1st MeetingJune 9, 2010

11:30 am – 2:00 pmDial-in:1-866-922-3257; Participant Code 654 032 36#

North Carolina Health Information Exchange

Clinical and Technical Operations Workgroup

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Agenda

Topic Leads Time

Welcome and Introductions Co-Chairs 11:30 – 11:45

Orientation and Overview• Project Background• Workgroup Process• Charter• Project Work Plan

Co-Chairs & Manatt

11:45 – 12:15

Principles and Priorities for Statewide HIE Co-Chairs & Manatt

12:15 – 1:00

Approaches to Implementing Statewide HIE Manatt 1:00 – 1:45

Public Comment Co-Chairs 1:45 – 1:55

Next Steps Co-Chairs 1:55 – 2:00

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Welcome

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Introductions Co-Chairs, Facilitators, and Members

Facilitators• Tim Kwan, Manatt• Brenda Pawlak, Manatt• Lammot du Pont, Manatt

Members• Deb Aldridge, National & State Baldridge

Examiner• Ben Alexander, WakeMed• Sam Cykert, AHEC, Moses Cone• John Graham, UNC Institute for Public

Health• John A. (Sandy) McNeill, NC Health Care

Facilities Association• Susan Helm-Murtah, BCBSNC

Co-Chairs• Allen Dobson, NC Health Quality Alliance• J.P. Kichak, UNC Hospital

• Arlo Jennings, Mission Hospitals• Keith McNeice, Carolinas

Healthcare System• Don Spencer, CCNC• Angela Taylor, NC DHHS• John Torontow, Piedmont Health

Services

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Meeting Objectives

• Confirm Workgroup charter– Long term goal – Near term deliverables

• Review project plan and revise based on Workgroup discussion

• Initial screen of principals and priorities

• Review clinical and technical approaches for statewide HIE

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Orientation and Overview

7Discussion Document – Not for Distribution

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Definitions – ARRA & HITECH

HITECH ActHealth Information Technology for Economic & Clinical

Health Act

Title XIII and Title IV of the ARRA, the section of the stimulus package focused on supporting the more widespread adoption of health

information technology.

ARRAAmerican Recovery & Reinvestment Act

$787 Billion federal stimulus package passed by Congress and signed by President Obama in February 2009.

8Discussion Document – Not for Distribution

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$1.2 B for loans, grants & technical assistance for:

Regional Extension Centers ($640M)

Workforce Training ($80M)

Research and Demonstrations

Medicare & Medicaid incentives for HIT adoption

~$19.1 to $29.8 B total in expected outlays (revised estimate)

$564 M for Statewide HIE Development

States receive between $4M & $40M

$220 M for “Beacon” Community Program

15 HIEs receiving between $10-$20M

$4.3 B for broadband & $2.5 B for distance learning/ telehealth grants

$1.5 B in grants through HRSA for construction, renovation and

equipment, including acquisition of HIT systems

New Incentives for Adoption Funding for Health IT

Funding for HIE

Broadband and Telehealth

Community Health Centers

HITECH FundingHIT & HIE infrastructure

9Discussion Document – Not for Distribution

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North Carolina Health IT AwardsARRA:

•State HIE Cooperative Agreement: $12.9 million

•Medicaid Meaningful Use Planning: $2.29 million

•Regional Extension Center: $13.9 million NC AHEC (North Carolina Area Health Education Centers Program and UNC Chapel Hill)

•Beacon Community: $15.9 million Southern Piedmont Community Care Plan

•Health IT Workforce Community College Consortia Program (non degree programs): $10.9 million Pitt Community College

•Health IT Curriculum Development: $1.8 million Duke University

•University-level Health IT Workforce Training (degree programs): $2.1 million Duke University

•Broadband: $28.8 million MCNC / North Carolina Research and Education Network (NCREN)

•CHIPRA (non-ARRA): $9.2 million (one of 10 state awards)

–Testing medical home for children with special health care needs through three provider-led community-based models

–Implementing a model electronic health record format for children

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Overview of Workgroup Process and Tasks

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State HIE Cooperative AgreementGoals and Planning Requirements

Domains toAddress

Domains toAddress

RequiredPlans

RequiredPlans

Goal: Plan and develop the HIE infrastructure to ensure• Widespread interoperability across entire state• Providers and hospitals can achieve meaningful use

Goal: Plan and develop the HIE infrastructure to ensure• Widespread interoperability across entire state• Providers and hospitals can achieve meaningful use

- Strategic Plan: State’s vision, goals, objectives and strategies for statewide HIE; including plans to support

provider adoption( Submitted to ONC Oct. 09 , to be

verified via Operational Plan process)

- Operational Plan: Detailed explanation, targets, dates for

execution of strategic plan

-Governance-Finance-Technical infrastructure-Business & Technical Ops-Legal and Policy

Types of Exchange

Types of Exchange

– Eligibility & claims transactions

– eRx & refill requests– Lab ordering & results

delivery– Public health reporting– Quality reporting– Rx fill status/med fill Hx– Clinical sum for care

coordination & patient engagement

12Discussion Document – Not for Distribution

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Operational Plan Workgroup Deliverables

Workgroup Deliverables

Governance • Description of coordination and interdependencies with relevant ARRA programs (e.g. REC, broadband, and workforce development)

• Description of governance and policy structures, including their ongoing development

Finance • Detailed cost estimate for the implementation of the Strategic Plan • Detailed schedule describing the tasks and sub-tasks to be completed, including resources, dependencies, and specific

timeframes • Description of proposed resolution and mitigation methods for identified issues and risks • Staffing plans for the project, including project managers and description of key roles• Description of activities to implement financial policies, procedures, and controls to ensure compliance with GAAP and OMB

Circulars

Technical Infrastructure

• Description of efforts to become consistent with HHS adopted interoperability standards and certification requirements as part of the planned implementation

• Description of the technical architecture and how its requirements will ensure statewide availability of HIE among healthcare providers, including plans for protection of health data

• Description of how the technical architecture will align with NHIN core services and specifications • Description of technical solutions to develop HIE capacity and enable meaningful use

Business & Technical

Operations

• Project schedule describing tasks and sub-tasks to be completed to enable statewide HIE• Identification and description of issues, risks, and interdependencies within the overall project • Description of how the state will leverage current HIE capacities • Description of state-level shared services and repositories to be leveraged (if applicable) • Explanation of standard operating procedures and processes for HIE services will be developed and implemented (not

required)

Legal/Policy • Description of how statewide HIE will comply with applicable federal and state legal policy requirements, including the process for developing and implementing policy requirements

• Description of interdependence of governance and oversight mechanisms• Description of plans for privacy and security harmonization and plans for interstate coordination • Address how state will comply with federal requirements for data protection

Consumer Engagement

• Consumer engagement and outreach plan• Communication messages and educational deliverables for dissemination

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Work Group ProcessCross-Workgroup Coordination

Clinical & Tech Operations Work Group

Clinical & Tech Operations Work Group

Legal & Policy Work Group

Legal & Policy Work Group

Finance Work Group

Finance Work Group

•Identify clinical, technical, & business objectives

•Define architecture•Identify services•Detail functions, options•Develop high-level costs

•Identify privacy issues•Define options•Identify policy/tech requirements

•Collect relevant environment data

•Define revenue sources •Identify funding constraints and timing considerations

Implementation Requirements

•Technical specifications•Implementation sequencing

•Detailed cost estimates•Detailed, 4 yr budget•Evaluation strategy

Governance Work GroupGovernance Work Group

•Define roles, decision making authority

•Identify goals•Define measures

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Work Group Activities

Work Group Deliverables

May June

IdentifyKey

Issues

Assess Options

Refine Plan

Membership

Charters• Clinical/business

priorities

• Use cases

• Tech architecture

Clinical/business priorities

Use cases

Technical approach

Implementation req’ments

Sustainability model

Budget

Operational Plan 1st Draft

FinalizePlan

Work Group Process High-level Timeline

July Aug

Completed Operational Plan

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Clinical and Technical Operations WorkgroupOur ChargeProposed Tasks Modification

1. Define high-value/high priority uses and/or use cases for HIE consistent with proposed meaningful use of certified EHR technology & additional clinical priorities.

2. Develop strategy for statewide HIE infrastructure to address high-priority use cases and clinical objectives.

3. Development of a flexible and scalable statewide technical architecture that supports the interoperable exchange of health information statewide

4. Whether or how shared technical services may be utilized for the state’s approach to fulfill the transactions specified in Cooperative Agreement:

– Electronic eligibility and claims transactions– Electronic prescribing and refill requests– Electronic clinical laboratory ordering and results delivery– Electronic public health reporting (i.e., immunizations, notifiable lab

results)– Quality reporting– Prescription fill status and/or medication fill history– Clinical summary exchange for care coordination and patient engagement

5. Strategy to support health IT and HIE adoption and meaningful use among North Carolina providers.

6. Develop and execute evaluation of project including data collection & performance measurement.

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Clinical and Technical Operations Workgroup Our Deliverables

Proposed Deliverables Modification

1. Landscape survey of relevant health IT/HIE assets across key stakeholders

2. Clinical opportunity analysis as relates to NC HIE meaningful use and operational goals

3. Selection of high-value uses and/or use cases

4. Straw technical architecture and approach based upon use cases

5. Description of how the technical architecture will align with NHIN core services and specifications

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Clinical and Technical Operations Workgroup Our Project Plan

Week of Action Items & Key Workgroup Deliverables Reach Agreement On

June 21 • Recommend clinical and technical principles• Recommend clinical objectives• Discuss prioritization and sequencing of statewide HIE core and

value-added services • Discuss operational oversight considerations

July 5 • Review “strawman” statewide HIE infrastructure • Refine HIE service definitions and discuss specific use cases in light

of final Meaningful Use criteria• Recommend core services and candidate value-added services.

July 19 • Update on definition of core services and candidate value-added services

• Update on refined use cases, discuss who will use, what services needed, who will need to be involved in further development of specifications

• Review rough draft of implementation timeline and key milestones• Review technical services for Medicaid SMHP

Aug 2 • Review and finalize recommended clinical and technical sections of Operational Plan draft.

• Review first draft of HIE service RFP

Aug 9 • Discuss revisions to Operational Plan draft on Conference call

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Principles and Priorities

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Principles for Statewide HIEClinicalPrinciples from Existing Strategic Plans Modification

1. The HIE solution must be consumer‐centered. A critical element toward improving health is an engaged consumer who has the means, information, opportunity and the know how to better manage their own health and lifestyle choices. Engaged consumers will have easier access to and more control over their individual health records and they will be able to play a more active role in managing their own health.

2. Better health, not just better healthcare, must be the goal.Better health requires looking beyond just HIT and the traditional practices of healthcare providers and payers to create a virtual “health home” where care is coordinated and collaborative. Prevention is the key. It must be a shared commitment of public and private employers, government non‐governmental organizations, communities and individuals.

3. HIT investments must support improved individual health as well as population health.Use the federal stimulus funds to drive the changes needed in the overall system that will create sustainable and continuous quality health improvements. The new HIT system and policies should leverage existing investments in technology, take advantage of innovations, and identify opportunities for new investments.

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Principles for Statewide HIEClinical...ContinuedPrinciples from Existing Strategic Plans Modification

4. HIT capacity is based on a commitment to delivering the right care, at the right time and in the right setting.

5. Providers must see value in adopting EMRs and participate in HIEs. Value will come in the form of incentives, improved outcomes, or provider satisfaction. Participation should not be mandatory or exclusive.

6. All providers must report the required minimum data set to the NC HIE. Under existing state law, certain specific health data is already being reported to the state primarily for the purposes of public health and communicable disease control. Additionally, a new minimum data set is expected to be established that identifies the required elements for the NC HIE and must be shared if the patient does not opt out of the NC HIE.

7. Data must be made available for biomedical research purposes. Research and development are critical elements of an evidenced-based system of quality improvement. Any research requiring access to personal health information must be approved by an appropriate Institutional Review Board and follow accepted best practices of confidentiality and data quality.

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Principles for Statewide HIETechnicalPrinciples from Existing Strategic Plans Modification

1. The system must be standards based.

2. This is a marathon not a sprint. HIT systems will be built incrementally. Every stakeholder in the process must be able to move ahead from where they are on the continuum from minimum HIT involvement to fully electronic and interoperable networks. This means that the implementation process will accommodate a broad range of participants including the small independent community practitioner as s/he decides to implement an EHR in the practice, as well as a large hospital health system with an existing sophisticated HIT system.

3. HIT investments must support improved individual health as well as population health.Use the federal stimulus funds to drive the changes needed in the overall system that will create sustainable and continuous quality health improvements. The new HIT system and policies should leverage existing investments in technology, take advantage of innovations, and identify opportunities for new investments.

4. Specifications should be vendor neutral, allowing for implementation in the widest range of hardware and software, including open-source and proprietary operating systems, programming languages, and connectivity tools.

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Principles for Statewide HIETechnical...ContinuedPrinciples from Existing Strategic Plans Modification

5. Wherever possible Services Oriented Architecture (SOA) design principles and Web Services should be utilized.

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Priorities for Guiding Implementation Key Questions

• What activities and processes represent “low-hanging fruit”? – Highly-valued in terms of clinical priorities, business processes,

and incentive programs– Can be easily, cost-effectively augmented and amplified by HIE

services

• What technical capacities/functions will help providers to satisfy MU criteria?

• When must these technical capacities/functions be available to providers in order to meet MU? What contingency plans are needed?

• While meaningful use incentives and Regional Extension Center efforts will expand the use of health IT within organizations, how will we ensure data can be shared across systems?

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Statewide HIE Approaches and Options

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Statewide HIE ImplementationKey Decisions

Continuum of Options to Support Statewide HIE• Minimal Standards Approach• Statewide Technical Architecture• Hosted Shared HIE Services• Single, Statewide HIE

Components of Statewide Technical Infrastructure• Participants• Core Infrastructure• Value-Added Services

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Support of Statewide HIEContinuum of Options

Standards-Based Approach

Hosted, Shared HIE Services

Statewide Technical Architecture

Standards Operate

Single Statewide HIE

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Support of Statewide HIEOption 1: Standards-Based

Overview Pros ConsState selects and suggests minimal federal standards and lets existing efforts work as they see fit to integrate based on those standards.

• Maintains consistency with federal approach

• May better address specific implementation requirements among local providers

• Localized implementations will be more difficult to interoperate statewide

• Potentially limits provider participation

• Implementations may not comply with State privacy and security requirements

• May not guarantee compliance with State reporting, surveillance requirements, and health outcomes

• Results in multiple development efforts that may not align

Minimal Standards Approach

State Hosts Shared HIE Services

Statewide Technical Architecture

Standards Operate

Single Statewide HIE

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Support of Statewide HIEOption 2: Statewide Technical Architecture

Overview Pros ConsStatewide architecture conforms to federal standards.

Multi-stakeholder group defines architectural requirements and implementation guidelines including specific standards implementations to enable broad interoperability; and establishes standards and protocols for HIE functions including infrastructure, data exchange, terminology mappings, etc.

• Optimizes use of funds through a common technical approach and evaluation of statewide demand for shared services

• Builds collaborative culture to support technical decisions

• Leverages knowledge and resources across the private and public sectors

• Ensures state compliance with federal standards

• Allows for regional technical variation within limits

• Resource intensive process may lengthen implementation timelines

• May require adjustment in regional and/or State direction

• May require voluntary compliance

• Operations requires buy-in and support from participants

• Unification of existing technologies require significant effort and change

Minimal Standards Approach

State Hosts Shared HIE Services

Statewide Technical Architecture

Standards Operate

Single Statewide HIE

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Support of Statewide HIEOption 3: Hosted, Shared HIE Services

Overview Pros Cons

Multi-stakeholder group defines architectural requirements and implementation guidelines including specific standards implementations to enable broad interoperability; and establishes standards and protocols for HIE functions including infrastructure, data exchange, terminology mappings, etc. 

In addition, entity hosts or contracts for specific HIE services that are determined valuable to offer at a State-level.

• Straightforward approach

• Requires minimal consensus

• State retains control and management of some assets

• Facilitates interoperability among HIEs using State services

• Provides on-ramp for existing technologies to participate in statewide exchange

• Regions maintain flexibility

• There may not be consensus as to what services the State should host

• Some efforts may have existing implementations that are not compatible with State services

Minimal Standards Approach

State Hosts Shared HIE Services

Statewide Technical Architecture

Standards Operate

Single Statewide HIE

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Support of Statewide HIEOption 4: Single Statewide HIE

Overview Pros Cons

A single statewide HIE that all stakeholders are required to participate in to gain access to public funds and State data is established and maintained.

• Promotes consistency • Facilitates statewide

interoperability

• May require adjustment in regional and/or State direction approaches

• Resource intensive process may lengthen implementation timelines

• May require voluntary compliance

• Implementation decisions may result in difficult on-boarding of existing systems

Minimal Standards Approach

State Hosts Shared HIE Services

Statewide Technical Architecture

Standards Operate

Single Statewide HIE

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Statewide HIE ServicesVisual Representation

Core Infrastructure:

Master Patient Index

Master Patient Index

Master Facilities

Index

Master Facilities

Index

Master Clinician

Index

Master Clinician

IndexNHIN

Gateway

NHIN Gateway

Security Services

Security Services

Service Access Layer: Transport, Orchestration, Audit, Reporting

Candidate Value-Added Services:

Routing of Labs for Required

Reporting

Routing of Labs for Required

Reporting

Immunization Registry

Immunization Registry

Medication Management

Medication Management

Quality Reporting

Quality Reporting

Patient AccessPatient Access

Eligibility Checking

Eligibility Checking

Participating Organizations: With gateways to access Core Infrastructure

HIOHIO Hospital-Provider

Hospital-Provider Clinic

Network

ClinicNetwork

Fed Agenc

y

Fed Agenc

y

Decision Support

Decision Support

Lab Translation

Lab Translation

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Statewide HIE ServicesKey Considerations for Participants

• What technical gaps existing for participant organizations to reach meaningful use and health information exchange?

• Which statewide technical services best augment currently planned or targeted HIE functions?

• What infrastructures are and will be in place for health information exchange directly from participants?– Clinical data repositories– Direct messaging / push to trading partners– Open and accessible indexes for patients, providers, and users– Access to existing systems

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Statewide HIE ServicesKey Considerations for Infrastructure & Services

• What is the scope of specific services?– Clinical Data Exchange – will all HIOs store and maintain their own clinical

documents?– Identity Services – will the state link to existing identifiers or maintain an

infrastructure to provide new ones?

• Who will be hosting various services?– Scope of services– Statewide context– Distributed services

• What infrastructures are and will be in place for health information exchange?

– Clinical data repositories– Direct messaging / push to trading partners– Open and accessible indexes for patients, providers, and users– Access to existing systems

• What type of commitment will be in place to utilize these statewide services?

• What types of statewide technology assets will be incorporated as endpoints for statewide exchange?

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Public Comment and Next Steps

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Public Comment

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Next Steps

• Finalize clinical and technical principles• Discuss prioritization and sequencing of statewide HIE

core and value-added services • Discuss operational oversight considerations

Upcoming Meetings– Board of Directors– June 15th – Clinical and Technical Operations Workgroup – June 23rd

Questions or Comments? Contact anita.massey@nc.gov.

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ATTACHMENTS