The Massachusetts Health Information Exchange Strategy

The Massachusetts Health Information Exchange Strategy

June 8, 2012

- -

Massachusetts Approach To Statewide HIE Services Funding (pre-Sep 2011)

• Massachusetts

Technology Collaborative

• Massachusetts eHealth

Institute

• HIT Council • MassHealth (Medicaid)

• Secretary of Health and

Human Services

• HIE/HIT Advisory

Committee

ONC

Cooperative

Agreement

CMS

SMHP

ONC

Challenge

Grants

Regional

Extension

Center

Statewide HIT/HIE Adoption

Statewide HIE Infrastructure

SDE

State HIT

Fund

$14M $12M $3.4M $11M

“Coordination”

?

HIE Services in Previous Plan

“…support for Consent management will be started. Initially, the focus will be on provider obtained consent

supporting clinical exchange and reporting. Planning will be started for a statewide service to enable consumers

to manage their own consent preferences”

- MEHI Strategic and Operational Plan, August 30, 2010

- -

Massachusetts Approach To Statewide HIE Services Funding (post-Sep 2011)

• Massachusetts

Technology Collaborative

• Massachusetts eHealth

Institute

• HIT Council • MassHealth (Medicaid)

• Secretary of Health and

Human Services

• HIE/HIT Advisory

Committee

ONC

Cooperative

Agreement

CMS HITECH/

MMIS

ONC

Challenge

Grants

Regional

Extension

Center

Statewide HIT/HIE Adoption Statewide HIE

Infrastructure

SDE

State HIT

Fund

$14M $12M $3.4M $11M $XXM for Phase

1

Complementary

90/10

funding

Private

funding

$472K per

year

Workgroup Structure, Leadership, and Staffing

Legal & Policy

Workgroup

Technology &

implementation

Workgroup

Finance &

sustainability

Workgroup

Consumer and public

engagement

workgroup

Provider

engagement &

adoption workgroup

Co-Chairs:

-Wendy Mariner

-Gillian Haney

Facilitator:

-Ray Campbell

Business Analyst:

-Christina Moran

Co-Chairs:

-John Halamka

-Manu Tandon

Facilitator:

-David Delano

Business Analyst:

-David Delano

Co-Chairs:

-Andrei Soran

-Steve Fox

Facilitator:

-Micky Tripathi

Business Analyst:

- Christina Moran

Co-Chairs:

-John Halamka

-Manu Tandon

Facilitator:

-Micky Tripathi

Business Analyst:

-Mark Belanger

Co-Chairs:

-Jessica Costantino

-Kathleen Donaher

Facilitator:

-Christina Moran

Co-Chairs:

-Michael Lee, MD

-Dirk Stanley, MD

Facilitator:

-Mark Belanger

HIT Council

HIE-HIT Advisory Committee

- -

Various projects can be mapped into phases using criteria

assessing difficulty, market demand, and market gaps

Difficulty

•Are there significant business,

technical, governance, or legal

complexities that need to be resolved

before deploying the service/

Demand for HIE service

•Is there immediate market demand for

the transaction as a statewide HIE

service?

Gap in market today

•Is there a gap in the market today?

•Ready to go

•Move to requirements and RFP

development

•No significant technical or policy

barriers

•Needs governance & business

model development

•Needs scoping and budgeting

•Multiple barriers to tackle

•Needs policy, technical,

governance, and business model

development

•Needs scoping and budgeting

Phasing criteria Phasing HIE projects

Phase 1

Phase 2

Phase 3

Phasing defines Roadmap for Statewide HIE Program (from Sep 19, 2011 HIT Council Presentation)

•Create infrastructure to facilitate data aggregation/analysis

•Will support Medicaid CDR and quality measure infrastructure

•Will support vocabulary translation services (lab, RX)

Increasing cost and complexity

Facilitate

normalization and

aggregation

Enable queries for

records

Information Highway

•Create infrastructure to enable secure transmission (“directed

exchange”) of clinical information

•Will support exchange among clinicians, public health, and

stand-alone registries

•Focus on breadth over depth

Analytics and Population Health

•Create infrastructure for cross-institutional queries for and

retrieval of patient records

Search and Retrieve

Phase 2

Phase 3

Phase 1

8

Network functions

Send/receive:

• Referral/Consult

• Admission notification

• Post-encounter summary

• Discharge Summary/Instructions

• Lab Order/Results

• Death Notification

• Uniform Transfer Form

• Public health (SS, Imm., ELR)

• Provider address search

Network participants

• Hospitals (inc. labs and imaging)

• PCP or Specialist

• Health plans

• Long-term care facilities

• Other care setting

• Patients*

• Quality Reporting Service *

• Public health*

Phase 1:

Phase 2:

Additional network participants

• More providers and payers and quality

reporting services

• Commercial diagnostic facilities

• Imaging centers

• Labs

Additional network functions

Send/receive:

• Public Health Alerts

• Quality Measure Reports

• Patient-matching service

• Vocabulary normalization service

Additional network participants

More providers and payers

Additional network functions

Search and retrieve:

• Patient record

• Patient consent/authorization

Phase 3:

*single-direction exchange

Statewide HIE Services Overview

High-level Deliverables by Phase (from Sep 19, 2011 HIT Council Presentation)

Phase 1:

Information Highway

Phase 2:

Analytics & Population Health

Phase 3:

Search and Retrieve

Legal & Policy

Workgroup

Technical and

Implementation

Finance and

Sustainability

Consumer & Public

Engagement

Provider engagement

& adoption

•Governance model for statewide HIE

services

•Consent policy for routing services

•Security/policy framework for statewide

services

•Operational model for statewide HIE

services

•Requirements for Phase 1 RFPs

•Financial models for Phase 1 services

•Cost allocation MOUs for Phase 1

services

•Public input on statewide HIE plan

•Consumer participation in functional

working groups

•Provider input on statewide HIE plan

•Provider participation in functional

working groups

•Consent policy for registry and

warehousing services

•Governance model for quality data

infrastructure

•Technical requirements for warehousing

& registry infrastructure




services

•Public input process on warehousing

and registries


working groups

•Provider input on warehousing and

registries

•Provider participation on functional

working groups

•Consent policy for search and retrieve

functions

•Governance model for EMPI/RLS

functions

•Technical requirements of

query/retrieve, EMPI, and RLS




services

•Public input process on query/retrieve,

EMPI/RLS models


working groups

•Provider input process on

query/retrieve, EMPI/RLS models

•Provider participation in functional

working groups

Clinical document type prioritization by Provider Adoption WG

• High-priority and high- to medium-maturity

• Discharge Summary

• Consult Note

• ER Note

• Encounter Summary

• Lab Results

• Syndromic Surveillance

• Immunization Record

• Imaging Results

• Universal transfer form (UTF)

• Referral

• Medical Summary

• Lab/imaging Order

• High-priority and low- to medium-maturity

• Advance directives

• Death notification

• Admission notification

• Request for medical summary

Recommend to Technology and

Implementation WG to identify standardized

approaches for electronic exchange

Recommend to Technology and

Implementation WG to confirm standards and

identify implementation guides

- - Massachusetts eHealth Collaborative

filename © MAeHC. All rights reserved.

Project schedule and updates

Initiative Completion date

1) Develop new approach and confirm with stakeholders Completed Oct 2011

2) Submit APD-U and SMHP to CMS with MoUs Completed Nov 2011

3) EHR/HIE Vendor Roundtable Completed Dec 2011

4) Network Users Roundtable – Eastern MA Completed Jan 2012

5) Network Users Roundtable – Western MA Completed Jan 2012

6) Confirm availability of State Share for APD Completed Jan 2012

7) Develop RFR for Medicaid HIE Infrastructure implementation Completed Jan 2012

8) CMS approval of APD-U/SMHP; CMS approval of RFR Completed Feb 2012

9) RFR for Phase 1 services released to Infrastructure Vendors Completed Feb 2012

10) Submit updated SOP to ONC Completed March 2012

11) ONC approval of SOP and SOP budget Completed May 2012

12) Infrastructure Vendor selected and under contract June, 2012

13) Go-live for phase 1 “Information Highway” (Direct Gateway) Oct 15, 2012

14) Go-live for Last Mile program Oct 15, 2012

15) Go-live for phase 1 Public Health Gateway (CBHI, SS) Dec 14, 2012

Current state of the market favors a network of networks connected via a single statewide open HISP supported by centralized project management

Illustrative example

Berkshire Health

System NEHEN

SafeHealth MD

MD

MD MD Fallon Clinic

UMass

Memorial

Statewide HISP

PKI/certificate mgmt Web

portal

Provider/entity

directory

Audit

log

MD MD

MD

MD MD

MD

BIDMC Partners

Direct gateway

services

EOHHS NwHIN

MassHealth

DPH

Atrius



Trust Fabric (Illustrative)

Commwealth HIE

HISP

Commonwealth HIE Trust Fabric

MMS

HISP

NEHEN HISP

AthenaHealth

HISP

New

Hampshire

HISP

Berkshire Health

HISP

Part

ners

HIS

P

Basic Commonwealth HIE Services Description

Provider directory

Certificate repository

DIRECT gateway

Web portal mailbox

Repository of physician names, entities,

affiliations, and security credentials

Repository of security certificates for

authorized users of HIE services

Adaptor that transforms messages from

one standard to another without

decrypting the message

Secure, encrypted mailbox for users

without standards-compliant EHR

“Lookup” services

“Message-handling” services

HIE Services

Generic Process for HIE Transactions

Provider directory


DIRECT gateway

Web portal mailbox

HIE Services

Sender creates message

Lookup provider information in

Provider Directory

Get certificate information from

Certificate Repository

Encrypt message

Send securely to HIE

HIE processes message and

sends to recipient

Recipient decrypts message and

processes message

Users will have 2 ways to connect to Commonwealth HIE

Provider directory


DIRECT gateway

Web portal mailbox

HIE Services User types

2 methods of accessing

HIE services

EHR connects directly

Browser access to webmail inbox

Physician practice

Hospital

Long-term care

Other providers

Public health

Health plans

Labs and imaging

centers

In general, who will use which method?

EHR connects directly Browser access to webmail inbox

• Hospitals

• Large practices including FQHCs

• Smaller practices on Direct-capable

EHRs (facilitated by Last Mile Adoption

Program)

• Health plans

• Some LTC and VNA

• Labs and imaging centers

• Smaller practices on less capable EHRs

• Most LTC and VNA

• Behavioral health

Likely to be many webmail at outset, but expect this to shift over time as EHR penetration

grows and national standards get traction

Five Basic Patterns for HIE Transactions


Browser access to

webmail inbox


Browser access to

webmail inbox

4a

3

2

1

4a

3

2

1 Webmail-to-Webmail

Webmail-to-EHR

EHR-to-Webmail

EHR-to-EHR (via Direct Gateway)

4b

4b EHR-to-EHR (point-to-point)

Different patterns “touch” different parts of the HIE

Webmail-to-

Webmail

Webmail-to-

EHR

EHR-to-

Webmail

EHR-to-EHR

(via Direct

Gateway)

EHR-to-EHR

(point-to-point)


DIRECT gateway

Web portal mailbox

Provider directory

4a 3 2 1 4b

“Lookup”

services

“Message-

handling” services



VGShared Service

Virtu

al G

ate

wa

y

VG Shared Services

Virtu

al G

ate

wa

y

HIE Users (Medicaid & Non-Medicaid)

Statewide HISP

Direct Gateway**

Medicaid & Public Health Applications

SMHP & MMIS Phase 1: Leverage Existing Infrastructure

Syndromic

Surveillance

MMIS

Claims Engine Provider Online

Service Center

MMIS Base Application

MMIS Users

CBHI (Children’s Behavioral

Health Initiative )

Immunization Electronic

Laboratory Reports

Existing enterprise shared services include:

* Upgrade/Expansion

** New

AIMS (Access and

Identity Management)

Other Existing

Enterprise Shared

Services

Clinical Gateway (HL7 Interfaces)

AIMS* (Access and



PKI** (Public Key

Infrastructure)

Provider Directory**

Syndromic

Surveillance


Health Initiative )



Simplify User Access and Repurpose New and Existing Components

MMIS Shared Service

Virtu

al G

ate

way


Syndromic

Surveillance

MMIS


Service Center



Health Initiative )


Laboratory Reports

Statewide HISP

Direct Gateway**

VG Shared Service

Virtu

al G

ate

way

AIMS (Access and


Other Existing Enterprise

Shared Services


AIMS* (Access and



PKI** (Public Key

Infrastructure)

Clinical Gateway* (HL7 Interfaces)

Syndromic

Surveillance


Health Initiative )

HIE Users (Medicaid and non-Medicaid)

Security and Provider Directory

services leveraged for Statewide

HISP

Architecture and usage patterns

identical for all users

~80K providers already

using Virtual Gateway

EHR (Direct enabled)

Labs (HL7)

Clinical documents (CDA)

XDR or SMTP

EHR (not Direct enabled)

Labs (HL7)

Clinical documents (CDA)

Web

portal

No interoperable EHR

Clinical documents

Web

portal



Building an infrastructure is no guarantee that it will used Need to Build “Network Effects” As Rapidly As Possible

Value of statewide HIE network and services will increase exponentially with the number of users

Removing adoption barriers is key to increasing number of users

• Up-front cost and difficulty of system integration is significant barrier to adoption to most users, especially small practices and safety-net providers

Can address this barrier through a variety of means

Align all funding streams to maximize opportunities for synergy

Leverage existing assets

Build services where the users are

Lower the cost and ease the difficulty of using the statewide HISP



Complement Infrastructure with Multi-Pronged Adoption Program

MMIS Shared Service

Virtu

al

Gate

wa

y


Syndromic

Surveillance

MMIS


Service Center



Health Initiative )


Laboratory Reports

Statewide HISP

Direct Gateway**

MMIS Shared Service

Virtu

al

Gate

wa

y

AIMS (Access and


Other Existing Enterprise

Shared Services


AIMS* (Access and



PKI** (Public Key

Infrastructure)

Clinical Gateway* (HL7 Interfaces)

Syndromic

Surveillance CBHI (Children’s Behavioral

Health Initiative )

1. Managed procurements,

2. Grants, and PM/technical

support

3. Statewide outreach,

recruitment, and training

Individual interfaces

Ambulatory practices

CAHs

Long-term care

Web portal recruitment and training

Behavioral health

Vendor-specific hubs (or HISPs)

Hospital EHR vendor

Ambulatory EHR vendor

Sub-network hubs (or HISPs)

HIE (eg, SafeHealth)

Hospital network

(e.g., Berkshire)

CMS SMHP/MMIS (infrastructure) ONC Cooperative Agreement (last-mile services)

Synergies

with REC

Pricing and Participation Principles for Private Contributions Finance and Sustainability WG recommendations

• Fee distribution: HIE private sector customers utilizing these services collectively should pay a share of ongoing operating costs as outlined in the agreements between EOHHS and CMS. For now, and for the foreseeable future, that amount is approximately $450,000 per year.

• Pricing philosophy: Private sector customer fees for entities utilizing these services should be "cost-based" where a share of ongoing operating costs are divided among private sector. It is anticipated that prices will vary for certain distinct customer segments

(to be defined) in a manner still to be determined.

• Fee basis: Private fees should be structured through a subscription model rather than a transaction model. A subscription model encourages HIE service usage and provides

customers with predictable fees.

• Fee mandates: Private funding of statewide HIE services should be on a voluntary basis. No organization should be compelled to pay for HIE services through statutory,

regulatory, or administrative channels.

• Funds administration: EOHHS needs to identify how privately contributed funds will be managed and administered. In particular, private sector fees and contributions need to

be protected from other State uses and policies and governance developed to guide how such funds will be utilized

- - - -

Next Steps

• Contracting complete in June

• Complete policy development and infrastructure build by September, 2012

• Go live October 15, 2012 - the Golden Spike!

• Complete SEE (CDA viewer/editor) application features by December 2012

• Last Mile program ensures providers in the Commonwealth will be ready for Meaningful Use 2014 edition by the October 2013 reporting start date

Documents

The Massachusetts Health Information Exchange Strategy