HIT Policy Update on Health Information Exchange

Update on the State HIE Program

Claudia Williams, DirectorFebruary 1, 2012

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Existing environment

Little exchange occurring• Almost three quarters of the time (73 percent) PCPs do not get discharge info within two

days. Almost always sent by paper or fax (2009, Commonwealth)• Only 19 percent of hospitals report they are sharing clinical information electronically with

providers outside system (2010, AHA)Cost of exchange high , time to develop is long• Interfaces cost $5K to $20K due to lack of standardization, implementation variability,

mapping costs• Community deployment of query-based exchange often takes years to developPoised to grow rapidly, spurred by new payment approaches• New payment models are the business case for exchange• More than 70 percent of hospitals plan to invest in HIE services (2011, CapSite)• Number of active “private” HIE entities tripled from 52 in 2009 to 161 in 2010 (2011, KLAS)Many approaches and models• In addition to RHIOs, many other approaches emerging, including local models advanced by

newly emerging ACOs, exchange options offered by EHR vendors, and services provided by national exchange networks

• Seeing a full portfolio of exchange options, meeting different needs

Office of the National Coordinator for Health Information Technology 2

Evolving conception of the role of state HIE program

Prior Assumption• One state-run HIE

network serving majority of exchange needs of the state

• Focus on developing query-based exchange

Current• There will be multiple

exchange networks and models in a state

• Key role of the state HIE program is to catalyze exchange in state by reducing costs of exchange, filling gaps and assuring common baseline of trust and interoperability, building on the market and focusing on stage one meaningful use


Focus and Approach

• Focus - Give providers viable options to meet MU exchange requirements– E-prescribing– Care summary exchange– Lab results exchange– Public health reporting– Patient engagement

• Approach – Make rapid progress– Build on existing assets and private sector investments– Every state different, cannot take a cookie cutter approach– Leverage full portfolio of national standards


We are here today…

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Receipt of Discharge Information by PCPs

*Respondents could select multiple responses. Base excludes those who do not receive report. Source: 2009 Commonwealth Fund International Health Policy Survey of Primary Care Physicians.

27%

Less than 48 Hours

29%

2 to 4 Days

26%

5 to 14 Days

1%

More than 30 Days

6%

Rarely/Never Receive Adequate Support

4%

Not Sure/Decline to Answer

15 to 30 Days

6%

Time Frame (n=1,442)

62%

Fax

30%

Mail

8%

Email

Remote Access

15%

1%

Not Sure/ Decline to Answer

11%

Other

Delivery Method (n=1,290)*

19 percent of hospitals are exchanging clinical care records with ambulatory providers outside system (2010)

Will we soon see this curve? For care summary exchange? For lab exchange?

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Texas White Space


Texas White Space

State HIE program opportunities to fill gaps, lower cost of exchange and assure trust

Opportunity Description

White Space Large areas of state don’t have viable exchange options for providers

Duplication Every exchange creates own eMPI, identity solution & directories

Information Silos Unconnected exchange networks don’t support info following patient across entire delivery system

Disparities Low capacity data suppliers do not have resources or technical capacity to participate in exchange

Emerging Networks

Emerging networks need resources and technical support

Public Health Capacity

States’ numerous reporting needs are resolved in one-off ways or aren’t electronic

No Shared Trust/Interop Requirements

Lack of common technical and trust requirements makes negotiations and agreements difficult and slows public support and exchange progress


Strategies

Opportunity Strategies to Address Number

White Space Directed Exchange - Jumpstart low-cost directed exchange services to support meaningful use requirements

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Duplication Shared Services - Offer open, shared services like provider directories and identity services that can be reused

54

Information Silos

Connect the nodes - Infrastructure, standards, policies and services to connect existing exchange networks

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Disparities REC for HIE - Grants and technical support for CAHs, independent labs, rural pharmacies to participate in exchange

20

Emerging Networks

Support local networks – Connectivity grants and trust/standards requirements for emerging exchange entities

5

Public Health Capacity

Serve reporting needs of state - Support public health and quality reporting to state agencies

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No Shared Trust/Interop Requirements

Accreditation and validation of exchange entities against consensus technical and policy requirements

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HIE Models

OrchestratorElevator Public UtilityCapacity-builder

$ $

Rapid facilitation of directed exchange capabilities to support Stage 1 meaningful use

Bolstering of sub-state exchanges through financial and technical support, tied to performance goals

Thin-layer state-level network to connect existing sub-state exchanges

Statewide HIE activities providing a wide spectrum of HIE services directly to end-users and to sub-state exchanges where they exist

Preconditions: Operational sub-state nodes Nodes are not connected No existing statewide

exchange entity Diverse local HIE approaches

Preconditions: Operational state-level entity Strong stakeholder buy-in State government

authority/financial support Existing staff capacity

Preconditions: Sub-state nodes exist, but

capacity needs to be built to meet Stage 1 MU

Nodes are not connected No existing statewide

exchange entity

Preconditions: Little to no exchange activity Many providers and data

trading partners that have limited HIT capabilities

If HIE activity exists, no cross entity exchange 10

Delaware Directed exchange - Jumpstart low-cost directed exchange services to support meaningful use requirements

• Provider outreach focused on how service can help providers coordinate care and meet meaningful use requirements:– Sharing a care summary when patient referred– Immunization reporting– LTPAC transitions

• Offered a time-limited free sign-up period to create a sense of urgency among eligible providers and hospitals

• A month after launch, more than 500 providers have signed up for service


Wisconsin Shared services - Offer open, shared services like provider directories and identity services that can be reused

• One of the key factors for a large scale adoption of a provider directory is for it to be flexible and provide accurate and up-to-date information

• Every provider added to the provider directory is checked against 13 discrete elements leading to an accuracy rate of 98% with elimination of duplicates

• The provider directory is easily configured and integrated into other existing systems such as the WHIO (Wisconsin Health Information Organization), WCHQ (Wisconsin Collaborative for Healthcare Quality), and the WCMEW (Wisconsin Council on Medical Education and Workforce)

• Currently the provider directory only has capabilities that allow end-users to search for physicians and clinics, but future plans will allow for the HISP to synchronize Direct certificates and addresses to fields within the provider directory


Indiana Connect the nodes - Infrastructure, standards, policies and services to connect existing exchange networks

• Indiana has five operational HIEs: HealthBridge, HealthLINC, IHIE, MHIN, and The Med-Web

• The state HIE program is funding these exchange organizations to begin sharing information across exchange entities, with the goal that patient information can securely follow patients wherever and whenever they seek care in the state

• The state’s HIEs are working together to agree on a shared set of privacy and security requirements and implement the NwHIN Exchange service stack

• While the state’s SDE is facilitating the work between HIEs and holding them accountable for deliverables and consensus, the resulting connected nodes will each maintain independent architectures and governance processes


Ohio REC for HIE - Grants and technical support for CAHs, independent labs, rural pharmacies to participate in exchange

• Many hospital labs in OHIO currently do not exchange electronic laboratory data in a structured format

• Ohio Health Information Partnership’s (OHIP) is focusing on enabling this capability for 69 hospital labs located in the underserved area

• OHIP will support “lab over Direct” and provide a data management service to enable LOINC coding

• OHIP, the Ohio Department of Health and the CDC-funded Laboratory Interoperability Cooperative are working collaboratively with the Ohio Hospital Association (OHA) in these efforts


CaliforniaSupport local networks – Connectivity grants and trust/standards requirements for emerging exchange entities

• The Cal eConnect HIE Expansion Grant Program funds community based initiatives that support providers in meeting MU requirements and are consistent with national and statewide policies, standards and services. Five grants totaling $3 million have been made to date:

– EKCITA (Central Valley) will support providers to receive structured lab results from labs, share patient care summaries and connect to immunization registries

– Los Angeles Network for Enhanced Services (LANES) is partnering with the Regional Extension Center to connect REC supported EHRs to HIE services with focus on underserved providers

– Redwood MedNet will support EHR connectivity to labs (results and orders), hospital sharing of discharge summaries with PCMH, provider sharing of care summaries with referring providers and patients (PCHR)


KentuckyServe reporting needs of state - Support public health and quality reporting to state agencies

• Providers can use the Kentucky Health Information Exchange (KHIE) to submit data to the KY Immunization Registry. To date, nine providers have tested immunization messages via KHIE to facilitate their MU attestation to Medicare

• The state will use KHIE to transmit electronic results from newborn screening to providers across the state. This functionality will go live the first quarter of 2012

• Approximately 55,000 babies are born every year in Kentucky and all of them have 48 metabolic screening tests performed in the Kentucky State Laboratory. The results are currently paper-based and are either mailed or faxed to providers


Rhode Island Accreditation and validation of exchange entities against consensus technical and policy requirements

• The Rhode Island Quality Institute created a “HISP Vendor Marketplace” and RI trust community to support rapid scaling of directed exchange to support providers sharing care summaries for referrals and other uses

• HISP Marketplace: Chose 4 vendors to be listed in the Marketplace www.docEHRtalk.org and available at a discount to Rhode Island providers. Selected based on meeting technical, process, and organizational best practice criteria

• RI Trust Community: Validates and authenticates users and issues digital certificates


http://www.docehrtalk.org/

Measuring progress


Emerging Issues

• Provider adoption and workflow for key exchange tasks• Alignment with care transformation and payment reform efforts• Scaling directed exchange• Broader adoption of query-based exchange• Sustainability• Business practices


Achieving Interoperability

Doug Fridsma, MD, PhD, FACMIDirector, Office of Standards & Interoperability, ONC

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How do we achieve interoperable healthcare information systems?

Team convened to

solve problem

Solutions& Usability

Accuracy & Compliance

Enable stakeholders to

come up with simple, shared

solutions to common

information exchange challenges

Curate a portfolio of standards,

services, and policies that accelerate information exchange

Enforce compliance with validated information exchange standards, services and policies to assure interoperability between validated systems 21

Direct and NwHIN

Exchange focus at these

levels

Direct and NwHIN

Exchange focus at these

levels

Vocabulary & Code Sets

Content Structure

Services

Transport is necessary,but not sufficient

How should well-defined values be coded so that they are universally understood?

How should the message be formatted so that it is computable?

How does the message move from A to B?

How do we ensure that messages are secure and private?

How do health information exchange participants find each other?

Transport

Security

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An Example Patient Scenario

• A primary care doctor orders a lab test and gets the test back from the lab. She schedules the patient to be seen in the office to discuss the results.

• Based on the results of the test, the primary care doctor decides to send the patient to a subspecialist. She sends a summary of care record to the subspecialist electronically with a summary of the most recent visit.

• When the patient sees the subspecialist, it becomes apparent that there is a missing test that was done at a different hospital that would be helpful in taking care of the patient. Rather than repeating the test, the doctor queries the outside hospital for the lab test that she needs.

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Vocabulary & Code Sets

Content Structure

Transport

Security

Services


What will this transaction require?

How should well-defined values be coded so that they are universally understood?

How should the message be formatted so that it is computable?

How does the message move from A to B?

How do we ensure that messages are secure and private?

How do health information exchange participants find each other?

X.509: to ensure it is safely transmitted to the

intended recipient

Direct: to securely send the lab result from the

lab to the EHR

DNS+LDAP: to find the recipient’s X.509

certificate

LOINC: to code lab results & observations

The physician ordered an outpatient lab test on a patient, and the lab sends the information to your office. The patient is here to discuss the results.

HL7 2.5.1: to format the lab result so EHRs can

incorporate it

Direct Project

• The Direct Project began as an independent, open government project to specify a standard for secure, directed health information exchange. Based on its success, OSI modeled the S&I Framework after Direct, and Direct has now become one of the S&I Initiatives.

• More than 35 vendors implemented Direct by Fall of 2011, with several more (10 at last count, but the count is old) publicly announcing that Direct specifications are included in their product roadmap .

• Direct is part of the core strategy of 40+ State HIE Grantees, 4 of whom already started implementing it in late 2011

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Direct Project Metrics - Ecosystem

Direct ProjectMetrics – Ecosystem

Direct Project Ecosystem Survey

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NwHIN Exchange

Exchange is currently operational and demonstrating value to participants, including: Federal agency benefit determination is expedited (shortened turnaround time by 45%)

Expedited benefit payments to disabled

Improved benefits in clinical decision making, including avoiding prescribing multiple narcotics based on information shared

As of January 2012, 22 organizations are exchanging data in production, representing: 500 hospitals

4,000+ provider organizations

30,000 users

1 million shared patients

Population coverage~65 million people

90,000 transaction as of Sept 2011, and growing dramatically each month

Exchange CC is developing business and transitional plan to guide the Exchange to a sustainable, scalable and efficient public-private model

Exchange can serve as basis for HIE innovation and critical element in nationwide health information infrastructure

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Exchange Organizations in Production

Current Exchange Activities Alaska HIE and Medical University

of South Carolina (MUSC) in conformance testing phase

Quality Health Network (QHN) has completed Conformance testing and currently in the Interoperability testing phase

Health Information Partnership for Tennessee (HIP-TN) and Redwood MedNet are preparing for conformance testing

• NRAA is currently working on setting up their production environment (partner with CMS) Number of

Organizations in Production

Number of Organizations

currently On Boarding

Estimated Number of Organizations in Production for Q1-

2012

22 (14 Federal, 6 HIEs, 2 Beacons)

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Federal: An organization that is a Federal Agency or has a contract or other agreement with a Federal Agency.HIE: An organization that is part of a State HIE or has a cooperative agreement with a State HIEBeacon: An organization that received grant money for the program 28

Data Use and Reciprocal Support Agreement (DURSA)• In effect since December 2009 and provides the legal framework

for the exchange of health information among a group of federal and non-Federal entities as part of the NwHIN Exchange (“the Exchange”).

• Amended DURSA 2011 • removes all references to governance of the NwHIN• clarifies that the Exchange is a voluntary group of exchange

partners (i.e., the organizations participating in the Exchange, not “the nationwide health information network.”)

• indicates that the Exchange Coordinating Committee only has authority with regard to these exchange partners and that it has no authority with regard to “the nationwide health information network.”

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Exchange ParticipationUnder New Circumstances

• Non-Federal entities may continue to participate under their existing valid legal instrument, such as a federal contract, grant, or cooperative agreement.

• The legal instrument should continue to include NwHIN activities in the scope of activities to be performed by the non-federal entity.

• Upon expiration of current contracts/grants/cooperative agreements, entities’ signature of Joinder Agreement DURSA will be sufficient to continue participation.

• New non-Federal entities may participate by executing the Joinder Agreement to the DURSA, without contracts/grants/cooperative agreements.

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Strategic Road Map: Transition to Sustainability

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•Early adopters

•Shared services

•Federal business cases

•Early lessons learned

•Success / viability

•Plan for transition

• Define strategic road map

• Refine and scale

• Expand value cases

• Grow participation/volumes

• Align with governance rulemaking and national standards

• Transition to non-profit org

• Implement sustainability model

• Capable of nationwide deployment

• Revenue model sustains business

• Interoperable exchange among private entities

Phase 1 Phase 2 Phase 3

Questions/ Discussion

Questions/Discussion

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Health & Medicine

HIT Policy Update on Health Information Exchange