the focus of the strategic plan: accountability, efficiency, effectiveness, excellence in customer service, and transparency. The following are goals and action items that could benefit from interoperability that supports the exchange of PHI.

Provide efficient and effective medical and behavioral health services. o Continue managed care expansions and further integrate Medicaid physical and

behavioral health services, and support the integration of consolidated Medicaid functions at the HHSC

o Oversee, coordinate, and negotiate the Texas Healthcare Transformation and Quality Improvement Program 1115 Waiver

o Provide long-term services and supports through Medicaid and Medicaid waivers in homes and community settings that will enable aging individuals, individuals with

http://www.dshs.texas.gov/


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disabilities, and others who qualify for nursing facility care but can be served at home or in the community to maintain their independence and prevent institutionalization

o Enhance statewide coordination of women’s health programs in Texas to improve the way health care services are delivered to low income women through better continuity of care and use of best clinical practices

o Promote behavioral health by coordinating and contracting for statewide services for adults and youth, including crisis services, community mental health services, and substance abuse prevention, intervention, and treatment

o Provide specialized health services, including services for children with disabilities and their families

Provide efficient, effective social services o Encourage self-sufficiency, safety, and long-term independence for families o Provide efficient and effective social services to blind children to improve the quality of

their lives and to enable their full participation in society o Ensure prompt and accurate eligibility determination and enrollment of qualified

individuals into financial assistance and benefit programs o Make efficient and effective medical determinations on behalf of the Social Security

Administration for Supplemental Security Income and Social Security Disability Insurance

Coordinate with diverse communities and organizations to strengthen and to support the provision of a spectrum of medical, health, and social services o Provide efficient and effective services to Texans with disabilities and families with

children who have developmental delays to improve the quality of their lives and to enable their full participation in society

Provide efficient, effective services for individuals in 24-hour state facilities o Improve the efficiency and effectiveness of SSLCs o Ensure state psychiatric hospitals and other related state facilities are safe, effective,

and recovery-oriented Promote consumer health and safety through focused regulatory and licensing activities

o Decrease occurrences where children are placed at serious risk in licensed day care facilities, licensed residential facilities, and registered family homes

Ensure the integrity of HHS programs through the IG o Identify, deter, and act on fraud, waste, and abuse through timely and quality audits,

investigations, and inspections. o Generate and disseminate excellent work products that demonstrate mission

performance, inform stakeholders, and educate the citizens of Texas o Identify and implement best practices in all areas of the organization, including

improving business operations and researching and obtaining an effective data analytics tool and other technologies to improve productivity and effectiveness


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o Develop and maintain outstanding internal and external relationships to promote transparency and accountability

Improve the effectiveness and efficiency of system oversight and program support Improve services and accountability through organizational transformation and monitoring

for efficiency and effectiveness of the consolidated functions as an ongoing process Discover, understand, access, use, and share accurate data and information to improve decision-making and service delivery Provide guidance and support to agencies to ensure equitable and appropriate delivery of programs and services to improve outcomes for all people

Improve behavioral health coordination and provide broad oversight and consultation among state agencies, local governments, and other entities to ensure a strategic statewide approach to providing services31

The integration of primary and behavioral health care can also benefit from interoperability improvements.

These goals are supported by the HIT roadmap being drafted by the HHS agencies. The draft mission and vision, respectively are:

Health IT Mission The HHS System strives to improve public health, health service delivery, increase effectiveness, efficiencies, and reduce costs through the appropriate and secure use of health information and technology.

Health IT Vision The Health IT vision is to provide high quality health information and technology that is business-driven, secure, accessible, and available when and where it is needed to improve and protect the health and well-being of all Texans. The draft roadmap will be reviewed by the eHealth Advisory Committee prior to its publication. Data Needs Interoperability should be enabled when it meets a business need and sufficient resources exist to implement exchange using appropriate, secure methods. Business requirements dictate the nature of the information to be exchanged, how data must be formatted, the frequency at which information should be provided, and who should have access to the information. Program areas across HHS agencies have varying requirements for data, based on their purpose, ranging from:

31 Texas Health and Human Services Commission. Texas Health and Human Services System Strategic Plan 2017–2021.


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Real-time data to manage patient health in the inpatient settings of a state hospital or SSLC; Data submitted by substance abuse service providers used to manage patient care; Data needed to establish clients’ eligibility for Medicaid or other programs; Data submitted by Medicaid providers for billing purposes, which must be submitted within

required billing periods; Patient data from Local Mental Health Authorities (LMHAs) or Local Intellectual and

Developmental Disability Authorities (LIDDAs), used for contract management; and Data to meet public health reporting requirements, which may be near-real time for certain

reportable conditions, annually for certain programs, or on other schedules, based on how the data may be utilized.

Some systems, especially those that are clinically-oriented such as DSHS’ laboratory systems, client management systems like Clinical Management for Behavioral Health Services (CMBHS), or Medicaid claims systems may be designed to support bi-directional access. Others, such as the National Electronics Disease Surveillance System (NEDSS), do not currently support providers’ access to the system. As the health care system and technology capacity evolves, such as the data necessary for the delivery of precision medicine, there may be new use cases that require additional data, or that require bi-directional access. HHS agencies are interested in working with stakeholders to identify such use cases, determine the impact of the use case, and, where appropriate, develop funding requests to operationalize necessary functionality. Security, Confidentiality, and Patient Privacy Interoperability requires the use of appropriate security tools to maintain client confidentiality and privacy. Data must be managed within the context of applicable law, including, but not limited to: The Health Insurance Portability and Accountability Act (HIPAA); 42 Code of Federal Regulations (CFR) Part 2, which addresses the confidentiality of alcohol

and drug abuse patient records; The Genetic Information Nondiscrimination Act of 2008 (GINA); The Texas Medical Records Privacy Act; and The Texas Identity Theft Enforcement and Protection Act.

Only authorized users should have access to data, and, where HIPAA applies, only that data necessary to accomplish the business purpose should be provided. Patients may consent to share information, but consent is not required for exchanging data for payment, treatment, or health care operations activities. General patient consent may not be applicable to all patient information, such as substance abuse treatment information or psychotherapy notes. Consent is also not required for disclosure to public health authorities for public health purposes including, but not limited to, public health surveillance, investigations, and interventions.


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Status of Interoperability within HHS System Agencies HHS agencies have developed a HIT program, policy, and technical infrastructure, with a significant number of information systems currently supporting standards-based exchange of PHI and other information with healthcare providers. Development of systems to support Medicaid, including the core Medicaid Management Information System (MMIS) and ancillary systems, are developed in a manner consistent with the Medicaid Information Technology Architecture (MITA).32, 33 CMS requires periodic self-assessments by states to measure progress along a MITA maturity scale developed by CMS. To receive enhanced funding states must demonstrate to CMS the compliance of information system component implementations with the twelve conditions and standards (12SC) for those systems. Information systems containing PHI are used for a variety of business purposes by HHS agencies and the business purposes drive the frequency at which data may be exchanged to meet those needs. Not all systems within HHS that contain PHI are used to directly manage clients' ongoing medical care and may not contain up-to-date information regarding the client’s current status. For example, data regarding patient care are entered very quickly into the EHR systems utilized by the state hospitals and SSLCs, but data are not generally submitted by providers who diagnose or treat cancer until after a patient’s first course of treatment is complete. It is essential for trading partners to understand systems’ purposes when engaging in bi-directional interoperability so that data can be used appropriately and no inappropriate conclusions are made.

32 Medicaid Information Technology Architecture (MITA). https://www.medicaid.gov/medicaid-chip-program-information/by-topics/data-and-systems/medicaid-information-technology-architecture-mita.html. Accessed September 10, 2016.

33 Re: Mechanized Claims Processing and Information Retrieval Systems – APD Requirements. State Medicaid Directors’ letter 16-009, https://www.medicaid.gov/federal-policy-guidance/downloads/smd16009.pdf. Accessed September 26, 2016.

MITA is “[A] national framework to support improved systems development and health care management for the Medicaid enterprise. MITA has a number of goals, including development of seamless and integrated systems that communicate effectively through interoperability and common standards.”1 Systems developed using Medicaid Advanced Planning Document funds must follow CMS’ “Twelve Conditions and Standards” to receive funding. The third condition is industry standards: “States must ensure alignment with, and incorporation of, industry standards: the Health Insurance Portability and Accountability Act of 1996 (HIPAA) security, privacy and transaction standards,” extended in a June, 2016 State Medicaid Directors’ letter to include certain standards adopted by the Office of the National Coordinator. (FN) The seventh condition is interoperability: “Systems must ensure seamless coordination and integration with the Exchange (whether run by the state or federal government), and allow interoperability with health information exchanges, public health agencies, human services programs, and community organizations providing outreach and enrollment assistance services.” 2 The same Medicaid Directors’ Letter that extended the industry standards condition also extended the interoperability condition, requiring that Medicaid eligibility and enrollment systems “Support seamless coordination and integration with the Marketplace, whether the Federally-facilitated Marketplace (FFM) or a State-based Marketplace (SBM), as well as the Federal Data Services Hub (FDSH).” 3

1-“Re: Mechanized Claims Processing and Information Retrieval Systems – APD Requirements,” State Medicaid Directors’ letter 16-009, https://www.medicaid.gov/federal-policy-guidance/downloads/smd16009.pdf, retrieved September 26, 2016. 2- ibid 3- ibid


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HHS Structural Supports for Interoperability Interoperability is a primary concern for HHS programs exchanging PHI with trading partners both internal and external to HHS. A number of entities and other resources have been established within HHS to help support program areas in the exchange of health information.

HHS Office of eHealth Coordination (OeHC) OeHC was established within the HHSC Office of Health Services (OHS) in 2010. OeHC serves as the single point of contact in HHS for health information policy and state funding opportunities under Title XIII of the American Recovery and Reinvestment Act (ARRA)/HITECH. The OeHC Director is designated as the State HIT Coordinator, an ex-officio member of the THSA board of directors, and staffs the Texas HHS Health Information Executive Steering and Management Committees. The OeHC serves as the central health IT coordinator within the Texas HHS agency system.34

With the transformation of the HHS agencies, the OeHC now reports to the Medical and Social Services (MSS) Deputy Executive Commissioner. The new cross-divisional coordination roles implemented as part of transformation will strengthen the office's ability to facilitate coordination across the system and coordinate efforts between MSS and other health technology initiatives that exchange PHI across the HHS System.

Medicaid Health Informatics Services and Quality Medicaid established a Health Informatics unit to manage health IT initiatives and provide policy advice on HIE and EHR issues that affect Texas Medicaid, including providers and clients. The Health IT unit within HHSC’s Medicaid and CHIP Services Department is responsible for implementing the Medicaid EHR Incentive Payment Program and for planning and coordinating health IT services and programs within the department. The unit also serves as the lead business operations area for the Texas Medicaid Health IT Plan.

HHSC IT HHSC IT, under the direction of the HHSC Deputy Executive Commissioner for Information Technology, supports the business operations areas by providing oversight and collaborating on systems, technology, and architecture solutions to meet their needs. HHSC’s Chief Technology Officer (CTO) and staff work with OeHC, the DSHS Center for Health Policy and Performance, and other groups on the planning and development of interoperability strategy. The consolidation of IT into one organization that reports to the Chief Information Officer (CIO) enables improved coordination and planning of ongoing relevant initiatives.

34 Texas Health and Human Services Commission. HHS Circular C-032, Health and Human Services Enterprise, Office of e-Health Coordination. January 7, 2010.


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HHSC Office of the Chief Data Officer (OCDO) OCDO resides within the Policy and Performance Office and is responsible for managing data and creating the governance structure for data created, managed, or maintained within HHS. OCDO’s mission is to enable the efficient use of data to improve health and human services and the lives of Texans.

DSHS Center for Health Policy and Performance (CHPP) CHPP provides support for the agency’s activities regarding HIT and interoperability including staff for the agency’s HIT Executive Steering Committee, subject matter expertise, the development and management of HIT policies, and liaison services with other HHS and external entities.

Electronic Health Information Exchange Advisory Committee (EHIEAC) The EHIEAC was established in 2009 in accordance with H.B. 1218, 81st Legislature, Regular Session, 2009, to advise HHSC on issues regarding the development and implementation of the electronic health information exchange system. The committee was chaired by a member of the healthcare provider community and offered valuable stakeholder insight regarding HHS HIT and HIE activities.

HHSC eHealth Advisory Committee (eHAC) S.B. 200, 84th Legislature, Regular Session, 2015, removed more than 20 HHS-related advisory committees from statute, including the EHIEAC, and gave the executive commissioner the authority to redesign its advisory committees in rule. HHSC conducted a comprehensive analysis of its advisory committees and solicited stakeholder input on recommendations regarding the advisory committee structure. A new advisory committee, the Electronic Health Advisory Committee (eHAC), was formed, collapsing and extending the responsibilities of the DSHS Healthcare Information Technology, HHSC Telemedicine/Telehealth, and Health Information Exchange Advisory Committees. The newly formed advisory committee will advise HHS agencies on strategic planning, policy, rules, and services related to the use of HIT, health information exchange systems, telemedicine, telehealth, and home telemonitoring services. The first eHAC committee meeting was held in November 2016.

Privacy and Security Privacy and security are of the utmost importance for electronic health information data assets. Ensuring that only authorized users have access to data to meet specific needs is a key factor in system design and establishing interoperability across systems. Access controls must be maintained for each data element. Security controls must ensure data is secure when in transit or at rest. HHS staff from both of the areas below are participants in all activities relating to the exchange of information.


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HHS Privacy Office The HHS Privacy Office is housed within the HHSC Legal Services Division and provides support regarding privacy, security, breach notification and regulatory compliance. Legal Services is responsible for all legal agreements regarding data security and privacy including the data use agreement referenced in this document.

HHS Information Security Office The Chief Information Security Office is housed within the HHSC IT Division and is responsible for maintaining a security posture that protects all HHS data assets whether they are maintained by state resources or contracted entities. The HHS security program is aligned with the National Institute of Standards and Technology (NIST) and consists of policies, standards, controls, and guidelines. The security control requirements are published in the Enterprise Information Security Standards and Guidelines (EISSG) and various security technologies are used for monitoring and protecting the agency's information assets. The Chief Information Security Officer has oversight over all HHS technology implementations.

Shared Resources and Tools The following shared tools and resources also support agencies in their work to implement interoperability:

Data Use Agreement (DUA) HHS agencies are continuously working to protect all types of confidential information and to comply with state and federal requirements applicable to confidential information, including the HIPAA Omnibus Rule of 2013. As part of this effort, HHS has developed a new DUA for use across the HHS system. All HHS agency contractors with access to HHS confidential information must sign and comply with this new DUA. The new DUA specifically outlines the requirements for contractors to protect and safeguard agency information.

Data Asset Repository The OeHC led a cross-functional workgroup to help define interoperability planning approaches and identify information necessary to facilitate the planning process. Workgroup participants included members from OCDO who incorporated information related to interoperability planning in OCDO’s project to collect data across HHS agencies to create a Data Asset Repository (DAR). One of OCDO's initiatives was an inventory of all the data assets across the HHS agencies, in accordance with the Sunset Advisory Commission’s recommendation in its 2015 report on the HHS system.35

35 Texas Sunset Commission. Sunset Advisory Commission Staff Report with Final Results, Health and Human Services Commission and System Issues. July 2015. pp 95-102.


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In June 2016, OCDO completed the first phase of the project—an inventory of data assets across HHS. Information in the DAR can be updated by program area staff and is used by OCDO to collect and publish information about data (business metadata) used across the HHS system, in business terms. The data assets were also categorized to increase the ability to make data comparisons. For example, these categorizations enable staff to search across all documented data assets to determine where PHI resides regardless of agency or program boundaries. The DAR also documents the Information Exchanges (IE) between sets of data and data assets. Each set of data identifies data standards utilized today. This information will be used as a baseline to support the HHS Interoperability Planning Framework.

Identity Resolution Services OCDO also created an identity resolution process for all Medicaid clients and providers that supports the ability for IT systems across the HHS system to match data. This will provide assistance to the Medicaid staff's increased use of information exchange in their business processes.

Public Health Gateway DSHS has developed a public health gateway to serve as a single connection point for multiple program areas. This approach enables trading partners to implement one interface that can support multiple message types. As new IT projects for either existing or new systems that involve information exchange are undertaken, they are reviewed for incorporation into the gateway’s services.

Interoperability Governance at HHS Agencies Governance regarding the interoperability of systems works at many levels across the HHS agencies. Each agency has their own governance process within a broad framework established by HHSC. The Enterprise Information Technology Governance Policy and IT Project Management Policy define the process and procedure associated with the HHS System IT functions, including portfolio and project management, system integration, interoperability and strategic planning. HHS Circulars C-09 and C-010 describe these policies in more detail and are included in Appendices C and D, respectively.

In implementing H.B. 2641 across the HHS system, OeHC works in collaboration with all HHS agencies to define and implement HHS policies and processes supporting interoperability. Circular C-032 is included in Appendix E as an example of how HHS further refines the guidance for HIT systems, adding additional review beyond that which is required for general IT activities. C-032 was updated in October 2015 to align with the interoperability goals set out by H.B. 2641 and refine the governance structure for HIT.


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HHS System Health Information Executive Steering Committee (HIESC) Working across the system level there are multiple governance committees, including the HHS System HIESC and the Health Information Management Committee (HIMC), to oversee the planning and procurement of information systems that exchange PHI. The HIESC provides strategic direction about projects or policy concerns regarding health information, oversight, and guidance on HIT and HIE strategic planning, data governance, interagency data sharing, project dependencies and HIT and HIE standards.

The HIESC is co-chaired by the HHSC CIO and other HHS agency executive level staff as well as representatives designated by the commissioners of each HHS agency and major program areas within HHSC. The HIESC incorporates the approach and guidance in C-032 on the use of standards as part of their oversight of new system implementations.

HHS System Health Information Management Committee (HIMC) The HIMC is guided by and supports the HIESC. It has representation from all HHS agencies. HIMC creates workgroups to address specific HIT and interoperability topics, policy issues, or projects as directed by HHS leadership through the HIESC. This committee is co-chaired by the Director of OeHC and the HHS Chief Technology Officer.

Data Governance HHS System data governance, managed through OCDO and through the Enterprise Data Governance Council with representation from across the system, aligns with HHSC IT governance and collaborates in areas such as data management strategy, policy, standards, and technology including HIT.

In 2015, OCDO began gathering information to support a system wide DAR which includes information about the data standards being used, as discussed above.

Agency HIT and Information Resources Governance HHSC, DFPS, DADS, and DSHS all have governance processes that have been effective in overseeing their agency's processes. For example, DSHS has a HIT Executive Steering Committee, governance regarding project prioritization, and a review of system architecture for every IT project it undertakes. In addition, HHSC has conducted governance activities overseeing several system wide areas. In light of the consolidation of IT functions as part of HHS Transformation, these processes will need to be optimized for the new organizational parameters.

The governance process includes the review of standards in use at HHS, operating rules, ONC Roadmaps, and the progress being made on other national private public interoperability


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initiatives. This allows for decision making to be informed and consider the most recent accomplishments in the rapidly changing HIT environment.

Select Programs Currently Using Standards-based Interoperability HHS agencies recognize the importance of using standards to facilitate the exchange of information and have a long history of using systems that support standards-based interoperability with trading partners. Examples of programs and systems currently in place are described below.

Select Programs and Systems at HHSC

Medicaid Systems-General One of the biggest HHS information systems that regularly exchanges PHI with the healthcare provider community is the Medicaid Management Information Systems (MMIS). HHSC has ensured that national HIT standards are implemented in the solutions provided by the Medicaid Claims Administrator. The use of standards dominates MMIS information exchanges, making these transactions interoperable with healthcare providers’ systems. These exchanges are voluminous and rapid, with Electronic Data Interchange (EDI) transactions totaling in the tens of millions daily. HHSC continually expands and improves the capabilities of the Medicaid portal to include support for care management, Long Term Care and Children with Special Health Care Needs services, electronic signatures, and attachments. Appendix G to this document includes a listing of standards-based transactions implemented by the Medicaid Claims Administrator.

In support of the Medicaid program, providers use interoperability standards to accomplish a number of tasks including eligibility verification, claims submission, claim status inquiry, electronic remittance and status reports, and appeals. Providers can submit claims through the EDI Gateway, submit data directly, or use third-party services. Providers can also use the Medicaid Eligibility and Health Information System to access patient information.

Since the 2012 Medicaid Information Technology Architecture State Self-Assessment, HHSC has successfully completed projects that advance interoperability, including the Balancing Incentives Program; International Classification of Diseases, Tenth Edition (ICD-10) implementation; and support for the Council for Affordable Quality Healthcare Committee (CORE) Operating Rules (Phases 1 - 3).

The Affordable Care Act required state Medicaid agencies to implement Operating Rules developed by the CAQH. The Council is a collaborative effort that includes the participation of over 130 healthcare-related organizations as well as state and federal governments. The Operating Rules further standardize the format and content of HIPAA-standard transactions to promote interoperability by making "electronic transactions more predictable and


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consistent."36 The rules are similar to the operating rules the banking industry implemented for ATM networks. Medicaid implemented the first three phases of the CORE Operating Rules and exceeded the CORE standards for system availability and response times.

Pharmacy Claims HHSC contracts for the management of Pharmacy Claims and Rebate Administration (PCRA). This includes the processing of pharmacy claims, collection of associated data, and management of rebates. The PCRA system, along with systems for drug prior authorization and utilization review, will be replaced as part of MMIS modernization efforts. The current PCRA system includes an interface to a national e-prescribing network. This connection allows prescribers with a certified EHR to access medication history for Medicaid clients and Medicaid formulary and pharmacy benefit information during the electronic prescribing process.

E-Prescribing E-prescribing illustrates successful end-to-end, standards-based interoperability. In this instance, the standards were developed in advance of interoperability requirements. The National Council for Prescription Drug Programs (NCPDP), an American National Standards Institute (ANSI) accredited organization, adopted the SCRIPT standard for electronic prescribing in 2004. In 2007 CMS required the use of the SCRIPT standard for electronically submitted prescriptions requiring federal reimbursement.37 This was then followed by the HITECH Act's Meaningful Use e-prescribing requirement. On the industry side of this equation, the pharmacy benefit managers (PBM) and pharmacies formed an alliance and created Surescripts© consortium which now dominates the market. With the standard predefined, EHRs were built with the ability to interoperate with Surescripts©.

36 CAQH. CAQH CORE Overview. http://www.caqh.org/core/caqh-core-overview. Accessed September 26, 2016. 37 42 CFR 423.160. 70 FR 67593, Nov. 7, 2005, as amended at 71 FR 36023. June 23, 2006.


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In Texas, from 2008 to 2014 the percent of physician e-prescribing through an EHR went from 6 percent to 67 percent.38 HHSC reported that in 2013 providers in the Medicaid EHR Incentive Program were transmitting over half of their prescriptions electronically.39 Within the Medicaid provider community, participants in the EHR Incentive Program utilize e-prescribing much more frequently than non-participants, as reflected in the chart to the right. The pharmacies are then able to electronically get these prescriptions authorized and paid using standard electronic transactions with the Medicaid PBM. Making medication histories available are one of the next challenges for the e-prescribing community.

Client Admission and Registration System (CARE) HHSC also operates systems that are used by multiple programs across multiple agencies to manage operations. One of these is CARE, which, is shared between the state hospitals, community mental health, and intellectual and developmental disabilities (IDD) programs. First developed approximately 30 years ago, CARE is utilized to track and share information about clients receiving mental health or IDD services. Contracted providers submit information to the system using a standard developed by HHSC, DSHS, and DADS in consultation with LMHAs and the LIDDAs. The HHS Community Mental Health program has initiated a project to migrate away from CARE, based on analysis conducted in the last biennium in which it was determined that CARE should be retired. The IDD program is working on a different timeline to migrate away from CARE.

Clinical Management for Behavioral Health Services (CMBHS) Since deployment in 2010, CMBHS, a custom, web-based application serves as an EHR for substance abuse treatment service providers, a data reporting system for mental health care providers, and a platform for the secure, patient-authorized exchange of behavioral health data. Current users include state-contracted providers of mental health and substance abuse treatment, intervention, and prevention services, and Medicaid managed care providers of

38 Husfstader M, Swain M. E-Prescribing Trends in the United States. ONC Data Brief. No. 18. July 2014. 39 Texas Health and Human Services Commission. Report on Electronic Prescribing in Medicaid and the Children's Health

Insurance Program (CHIP) As Required by SB 59, 83rd Texas Legislature, Regular Session, 2013. March 2015.


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mental health services. CMBHS is used at more than 3,000 organization and clinic locations in Texas.

CMBHS currently includes support for contracted behavioral health service providers to document clinical information such as screenings, diagnosis, treatment plans, and clinical progress notes. It includes Texas-specific standardized assessments for people with mental health and/or substance use disorders, substance abuse service treatment plan development and review, and discharge activities. For substance abuse service providers, CMBHS also enables clinicians to record progress notes, generate daily day-rate attendance records, tracking of medication orders, and other activities.

When CMBHS was initially developed there were no national data standards that met Texas’ reporting requirements and facilitated the exchange of behavioral health data. To enable information exchange, DSHS, in collaboration with the LMHAs, developed a custom standard which is still in use today. There is no known national exchange standard that currently includes all required data.

Substance abuse contractors currently use a web-based user interface (CMBHS Online) while mental health contractors may use either CMBHS Online or submit data using data exchange between locally managed information systems and CMBHS to report state-required data. CMBHS also provides an interface to which providers may connect their local systems to calculate a recommended level of care using DSHS-hosted business rules, simplifying system maintenance for providers. While part of DSHS, the Mental Health and Substance Abuse Services Division worked with other state agencies to either extend access to its systems or establish interoperability.

CMBHS includes an interface with the Texas Medicaid Healthcare Partnership (TMHP) to allow CMBHS users to get real-time information on their client’s Medicaid eligibility. Additionally, CMBHS includes functionality that supports the submission of individual claim data from provider records to the Source contract management system, and to TMHP. The Source and TMHP in turn make payments to contractors for these individual claims.

Information from CMBHS is shared with the Department of Public Safety and the Texas Juvenile Justice Department to enable an identification matching system to support jail diversion for individuals with a history of mental illness and receipt of public mental health services. Information is also made available to the state’s drug court program to facilitate coordination of drug treatment services.

To facilitate long-term services and supports, CMBHS includes screening tools to allow automatic referrals for clients whose screening indicated they may have a need for those services. CMBHS accepts referrals from Your Texas Benefits for clients who have an indicated


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need for mental health or substance abuse services. CMBHS also includes a data exchange process for referrals for tobacco cessation.

Select Programs and Systems at DADS SSLCs Life Record The SSLCs have recently implemented a new “life record,” enabled by a modified commercial-off-the-shelf (MCOTS) EHR system. The system is interoperable with a variety of systems, including the system utilized for tracking dental services provided to SSLC clients, using established standards, for managing client care and services.

Select Programs and Systems at DFPS Foster Care Passport STAR Health, a statewide managed care program for approximately 30,000 children statewide in foster care and DFPS conservatorship, uses an electronic health information system, the Health Passport. This program, initially funded through a $4 million Medicaid Transformation grant, was created by DFPS and HHSC as a result of S.B. 6, 79th Legislature, Regular Session, 2005. The Health Passport is a secure claims-based EHR that provides online access to a child’s health information for authorized users. When a child leaves foster care the Health Passport is available in electronic or printed formats to a child’s legal guardian, managing conservator, parent, or to the individual if he or she is at least 18 years of age or an emancipated minor.

Select Programs and Systems at DSHS State Psychiatric Hospitals Information Systems The state hospitals use a MCOTS EHR, myAvatar™, to track patient care. The system has interfaces allowing standards-based information exchange with the laboratory information management systems serving the hospitals. Information is also provided electronically to other systems such as CARE, as well as generating billing. As the result of a project completed in fiscal year 2017, select LMHAs and all the state hospitals can utilize national standards to exchange clinical records.

Public Health Information Systems In addition to the state hospitals, DSHS operates a broad range of information systems to support public health services. Included in its portfolio are systems used to manage vital statistics, general health care data, and health registries. DSHS also operates the state health laboratory, which utilizes a variety of systems. Several of the programs DSHS operates support providers participating in the CMS Electronic Health Record Incentive Programs (Meaningful Use) by receiving data using standards specified by the program.

Texas Electronic Vital Events Registrar (TXEVER) DSHS is currently engaged in implementing a MCOTS system, TXEVER, a fully integrated


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and comprehensive electronic vital records system – which will include electronic registration and data collection for birth, death, fetal death, marriage, and divorce – to replace its aged vital statistics information system. In addition to enabling registrars and other providers to enter and retrieve data using a web interface, the new system includes support for standards-based vital statistics messaging.

Center for Health Statistics-Inpatient and Outpatient Discharge Data The Center for Health Statistics at DSHS operates the Texas Health Care Information Collection (THCIC). THCIC was created by the 74th Legislature and is charged with collecting and reporting on health care activity in select healthcare facilities (hospitals and ambulatory surgery centers) and health maintenance organizations operating in Texas. The goal is to provide information that will enable consumers to have an informed choice on the charges and quality of health care in Texas. Information on inpatient and outpatient discharges from Texas hospitals and ambulatory surgery centers, including patient and facility characteristics, diagnoses, procedures, and charges, is collected. The current contracted system has expired and a new data collection system is in the process of being acquired. The new system will utilize the applicable ANSI claim file data standards and also be compliant with HIPAA and subsequent amendments.

Texas Cancer Registry (TCR) TCR collects, maintains and disseminates timely, complete and accurate cancer data that contributes towards cancer prevention and control, improving diagnoses, treatment, survival, and quality of life for all cancer patients. TCR cancer data is the foundation for measuring Texas’s cancer burden; comprehensive cancer control efforts; health disparities; and progress in prevention, diagnosis, treatment and survivorship. Information is collected in a variety of ways, including the electronic submission of data by providers using either a format developed by the North American Association of Central Cancer Registries (NAACCR) or an HL7 standard, consistent with the Meaningful Use requirements.

Communicable Disease Reporting (Electronic Laboratory Reporting) Electronic Laboratory Reporting enables hospitals and laboratories to electronically submit laboratory reports into Texas’ implementation of the NEDSS. NEDSS is a key system for conducting public health surveillance, used to identify and respond to disease outbreaks. Data reported are laboratory results with the patient demographic information for Texas and National notifiable conditions. Messages are submitted in a specific HL7 format.

ImmTrac, the Texas Immunization Registry ImmTrac is the immunization registry provided by the State of Texas. The web-based registry receives immunization information for children and adults from private and public health care providers across the state, including input from the Vital Statistics Unit, Medicaid, the Texas-


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Wide Integrated Client Encounter System (TWICES), and health plans. ImmTrac consolidates and stores immunization information electronically in a secure, central system. It allows registered providers to see immunization history for patients, add immunization encounters to patient records, and add consented individuals to the registry. Other types of users (e.g., school nurses, childcare centers) are also able to view the immunization histories of children. ImmTrac is also used for emergency responders and their family members, as well as for tracking immunizations, anti-virals and medications provided in response to or in preparation for a disaster.

ImmTrac currently supports flat-file format for batch interfaces and queries, including HL7 batch reporting. In 2011 and 2012, DSHS received grant awards to make interoperability enhancements to ImmTrac, which have been completed. The grant awards facilitated system enhancements for interoperability of EHRs and immunization information systems, which included:

Identification of large volume reporters (e.g., hospital systems, large multi-site clinics) whouse or plan to purchase EHR products;

Identification of EHR vendors who have a market presence in Texas; and Purchase of middleware applications to allow ImmTrac to exchange data in HL7 format.

The program conducted a successful HL7 pilot project with Texas Children’s Hospital (Houston) in July/August 2011. The project has since been extended to other major ImmTrac trading partners and is ongoing.

In 2013, a project was initiated to replace the software system, which will support a HL7 real-time, bi-directional interface. Replacement of the immunization registry is expected to be completed in 2017.


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Interoperability Supports in Texas outside of HHS Agencies

THSA Recognizing the important role HIEs could have in improving health care quality, reducing health care costs, and affecting population health, the Texas Legislature established THSA in 2007. THSA is “a public-private collaborative to implement the state-level health information technology functions identified by the Texas Health Information Technology Advisory Committee by serving as a catalyst for the development of a seamless electronic health information infrastructure to support the health care system in the state and to improve patient safety and quality of care.”40 The organization is governed by a board of directors that currently includes two representatives from HHS agencies in an ex officio capacity. The THSA’s vision in 2010, was “To enhance health care quality and effectiveness for all patients, the health care sector should be supported by an infrastructure made up of interoperable, electronic health records composed of standardized, structured data elements that are exchanged among authorized health care organizations and providers across secure regional and statewide networks.” In its 2014 Strategic Plan, THSA amended its vision to “We will be recognized as a trusted leader in the development of electronic health information infrastructure that enhances health care quality and efficiency for all patients,” and defined its mission as, “We will promote and coordinate the development of a seamless electronic health information infrastructure to improve the quality, safety, and efficiency of the Texas health care sector while protecting individual privacy.” Based on the analysis conducted by the Texas Sunset Commission, the status and functions of the THSA under legislative authority are currently set to expire on September 1, 2021.41

The THSA, under contract with HHSC, developed a State HIE Plan (HIE Plan) in 2010 to meet requirements of the ONC’s State HIE Cooperative Agreement Program. The objective for the State of Texas specified in the HIE Plan was “to provide direction and guidance to establish and

40 Texas Legislature. House Bill 1066, 80th Legislature, Regular Session, 2007. http://www.legis.state.tx.us/tlodocs/80R/billtext/pdf/HB01066F.pdf#navpanes=0. Accessed October 31, 2016.

41 Texas Legislature. Senate Bill 203, 84th Legislature, Regular Session, 2015.

HIEs are defined in Texas Health and Safety Code,

182.151as"health information exchange" means an organization that:(1) assists in the transmission or receipt of health-related information among organizations transmitting or receiving the information according to nationally recognized standards and under an express written agreement with the organizations;(2) as a primary business function, compiles or organizes health-related information designed to be securely transmitted by the organization among physicians, other health care providers, or entities within a region, state, community, or hospital system; or(3) assists in the transmission or receipt of electronic health-related information among physicians, other health care providers, or entities within: (A) a hospital system; (B) a physician organization; (C) a health care collaborative, as defined by Section 848.001, Insurance Code; (D) an accountable care organization participating in the Pioneer Model under the initiative by the Innovation Center of the Centers for Medicare and Medicaid Services; or (E) an accountable care organization participating in the Medicare Shared Savings Program under 42 U.S.C. Section 1395jjj.


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maintain a network of regional networks that effectively provides statewide HIE functionality. The HIE functionality must support or integrate with statewide services for Medicaid, disease registries, syndromic surveillance, and chronic disease management, behavioral health, emergency preparedness, as well as connectivity to NHIN and national health services.”42

The THSA’s Collaboration Council includes local HIEs, white space Health Information Service Providers, state agency representatives, and other entities (The white space is a fifty county region in West Texas that is not currently covered by a local or regional HIE). It helps oversee the statewide HIE and makes policy recommendations, including data standards to the Board of Directors.

The 2010 HIE Plan presented a statewide “network of networks” approach to interconnectivity and provided for the development of a state-level hub that would serve as a connection point for locally-controlled HIEs, a gateway to the national health information network, and provide access to state-level services and data resources. It included support for a grant program for local HIE initiatives.

In 2014, THSA developed an updated strategic plan with four significant goals:

Increasing the size, scope and services supported through the Texas statewide HIE networkby improving core state-level HIE technical operations, rural HIE planning and development,and state and federal agency connectivity

Continuing to build confidence and trust in the state’s HIE through policy initiatives,governance structure, HIE accreditation and covered entity certification

Empowering patients through Health IT and HIE, including communications marketing,provider adoption, patient education, and engagement

Supporting contingency planning through both technical and financial programs43

Both THSA and the HHS agencies can benefit from collaboration in working towards these goals. Reliable, cost-effective connectivity to HIEs can benefit providers in serving Texans, including Medicaid beneficiaries, by providing access to information for coordination of care as well as engaging in other activities (e.g., supporting faster processing of disability claims, public health reporting, improved sharing of information) to enable improved understanding regarding the quality of health care being delivered. Confidence and trust in HIEs, as well as an assurance of reliability for continued data access, by both providers and patients, will foster additional participation. Patient access to information enables improved understanding of one’s

42 Texas Health Services Authority. Strategic and Operational Plans for Statewide Health Information Exchange. http://hietexas.org/component/docman/doc_download/10-texas-hie-strategic-and-operational-plans-approved-by-onc?Itemid=. p. 66. Accessed September 22, 2016.

43 Texas Health Services Authority. THSA Finalizes Strategic Plan for HIE Growth in Texas. http://www.hietexas.org/summer-2014/thsa-finalizes-strategic-plan. Accessed September 25, 2016.

http://hietexas.org/component/docman/doc_download/10-texas-hie-strategic-and-operational-plans-approved-by-onc?Itemid


http://www.hietexas.org/summer-2014/thsa-finalizes-strategic-plan



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health condition, which encourages independence and supports activities like person-centered planning.

Local HIEs As of 2016, there are six HIEs remaining that originally received support through the HIE Cooperative Agreement program that are currently facilitating the exchange of data at the local level. Several of these HIEs are connected to each other through THSA’s “HIETexas” statewide HIE. There are also a number of other HIEs operating in Texas, some facilitated by EHR vendors that have established connections between different providers using their systems, some hospital-centered, and other, community-based initiatives. There is still a considerable area of Texas not currently served by HIEs. THSA is working to develop a “white space” strategy to enable connectivity to HIEs to providers in these areas.

Regional Extension Centers Four of the 70 regional Health Information Technology Extension Centers funded by ONC were established in Texas. Three state universities and one private foundation, with coordinating support from the Texas Medical Association, were awarded nearly $36 million to start up and provide services to nearly 6,800 primary care providers (PCPs) in private practice, community health centers or rural health centers with 10 or fewer providers, and received an additional $2 million in ONC funding to support adoption of certified EHRs in the outpatient settings of critical access and rural hospitals in Texas with fewer than 50 beds.

Provider and Industry Associations HHS agencies recognize that organizations like the Texas Medical Association, the Texas Hospital Association, the Texas Council of Community Centers, the Association of Substance Abuse Programs, the Texas eHealth Alliance, Texas Health Information Management Association, and the Texas Association of Health Information Organizations are important collaborative partners and stakeholders in advancing interoperability between HHS and provider systems.


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Standards and Standards Development HHS agencies have a long history of using national standards for exchanging data, where those standards exist and where there are no Texas-specific requirements that cannot be accommodated by the national standards. For example, the systems DSHS uses to support providers in their participation in the federal EHR incentive payment programs use HL7 standards for exchanging messages, while providers submitting data to Medicaid for billing use ASC X12 standards and NCPDP for prescriptions. In some cases, HHS defined the standards used for exchange for some systems, such as CMBHS, CARE, and a data warehouse supporting mental health and IDD services.

Merriam-Webster defines “Standard” as “Something established by authority, custom, or general consent as a model or example.”44 In the realm of HIT, interoperability standards are used to enable connectivity between systems and between entities. The use of standards “[P]rovides the fundamental definitions for and structures of the data that can be communicated across a wide variety of use cases.”45 Furthermore, “Data standards provide a method to codify in valid, meaningful, comprehensive, and actionable ways, information captured in the course of doing business.”46 Healthcare providers and related entities apply and utilize standards to facilitate the interoperability of IT systems to support the delivery of health care.

Advancing interoperability between IT systems and providers is essential to the successful transformation of the health care system to achieve the triple aim established by the Institute for Healthcare Improvement: improving the experience of care (including quality and satisfaction), improving the health of populations, and reducing per capita costs of health care.47 To

44 Merriam-Webster. Online dictionary. http://www.merriam-webster.com/dictionary/standard. Accessed September 9, 2016. 45 Healthcare Information and Management Systems Society. Evaluating HIT Standards.

http://www.himss.org/sites/himssorg/files/FileDownloads/2013-09-23-EvaluatingHITStandards-FINAL.pdf. Accessed September 22, 2016.

46 Public Health Data Standards Consortium. Data Standards. Health Information Technology Standards. 2013. http://www.phdsc.org/standards/health-information/d_standards.asp. Accessed September 10, 2016.

47 Institute for Healthcare Improvement. The IHI Triple Aim. http://www.ihi.org/engage/initiatives/tripleaim/pages/default.aspx. Accessed September 10, 2016.

Messaging Standards. Messaging standards are used to define the format and construction of the message that will be used to convey the information. For example, a messaging standard for HIT may require that a patient name, diagnosis, or other content be provided in a certain format at a certain place in the message. Examples of message standards for HIT include HL7 v 2.x, HL7 v 3.x, HL7 v3 Clinical Document Architecture, North American Association of Central Cancer Registries version 15, American Standards Committee (ASC) X12 5010, and Digital Imaging and Communication in Medicine (DICOM). Messaging standards may require the use of specific terminology and vocabulary standards, the use specific Web Services standards, and/or the use of specific transport standards to enable the successful exchange of information.

Terminology/Vocabulary Standards. Terminology and vocabulary standards used in clinical contexts are used to facilitate communication between providers what the information being exchanged between providers means is understood in a consistent manner. Examples of terminology and vocabulary standards include International Classification of Diseases, Tenth Edition (ICD- 10), the Logical Observation Identifiers Names and Codes (LOINC), and Systemized Nomenclature of Medicine (SNOMED-CT.

Web Services Standards. Web Services are an approach to enable the real-time interoperability of systems across the Internet. The two most common standards for Web Services are Representational State Transfer (REST) and Simple Object Access Protocol (SOAP).

Transport Standards. Transport standards define the network protocols used to exchange data between systems. Examples include Hypertext Transport Protocol (HTTP), File Transfer Protocol (FTP), and Public Health Information Management System (PHIN-MS).

http://www.merriam-webster.com/dictionary/standard

http://www.himss.org/sites/himssorg/files/FileDownloads/2013-09-23-EvaluatingHITStandards-FINAL.pdf

http://www.phdsc.org/standards/health-information/d_standards.asp

http://www.ihi.org/engage/initiatives/tripleaim/pages/default.aspx


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accomplish the exchange of health information, a variety of types of standards are used to actually exchange messages between systems and entities. It is also necessary to maintain standards, adjusting them to meet new business requirements or to leverage new technological developments. The graphic below presents the cycle for standards development and maintenance.

Cycle for Standards Development and Maintenance

Create Plan for Standard

Development/Modification

Develop Support

Draft Standard/Update

Ballot Standard

Gain Approval

Implement Standard/Changes


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Open vs. Closed Standards Open standards support interoperability in that they are made available to the general public, are intended for widespread adoption, facilitate exchange across different products, and are developed (or approved) and maintained via a collaborative and consensus-driven process.48 The development of open standards are generally focused on balancing interest groups and all parties’ viewpoints are considered during standards development. The rights to use the standards are under reasonable terms and conditions and either free or are available at a reasonable price.

Closed standards are not available to the public, enabling the developer to manage the resource – including the development of improvements – and sell or license the code and data format, setting criteria under what terms the standards may be used.

Standards’ use may be voluntary, required for participation or membership in industry groups or associations, or required by government agencies.

Standards Development Organizations Standards may be developed by any entity with the resources to engage in defining a message that needs to be exchanged and how that information may be exchanged. To be successful in having a standard adopted, entities need strong connections with the organization(s) that may use the standards to conduct business transactions or otherwise benefit from the exchange of information. Examples of these types of organizations include standards development or standards setting organizations, trade unions, and associations. A standards development organization (SDO) has as its principle functions the development, coordination, promulgation, maintenance, interpretation, or other related activities associated with standards that are intended to address the needs of a wide base of affected adopters. SDOs play important roles as they can develop or package standards in support of specific use cases.

48 International Telecommunication Union. Definition of "Open Standards. http://www.itu.int/en/ITU-T/ipr/Pages/open.aspx. Accessed September 22, 2016.

About the American National Standards Institute (ANSI) ANSI oversees the creation, promulgation, and use of thousands of norms and guidelines that directly impact businesses. ANSI Accreditation provides assurance that standards meet essential requirements and that accredited SDOs are technically competent and impartial.

About the International Standards Organization (ISO) ISO was established in 1947 and includes representation from over 145 individual countries. It oversees the creation and promulgation of standards that "facilitate the international exchange of goods and services."1

ANSI is the only U.S. representative in ISO and "[H]as immediate access to the ISO standards development processes." 1 - American National Standards Institute, ISO Programs- Overview. https://www.ansi.org/standards_activities/iso-programs


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Two organizations, the American National Standards Institute (ANSI) 49 and the International Organization for Standardization (ISO)50 are the recognized entities that accredit SDOs.

A variety of formal SDOs exist to meet the needs of healthcare providers. Some, like HL7 and, the North American Association of Central Cancer Registries (NAACCR) create and maintain standards. Organizations like Integrating the Healthcare Enterprise (IHE) combine different base standards into profiles that are used to define a specific function or use case.

Below is a table of some of the national and international SDOs involved in standards used in health care:51

Sample Standards Development Organizations involved in Health Care Acronym Organization Name Healthcare Related Standards Development

Activities

ASME American Society of Mechanical Engineers

Covers the field of bioengineering which includes bioinstrumentation, biomaterials, biomechanics, cellular, tissue and genetic engineering, clinical engineering, medical imagery, orthopedic bioengineering, rehabilitation engineering and systems physiology.

ASTM American Society for Testing and Materials International

Includes standards for: test methods for medical/surgical instruments, orthopedic devices, implant systems; Ceramics, metals and polymers as well as biocompatibility and magnetic resonance imaging; healthcare informatics includes architecture, content, storage and communication of healthcare information; universal patient identification; nanoscale cancer drugs; safety of consumer rubber products, and standards for medical systems.

CAQH-CORE CAQH established the Committee on Operating Rules for Information Exchange

CAQH CORE is a stakeholder collaboration focused on operating rules for administrative transactions. CORE’s operating rules support standards such as X12, and

49 American National Standards Institute. ANSI Accreditation. https://www.ansi.org/accreditation/Default.aspx. Accessed September 22, 2016.

50 American National Standards Institute. ISO Programs – Overview. https://www.ansi.org/standards_activities/iso_programs/overview.aspx?menuid=3. Accessed September 22, 2016.

51 American National Standards Institute. Resources: Standards Developing Organizations (SDOs) https://www.standardsportal.org/usa_en/resources/sdo.aspx#ISecBis149. Accessed September 26, 2016.


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Acronym Organization Name Healthcare Related Standards Development Activities

then specifies the business actions to which each party must adhere.52

CLSI Clinical and Laboratory Standards Institute

Focus is continual improvements in clinical laboratory testing standards.

HL7 Health Level Seven Comprehensive framework and standards for the exchanging, integrating, sharing and retrieval of electronic information that supports clinical practice and the management, delivery and evaluation of health services. 53

INCITS InterNational Committee for Information Technology Standards

Standards development for biometric identification, wireless sensor networks and worldwide infrastructure standards for e-Commerce in healthcare management.

NEMA National Electronics Manufacturers Association

Standards for healthcare communications and emergency call systems, healthcare facility equipment including X-ray, molecular, magnetic resonance, medical imaging informatics, radiation therapy and healthcare IT.

PCHA Personal Connected Health Alliance

Interoperability of personal connected health devices and systems.

X12 X12 X12 standards are utilized for a variety of processes related to health insurance, including enrollment and claims processing. HIPAA requires the use of X12 standards.54

In order to enable the electronic exchange of health information between systems, standards are needed to establish a pathway that facilitates communication between systems seamlessly.

52 CAQH. CAQH CORE Overview-Operating Rules Streamline the Business of Healthcare. http://www.caqh.org/core/caqh-core-overview. Accessed September 26, 2016.

53 Health Level 7. About HL7. http://www.hl7.org/about/index.cfm?ref=common. Accessed September 22, 2016. 54 X12. Subcommittee, X12N – Insurance. http://www.x12.org/x12org/subcommittees/asc-x12-rosters.cfm?strSC=N. Accessed

September 26, 2016.


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Examples of Standards Some common standards used in healthcare today are: HL7; Fast Healthcare Interoperability Resources (FHIR); Digital Imaging and Communications in Medicine (DICOM); and NAACCR standards, Version 15.

HL7 The HL7 standard is structured to accommodate various types of messages transfers using different implementation guides. There are different HL7 structures for a broad range of purposes, including electronic laboratory reporting and immunization. Even though these HL7 message types differ the healthcare industry understands the different subtypes as parts of a broader system.55

FHIR The FHIR standard is a new specification from HL7, based on emerging industry approaches, but informed by years of lessons around requirements, successes and challenges from previous experience with standards. FHIR can be used as a stand-alone standard, but can also be used in conjunction with other standards. FHIR is easy to implement compared to most standards presently used in the health care industry.56

DICOM The DICOM standard is used for medical images encompassing several areas like X- ray, CT, MRI, ultrasound, dentistry and so on. It has enabled digital images to be transmitted with ease globally.57

North American Association of Central Cancer Registries (NAACCR) Version 15 The NAACCR standards are used for submitting data to central cancer registries. 58

Status of Interoperability within HHS Agencies and Between HHS and Other Healthcare Entities As demonstrated above, HHS agencies are currently interoperable with trading partners across a number of program areas and systems. The agencies are continuing to:

Expand interoperability and use national standards, where available, to better addressbusiness needs,

Identify use cases based on legislative and regulatory changes,

55 Health Level 7. Introduction to HL7 Standards. http://www.hl7.org/implement/standards/index.cfm?ref=quickLink. Accessed September 22, 2016.

56 Ibid. 57 DICOM. About DICOM. http://dicom.nema.org/Dicom/about-DICOM.html. Accessed September 22, 2016. 58 National Association of Centralized Cancer Registries. About NAACCR, Inc.

http://www.naaccr.org/AboutNAACCR/NAACCRMission.aspx. Accessed September 22, 2016.


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Identify opportunities for revising business processes to improve quality and reducecosts, and

Continue collaboration with stakeholders.

Challenges include the availability of standards and the capacity of providers’ systems to utilize open standards. HHS agencies recognize that systems will have to be built with enough flexibility to accommodate periodic changes to the standards used in the healthcare provider community. Until there is a more widely regimented use of standards among the healthcare industry's EHR vendors, interoperability will exist for a limited number of reporting requirements when information is reported either directly to state information systems or through HIEs.

The Impact of Transformation on Interoperability As the programs across the HHS system are realigned, improvements are being planned to adjust the internal IT structure and information systems. These changes will facilitate improved collaboration across and within program areas and IT and will have a significant impact on interoperability. They will also facilitate improved collaboration with stakeholders who are engaged with multiple programs.

A revised governance structure, informed by the new organizational arrangements, will allow for better coordination on the use of standards across HHS agencies.

A major impact of transformation will be realized by the healthcare community through HHS' unified voice and agility in its interoperable solutions to healthcare use cases.

New Systems in HHS Agencies that Exchange Protected Health Information and have been Planned or Procured since September 1, 2015 Most work in creating new functions using technology within HHS involves maintenance or enhancements to existing systems rather than purchasing new systems or replacing existing systems. Consequently, there are few new systems that may be subject to the standards requirements established by H.B. 2641. The use of applicable standards is included in the architectural requirements for projects, discussed during the concept development phase of project development, specified in the planning phase of the project, and reviewed as part of the CTO’s architectural review. Systems or projects planned or procured since September 1, 2015, and therefore subject to H.B. 2641, include:

Agency System/Project Name

Description Standards Impact

Status

DSHS Texas Syndromic Surveillance (TxS2)

As described elsewhere in this report, TxS2 establishes

System requires the

System being configured to


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Status

statewide syndromic surveillance, utilizing both direct data collection from hospitals and urgent care centers as well as indirect collection through regional centers.

use of HL7 standards.

utilize standards, as designed.

DSHS High Consequence Infectious Diseases (HCID) Assessment

General Appropriations Act, H.B.1, 84th Legislature, Regular Session, 2015 (Article II, Department of State Health Services, Rider 77), appropriated $13.3 million to DSHS to enhance preparedness and outbreak response for HCIDs. Of the appropriated funding, $3.2 million was designated for IT investments. Assessment projects were conducted to detail business requirements.

Assessment discussed use of applicable standards.

Assessment project complete. Implementation projects pending.-RFP will address standards requirements, when published.

DSHS HRAR Planning and Assessment Project HIV = Human immunodeficiency virus RECN = Real-time Education and Counseling Network AIDS = Acquired immune deficiency syndrome ARIES = AIDS Regional Information Evaluation System

The HRAR Assessment & Planning Project started 09/01/15 and ended 02/29/16. The project produced a draft Business Case and Workbook that promoted interoperability. The goal of the project was to ensure critical functionality within the HIV system, RECN system, and ARIES can continue to meet the agency vison of “A Healthy Texas.” Goals and objectives included: documenting functional requirements and Business Process Maps, determining cost and benefits of integrating the functionality of the three systems; and determining the cost, scope and duration of a major information resources project to implement the integration.


Assessment project complete. RFP will address standards requirements, when published.


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Status

DSHS HRAR Planning Project

The initial and critical focus for the HRAR Planning project is on finalizing and submitting the Business Case and Statewide Impact Analysis (SIA) to the LBB. The Project will refine requirements and provide finalized Business Process Maps for several systems; address business issues identified for the Disease Control and Prevention Services (DCPS) HIV Program and the existing data applications; and use requirements to produce documents to advance a vendor procurement for solution of a single system for HIV2000, RECN, and ARIES functionality.


Project started 03/01/16 and has the estimated end date of 08/31/17. Project incorporates interoperability requirements.

DSHS Center for Health Statistics/THCIC Inpatient and Outpatient Discharge Data

The system DSHS utilizes to collect inpatient and outpatient discharge data from Texas hospitals and ambulatory surgical centers, including patient and facility characteristics, diagnoses, procedures, and charges is provided and operated by a third party. The goal is to provide information that will enable consumers to have an informed choice on the charges and quality of health care in Texas.

New system will utilize applicable standards- ANSI claim file and be compliant with HIPAA and its subsequent amendments.

Planning/ Procurement

HHSC Pharmacy Benefits Management System (PBMS)

The Medicaid/CHIP Vendor Drug Program PBMS system uses include: prescription processing for the Medicaid, CHIP, Children with Special Health Care Needs, Healthy Texas Women and Kidney Health programs; claims and encounter processing; rebate processing; operating a point of

New system will be compliant with CMS' conditions and standards and MITA and utilize

Planning/ Procurement


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Status

sale system with over 4,000 pharmacies across the state.

the NCPDP standard.

Interoperability Progress Information Management The OCDO is working with OeHC on enhancements to the governance process for systems that exchange PHI with healthcare providers. These enhancements will make available more insightful information on the use of standards and the credibility, interoperability, and accessibility of the data included in new HHS information system projects. In addition, OCDO will facilitate the development of a standards and process glossary that describes and harmonizes the terms used across the system, creating a system-wide semantic layer. This semantic layer enables shared data definitions to support the accurate reuse of data across the system. All these activities serve to increase the accessibility of information on existing HHS data assets and provides for continuous improvements in governance and system development processes' ability to support and further interoperability. The guiding principles of the OCDO and associated policies and responsibilities are documented in HHS Circular C-049 (see Appendix F).

Exchange of Encounter Data for Medicaid Claims Medicaid is implementing Phase 4 of the CORE Operating Rules. This will give the managed care organizations (MCOs) the capability to submit encounters following the CORE rules for information exchange. This implementation should be completed in 2016.

Syndromic Surveillance In Texas, there is statutory authority but no statutory requirement for the reporting of syndromic surveillance data.59 As of September 2016, two syndromic surveillance systems operate in Texas: a regional system hosted by Tarrant County Public Health and the former Texas Association of Local Health Officials (TALHO) system currently maintained by DSHS. Approximately one-third of the data providers in Texas are participating in syndromic surveillance through the Tarrant County system or the TALHO system; however, the two systems do not share data. In addition, a regional system hosted by Houston Health Department is in development.

Syndromic surveillance is transforming in Texas. In collaboration with public health partners across the state, DSHS is in the process of implementing a statewide syndromic surveillance

59 Texas Health and Safety Code, Chapter 81


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system, TxS2. TxS2 will accumulate data, using national data standards developed by HL7, through feeds from emergency departments across the state, as well as from the regional systems hosted by Tarrant County Public Health and Houston Health Department. Tarrant County will serve providers in 49 counties located in north Texas in the Dallas-Fort Worth area and the Houston Health Department will serve providers in a 16 county area in southeast Texas around Houston. TxS2 will collect data directly from healthcare providers in the remainder of the state, enabling both regional and statewide analysis.

Psychiatric Hospital Clinical Data Exchange Enhancements DSHS is in the process of further updating clinical data exchange to support enhanced continuity of care between inpatient services provided by the state psychiatric hospitals and community-based mental health services providers. This functionality supports the state hospital system’s vision to partner with consumers, family members, volunteers, service providers, and policymakers to provide quality services responsive to each patient’s needs and preferences.

Clinical Management for Behavioral Health Services New projects that are part of the planned information technology roadmap are the addition of diagnosis information from the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5) to CMBHS, advancement of an expanded continuity of care document (CCD) with support for additional behavioral health information for hospitals and mental health community centers, and advancement of standards for data exchange, all currently underway.

Additionally, information from CMBHS will be made available to the Office of Court Administration to allow courts to access information on the status of certain types of involuntary commitments and client programs.

Advancing Interoperability through HIEs HHS agencies are working to support a variety of connections to providers including directly connected to HHS, through local public and private HIEs directly connected to HHS, and through HIEs connected via HIETexas to HHS. This multi-pronged approach is necessary because HIEs do not cover the whole state and not all providers in HIE service areas are connected to an HIE.

HHS agencies are also working to enable providers to choose to use HIEs when interacting with HHS. A variety of activities are being undertaken to advance connectivity with HIEs and enable information exchange including improving connectivity, establishing legal agreements, and establishing message exchange and information flow policies.


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HHS agencies recognize the importance of information exchange across the healthcare continuum and collaborate with partners such as THSA and the local HIEs to help establish local connectivity opportunities.

HIE Connectivity and Infrastructure Improvements Texas Medicaid and OeHC have planned several projects that will make services available to HIEs statewide and enhance the existing suite of shared services offered through THSA. These projects include connecting local HIEs to HIETexas, supporting implementation of white space HIEs, medication history service, and a state-level provider directory. OeHC, HHSC Legal Services Division and Procurement and Contracting Services are instrumental in creating the procurement vehicles for these projects. Work on this procurement is anticipated to begin in early 2017.

Medicaid Provider HIE Connectivity Texas Medicaid plans to connect to Medicaid providers that use certified EHR systems with the connectivity available to public HIEs using THSA as the starting point. In this way, Medicaid, the HIE and the provider can be connected using one connection instead of costly multiple point-to-point connections. A pilot project is underway that will fund the HIE's initial costs of connecting to selected Medicaid providers in their areas that are participating in the Meaningful Use project. These connections will make electronic reporting and data exchange possible between Texas Medicaid and providers.

Texas Medicaid wants to implement a rebate program to pay connection expenses incurred by HIEs while onboarding Medicaid providers and is publishing a Request for Information to gather information on how this can be implemented. Texas Medicaid anticipates it will start connecting providers in early 2017.

Legal Agreement with THSA Ensuring patient confidentiality is a high priority. HHSC continues to work with THSA to establish a contractual relationship as part of an updated State-Level Trust Agreement (SLTA) to serve as a foundation for secure, confidential information exchange between HHS agencies and local HIEs participating in HIETexas. This approach can minimize additional administrative activities for HHS agencies and HIEs participating in HIETexas because HIEs signing the SLTA will be bound to all its terms and will not be required to engage in separate negotiations with HHS agencies. This agreement will serve a foundation for developing agreements with HIEs that do not connect to HIETexas.


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THSA Patient Consent Enhancements THSA is working on implementing an approach to consent that will allow clients to record, through their local health provider or HIE, privacy preferences. Once fully implemented, only those documents meeting consent requirements will be shared.

Messaging Testing with HIETexas DSHS has completed basic testing between the DSHS Health Services Gateway and HIETexas using two different protocols. This will serve as a basis for forthcoming advanced testing, based on use cases developed for public health reporting.

Public Health Reporting through HIEs H.B. 2641 allowed DSHS to establish information flow through HIEs for several programs: the Texas Cancer Registry, ImmTrac, and communicable disease reporting (Electronic Laboratory Reporting). The legislation also established a framework to support not only current services, but also provides capacity for future activities relating to bi-directional exchange. To operationalize the legislation, DSHS presented rules to the DSHS Council at their August 2016 meeting. The rules were published for public comment in the Texas Register in November 18, 2016.

DSHS is collaborating with healthcare providers, the local HIEs, and THSA to develop, test, and utilize technology to enable exchange. Several models of exchange developed by the Office of the National Coordinator and the Centers for Disease Control and Prevention were presented to stakeholders by DSHS and, by mutual consent, a new model that includes support for bidirectional exchange is in development. A phased-in approach is expected, with a near-term focus on utilizing existing technologies, capacities, and processes, including leveraging changes currently in process such as the replacement immunization registry system. In the mid- and longer-term, capacity will be expanded to support bi-directional exchange, based on use cases related to the immunization registry as well as additional use cases to be developed.

HHS Agencies Interoperability Planning Framework, 2017-2022 Based on the HHS Strategic Plan, past experience in working to implement interoperable systems, and recognizing the strength in advancing collaborative activities, HHS agencies have identified a number of strategic domains that require additional planning and subsequent activities in 2017-2022: infrastructure, governance, trust, business/technical operations, policy and practice, and communications. Collaboration between and among HHS agencies and their trading partners is essential both in establishing a detailed interoperability plan and realizing the plan’s goals.


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HHS agencies will work with the newly-established eHAC and other stakeholders to develop plan details. Substantial focus will be directed at identifying appropriate methods of measuring advancements in interoperability across HHS systems.

Advancing this framework will improve interoperability between healthcare providers and HHS agencies to meet agencies’ business needs, advance HHS agencies’ mission, and realize HHS’ vision. HHS agencies will continue to utilize a needs- and resource-based approach to collaborate with trading partners to identify opportunities to invest in expanding interoperability. Key resources to use in subsequent development include the DAR and the established governance framework. The following pages provide additional information about goals, provide a context for action, identify potential strategies, identify current programmatic activities, and indicate potential future undertakings.


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Goal 1: Optimize HHS infrastructure to improve connectivity and interoperability for trading partners and between HHS programs.

Strategic Domain Infrastructure

Context There are currently a variety of separate connections that must be established to complete business activities with different HHS programs, such as the Medicaid portal and various DSHS public health registries. Improving alignment between the different programs can reduce the number of connections a provider must establish and improve the ability of HHS program areas to exchange information.

Strategies Develop framework to align interfaces between HHS agenciesand trading partners to optimize the number of connectionsrequired.

Develop measures for tracking interoperability progress, withinput from eHAC.

Monitor improvements in interoperability. Facilitate sharing of information across program areas. Utilize HIEs to leverage connectivity between providers and HHS

agencies. Share interoperability technologies to support multiple

programs. Expand the infrastructure to meet changing business needs. Explore opportunities for consolidating trading partner

registration.

Ongoing Programs and Activities

DSHS is currently working to consolidate interfaces into a DSHSHealth Services Gateway.

DSHS is working to establish information flow through HIEs forselect program areas.

Master data management and universal client directory beingdeveloped by OCDO.

Potential New Programs and Activities

Medicaid Health Informatics is developing a plan to providefinancial support to HIEs to connect Medicaid providers.

Include information flow through HIEs. Expand master client indexing capabilities.


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Goal 2: Ensure appropriate governance is in place to utilize and manage standards.

Strategic Domain Governance

Context Many information systems at HHS are capable of exchanging PHI across systems and between HHS and trading partners. As systems are replaced, ensuring these systems utilize applicable national standards will make it easier and more cost efficient for trading partners to exchange information with HHS agencies.

Coordination of the standards utilized can minimize the number of standards providers are required to implement.

Strategies Revise system-wide information governance to reflect neworganizational structure and facilitate compliance withapplicable policies.

Implement a process to coordinate standards utilization. Work to address the incorporation of Texas’ needs into national

standards.


HHSC, DFPS, DADS and DSHS all have governance processes thathave been effective in overseeing their agency's processes.

DSHS has a well-developed information systems governanceprocess and technology review process to ensure projects arealigned with applicable standards and that relevant programareas are aware of system improvements.

OCDO reviews all significant data projects for alignment withdata management strategies.

The DAR serves as a foundation for the identification ofstandards currently used. Continue to maintain the DAR.

Community Behavioral Health continues to collaborate withstakeholders on standards development.

Development of national standards are monitored.


Review the DSHS model and determine if the model can beexpanded or replicated across the HHS system.

Revise governance to reflect optimal alignment with newbusiness organizational structure.

Expand participation in standards development.


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Goal 3: Utilize data standards and interoperability between systems to minimize manual data entry, improve efficiency, and facilitate utilization of information.

Strategic Domain Business/Technical Operations

Context The utilization of interoperable information systems, with a focus on semantic interoperability, minimizes the need for repetitive data entry and reduces the likelihood of repeated data entry errors. Semantic interoperability ensures that the data can be used in an automated fashion for business purposes by end users and data providers including health care providers, government, and other entities.

Ensuring data standards meet business needs is essential. Participating in data standards development will help ensure data requirements are being met.

Strategy Utilize interoperable systems to minimize re-entry of data and improve utilization of data by both HHS and trading partners.


Many HHS program areas currently have systems that areinteroperable, both across program areas and betweenprograms and trading partners.

The OCDO has published guidelines for managing data in newdevelopment and enhancement projects.


Expanded participation in data standards-setting activities. Look to academia and trading partners for implementing

standards that advance semantic interoperability across healthcare; identification of new, value-based use cases and new waysof analyzing data.

Adoption of several outputs from the HHS Insights project formore effective data management.


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Goal 4: Maintain and expand business practices that support efficient use of HHS information for improvement in delivery of services, managing costs, and improving population health.

Strategic Domain Policy and Practice

Context Policies and practices adopted by HHS agencies should ensure any interoperability with HHS systems advances the delivery of services, manages costs, and improves population health; reflect best practices identified by HHS; and are implemented consistent with applicable law.

Strategies Develop a comprehensive business roadmap for interoperabilityto align activities across programs.

Develop an interoperability posture that accounts for multipleways of connecting to HHS systems.

Ensure legal issues related to privacy and security areaddressed.

Optimize secure sharing of client information across HHSprograms and with authorized users, while ensuring patientprivacy and confidentiality is maintained.

Ensure contracted services adhere to required use of standardsand meet HHS interoperability needs.


Negotiating legal agreement with THSA to supportinteroperability through HIEs.

Technical project reviews by CTO and OCDO for standardscompliance.

Usage of the HHS Data Use Agreement. Compliance with applicable laws.


Enable patient-centered information sharing across HIPAA-covered components in the HHS System, consistent withapplicable law.

Develop schedules for standards adoption thatcomprehensively accounts trading partner capabilities.

Continue to work with internal and external entities to identifybusiness use cases that utilize interoperability.


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Goal 5: Empower patients and providers through interoperability.

Strategic Domain Communications

Context As HHS agencies evolve interoperability, through improved alignment with national standards and connectedness with HIEs to support interoperability, there will be a need to communicate opportunities and share information with providers, HIEs, other trading partners, and patients.

Strategy Collaborate with trading partners and patients to identify priorities for which systems may benefit from enhanced interoperability, the selection and implementation of relevant standards and the frequency of change.


HHS agencies regularly present at the THSA board meetings. HHS conducted an annual HIT day for stakeholders, associated

with an industry conference. Medicaid Health Informatics is developing a website for

providers to communicate about HIT. HHSC distributes information to Medicaid providers. Program areas use their website and other communication

tools such as broadcast messages to communicate withproviders.

DSHS has been working with stakeholders to advance publichealth reporting, consistent with H.B. 2641.

Presentations at industry conferences.


The new eHAC will provide another forum for developingstrategies for prioritizing and advancing interoperability.

Outreach to other newly-established advisory committees. Engage providers through communications from OeHC. Engage Medicaid providers through an improved HIT website. Leverage National HIT week. Schedule regular discussions with stakeholders. Facilitate personal health records/client access to information. Collaborate with stakeholders on developing consumer

education regarding interoperability


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Conclusion HHS agencies have had a long interest in and commitment to utilizing interoperability to improve the ability to understand, deliver, and respond to health needs and health services. The recent expansion of technology has resulted in increased interest in health data, going beyond basic billing and reporting of data for public health purposes. The advent of the EHR system increased the ability of healthcare providers to record and potentially exchange information about patients.

Interoperability requires consensus from a variety of interested parties regarding what information needs to be shared, how to describe that information, when the information needs to be shared, whose information needs to be shared, with whom to share the information, and how to measure success. Collaboration between many actors, including health care providers, payers, vendors, standards development organizations, government agencies, clients, and public health organizations is key. Texas HHS agencies have a strong framework to support collaboration, and will continue to adapt, building a framework that supports an increasingly interoperable posture with its stakeholders.

Improved interoperability, communication, and collaboration will enable an increased quality of health care, reduction in health care costs, and improved health. Challenges with the use of electronic health information have included developing technology to exchange relevant data and the lack of interoperability between providers’ systems. As the roles of healthcare payers change, from simply paying the bill to developing skills to manage patient care, there is interest in expanding capacity to receive data from providers since that same data can be used to evaluate providers’ ability to deliver cost-effective, quality health care.

Agencies rarely replace entire systems, however regularly perform incremental modifications to meet changing requirements and standards. HHS recognizes changes in the marketplace and technology available to stakeholders, and will work collaboratively with stakeholders to advance technology that can realize efficiencies.

Increased understanding of the value of interoperability across the healthcare continuum is needed. Efficient interoperability across the HHS system will help ensure populations served have good health outcomes and that medically appropriate and cost-effective programs in coordination with the private sector are done in a cost-effective manner.

Currently, EHR design is more in alignment with billing and accounting processes than care coordination. As EHRs evolve, they will increasingly focus on interoperability, expanding their ability to offer more complete patient profiles and support coordination of care between medical, behavioral, health, and social services. This sharing of information will aid patients and their caregivers in making informed healthcare decisions. Although there is increased interest in


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leaving information in place and allowing access as necessary, it is anticipated that personal health records or distributed data storage locations may change as new technology enables new functionality. ,

Economics is a driver of interoperability— the perceived need for interoperability will change as payment reform evolves. With the adoption of the accountable care concept, coordination of care will be increasingly valued.

Intelligent investments in technology will facilitate interoperability and provide HHS agencies the flexibility to adapt to changing requirements. To support adaptability, it is essential that HHS maintain oversight and governance for projects and resources that utilize funds secured by HHS agencies and serve as key resources advancing interoperability.

Existing HHS supports, governance, and standards have been well leveraged to support interoperability. Going forward, these constructs can be adapted to remain in alignment with advances in the expanded use of standards and support more meaningful information exchange through the adaption of existing and new technologies.

The transformation of the HHS agencies provides many opportunities for targeting improvements and changes that will improve how HHS agencies communicate and exchange information to meet the diverse health needs in Texas, including health promotion, disease control and prevention, emergency preparedness, population health management and healthcare services outcomes.


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List of Acronyms

Acronym Full Name ACA Affordable Care Act ANSI American National Standards Institute APM Advanced Alternative Payment Methods ASME American Society of Mechanical Engineers ASTM American Society for Testing and Materials International CARE Client Admission and Registration System CAQH Council for Affordable Quality Healthcare CCD Continuity of Care Document CDC Centers for Disease Control CDO Chief Data Officer CIO Chief Information Officer CISO Chief Information Security Officer CLSI Clinical and Laboratory Standards Institute CMBHS Clinical Management for Behavioral Health Services CMS Centers for Medicare and Medicaid CORE Committee on Operating Rules CTO Chief Technology Officer DADS Department of Aging and Disability Services DARS Department of Assistive and Rehabilitative Services DFPS Department of Family And Protective Services DSHS Department of State Health Services DICOM Digital Imaging and Communications in Medicine DUA Data Use Agreement DAR Data Asset Repository DSM-5 Diagnostic and Statistical Manual of Mental Disorders, 5th Edition EDI Electronic Data Interchange EHR Electronic Health Record EHAC Electronic Health Advisory Committee EHIEAC Electronic Health Information Exchange Advisory Committee EISSG Enterprise Information Security Standards and Guidelines FHIR Fast Healthcare Interoperability Resources GAO Government Accountability Office GINA Genetic Information Nondiscrimination Act


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Acronym Full Name HCID High Consequence Infectious Diseases HHS Health and Human Services HHSC Health and Human Services Commission HHSC IT Health and Human Services Commission Information Technology HIE Health Information Exchange HITECH Health Information Technology for Economic and Clinical Health HIETexas Health Information Exchange public network in Texas HIESC Health Information Executive Steering Committee HIPAA Health Insurance Portability and Accountability Act HIMC Health Information Management Committee HIMSS Health Information Management Systems Society HIT Health Information Technology HITAC Health Information Technology Advisory Committee HL7 Health Level Seven HRAR Human immunodeficiency virus, Real-time Education and

Counseling Network, Acquired immune deficiency syndrome, AIDS Regional Information Evaluation System

ICD International Classification of Diseases IE Information Exchange IMMTRAC State of Texas Immunization Registry INCITS InterNational Committee for Information Technology Standards ISA Interoperability Standards Advisory ISO International Standards Organization IDD Intellectually and Developmental Disability LIDDA Local Intellectual and Developmental Disability Authority LMHA Local Mental Health Authority LTC Long-Term Care MACRA Medicare Access & CHIP Reauthorization Act of 2015 MCOTS Modified Commercial-Off-the-Shelf Software MITA Medicaid Information Technology Architecture MEHIS Medicaid Eligibility and Health Information System MH Mental Health MMIS Medicaid Management Information System NAACCR North American Association of Central Cancer Registries NCPDP National Council for Prescription Drug Programs NEDSS National Electronic Disease Surveillance System NEMA National Electronics Manufacturers Association NIST National Institute of Standards and Technology


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Acronym Full Name NHIN National Health Information Network OCDO Office of the Chief Data Officer ONC Office of the National Coordinator for HIT PBM Pharmacy Benefits Manager PCHA Personal Connected Health Alliance PCRA Pharmacy Claims and Rebate Administration PCP Primary Care Provider PHI Protected Health Information REC Regional Extension Centers S & I Standards and Interoperability Framework SCRIPT NCPDP Standard Used in Electronic Prescribing SDO Standards Development Organization SSLC State Supported Living Centers SLTA State-Level Trust Agreement TCR Texas Cancer Registry THCIC Texas Health Care Information Collection THSA Texas Health Services Authority TWICES Texas-Wide Integrated Client Encounter System TxS2 Texas Syndromic Surveillance TXEVER Texas Electronic Vital Events Registrar X12 ASC X12 Standard for Electronic Data Interchange for the U. S.


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Appendices

HHS HIT Roadmap


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Appendix A - Texas Health and Human Services’ Health Information Technology Roadmap

Executive Summary This Health IT Roadmap is intended to provide the strategic direction and collaborative vision for Texas HHS system health information technology (Health IT) and health information exchange (HIE) advancements over the next five years.

This Roadmap defines the overall HHS System Health IT mission, vision, strategies, and goals to assist the HHS System in the accelerated adoption and use of health information technologies and health information exchange to improve the health, safety, and well-being of all Texans.

Health IT Mission The HHS System strives to improve public health, health service delivery, increase effectiveness, efficiencies, and reduce costs through the appropriate and secure use of health information and technology.

Health IT Vision High quality health information and technology that is business-driven, secure, accessible, and available when and where it is needed to improve and protect the health and well-being of all Texans.

Health IT Values and Priorities

Strategic: Support the HHS Mission and Objectives.o Align and optimize business processes and information resources to support

overall HHS System strategic objectives. Quality and Value-Based: Focus on quality and value.

o Support alignment between business needs and information resources.o Health IT policy will target solutions that improve public health, individual health

and care quality, efficiency, safety, affordability, and access. Person-Centered: Empower individuals and respect individual rights and preferences.

o Honor individuals’ privacy, needs, values, and choices regarding theirinformation, health, and care.

o Health IT will be used to empower individuals to better understand and improvetheir health.

Secure and Accessible: Build a culture of secure accessible electronic healthinformation.

HHS HIT Roadmap


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o Help establish an environment where secure, universal health informationexchange and use are expected and accepted so that everyone benefits fromsimple, timely, equitable, efficient, and appropriate electronic access to andsharing of health information.

o Health IT will serve the breadth of the state. Collaborative: Encourage collaboration within and across HHS agencies, and with

external parties.o Engage trading partners and stakeholders in discussions regarding HIT and

coordinate data collection and exchange efforts within and across agencies andprograms, as well as with external entities.

Business Driven: Business processes will drive health informationtechnology/information resource solutions.

o Develop agile business processes that specify information technologyrequirements that address the needs of a changing health and human servicessystem.

o Design information resources to be quickly and effectively adapted to evolvingbusiness needs and processes.

Legal and Ethical: Ensure Compliance with Laws, Regulatory, and Ethical Requirementso Manage and utilize accurate data and tools to ensure compliance with applicable

rules and regulations including those addressing privacy and confidentiality. Continuous Learning: Create an environment of continuous learning and improvement.

o Develop staff knowledge and skills to effectively adopt, maintain, and use healthinformation technologies.

o Policies and actions seek to strengthen feedback loops between HHS, scientific,academic, and health care communities.

o Translate evidence generated from HHS data and health information exchangeinto practice and learn how to improve public health and service delivery.

Innovative and Competitive: Encourage innovation and competition.o Policies, guidance, and programs will support continued innovation and

competition in the health and health IT marketplaces to foster highly usefulsolutions that lead to better health and health care.

Transparent and Responsible: Be a worthy steward of the public’s money and trust.o Developing governmental policies through open and transparent processes.o Use resources judiciously relying to the fullest extent possible on private

markets.o Inspire confidence and trust in state government.

HHS HIT Roadmap


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Primary Focus Areas for Goals

Implementing appropriate standards Achieving interoperability Engaging in meaningful health information exchange Collaborating within HHS and following governance framework to align and optimize

Health IT Systems Reducing redundancy, manual or paper-based processes Enabling timely health information accessibility & portability Ensuring security, privacy, and compliance


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Appendix B - Select State Legislation Related to HIT and Interoperability

The State of Texas – H.B. 1218, 81st Legislature, Regular Session, 2009

HIE Pilot Program H.B. 1218 authorized HHSC to establish a health information exchange pilot program to determine the feasibility, costs and benefits of Medicaid and CHIP exchanging secure electronic health information with local and regional HIEs comprising hospitals, clinics, physicians’ offices and other health care providers. The pilot program consisted of bidirectional exchange of filled prescription histories between HHSC and a local HIE. The purpose of the pilot program was to explore the feasibility of exchanging clinical data and begin identifying legal, policy, and other procedural barriers to implementing HIE initiatives.

Medicaid Electronic Health Information Exchange System H.B. 1218 authorized HHSC to develop an electronic health information exchange system to improve the quality, safety and efficiency of health care services provided under the CHIP and Medicaid programs. The legislation requires that the system be developed in accordance with the Medicaid Information Technology Architecture (MITA) initiative of CMS’s Center for Medicaid and State Operations and conform to other standards required under federal law. The System is being implemented in three stages:

Stage 1 directs HHSC to implement a health information exchange system that offers anelectronic health record for all Medicaid recipients. In addition, Stage 1 requires HHSC tocoordinate e-prescribing tools used by health care providers and health care facilitiesunder the Medicaid and CHIP programs and develop a claims-based electronic healthrecord in Medicaid.

Stage 2 would expand the EHR to include CHIP program clients; add state laboratoryresults, including the results of newborn screenings and tests conducted under theTexas Health Steps (EPSDT) program; improve data gathering capabilities; and useevidence-based technology tools to create client profiles.

Stage 3 involves developing evidence-based benchmarking tools that can be used byhealth care providers to evaluate their own performances on health care outcomes andoverall quality of care as compared to aggregated performance data regarding peers;and expanding the system to include data exchange with state agencies, additionalhealth care providers, laboratories, diagnostic facilities, hospitals, and medical offices.

HIE Systems Advisory Committee /e-Health Advisory Committee The HIE Systems Advisory Committee established under H.B. 1218 advised HHSC on Medicaid activities related to health information technology. A key objective of the Committee was to

State Legislation Related to HIT and Interoperability


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ensure Medicaid/CHIP HIE is “interoperable” with broader statewide health information exchange being planned through the THSA.60 The advisory committee was responsible for advising HHSC on issues regarding development and implementation of the electronic health information exchange system, including: data to be included; presentation of data; useful measures for quality of services and patient health outcomes; federal and state laws regarding privacy of private patient information; incentives for increasing adoption and usage; and data exchange with regional health information exchanges. The advisory committee is being replaced with a new eHealth Advisory Committee.

Health Information Technology Standards The State of Texas – H.B. 921, 80th Legislature, Regular Session, 2007 House Bill 921 required the identification of data standards to be used by state agencies providing health and social services. The HCPC established a workgroup, including representation from HHS agencies, to identify standards for sharing information between agencies.

The State of Texas – H.B. 1218, 81st Legislature, Regular Session, 2009 H.B. 1218 requires that any health information technology used by HHSC or any entity acting on behalf of HHSC, in the Medicaid program or CHIP conform to standards required under federal law.

The State of Texas – H.B. 2641, 84th Legislature, Regular Session, 2015 HB 2641 mandated that the state’s health and human service agencies adopt nationally recognized standards in their IT systems that interface in sending or receiving protected health information for new systems planned or procured September 1, 2015 or later. H.B. 2641 also amended a number of mandatory public health reporting statutes to enable DSHS and appropriate entities to exchange data through health information exchanges. Additionally, the language in H.B. 2641 protects providers that submit information to an HIE from litigation if the HIE or another provider accessing the information uses it in a way that violates state or federal privacy and security laws relating to the disclosure of protected health information. Lastly, H.B. 2641 directed the Texas Health and Human Services Commission (HHSC) to develop a method, if determined feasible and cost effective, for reimbursing Medicaid providers who review and transmission of electronic health information through HIEs.

60 Schneider J. Health Information Technology (HIT) and the Medicaid/CHIP Health Information Exchange (HIE) Advisory Committee. http://www.senate.state.tx.us/75r/senate/commit/c610/h2010/0415-JosephSchneider.pdf. Retrieved September 8, 2016.

http://www.senate.state.tx.us/75r/senate/commit/c610/h2010/0415-JosephSchneider.pdf


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Appendix C - HHS Circular C-009

Health and Human Services Enterprise

Information Technology Governance Policy

Purpose

The purpose of this policy is to establish centralized information systems planning authority

including the authority of Health and Human Services (HHS) Information Technology (IT) to

develop enterprise-wide policies and procedures for the management of information technology

functions.

Background

HHS IT is responsible for providing vision, leadership, and strategic direction in the delivery of

information technology services for the health and human services system of agencies. The

consolidation of the HHS system was proposed to drive efficiencies in administrative services,

such as IT.

At the enterprise level, governance involves the assignment of decision rights and related

accountability in regulating the proceedings of the enterprise. IT governance defines the

assignment of decision rights and related accountability in the use of information technology.

Goals and objectives for IT governance include:

Providing appropriate executive oversight of IT governance portfolios;

Improving accountability for results;

Reducing risks, inefficiencies, and complexity;

Improving resource utilization through focused IT spending;

Improving system integration and interoperability;

Providing for more effective strategic planning; and

Clarifying roles, responsibilities and processes related to all facets of IT proceedings.

Policy

The HHS IT division is responsible for planning and managing information resources across the

HHS System. To accomplish this, the Deputy Executive Commissioner for IT and Chief

Information Officer has the authority to develop enterprise-wide policies and procedures for the

consolidated delivery of IT services to the health and human services agencies. These IT policies

may be in addition to policies issued using the HHS Executive Clerk formats for circulars,

bulletins, and memoranda.


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The Deputy Executive Commissioner for IT and Chief Information Officer will also coordinate a

governance structure with representation from all member agencies at appropriate organizational

levels to participate in IT decision making. This structure will also provide a forum for

notification of IT policies to facilitate awareness and compliance, which will assist with

implementing and sustaining the desired streamlined, standardized, and simplified service

delivery model for IT services.

Inquiries

Inquiries regarding this circular should be directed to Deputy Executive Commissioner for

Information Technology and Chief Information Officer, HHSC, at (512) 424-6990 or

[email protected].


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Appendix D -HHS Circular C-010

Health and Human Services Enterprise Information Technology Project

Management Policy

Purpose

This policy communicates the agency-wide approach for information technology (IT) project

management practices within the Texas Health and Human Services Commission.

Background

The Texas Legislature, the Governor, and oversight agencies, including the Department of

Information Resources, Legislative Budget Board, and the State Auditor’s Office have endorsed

the use of a structured project management methodology as a key tool for improving Texas IT

project performance. This policy is provided, in part, as a measure to protect health and human

services (HHS) agencies’ IT investments in meeting the needs of HHS clients and constituency.

The Texas Project Delivery Framework provides guidance to agency heads by presenting

fundamental information about major Information Resources projects and certain major

contracts to help them assess the agency’s ability to manage state investments. The Texas

Project Delivery Framework also assists agency heads with deciding whether the project or

contract is ready to proceed to the next review gate. Additionally, the Texas Project Delivery

Framework should function in concert with existing project management practices established at

the agency level.

The Texas Project Delivery Framework provides a toolset for practitioners directly involved

with delivery of the project or contract. The toolset includes templates, questionnaires,

checklists, and guidelines that are consistent with other statewide efforts that overlap with the

Texas Project Delivery Framework, such as the Comptroller of Public Accounts Contract

Management Guide and Quality Assurance Team processes.

References

Texas Government Code, Chapter 2054, Subchapter G, Project Management Practices

http://www.statutes.legis.state.tx.us/SOTWDocs/GV/htm/GV.2054.htm


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Texas Government Code, Chapter 2054, Subchapter J, Texas Project Delivery Framework

http://www.statutes.legis.state.tx.us/SOTWDocs/GV/htm/GV.2054.htm

Project Management Standard for Health and Human Services Information Technology

Projects. http://hhscx.hhsc.state.tx.us/tech/policy/default.shtml

Project Management Process Guide for Health and Human Services Information Technology

Projects. http://hhscx.hhsc.state.tx.us/tech/policy/default.shtml

Major IR Project Deliverables Standard for Health and Human Services Information

Technology Projects. http://hhscx.hhsc.state.tx.us/tech/policy/default.shtml

Major IR Project Deliverables Process Guide for Health and Human Services Information

Technology Projects. http://hhscx.hhsc.state.tx.us/tech/policy/default.shtml

Comptroller of Public Accounts Contract Management Guide

http://www.window.state.tx.us/procurement/pub/contractguide

HHS Contract Management Handbook

http://www.hhsc.state.tx.us/about_hhsc/contract-manual.pdf

HHS Procurement Manual http://www.hhsc.state.tx.us/about_hhsc/procurement-manual.pdf

Policy

It is the policy of the Health and Human Services Enterprise that:

All HHS agencies’ initiatives that meet the HHS standard criteria as IT projects and

information technology contracts (reference Project Management Standard section 4.0)

follow the HHS Project Management Standard and process guidelines for IT projects.

The application of this policy and the related project management standards and process

guidelines to Information Technology projects that do not meet the minimum criteria is at

the discretion of member agencies.

All HHS agencies’ initiatives that meet the criteria as a major information resources

project and information technology contracts that meet the test as a major contract

(reference major IR Project Deliverables Standard section 4.0) follow the HHS major

Information Resources Project Deliverables Standard and process guidelines, in addition

to the HHS policy subsection above for Information Technology project management.

Responsibilities

The HHSC Executive Commissioner and each agency Commissioner:

Enforces this policy.

Ensures provisions of Texas Government Code, Chapter 2054, Subchapters G and J,

are fulfilled.

http://hhscx.hhsc.state.tx.us/tech/policy/default.shtml





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Reviews and approves required project and contract deliverables and project review

gate documents.

Holds managers accountable for compliance.

Each Information Resource Manager (IRM) (or Chief Information Officer in the case of

Enterprise IT Projects):

Designates individuals to execute policy for IT projects.

Enforces management and supervisory responsibilities for IT projects and

information technology contracts under this policy.

Ensures that IT projects use project management practices suitable, and scaled, to enable

a successful outcome.

Reviews related projects for common business elements to identify projects that should

be grouped together as a single larger project or program.

Ensures that any individual or company entering into a contract with an HHS agency

to deliver IT project services will comply with appropriate policies, related standards,

processes, and deliverables, or provides written proof of acceptable methods and

documentation.

Holds managers accountable for compliance.

Management Level:

Establishes, monitors, and remediates performance measures that relate to this policy for

the project team.

Promotes the use of this policy and the related standard and processes to the project

team, including contractors who are also required to comply.

The Information Technology Project Manager:

Manages assigned IT projects and information technology contracts in accordance with

applicable policies and standards.

Ensures that IT contracts are procured and managed in accordance with the HHS

Enterprise Procurement Manual and Contract Management Handbook.

When required, follow the framework developed by the Department of Information

Resources that provides guidance and tools for development of deliverables, and the

review, assessment, and approval of outcomes.

When required, ensure necessary reports are prepared, reviewed and submitted to the

QAT in a timely manner and that all inquiries made by the QAT are responded to

satisfactorily and on time.


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Inquiries

Inquiries regarding this circular should be directed to the Deputy Executive Commissioner for

Information Technology and Chief Information Officer, Health and Human Services

Commission, by telephone at (512) 424-6990 or by e-mail at [email protected].


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Appendix E - HHS Circular C-032

Health and Human Services Enterprise

Office of e-Health Coordination

Purpose

To establish and maintain an Office of e-Health Coordination (OeHC) within the Health

Policy and Clinical Services (HPCS) division and governance structure to coordinate Health

Information Technology (Health IT) and health information exchange (HIE) initiatives.

These initiatives are referred to as health information (HI) strategic initiatives and

coordination occurs across the health and human services (HHS) enterprise.

Definition

Health IT refers to the application of information processing involving both computer

hardware and software that deals with the storage, retrieval, sharing, and use of health care

information, data, and knowledge for communication and decision making.61

The goal of Health IT is to allow comprehensive management of health information and its

secure exchange between health care consumers, providers, government, and payers. Health

IT initiatives include, but are not limited to, electronic health records, electronic prescribing,

and health information exchange systems.

Background

There is an increased focus on Health IT at the national, state, regional, and local levels as a

means of improving health care quality, safety, and efficiency (reducing costs). Given the

importance and breadth of Health IT for HHS agencies, and related federal and state legislation,

the HHS enterprise needs a single point of coordination for HI initiatives.

1 Brailer, D. (2004). The decade of health information technology. HHS Report, July, 21.


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The HHS enterprise is working in multiple ways to use Health IT to transform and better

coordinate care for Texans enrolled in Medicaid and other state programs, as well as improve

the overall health and well-being for all Texans. Examples of such projects include the Health

Passport for Medicaid Children in foster care, Electronic Health Records or Life Records

Systems for state hospitals and state supported living centers, Medicaid Electronic Health

Records Incentive Program

and public health reporting in support of Meaningful Use, and the Clinical Management for

Behavioral Health Services System.

As early as 2009, H.B. 1218, 81st

Legislature, directed the Health and Human Services

Commission (HHSC) to develop an electronic health information exchange system to improve

the quality, safety, and efficiency of health care services provided under Medicaid and the

Children’s Health Insurance Program (CHIP). The American Recovery and Reinvestment Act

(ARRA) of 2009 provided substantial funding opportunities to assist hospitals, physicians,

and other health care providers in the adoption of certified EHR systems and to further

advance health IT and HIE in the public and private sectors. Most recently, H.B. 2641, 84th

Legislature, 2015, directs the HHS enterprise to engage in interoperability planning, and

enables both Medicaid and public health to further engage in health information exchange-

related activities.

Coordinating and promoting Health IT and HIE initiatives at the federal, state, and local levels

will directly impact Medicaid and other state HHS programs that collect, store, and exchange

HI on individuals in Texas, especially those receiving health care through state and federally

supported programs. At the state level, one of the ways in which Texas recognized the

importance of statewide HIE, was through establishing the Texas Health Services Authority

(THSA). The THSA is a public-private nonprofit corporation established by the Texas

Legislature to improve patient safety and quality of care by coordinating the development of a

voluntary and secure electronic HIE infrastructure for the state health care system. The OeHC

serves as the primary point of contact and HHS liaison to the THSA.

Directive

Office of e-Health Coordination (OeHC)

The OeHC is under the direction of the Deputy Executive Commissioner for Health Policy and

Clinical Services. The OeHC Director serves as the State Health IT Coordinator and HHS

liaison with the Office of the National Coordinator for Health IT. The office ensures that

Health IT and HIE initiatives relating to HHS programs (Medicaid, the Children’s Health

Insurance Program, and other HHS programs) are coordinated across the HHS enterprise. In

this capacity, OeHC is responsible for:


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creating and managing a formal, enterprise-wide collaboration and coordination infrastructure

to support HHS-related HI policy and technology activities, and, in particular, activities

involving multiple HHSC divisions and multi-agency projects;

serving as the single point of contact and lead for the HHS enterprise in regard to state

funding opportunities under Title XIII of ARRA;

acting as a single point of contact for HI policy for the HHS system;

coordinating the development of interoperability planning required by H.B. 2641,

84th Legislature, 201, and HHS Circular C-044;

staffing the HHS Health Information Steering Committee;

serving as co-chair of the Health Information Management (HIM) Committee;

working with the HI and HIM committees in identifying and prioritizing HI initiatives that

can help improve health outcomes;

collaborating with the Medicaid Electronic Health Information Exchange System Advisory

Committee established in Section 531.904 of the Government Code, and other state-level

health IT stakeholders and leadership bodies;

serving as a business partner to agency and Enterprise IT staff, Office of the Chief Data

Officer (CDO), and HHS Privacy Office to coordinate overlapping IT, CDO, Privacy, and HI

projects; and

supporting the state-level HI infrastructure efforts of the Texas Health Services Authority.

The OeHC will not directly manage Health IT initiatives across the enterprise. The Medicaid-

CHIP Division will also remain the lead for the state Medicaid Health IT plan and Medicaid

provider incentives under Title IV of ARRA.

Health Information Strategic Initiatives

The Health Information strategic initiatives that deal with particular HI topics or projects will be

governed through the HHS Health Information (HI) Steering Committee, Health Information

Management (HIM) Committee, and HIM workgroups.

The HHS HI Steering Committee provides HHS enterprise oversight and guidance on issues such

as Health IT and HIE strategic planning, data governance, interagency data sharing, project

dependencies, Health IT and HIE standards. The committee also provides strategic direction on

issues that may arise about individual projects or policy concerns regarding HI. The HI Steering

Committee is chaired by the Deputy Executive Commissioner for Health Policy and Clinical

Services and Deputy Executive Commissioner for Information Technology and Chief Information

Officer. The HI Steering Committee includes representatives designated by the commissioners of

each HHS agency and major programs within HHSC, including the Office of the Chief Data


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Officer, HHS Privacy Office, administrative, and Legal Services. The HHS HI Steering

Committee meets as needed.

The Health Information Management (HIM) Committee and its workgroups are guided by the HI

Steering Committee, and includes representation from all HHS agencies. HIM work groups

address particular Health IT and HIE topics, policy issues, or projects charged by the HI Steering

Committee or requested by HHS agencies. The HIM Committee is chaired by the Director of the

Office of e-Health Coordination and the HHSC Chief Technology Officer. The HIM Committee

and its work groups meet as needed.

Inquiries

Inquiries regarding the content of this circular should be directed to Melanie Williams, Ph.D.,

Director of the Office of e-Health Coordination, Health Policy and Clinical Services, at (512)

490-3105 or by e-mail at [email protected]

mailto:[email protected]


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Appendix F - HHS Circular C-049 Health and Human Services System

Office of the Chief Data Officer

Purpose

To establish and maintain an Office of the Chief Data Officer (OCDO) within the Strategic

Decision Support section of the Transformation, Policy and Performance division for managing

data and creating the governance structure for data created, managed, or maintained within health

and human services (HHS) system. The OCDO supports the development and socialization of

governed data in conjunction with the Enterprise Data Governance Council. For the purpose of

this document the word “enterprise” is synonymous with “system.”

The mission of the OCDO is to enable the efficient use of data to improve health and human

services and the lives of Texans. The OCDO fosters innovation and elevates best practices to

strengthen and enable the HHS community to discover, understand, access, trust, use, and share

data and information.

The guiding principles of the OCDO are:

A determination of business value should be the driver for all Enterprise Information

Management activities.

Increased information sharing is dependent on data that is visible, accessible, understandable,

trusted, and governed.

o Visible

Data are discoverable.

o Accessible

Data are readily available for use by authorized stakeholders.

Data can be easily combined or compared with other information.

o Understandable

Data consistently represent the same business facts regardless of source.

Terms are defined, consistent, and socialized.

o Trusted

Data are of high quality, reliable, and documented.

Improved data transparency.

o Governed


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Data are managed from a system-wide perspective.

Clear lines of accountability for data.

Policy

HHS agencies shall adopt policies and procedures that support a system focus in data and

information management.

(A) Data are to be treated as an asset and handled accordingly. Treating data as an asset means

data are catalogued and safeguarded so they can be made visible, accessible, and shareable

and can be made understandable through the use of metadata and other data definition

methods. (Metadata describe or explain data.)

(B) Data are modeled, named and defined consistently across and within HHS system agencies.

Every effort is made to share data across the system and not maintain redundant data

without justification.

(C) Data have a standard set of metadata which are identified at the lowest level possible and

published in the metadata repository.

(D) Data are managed to ensure data stewards apply the standards of governance and data

quality consistent with guidance provided by the Enterprise Data Governance Council.

Responsibilities

HHS agencies are responsible for implementing the policies outlined in this circular. The

implementation may include the delegation of responsibilities as necessary.

(A) The HHS Chief Data Officer:

1. Reviews and approves significant data projects for alignment to the approved policies,

technology, and standards.

2. Collaborates with existing information technology, portfolio management, privacy,

and/or program management bodies.

3. Manages the implementation of this circular and instruction, as administered by the HHS

Chief Data Officer.

4. Obtains funding and approves expenditures for data management initiatives and projects

led by OCDO.

5. Chairs the Enterprise Data Governance Council.

6. Develops the HHS data strategy for data collected, created, used, managed, maintained,

shared, and stored by the HHS system (Enterprise Information Management), and

facilitates information management initiatives set forth in the strategy.


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7. Provides the authoritative source for enterprise data architecture guidance and

governance process.

8. Develops and provides guidance of Enterprise Information Management standards and

guidelines for HHS agencies and HHS contractors.

9. Leads HHS system data projects/programs including but not limited to the following:

HHS Insights Project (Master Data Management)

Enterprise Data Governance

Metadata Repository

Glossary and Terms are Defined, Consistent, and Socialized

(B) The Strategic Decision Support Business Intelligence Competency Center:

1. Promotes usage and improvement of the metadata repository during research of

potential analytic use cases and implementation of business intelligence/analytic tools.

2. Aligns with the policies and principles of the OCDO.

3. Participates in the governance and provides feedback for the glossary and taxonomy for

the health and human services system.

(C) The Director of the Office of e-Health Coordination:

1. Promotes standards, and best practices with respect to Enterprise Information

Management and interoperability of data.

(D) HHS agency commissioners and deputy executive commissioners:

1. Shall adopt enterprise information management policies and data standards.

2. Supports the use of HHS system guidance for developing and managing data to comply

with best practices and OCDO principles in a consistent manner.

3. Participates in the governance and provides feedback for the data glossary and

taxonomy for the HHS system.

(E) The HHS Chief Information Officer (Deputy Executive Commissioner for Information

Technology):

1. Supports OCDO principles and policies within new development efforts.

2. Directs information technology portfolio management to engage and seek approval from

the OCDO regarding projects expected to impact governed data.

3. Classifies and publishes a security classification for data.

4. Provides guidance and policies for safeguarding data.

(F) The HHS Chief Technology Officer:


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1. Collaborates with OCDO, in alignment with the strategic technology roadmap, to

increase HHS system maturity in standard data management practices.

2. Collaborates with OCDO, in alignment with the strategic technology roadmap, to

improve data architecture, data management, and data quality across the enterprise

system portfolio.

(G) The HHS Chief Privacy Officer:

1. Establishes and maintains governance over HHS confidential information.

(H) The Deputy Executive Commissioner for Procurement and Contracting Services:

1. Ensures all contractors that execute data use agreements (DUAs) with HHS agencies are

made aware of and comply with OCDO guidelines, policies, and required

documentation.

2. Ensures all DUAs are in place and appropriately governed.

(I) Records Management

1. Classifies and publishes (via Agency Records Retention Schedules) a records

classification for data. Once classified, maintains governance over the proper

disposition of agency records and data.

2. Ensures compliance with governing statutes and administrative rules of the Texas State

Library and Archives Commission regarding record and data disposition.

Inquiries

Inquiries regarding the content of this circular should be directed to Jarrel Jimmerson, Chief Data

Officer, by telephone at (512) 206-4731 or email at [email protected].


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Appendix G - Standards-Based Electronic Transactions Used at Texas Medicaid

The following table lists standards-based EDI transactions used at Texas Medicaid with information on inbound and outbound message formats.

Inbound Transaction

Inbound Format

Response Response Format

Business Area

270 Eligibility, Coverage or Benefit Inquiry

ASC X12N 5010 271 Eligibility, Coverage or Benefit Information

ASC X12N 5010 Acute Care

Long Term Care

276 Health Care Claim Status Request

ASC X12N 5010 277 Health Care Claim Information Status Notification


Long Term Care

278 Health Care Services Review Information

ASC X12N 5010 278 Health Care Services Review Information

ASC X12N 5010 Acute Care -Trusted and Non-Trusted sources

MCO Long TermCare Portal

275 Patient Information (Additional Information to Support a Health Care Claim Services )

ASC X12N 5010 NA NA Pre-admissionScreening andResident Review(PASRR)Authorizationattachment

837 Health Care Claim - Professional

ASC X12N 5010 277CA Claims Acknowledgement


Long Term Care Medical

TransportationProgram

MCO Encounters MTO Encounters

837 Health Care Claim - Institutional


ASC X12N 5010 Acute Care Long Term Care MCO Encounters


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Inbound Transaction

Inbound Format

Response Response Format

Business Area

837 Health Care Claim - Dental


ASC X12N 5010 Acute Care Long Term Care MCO Encounters

NA NA 835 Health Care Claim Payment/Advice - Electronic Remittance & Status

ASC X12N 5010 Acute Care Long Term Care

NA NA 277P Health Care Information Status Notification - Claim Activity

ASC X12N 5010 Acute Care Long Term Care

Post Adjudication Pharmacy Medicaid Drug Event

NCPDP PA 2.3 277CA Health Care Information Status Notification - Claims Acknowledgement

ASC X12N 5010 MCO PharmacyMedicaidEncounters

Post Adjudication Pharmacy Medicare Drug Event

NCPDP PDE TA1 Interchange Acknowledgement

ASC X12N 5010 MCO PharmacyMedicareEncounters

ORU R01 Observation Result Laboratory Event

HL7 v2.3 Observation Result Acknowledge

HL7 v2.3 ACK DSHS Clinical Labtransactions

ORU R01 Observation Result Laboratory Event

HL7 v2.5 Observation Result Acknowledge

HL7 v2.5 ACK DSHS Newborn Labtransactions

ITI-43 Retrieve Document Set

IHE ITI-43 Retrieve Document Set Response

IHE ITI-43 MEHIS DocumentRetrieval

Documents

Interoperability for Texas Powering Health 2016...HHS Transformation, as directed by S.B. 200, 84th Legislature, Regular Session, 2015, provides many opportunities for targeting improvements