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Arizona Health-eConnection Roadmap

April 4, 2006

“To facilitate the design and implementation of integrated statewide health datainformation systems that support the information needs of consumers, healthplans, policymakers, providers, purchasers, and researchers and that reduce health-care costs, improve patient safety, and improve the quality and efficiencyof healthcare and public health services in Arizona.”

Arizona Health-e Connection Mission Statement

Arizona Health-eConnection Roadmap April 4, 2006

Funded by St. Luke’s Health Initiativesand BHHS Legacy Foundation

With support and assistance by eHealth Initiative

Arizona Health-e Connection Roadmap 3

I. Executive Summary. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6A. Overview . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6B. Health Information Technology and Health Information Exchange . . . . . . . . . . . . . . . . . . . . . . . . . 6C. Finance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8D. Legal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8E. Governance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8F. Transition Team . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9G. Wrap-up . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10

II. Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11

III. Roadmap Fundamental Concepts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15

IV. HealthInformation Technology (HIT) Approach . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18

A. HIT Adoption Strategies. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18

Partnerships . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18

Standards . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18

Guidance, Direction and Education. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18

Provide Incentives . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19

Identify Barriers and Propose Solutions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19

Other Opportunities. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19

B. HIT Products and Functionality . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19

Electronic Medical Records . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19

e-Prescribing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20

Practice Management Systems . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20

Other Products and Functions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20

Strategic HIT Systems. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20

V. HealthInformation Exchange (HIE) Approach . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21

A. HIE Strategies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21

Regional HIE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21

Existing IT Projects and Rich Data Sources. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21

Key Statewide Resources . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21

B. HIE Products and Infrastructure Components . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21

Patient Health Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21

Statewide Web Portal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22

Results Delivery Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22

Statewide Patient Record Locator . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27

Table of Contents


Secured Messaging . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27

Public Health Alerts/Queries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27

Personal Health Records . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28

Telecommunication Broadband and Last Mile Issues . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28

Other Projects and Opportunities. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29

VI. Privacy and Security . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30A. Arizona Health Information Security and Privacy Collaboration . . . . . . . . . . . . . . . . . . . . . . . . . . . 30B. Business Practices Committee . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31C. Solutions and Implementation Committee . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31D. Solutions and Implementation Committee . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31E. Education Committee . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31F. Legal Challenges Related to Privacy and Security . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31

VII. Finance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35A. Central Coordination Organization. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35B. Health Information Exchange . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35C. Health Information Technology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37D. Cost Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38

VIII. Governance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39

A. Background . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39

B. Getting Started. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39

C. Governance Task Group Recommendations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40

Mission Statement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40

Statewide Governance Model . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40

Governance Board . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41

Statewide Stakeholder Representatives . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41

MTA Representatives . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42

Board Committees . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42

Full-Time Staff . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42

Council of Initiatives . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42

Technical Advisory Groups . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42

Roles and Responsibilities of Proposed Governance Structure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43


IX. Transition Plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44

A. Statewide Governance Organization . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44

B. Strategy for Statwide Engagement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44

C. HIE Initiatives . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45

D. HIT Initiatives . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45

E. Marketing and Education Plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45

X. Project Timeline . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47

XI. Implementation Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48

XII. Acknowledgements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49

XIII. Appendices . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55Appendix A: Governor’s Executive Order. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55Appendix B: Organization Structure for Roadmap Creation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58Appendix C: Process to Create the Roadmap . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59Appendix D: HIT Support Organizations. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 68Appendix E: Sample HIT Adoption Strategies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 70Appendix F: Business Case . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71

XIV. Glossary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 74

XV. Contact Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 79


I. Executive Summary

A. Overview

Arizona recognizes that a statewide infrastructure toexchange health information electronically willimprove the quality and reduce the cost of healthcarein Arizona by:

• Ensuring health information is available at the pointof care for all patients

• Reducing medical errors to improve patient safety

• Avoiding duplicative medical procedures

• Improving coordination of care between hospitals,physicians, and other healthcare professionals

• Furthering healthcare research

• Enhancing public health and disease surveillanceefforts

• Encouraging greater consumer participation in theirpersonal healthcare decisions

• Enhancing the business environment for both smalland large employers and reducing state expendituresby controlling healthcare costs

Through executive order, Governor Janet Napolitanorequested that a wide range of interests determine astrategy to achieve a vision of 100 percent electronichealth data exchange among payers, healthcareproviders, consumers of healthcare, researchers, andgovernment agencies, as appropriate. Hundreds ofArizonans representing diverse interests and geogra-phies voluntarily contributed to the process and areenthusiastic about the possibilities of moving e-healthforward. This Arizona Health-e Connection Roadmapis the result of that process.

The Roadmap articulates a path to improve the quali-ty and reduce the cost of healthcare in Arizona. Thispath ensures that the needs of rural communities andsmall physician practices are accommodated.

The Roadmap identifies key decision points by focus-

ing on the what, when, why and who – what actionneeds to occur, when the action needs to occur, whythe action is necessary, and who (individual/group/organization) is required to complete theaction. Many of the “how” questions are to beanswered in the implementation phase and are notaddressed in this Roadmap.

Choices identified in the Roadmap were consideredfrom the perspectives of urgency and feasibility. Urgentinitiatives bring relief to a problem in the healthcaresystem. They provide a high level of value to one ormore constituent communities (such as patients,providers, and payers). Feasible initiatives includeitems likely to immediately succeed as well as initia-tives that are necessary prerequisites to achieve an urgentpriority initiative. Implementation of a feasible initia-tive does not necessarily provide a high level of stand-alone urgent value.

The Roadmap is constructed with initiatives that pro-vide either a high level of urgent value or feasiblevalue or both. Sequencing of the recommended initia-tives was chosen to maximize impact and utility forthe sum total of all initiatives. The Roadmap plan isdesigned to be scalable.

Although the Roadmap is a statewide plan andincludes many elements of statewide coordination,some Roadmap initiatives will be implemented on aregional basis within the context of a medical tradingarea, or MTA. An MTA is usually a geographic areadefined by where a population cluster receives itsmedical services. It is an area in which groups ofphysicians, hospitals, labs, and other providers worktogether to serve a population of consumers.

B. Health Information Technologyand Health Information Exchange

The Roadmap advances an approach that recognizes afundamental distinction between health informationtechnology (HIT) and health information exchange(HIE). The combination of HIT and HIE approachesconstitutes much of the Roadmap. This fundamentaldistinction simplifies the interrelationships betweenvarious components and clarifies the strategies neces-sary for e-health implementation.


Health information technology is a local deployment oftechnology to support organizational business andclinical requirements. HIT is technology implement-ed within the physical space of a doctor’s office, labo-ratory, and hospital or virtually through a hospitalsystem. Items such as electronic medical records(EMR) systems, administrative systems (such asbilling), and workflow systems are examples of HITsystems.

Health information exchange is infrastructure to enabledata sharing between organizations. Services are builtonce and used multiple times by many. Items such asa central Web site, healthcare terminology translationtools, a master patient index (MPI), authenticationand authorization infrastructure, and applications toaggregate information from multiple sources areexamples of HIE resources.

The Roadmap uses the following strategies for HITand HIE. Specific recommendations presented inother sections of the Roadmap have been developedwith direct consideration of these HIT and HIEstrategies.

HIT ROADMAP STRATEGIES

• Partner with organizations already involved in HITadoption

• Set and adopt standards (especially for integrationwith HIE)

• Provide guidance, direction, and education

• Provide incentives

• Identify barriers and propose solutions

HIE ROADMAP STRATEGIES

• Begin by developing HIE regionally

• Leverage existing information technology projectsand databases

• Develop key statewide resources for data accessand sharing

HIT products recognized as key include electronicmedical records (EMRs), ePrescribing, and practice

management systems (e.g., billing). High-priorityHIE projects include a patient health summary,statewide Web portal, secure messaging and infra-structure, and a results delivery service (implementedon a regional basis).

The patient health summary has the most clinicalvalue of all potential initiatives. It provides an assem-bled view of a patient’s most pertinent medical char-acteristics, such as lab results and trends, allergies, andmedications prescribed. The data, once standardized,can also serve as the basis of a personal health record.Since many patients are treated by more than one cli-nician, compilation of this data affords advances insafety, quality of care, continuity of care, and cost effi-ciency. Although the patient health summary willinclude continuity of care information, the Roadmapdevelopment team has intentionally refrained fromusing the term “continuity of care record (CCR).”CCR is a term recognized by many in the healthcareindustry, but it is not a de facto national standard.The Arizona team found that use of the term CCRtended to confuse discussions because it means differ-ent things to different people.

The Roadmap makes a distinction between a “basic”patient health summary and an “enhanced” patienthealth summary. The basic patient health summary isenvisioned as a pilot project that compiles informa-tion from several existing statewide data sources. Itwill provide clinical value but is limited in scope onthe quantity, type, and standardization of data pre-sented. An enhanced patient health summary is, bycomparison, a more complete portrait of an individ-ual’s key clinical and administrative information.Several prerequisite activities, such as implementationof regionally based results delivery services, are neces-sary for realization of an enhanced patient healthsummary.

The regionally based results delivery service provides astandard mechanism for clinicians to request varioustypes of clinical data (such as laboratory, radiology,etc.) and a standard mechanism for delivery of theresults. It is especially important in that it will providea stream of data to populate core infrastructure com-ponents and will also provide a sustainable revenuestream to offset many of the costs to develop andoperate an e-health information exchange. Datagleaned from the results delivery service is essential to


establish items such as a directory of clinicians, a mas-ter patient index, and storage banks of “normalized”clinical data.

C. Finance

Funding for the Arizona Health-e Connection shouldbe obtained from a variety of sources. The Roadmaprecommends that different funding programs andparameters be considered for HIE, HIT, and a centralcoordination organization.

It is not necessary to invest large amounts of capitalin a central organization to create a top-down fundingstructure for all Health-e Connection exchange activi-ties. In fact, many projects should be funded on acase-by-case basis at an MTA level. In general, fund-ing for the Roadmap should be value driven. Costs forongoing operations should be borne by the organiza-tion(s) benefiting from the service. It follows thatprojects will be addressed when it makes economicsense to do so.

The central coordination organization is small andrequires a modest amount of funding, estimated at $3million to $4 million per year. Funding sources forthis function could include grants and donations,state funds, in-kind donations of staff, and varioustransaction fees.

Regional HIE efforts will require start-up funding ofabout $1.5 million to $3 million per one million peo-ple (population) over the first two years. Like the cen-tral coordination organization, potential sources offunding include grants and donations, state funds,and in-kind donations of staff. Ongoing operationalfunding for a regional organization is obtained from aresults delivery service via a self-funding model. Theannual funding required to sustain a regional organi-zation is estimated at $2.5 million to $4 million perone million people (population).

The Roadmap suggests that most HIT costs should beabsorbed by the organization that is the primary userof the HIT system. In fact, many Arizona clinicianshave already invested in such systems. A possibleapproach for clinicians who cannot afford a full EMRsystem is to offer a subset of those services through aWeb-based system. It is believed that this more

affordable option could be offered to clinicians forabout $3,000 per clinician per year.

D. Legal

Implementation of the Roadmap requires that variouslegal issues be addressed. Arizona must ensure that thehealth information included in an e-health informa-tion exchange is confidential and secure. In addition,consumers must trust that their health informationwill be kept confidential. Rigorous confidentialityprotection for the health information handled by ane-health information exchange is essential to the long-term success of the mission.

Specific legal issues to address include:

• Consumer control over their health information

• Appropriate handling of “special” healthinformation that has greater confidentialityprotection

• Appropriate handling of minors’ health information

• Identification of those who will have access toe-health information in the exchange and forwhat purpose

E. Governance

A statewide governance body is needed to develop auniform approach to legal issues and many otheraspects of Roadmap implementation. The Roadmaprecommends that a statewide nonprofit Health-e


Connection corporation be created to provide leader-ship, negotiate standards, and encourage cooperationand collaboration. This organization would strategi-cally collect and distribute funding, help align finan-cial incentives, develop statewide technical infrastruc-ture when needed, and advocate for needed policychange. The governance body would consist of a gov-ernance board, board committees, full-time staff, aCouncil of Initiatives, and a Technology AdvisoryCouncil.

The governance board would maintain and refreshthe vision, strategy, and outcome metrics underpin-ning the Roadmap. It would provide advocacy whenneeded and build trust, buy-in, and participation ofmajor stakeholders statewide. In addition, the boardwould assure that equitable and ethical approaches areused in implementing the Roadmap. It might alsoraise, receive, manage, and distribute state, federal,and private funds. It would prioritize and foster inter-operability for statewide and sub-state initiatives.Finally, it would implement statewide projects andfacilitate local/sector projects.

The Health-e Connection board would includestatewide stakeholder interests critical for Roadmapsuccess, including clinicians, hospitals, payers, con-sumers, employers, and service providers (such as lab-oratories). Statewide representatives would be joinedby representatives from each MTA to ensure integrat-ed decision-making at the state and local levels.

Board committees, chaired by board members, wouldpermit input by an even broader set of stakeholders,as well as content expertise in areas such as clinicalproblem-solving, technical architecture and standards,confidentiality and security concerns, and finance.Recommended standing committees includeClinician, Employer, Payer, and Consumer.

Participants of the many e-health initiatives inArizona would be asked to join a Council ofInitiatives to identify obstacles and solutions toenhance future interoperability of health informationsystems. The Council of Initiatives would be a forumfor all interested e-health projects, including thosewith a more limited scale than an MTA. In addition,technical advisory boards would be forums to proposetechnical standards, policies, and solutions.

The Health-e Connection board should be supportedby a full-time executive and supporting staff.Contractors may also be used to supplement the skillsof full-time employees. The staff would execute strate-gic, business, and technical plans. Staff would alsocoordinate day-to-day tasks and deliverables, includ-ing establishing contracts and participation withlocal/regional initiatives.

F. Transition Team

Even though the governance body is responsible forimplementing the full Roadmap, a transition team willimplement the governance body and the first deliver-ables. Transition is estimated to take about 12months.

One of the most important goals of transition is tomaintain the momentum established when develop-ing the Roadmap. The first activity during transitionis to finalize the transition structure, which includesobtaining commitments from the participants, identi-fying interim funding requirements, and acquiringthe funding. Obtaining commitments from partici-pants should take no more than one month.Identifying interim funding requirements and fund-ing sources will occur over the following severalmonths.

Once the participants commit to working on thetransition, other activities will commence. Theseactivities include:

• Establishing a statewide governance organization

• Establishing a practical strategy for statewideengagement in the Health-e Connection effort

• Implementing the first HIE initiatives

• Identifying and beginning to coordinate withcurrent Arizona HIT initiatives

• Implementing the committees that will address theprivacy, confidentiality, and legal issues

• Developing a marketing and education plan forRoadmap implementation


Key HIE initiatives to be implemented during thetransition phase include developing a basic patienthealth summary, setting up a statewide Web portalwith security infrastructure components, and estab-lishing the first MTA information exchange with aresults delivery service. The first results delivery serv-ice will immediately begin to develop a providerdirectory, establish a master patient index for theMTA, and launch the process of data normalization.

G. Wrap-up

There is no single method to undertake such a diversetask as creating an e-health infrastructure for Arizona.Stakeholders and participants in the process were ableto reach a general consensus on the direction of theRoadmap. However, the timing of events, technologieschosen, financial strategies employed, and other fac-tors ultimately will be received differently by eachstakeholder. The Roadmap balances various competingpriorities by advocating a representative governancestructure, and it incorporates flexibility to adapt tolessons learned, technical advancements, and nationalstandards as they emerge.

The process of implementation is incremental, long,and difficult. Dedicated commitment from multiplestakeholders is imperative. With persistence and dili-gence, however, Arizona can achieve GovernorNapolitano’s vision for e-health connectivity.

Finally, development of this Roadmap would not havebeen possible without the coordinated and concen-trated contributions and efforts of many Arizona pub-lic and private partners, each with a sense of urgencyand commitment to advance the Roadmap and its rec-ommendations. Their knowledge, input, assistance,and spirit of dedication and teamwork were essentialto successful completion of Governor Napolitano’sExecutive Order. The content presented in thisRoadmap is a direct result of thousands of hours ofvolunteered time.

II. Introduction

The delivery and management of healthcare hasextended beyond the walls of a single hospital or doc-tor’s office and has resulted in healthcare informationbeing located in a variety of institutions. Sincepatients and consumers often receive healthcare frommore than one location, it is of paramount impor-tance to move healthcare information with patients sothat it is available wherever and whenever they receivecare. Consensus has emerged within federal leadershipand both the public and private sectors that healthinformation technology (HIT) and health informa-tion exchange (HIE) play a key role in addressing themounting challenges facing our nation’s healthcaresystem. Several state governments are becomingengaged in the use of HIT and HIE to support policygoals and the improvement of healthcare delivery andoutcomes.

There is no standard, widely accepted solution.Indeed, early experience suggests that successfulefforts have different starting points, initial approach-es, emphases, organizational forms, and evolutionarypaths toward a common objective of a secure andubiquitous information exchange. Consistent withU.S. Department of Health and Human Services(HHS) Secretary Michael Leavitt’s maxim of “nationalstandards, neighborhood solutions,” state and localgovernments are beginning to collaborate and developa consensus among diverse stakeholders on the vision,goals, and plans required to foster improved health-care and outcomes through timely and appropriatehealthcare information exchange. It is likely that asstates begin to recognize the opportunities presentedby HIT and HIE, more state leadership and initia-tives will emerge.

On August 30, 2005, Governor Janet Napolitanoissued Executive Order 2005–25 to develop theArizona Health-e Connection Roadmap (see AppendixA: Governor’s Executive Order). Under theGovernor’s Executive Order, the Health-e ConnectionSteering Committee is charged with developing a planfor Arizona to achieve statewide electronic health dataexchange among insurance companies, healthcareproviders, and consumers of healthcare, as well as


exploring issues related to implementing electronicmedical records. The Roadmap is consistent with thegoals of President Bush and the HHS Office of theNational Coordinator for Health InformationTechnology (ONC) to “achieve 100 percent electronichealth data exchange between payers, healthcareproviders, consumers of healthcare, researchers, andgovernment agencies as appropriate.”

Since the Call to Action Summit in October 2005,several activities to support the Executive Order havebeen made possible with the support of St. Luke’sHealth Initiatives and the BHHS Legacy Foundationin collaboration with the eHealth InitiativeFoundation and its Health Information Exchangepartners. Subsequent to the Call to Action, the 42-member Steering Committee, five task groups(Clinical, Financial, Technical, Legal, andGovernance) with a total membership of more than250, and a project management team collaborated forfive months to create the Roadmap (see Appendix B:Organization Structure for Roadmap Creation). Underthe leadership of the Steering Committee co-chairs,the activities in Figure I have been completed to cre-ate the Roadmap:


The Health-e Connection Roadmap articulates a pathto improve the quality and reduce the cost of health-care in Arizona. The Roadmap identifies key decisionpoints by focusing on the what, when, why, and who— what action needs to occur, when the action needsto occur, why the action is necessary, and who (indi-vidual/group/organization) is required to completethe action. Specific values and guiding principles wereidentified at the onset of this initiative to guide theRoadmap development. The top-level values and guid-ing principles are listed in Figure II. The entire Valuesand Guiding Principles for Arizona Health-eConnection are listed in Appendix C: Process toCreate the Roadmap.

Figure II: Arizona Health-e Connection Top-LevelValues and Guiding Principles

The Roadmap reveals the recommended actions andkey milestones to achieve in the next five years toaccomplish the goals stated in the Executive Order.The overall goal is to achieve early adoption of astatewide e-health information infrastructure that willimprove the quality and reduce the cost of healthcare

• Create achievable, actionable, and practicalinitiatives

• Ensure that initiatives are consumer focused

• Provide technical basis for health data exchange

• Promote sustainability

• Increase the quality and performance of healthcarein Arizona

• Assist in healthcare research

Project Activity ImpactWeekly Project • Increased awareness of activities and scope managementManagement Meetings • Obtained stakeholder input and collaboration

• Initiated task group activities• Created the Roadmap

Arizona Briefing/ • Identified barriers and prioritiesAssessment Paper • Established a baseline of information Steering Committee Meetings • Established expectations and roles(five meetings total) • Provided leadership for the process and a communication channel

between the Governor and Steering Committee• Created Task Group charges• Provided guidance and approval of task group recommendations • Assured adherence to the Executive Order• Identified Roadmap Mission Statement and Values and Guiding

Principles Five Task Groups Meetings • Identified urgent and feasible priorities(17 meetings total) • Developed recommendations for RoadmapTask Group Leadership Meetings • Provided synchronization among all task groups

• Reviewed all task group work • Verified recommendations for feasibility and urgency

Figure I: Completed Activities


in Arizona. Other key benefits include improved caresafety and patient self-management and improvedsurveillance and response to public health problems.

Full achievement of the goals requires interoperablehealth information systems combining a) health infor-mation sufficiently standardized to be machine usable;b) health information technology that can send,receive, route, assemble, and interpret such standard-ized information when and where needed; c) healthinformation technology that includes automated deci-sion support for better self-care, patient care, andpublic health; and d) health information exchangesthat establish the legal and technical infrastructure tosecurely, confidently, and efficiently move the infor-mation between authorized users.

Healthcare, business, and government leadersthroughout Arizona are excited and enthusiastic aboutthe opportunity to improve patient care and deliverythrough health information exchange developed overa staged, multiyear plan. Through continued dialogueand collaboration among the diverse stakeholders inArizona, supported by lessons now being learned indifferent parts of the country, the state has the oppor-tunity to achieve significant gains in quality, safety,and efficiency through the effective and appropriateimplementation of the Roadmap and become anational leader in e-health information exchange.

Recognizing the Challenges

Arizona clearly faces significant technical, privacy, andsociopolitical challenges in sharing health informationstatewide. By recognizing these challenges, theRoadmap provides strategies to negate the hurdles.

First, a wide variety of stakeholders are at the tablewith very different expectations. Stakeholders includegovernment agencies, hospitals, physicians, dentists,nurses, pharmacies, labs, insurers/payers, a variety ofassociations, and consumer interests. The Roadmapprocess took all concerns into consideration in estab-lishing priorities and developing initiatives.

In addition to the variety of stakeholders, stakehold-ers’ adoption of HIT differs widely even among mem-bers of the same interest groups and the technologyproducts being used are diverse. Because of the differ-ences in the products and how they are used by vari-ous people or organizations, data standardization is

lacking. The Roadmap acknowledges stakeholderdiversity and takes into consideration the enormousamount of work required to remove the resultingambiguities between the current data sources and toprovide better guidance for future technologies thatwill be implemented.

Another related challenge is Arizona’s geographicdiversity. Each region has its own opportunities andchallenges. For example, some rural areas of Arizonaare fairly isolated without bandwidth to take advan-tage of many of today’s technologies. Some consumerslive on the borders of other states and receive medicalservices in those states. Also, some communities, suchas Yuma, have close relationships with the medicalcommunities in Mexico. The Roadmap takes into con-sideration the differences in each region.

Of course, there are the additional complexities oforganizational policy, laws, regulations, and challengesin paying for implementation of the Roadmap.

With all of these and other issues to address, we mustrecognize that there is no panacea for the challengesahead. The challenges are not insurmountable, butthey must be understood and respected.

The Roadmap considers the following points to enableit to meet these challenges:

• Not all of the challenges have been identified;therefore, not all of the answers are available. TheRoadmap is flexible to meet the challenges ahead

• Changes will occur in technology, medical science,and demographic factors that shape the overalldemand for care. The Roadmap embraces changes intechnology and leverages the future functionalityand opportunities that become available to helpaddress changes in medical science and demand pat-terns. In addition, older technologies will continueto be used and replaced only when participatingorganizations need additional functionality or have afinancial incentive to do so

• Each stakeholder has different needs and differentclinical and business processes. To meet these needs,vendors have developed many different but viableproducts for the market. There is no one-size-fits-allsolution. Organizations must be able to use HITproducts that address their needs, but also must be


able to exchange data with the rest of the healthcarecommunity. Also, current standards will be changedand improved, and those changes will be absorbedto help with the seamless sharing of data

• The Roadmap leverages local interests that wish toimplement local initiatives. It is in regional areasthat patients are served and where the challenges arebest met. The Roadmap encourages and supportslocal initiatives while providing guidance and infra-structure for sharing data among the various regionsin Arizona

• The Roadmap reduces the disparities between thehaves and the have-nots, whether this means thosewithout broadband in their community or thosewho lack funds to pay for critical infrastructure orproducts. While the Roadmap does not have all theanswers, it contains the ingredients needed toaddress these and other challenges going forward

• No single application determines success or failureof the Roadmap. Because of the enormous complexi-ty of the environment and challenges, it is possiblefor a misstep to occur along the way. The Roadmapcalls for work on key projects and objectives concur-rently. Momentum and advancement will continue,even if one project encounters difficulties. TheRoadmap also defines an infrastructure that enablesreevaluation and permits necessary course correc-tions along the way

• Momentum developed while creating the Roadmapwill be leveraged during implementation. Low-riskkey products will be developed in the early stages ofimplementation. An interim transition organizationwill also be established to immediately begin imple-menting the Roadmap. The transition organizationis tasked with establishing a permanent governancestructure, among other things. This approach willprovide the momentum needed to continue thegoodwill and interest established while developingthe Roadmap

• The Roadmap also seeks to leverage existing projectsand initiatives under the strategic Health-eConnection umbrella. Many good things are hap-pening in the Arizona Healthcare community andthey should be encouraged, supported, andleveraged to further the goals and objectives ofthe Roadmap

In recognizing the complexities of the environment,the Roadmap takes a phased approach based on geog-raphy, functionality, and audience. The phasedapproach reduces risk and recognizes the challengesassociated with location, the capabilities organizationsrequire, and the various stakeholders involved.

While there are challenges, some are fading and thenumbers of HIE and HIT initiatives are increasing.No challenge is identified as insurmountable inArizona’s quest to become a national leader in realiz-ing the benefits of HIT and HIE.


III. RoadmapFundamental Concepts

Several keys to understanding the Roadmap approachare presented in this section. The following three fun-damental concepts are identified as crucial in creatingArizona’s approach.

Fundamental Concept #1: Differences BetweenHealth Information Technology and HealthInformation Exchange

The Roadmap approach is based on a distinctionbetween health information technology (HIT) andhealth information exchange (HIE). This fundamen-tal distinction simplifies the interrelationshipsbetween various components and clarifies the strate-gies necessary for implementation.

Health information technology (HIT) is the deploy-ment of technology to support specific organizationalbusiness and clinical requirements. HIT is the tech-nology within the physical four walls of a doctor’soffice, laboratory, or hospital or a virtual hospital sys-tem. Items such as electronic medical records (EMR)systems, administrative systems (such as billing), andworkflow systems are examples of HIT systems.

Health information exchange is infrastructure to enabledata sharing between organizations. Services are builtonce and used multiple times by many. Items such asa central Web site, healthcare terminology translationtools, a master patient index (MPI), authenticationand authorization infrastructure, and applications toaggregate information from multiple sources areexamples of HIE resources.

Specific recommendations presented in the Roadmaphave been developed with direct consideration of thefollowing HIT and HIE strategies.

HIT ROADMAP STRATEGIES

• Partner with organizations already involved inHIT adoption

• Adopt or, if necessary, set standards (especiallyfor integration with HIE)

• Provide guidance, direction, and education

• Provide incentives

• Identify barriers and propose solutions

HIE ROADMAP STRATEGIES

• Begin by developing HIE regionally

• Leverage existing IT projects and rich data sources

• Develop key statewide resources for data accessand sharing

Some items do not fit neatly in either the HIT orHIE category. Those items are identified as suchwhen they are mentioned in the Roadmap. For exam-ple, ePrescribe systems typically have some compo-nents that fit the definition of HIE and some compo-nents that fit the description of HIT.

Fundamental Concept #2: Urgency Balanced byFeasibility Determines Timing of Roadmap Inclusion

A guiding principle of the Roadmap is to identify ini-tiatives that are practical, achievable, and actionable.The Roadmap team recognized that it was not possi-ble to do everything at once. Scarce resources (finan-cial, human, time, etc.) demand that careful examina-tion of all activities be conducted. In addition, it wasnecessary to identify and prioritize the proper activi-ties to build and sustain project momentum andenthusiasm.

Choices identified in the Roadmap were consideredfrom the perspectives of urgency and feasibility. Urgentinitiatives bring relief to a problem in the healthcaresystem. They provide a high level of value to one ormore constituent communities (such as patients,providers, and payers). Feasible initiatives includeitems likely to immediately succeed as well as initia-tives that are necessary prerequisites for achievement ofan urgent priority initiative. Implementation of a feasi-ble initiative does not necessarily provide a high levelof stand-alone urgent value.

The Roadmap is constructed with initiatives that pro-vide either a high level of urgent value or feasiblevalue or both. Sequencing of the recommended initia-tives was chosen to maximize impact and utility forthe sum total of all initiatives.


In the process of developing the Roadmap, several ini-tiatives were placed in a grid showing their relativeurgency and feasibility. Figure III lists key productsand infrastructure components identified in theRoadmap. Certain items not identified as prioritiesfrom a clinical or business perspective were includedin the grid based on their importance as infrastructurecomponents that enabled the important products.The grid’s horizontal axis lists the selections “HigherFeasibility” and “Lower Feasibility.” The vertical axislists the selections “Higher Urgency” and “LowerUrgency.” The products and infrastructure compo-nents were placed in the grid based on their urgencyand feasibility. From this grid, the timing of theproducts and infrastructure in the Roadmap wasdetermined.

The grid presents priorities for Year One of theRoadmap. Items identified as lower urgency or lowerfeasibility in the grid increase in priority in later stagesof the Roadmap as various prerequisite initiatives areimplemented.

Fundamental Concept #3: Medical Trading Areas

Many HIE projects will be developed within the con-text of a medical trading area (MTA). An MTA isusually a geographic area defined by where a popula-tion cluster receives its medical services. It is an areain which groups of physicians, hospitals, labs, andother providers work together to serve a population ofconsumers. Within an MTA, the medical serviceproviders or subsets of providers are often organizedeither formally or informally, and many are alreadyexploring projects to enable them to share patientdata.

Web portal (statewide)

Statewide (Basic) Patient Health Summary

MTA results delivery

MTA provider directory

MTA Master Patient Index (MPI)

MTA data normalization

Secure Infrastructure components

Secure messaging

Encourage HIT adoption

Statewide personal health record

Add public health functions

(Enhanced) Patient Health Summary -by MTA

(Additional MTAs) - results delivery,provider directory, MPI, data normalization


Statewide patient record locator


Add functions for oral health and other

professionals

Year 1 - 2 Year 3 -4

Year 3 - 4 Beyond

Higher Feasibility Lower Feasibility

HigherUrgency

LowerUrgency

Figure III: Urgency and Feasibility as Viewed in Year One of the Roadmap


The greater metropolitan Phoenix area is an exampleof an MTA. The population of the Phoenix area isserved by physicians, hospitals, labs, and otherproviders located in the same geographic area. Manyproviders have working relationships with each otherto serve their patients and they often want anincreased ability to share patient data in a secure andconfidential way.Because most data sharing will happen at a regionalarea with providers that already have relationships inserving consumers, it is much easier to develop trustbetween providers and it leverages the trust con-sumers have of their providers. Data-sharing agree-ments and data-use agreements will be much easier todevelop and control at the local level.

MTAs are not specific to a large metropolitan popula-tion. Rural areas are included in this process. Arizonamay develop several MTAs throughout the state tospecifically serve rural providers and to account forthe needs of all of Arizona’s populations.


IV. Health InformationTechnology (HIT)Approach

A. HIT Adoption Strategies

The HIT adoption strategies may be summarized infive approaches: 1) partner with other organizationsthat already have HIT adoption programs; 2) adoptand, if necessary, set standards; 3) provide guidance,direction, and education; 4) provide incentives; and5) identify barriers and propose solutions.

Partnerships

The statewide Health-e Connection governance bodywill partner with organizations that are alreadyfocused on HIT adoption strategies. The governancebody will coordinate activities with these partners asthe Roadmap is being implemented. A sample of theorganizations include the Health Services AdvisoryGroup (HSAG) and its efforts to implement thenational Doctor's Office Quality–InformationTechnology (DOQ-IT) initiative, the ArizonaChapter of the Healthcare Information andManagement Systems Society (HIMSS), the ArizonaHealth IT Accelerator (AHITA), and various medicalassociations. The governance body will partner withthese and other organizations and continue the workof HIT adoption in Arizona in a concerted way.

For descriptions of DOQ-IT, AZHIMMS, and AHITand how they propose supporting HIT adoptionwithin the structure of the Health-e ConnectionRoadmap, see Appendix D: HIT SupportOrganizations.

Standards

Working with partners, the statewide governancebody will adopt and set standards to ensure that HITefforts will be able to exchange data with Arizona’sHIE efforts. Arizona will adopt industry standardsand certification programs if they meet Health-eConnection objectives.

As the Roadmap is being implemented, the statewidegovernance body may determine that the various

national and industry standards or certification pro-grams are not detailed enough to adequately ensurethat data can be shared. If this is the case, the gover-nance body will provide additional guidance in theform of localized standards for the Arizona HIT com-munity. These localized standards will be developedwith input from medical trading areas or strategicHIT partners, depending on the types of standardsbeing developed.

Guidance, Direction, and Education

The statewide governance body will provide guidance,direction, and education to the community as part ofthe HIT adoption effort. Many of the potential part-ners working on HIT adoption provide a variety ofservices to the clinician community to encourage HITadoption. The statewide governance organization willpoint people to these programs. One way is by devel-oping a Web site that directs people to the classschedules, program descriptions, online tool kits,and other information and services dealing with HITadoption. The Web site could provide bulletin boards,online chat rooms, collaborative work tools, andother resources to help the clinician community. Inshort, the statewide governance body will be aclearinghouse of the available services at the stateand national levels.

The statewide governance body also will provideguidance on adopting federal policies and standards atthe clinician level. A lot of information is availableand it is difficult for people to understand the variousrequirements that have been developed.

For providers, health plans, and vendors that wish todo business in Arizona, the governance body can pro-vide guidance on requirements for inclusion in thehealth information exchange. This will provide poten-tial businesses with both the expectations and theopportunities available. This sets a level playing fieldwith all businesses located or wishing to do businessin Arizona.

Another area in which the statewide governance bodycan provide direction and guidance is in the opensource movement and how it plays into Arizona’sfuture plans. Many open source products are beingdeveloped for use in various aspects of healthcare pro-vision. The governance organization should review


these developments and provide direction to thehealthcare community.

HIT adoption would benefit by coordinated HITclasses in Arizona medical, nursing, and related fieldschools. As graduates enter the medical field, they willalready be trained to use HIT and know some of itsbenefits. The new doctors will be technology savvyand will want to work in offices that were earlyadopters.

There are numerous other areas in which the gover-nance body can become involved in providing guid-ance, direction, and education. Additional opportuni-ties include vendor product ratings, pricing informa-tion, sample requests for proposal (RFPs), samplecontracts, return-on-investment studies, readinessassessments, implementation plans, and HIE interfacespecifications. The governance body will work withvarious partners at appropriate times to provide helpto clinicians in adopting HIT solutions.

Provide Incentives

The Governor’s budget for FY 2007 includes $1.5million for grant money to be distributed to HITprojects in rural areas. This is to be administered bythe Arizona Government Information TechnologyAgency (GITA). There is other grant money for ruralHIT projects at the local and national levels as well.The statewide governance organization will identifyand make the clinician community aware of these andpossibly provide training in how to apply for them. Inessence, the governance body will be a clearinghouse,with information on the Web portal, for all availablegrants.The statewide governance organization will work withits partners to explore other financial incentives forclinicians implementing HIT. Incentives may includevarious HIT tax credits, low-interest loans, raisingmoney from foundations to redistribute as grants, etc.

For clinicians who cannot implement their own HITsolutions, Health-e Connection could provide datathrough a Web browser to encourage minimal adop-tion of HIT.

Identify Barriers and Propose Solutions

The statewide governance organization will work withits partners to continue identifying and proposingsolutions to barriers. It will get involved in activitiessuch as surveys of clinicians that gauge HIT adoptionand identify barriers to adoption.

Other Opportunities

There are many other areas in which the statewidegovernance organization could become involved inHIT adoption. Over time, the governance body willidentify areas based on experience that will have thegreatest impact. See Appendix E for a list of sampleHIT adoption strategies.

B. HIT Productsand Functionality

During the Roadmap development process, key HITproduct types were identified as priorities from a cli-nician point of view. The three priorities are (in noparticular order):

• Electronic medical records

• ePrescribe

• Practice management systems (e.g., billing)

Because they were identified as important to the clini-cal community during the Roadmap developmentprocess, these key HIT products are a priority foradoption. The following descriptions of the producttypes also provide some justification for their beingsingled out as priorities for adoption.

Electronic Medical Records

Electronic medical records (EMRs), which refer to thecapability to record, store, and retrieve patient med-ical records electronically, are central to improving thecare process. This is particularly true with advancesthat allow portability, remote access, import, storage,and export of machine-readable electronic informa-tion (not just text), connection to other applications


such as billing and ePrescribing, and the inclusion ofclinical decision support programs that alert cliniciansto possible safety or quality problems.

ePrescribing

ePrescribing allows clinicians to order prescriptionselectronically from a pharmacy, eliminating handwrit-ing errors and errors related to manual retranscriptioninto and out of paper forms. Many ePrescribing appli-cations also help check medications against patientallergies, interactions with other medications, andinsurance plan formularies and price lists. ePrescribeis a product that could have HIT and HIE implica-tions and deployment.

Practice Management Systems

Practice management software is the most widespreadelectronic information management application inmedical practices today. As payment systems forhealthcare become more complex (narrow providernetworks, multitiered health plans, medication for-mularies, preauthorization requirements, increased co-payments and deductibles, and personal health sav-ings accounts, among other developments), the abilityof a practice to negotiate claims with payers and col-lect fees from patients requires increasing amounts ofclinical information. This may be accomplishedincreasingly through the integration of practicemanagement systems with clinical electronicmedical records.

Other Products and Functions

Other products and functions were viewed as impor-tant to at least some segments of the healthcare com-munity, depending on the organizations’ roles andneeds. Continuous encouragement of these productswill also be encouraged when applicable. Otherimportant functions included:

• Disease management

• Chronic care management

• Home healthcare reporting

• Real-time results from medical and therapeuticmachines and instruments

• Task management

• Referrals

• Charge capture/right coding

• Decision support (alerts, best clinical practices,reminders, facilitate diagnoses)

• Patient education

• Drug-to-drug, drug-to-allergy alerts, etc.

Strategic HIT Systems

Certain HIT systems potentially have strategic valueto the Roadmap. The strategic value depends on theapplication, but in general the applications either aredata-rich resources for clinical information that mightbe shared or they provide functionality desirable toother Arizona stakeholders and could be shared toreduce the overall cost of the Roadmap. Examples ofArizona HIT systems with potential strategic impor-tance are the state’s immunization system, ArizonaHealth Query, Secure Integrated Response ElectronicNotification (SIREN) system, and certain ArizonaHealth Care Cost Containment System (AHCCCS)data. There are also national data sources and services.SureScripts, a service that provides prescription fulfill-ment information from pharmacies, is one example.The Roadmap’s approach to these potentially strategicHIT systems will be ascertained individually based ontheir strategic value and how they could be leveraged,if appropriate.

In addition, the governance body may determine that,for strategic purposes, it should develop an HIT sys-tem. For example, the governance body may deter-mine that it should provide ePrescribing for thosewithout HIT systems. This, in part, will help thosethat cannot afford or that face other barriers to imple-menting HIT systems.


V. Health InformationExchange (HIE) Approach

A. HIE Strategies

There are three strategies to develop a statewide HIEin Arizona: 1) begin by developing HIE regionally; 2)leverage existing IT projects and rich data sources;and 3) develop key statewide resources for data accessand sharing.

Regional HIE

While the ultimate aim is sharing health datastatewide, there are compelling reasons to start theprocess by developing the infrastructure regionally.The first reason is that medical delivery services arehighly regional. A look at the total number of medicalservices provided to the population shows that thevast majority of services take place relatively close tothe patients. Keeping the data close to where it isrequired enhances the speed and reduces the complex-ity of providing data to the patients’ clinicians. Data-sharing and data-use agreements will be much easierto develop and control at the local level.

When taking on a project of this scope and magni-tude, it only makes sense to implement it in portions.Dividing the work by geographic locations wheregroups already have established working relationshipsincreases the likelihood of success.

Existing IT Projects and Rich Data Sources

Because healthcare projects, initiatives, and databasesalready exist in Arizona, they should be leveraged aspart of the Roadmap. Early in the Roadmap develop-ment process, a high-level inventory was taken andmany current initiatives with strategic value wereidentified. For example, Health-e Connection willpartner with current initiatives to solve last mile andrural broadband issues.

Key Statewide Resources

Although Arizona will develop HIE regionally, certainresources should be provided statewide. For example,there should be one Web portal that provides accessto data available from the various regions. Anotherexample is a centralized patient locator service thatcan find all medical information about a patientthroughout the state, regardless of region.

B. HIE Products andInfrastructure Components

The following sections identify and describe themajor HIE products and required infrastructure com-ponents necessary to support statewide HIE.

Patient Health Summary

As Arizona works toward sharing health informationstatewide, many things need to be developed to makethat goal a reality. In the process, there are short-termmilestones that will add significant value to the quali-ty of healthcare in Arizona. One of these is a patienthealth summary1.

During the Roadmap development process, a patienthealth summary was identified as a product thatwould have the greatest short-term clinical impact onpatients. Creating a summary will enhance continuityof care for patients, which impacts quality of care,potentially lowering costs and increasing communica-tion between doctors providing the care. This willhelp reduce redundant and unneeded care while lim-iting delays in therapeutic care.


The patient health summary will provide a historicview made of data assembled from a variety of sourcesaccessible to all clinicians on a 24-hours-a-day, seven-days-a-week basis via the Internet. It will contain avariety of information, including result trends, dis-charge summaries, and procedure reports. Nine typesof information (topics) were identified as especiallyimportant. They are listed in Figure IV.

Figure IV: Topics of Information for Inclusion in thePatient Health Summary

It is highly likely that the patient health summary willbe developed in phases. The Roadmap makes a dis-tinction between a “basic” patient health summaryand an “enhanced” patient health summary. The basicpatient health summary is envisioned as a pilot proj-ect that compiles information from several existingstatewide data sources. It will provide clinical valuebut is limited in scope on the quantity, type, andstandardization of data presented. An enhancedpatient health summary is, by comparison, a morecomplete portrait of an individual’s key clinical andadministrative information. Several prerequisite activi-ties, such as implementation of regionally basedresults delivery services, are necessary to realize anenhanced patient health summary. The enhancedpatient health summary will be developed incremen-tally as the data becomes available and transformedon an MTA-by-MTA basis.

Statewide Web Portal

One milestone on the road to providing a patienthealth summary and eventual statewide sharing ofpatient data is developing a statewide Web portal.This will be among the first things to be implementedfrom the Roadmap. Providing a one-stop access pointto statewide resources is an important roadmap com-ponent because clinicians and citizens will need toknow only one Web address to obtain all of the infor-mation available to them. The Web portal will pro-vide several important functions.

The Web portal will play a marketing and educationrole for implementing the Roadmap. Any news,updates to functionality, and other developments willbe available on the Web portal. Another aspect of thisrole is providing clinicians and other providers withHIT adoption resources. Information about HITstandards, funding sources, and other pertinentresources will be available on the Web portal. TheWeb portal will be an important tool for increasingHIT adoption throughout Arizona and communicat-ing to the general public.

In addition, the Web portal will be an access point foronline services available now to clinicians and eventu-ally to the public. In the beginning, Web links toservices already available from other sources will beprovided. For example, currently there are onlinepublic healthcare eligibility tools for both cliniciansand potential clients. Having one place to find thesetypes of services adds value to the healthcare commu-nity and those who want to use those services. As theRoadmap is implemented and services are developed,they will be made available through the portal.

Because confidentiality, privacy, and security are socrucial, the Web portal will provide secured access tohealth information exchange.

Results Delivery Services

An astonishing volume of personal health informationmust be sent routinely among clinicians, serviceproviders such as laboratories and imaging centers,pharmacies, hospitals, insurance plans, public healthauthorities, and other parties. Most of this informa-tion is sent by paper or fax, with attendant problemsin confidentiality, information loss, labor, and errors

Medications—prescribedMedications—dispensed AllergiesImmunizationsLab results and trendsOther providers caring for patient (and contactinformation)Cumulative medical problem list (from billing andor EMRs)Insurance/eligibility and basic demographicinformation on patientHospital and emergency department dischargecare summary


created during transcription, sending, receiving, print-ing, copying, and filing.

Research indicated that one approach successfullyemployed by several locations is to establish a resultsdelivery service and leverage that capability to buildother important e-health components. The concept isto first develop a service that delivers results from labsand other providers to the ordering clinicians in theformats they require. Some clinicians want results onpaper, others want them sent via fax, and others wantthe results sent in electronic format to their automat-ed systems. If labs and hospitals have to establish onlyone electronic interface for all lab results and they donot have to provide delivery in various formats, thenthey should save money on delivering the results. Thesavings would fund sustainable operation of theresults delivery and additional infrastructure compo-nents necessary to enhance the services.

The results delivery service will be expanded toreceive results from all labs and similar providers.These providers include commercial labs, referencelabs, imaging centers, outpatient facilities, inpatientfacilities, emergency departments, and surgical cen-ters. The results delivery service will develop electron-ic interfaces to create data streams containing theresults from all of these providers. Examples of resultsin the data stream include blood tests, immunology,pathology reports, X-ray, CAT scan, mammography,transcribed reports, and other information. The serv-ice will deliver those results to the ordering physiciansand to other authorized recipients.

Over time, tools will be developed that glean datafrom the results to populate other important compo-nents necessary to provide a patient health summary.Also, data obtained via this mechanism will be instru-mental in populating full electronic medical andhealth records.

The first important component that will be developedis a clinician directory. Information about the clini-cians is necessary to deliver the results. Over time, theservice may ask for additional data about the clinicianto enhance the directory. During this process, theservice will follow national and industry data stan-dards to ensure that data is compatible with initiativesin later phases of the Roadmap. Appropriate informa-tion about these transactions can begin feeding publichealth systems.

One way to jump-start the clinician directory is topartner with the healthcare licensing or credentialingagencies and populate the provider directory withtheir data. The agencies may also be able to providethe administration services for clinicians accessing thedata through the Web portal.

Beyond results delivery, the provider directory isimportant because it would help one clinician look upanother clinician and find the appropriate address tosend a message through the secure network. Thiscould also be used to establish enhanced services suchas a patient referral system. (For example, see SecuredMessaging below.) Figure V provides an illustration ofthis first phase of results delivery.


Figure V: First Phase for Results Delivery

The second component to be developed will likely bea master patient index (MPI). Again, data will begleaned from the transaction and additional informa-tion will likely be requested to enhance the index.Data standards will be followed in creating the MPI.

The index is of utmost importance in that it a)enables the location of data about the patient and b)is required to connect data about the patient fromvarious sources. Figure VI provides an illustration ofthis second phase of results delivery.

Data Stream

Health Information Exchange: Phase 1

This phase enables the development and use of a

Clinician Directory

Public Health

ResultsDelivery

Clinician Offices

FAX

Phone

Mail

Electronic

EXAMPLE INFORMATION SOURCES

• Strategic HIT Systems• Service Providers • Hospitals - Inpatient • Hospitals - Outpatient • Hospitals - Emergency • Commercial Labs • Reference Labs • Imaging Centers • Ambulatory Surgery Centers• Prescription Fullfillment Records

EXAMPLE INFORMATION TYPES

• Demographics• Labs • Blood Chem., Immunology • Path Reports, Microbiology • Blood Bank, Prenatal• Radiology Reports • X-Ray, CT Scan, Ultrasound • Mammography, Vascular • Routine Diagnostic, Consults• Transcribed Reports • Emergency, Surgery • H&P, Discharge • Progress Notes, Rehab

Clinician Directory /Routing


Figure VI: Second Phase for Results Delivery

After the first two components are developed, theservice will break down the lab and other clinicalresults into usable and shareable data that followindustry and national standards. This process, calleddata transformation (or normalization), is a key stepin providing important clinical information and inter-faces necessary for populating a patient health sum-mary and, finally, comprehensive electronic healthrecords.

An enormous amount of work will be required toconvert the data stream into useable information. Itwill be a large and difficult task. Although many labsand others are already using the current industry stan-dards, they are afforded much variation in imple-menting the standards.

Once the data is standardized, it will be used to addinformation to a basic patient health summary. Thepatient health summary will be continually enhancedas data is transformed into shareable information. Inaddition, electronic interfaces that enable the seamlesspassing of data to the clinicians will continue to bedeveloped. With these in place, the results deliveryservice can begin passing data into various HIT sys-tems, including electronic medical records, practicemanagement, patient health records, chronic caremanagement, disease management, etc. Furthermore,more comprehensive data will be provided to publichealth systems. Figure VII provides an illustration ofthe third phase.

Data Stream


This phase enables the development and use of a master patient index (MPI)

Public Health

ResultsDelivery

MPIBuild

Clinician Offices

FAX

Phone

Mail

Electronic

ID Patient Specific

Data






Master Patient Index


Figure VII: Third Phase for Results Delivery

In addition to continuing the work of transformingthe data, the next task is to have clinicians share datathat they created about the patient with other treatingproviders. This is important to the final goal of shar-ing health information statewide. There are multiple

ways clinicians’ information can be shared. It willlikely be determined by the organizers of specificmedical trading areas in conjunction with thestatewide governance body in future phases of theRoadmap. Figure VIII provides an illustration of thefourth phase.

Data Stream


This phase adds data to a basic Patient Health Summary and provides limited data to

clinician HIT systemsPublic Health

ResultsDelivery

MPIBuild

Clinician Offices

Data Transformation:

Stage 1

EMRs

Prac. Mgt

PHRs

DiseaseMgt

Chronic Care Mgt







Add Data to Basic

Patient Health

Summary


Figure VIII: Fourth Phase for Results Delivery

Results delivery services and other related activitieswill be developed within the context of a medicaltrading area (MTA). An MTA is usually a geographicarea based on where a population cluster receives itsmedical services. It is also an area where groups ofphysicians, hospitals, labs, and other providers serve ageographic-based population of consumers. An MTAcan be a metropolitan or rural area. The medical serv-ice providers or subsets of providers are often organ-ized either formally or informally, and many areexploring projects that will enable them to sharepatient data.

Statewide Patient Record Locator

Ultimately, the central governance body will develop apatient locating service available through thestatewide Web portal where providers with legalaccess will be able to obtain all appropriate medicaldata for their patients, regardless of the data’s locationin Arizona. The patient record locator will search theMPIs of MTAs. As the central governance body devel-ops this capability, it will ensure that all appropriatedata-sharing agreements are in place, along with allsecurity controls and auditing functions.

Secured Messaging

Another priority identified by the Roadmap develop-ment process was the need for secured messagingbetween clinicians. This will enable timely and confi-dential communication between providers about apatient. This will be developed by leveraging commu-nication tools that doctors are already familiar with,but those communications will go through a secureinfrastructure that protects the data during transmis-sion. The infrastructure developed for secured messag-ing will be leveraged for other services developed, asoutlined in the Roadmap.

Public Health Alerts/Queries

Epidemics come and go, drugs and medical devicesare recalled, and problems as diverse as water contam-ination, bioterrorism, or heat waves may have impactson the health of thousands or millions of people.Public health agencies now rely on slow and inconsis-tent ways of receiving information about such prob-lems. In addition, some agencies have a difficult time

Data Stream

Federated Databases


This phase enables a full Patient Health Summary and

clinicians feeding data into the Exchange

Public Health

ResultsDelivery

MPIBuild

Clinician Offices


Stage 1


Stage 2

EMRs

Prac. Mgt

PHRs

DiseaseMgt

Chronic Care Mgt

PHS and Full EHRs







Add Data to Basic

Patient Health

Summary


disseminating clinical recommendations so that clini-cians can use them to prevent illness and injury. Aselectronic systems permit automated reporting of sur-veillance information to public health authorities,facilitating alerts and clinical decision support, prob-lems can be detected earlier and addressed rapidly bythe entire health system. As the HIE infrastructure isimplemented and earlier products are developed, pub-lic health capabilities will incrementally increase andthe additional capabilities of alerts and queries will beaddressed.

Personal Health Records

Personal health records permit patients to view, carry,and, in many cases, add to electronic documents con-taining their own important health information suchas allergies, immunizations, and medication lists. Suchrecords can serve various functions. At the simplestlevel they may facilitate providing information to cli-nicians, but they may evolve to help patients benefitfrom electronic health advice personalized to theirown medical information (e.g., tailored to the med-ications a patient takes). Some records are created bypatients; others are exported from records maintainedby insurance plans or clinicians. There is now littlestandardization among the various personal healthrecord formats, so they cannot electronically importor export information from different electronic med-ical records on a routine basis. While personal healthrecords are currently products in some HIT solutions,it is recommended that a more comprehensivestatewide approach to personal health records beaddressed during later phases of Roadmap implemen-tation.

Telecommunication Broadband and Last Mile Issues

A statewide electronic health information systemdepends on high-speed broadband connectivitybetween all points on the health network. But in therural communities of Arizona, consistently availablecapacity does not exist in many areas. Broadband isdefined as two-way communication of voice, video,and data at volumes of at least 1 megabit per second(Mbps). Broadband is available in only about half ofthe rural communities with a population of morethan 500. Communities with fewer than 500 peoplehave even less opportunity for broadband infrastruc-ture because traditional models of broadband build-out have always depended on higher population den-sity. The lack of broadband for rural healthcareproviders will hinder their participation in the fullimplementation of Health-e Connection.

A number of organizations have committed to theubiquitous availability of broadband across the state.The Governor’s Council on Innovation andTechnology (GCIT) recently established theCommunications Infrastructure Advisory Committee(CIAC) to assume a leading role and center of influ-ence to shed light on and help solve issues causingbroadband disparities and deficits. The ArizonaTelecommunications and Information Council(ATIC), the Arizona Technology Council (ATC), theSouthern Arizona Tech Council (SATC), and theGreater Arizona eLearning Association (GAZEL) areaddressing broadband availability. Because broadbandis such a basic component of economic development,many business groups are also involving themselves inthe discussions and issues.

The statewide governance organization will workclosely with organizations seeking to resolve thebroadband availability issue. Because of the closeworking relationship between Health-e Connectioninitiative and GITA, coordinating with CIAC andATIC is relatively easy.

One way the Roadmap transition and governancebodies can assist in the discussion is to help identifywhere broadband deficits exist. Just identifying anduniting the various segments of the demand into acommon voice can often create sufficient anchor ten-ancy for vendors to take notice and action. Demandaggregation is a major policy initiative promulgatedby GITA other telecommunications advocacy groups.


Other Projects and Opportunities

Although some very specific milestones and projectsare laid out above, this should not be seen as preclud-ing any other projects or techniques that might beused as the Roadmap is developed. The Roadmap isdeveloped specifically to take advantage of new ideas,changes in technology, and opportunities that maypresent themselves.

In fact, it is anticipated that various projects in themid to latter stages of the Roadmap will use the HIEcomponents developed in the early stages. For exam-ple, decision support capabilities, oral health func-tions, ePrescribe, integrated clinical/billing informa-tion flow for preauthorization and claims, and manyother projects will most likely become feasible forimplementation.

It is also recognized that changes in priorities maychange because of changes in the economy, politicalclimate, and other areas. While the focus has been onclinical data, the Roadmap is flexible enough tochange gears and refocus efforts through the directionof the statewide governance body.


VI. Privacy and Security

A variety of federal and state statutes and regulationsaffect the formation of an e-health informationexchange in Arizona. These include federal and statelaws on medical record confidentiality, consumerrights, medical record administration, telemedicine,electronic signatures, fraud, abuse, and antitrust.

One of the legal challenges Arizona will face is toensure that the health information included in an e-health information exchange is confidential andsecure. For an e-health information exchange to besuccessful, consumers must trust that their healthinformation will be kept confidential. Rigorous confi-dentiality protection for the health information han-dled by an e-health information exchange is essentialto the long-term success of the mission.

The resolution of many of these challenges willdepend greatly on how the e-health informationexchange is structured, the type of e-health informa-tion to be included, the types of participants in theexchange, and the reasons participants access theexchange. For example, many of these issues will beresolved differently if the exchange involves only lim-

ited information, such as medication information or apatient health summary, versus the statewide sharingof health information.

A. Arizona Health InformationSecurity and Privacy Collaboration

In an effort to address the privacy and security issuesthat will arise during Roadmap implementation, thetransition effort will leverage the process outlined inArizona’s response to the request from the U.S.Department of Health and Human Services and theNational Governors Association for proposals to cre-ate a Health Information Security and PrivacyCollaboration. The purpose of the HealthInformation Security and Privacy Collaboration is toidentify barriers to e-health exchange in state privacyand security business practices and state laws and reg-ulations, and to suggest methods of alleviating thosebarriers and encouraging harmonization of privacyand security practices to encourage e-health dataexchange. The Arizona Health Information Security and PrivacyCollaboration (AzHISPC) structure (Figure IX) will

Figure IX: AzHISPC Organizational Structure

State of Arizona Governor's Office

Executive Leadership

Team

Steering Committee

Business Practices

Committee

Legal Analysis Committee

Solutions and Implementation

Committee

Education Committee

Project Management

Team


operate with functional oversight by the Health-eConnection Steering Committee. The SteeringCommittee will be assisted in this effort by fourworking groups: the Business Practices Committee,the Legal Analysis Committee, the Solutions andImplementation Committee, and the EducationCommittee.

B. Business Practices Committee

The Business Practices Committee will assess varia-tions in organization-level business policies and prac-tices related to the privacy and security of healthinformation, and categorize them as barriers, bestpractices, or neutral with respect to interoperability.

C. Legal Analysis Committee

The Legal Analysis Committee will assess applicableprivacy and security laws, regulations, and court casesto identify legal sources of barriers to sharing healthinformation statewide. The group will be tasked withreviewing the barriers uncovered in the business poli-cy assessment conducted by the Business PracticesCommittee and mapping those barriers to applicableprivacy and security legal requirements. Members ofthe Legal Analysis Committee will also work with theSolutions and Implementation Committee (definedbelow) to ensure that laws are accurately and consis-tently interpreted throughout the process offormulating solutions, planning, and implementation. In addition to the responsibilities outlined above, the

Legal Analysis Committee will also be responsible forassisting the transition team in answering the legalchallenges that arise during the transition phase. (Seethe Legal Challenges section.)

D. Solutions and ImplementationCommittee

The Solutions and Implementation Committee willreview the assessment of variation of state laws, busi-ness policies, and legal requirements identified as bar-riers by the Business Practices Committee and theLegal Analysis Committee. The committee will devel-op an implementation plan to recommend policiesthat are consistent with federal and Arizona laws and

will recommend any legislative or regulatory changenecessary to reduce state law barriers to e-health dataexchange.

E. Education Committee

This committee is expected to conduct outreach andeducational sessions about the privacy and securityissues involved in e-health data exchange. The com-mittee will also direct other e-health exchange projectsto collaborate with regional and national educationalefforts as needed.

It is anticipated that the AzHISPC will continue forone year, as outlined in the HHS grant proposal andalso as structured in the overall transition plan of theRoadmap. Once the governance organization is estab-lished during the first year of the Roadmap, the gover-nance organization will be responsible for addressingprivacy, security, and other legal challenges.

F. Legal Challenges Related toPrivacy and Security

The e-health information exchange faces foursignificant challenges:

1. How will the e-health information exchangeaddress consumers’ control over their own healthinformation?

2. How will the e-health information exchangehandle “special” health information that hasgreater confidentiality protection?

3. How will the e-health information exchangehandle minors’ health information?

4. Who will have access to the e-health informationin the exchange and for what purpose?

Challenge 1: How will the e-health informationexchange address consumers’ control over theirhealth information?

E-health information exchanges across the countryface the difficult task of determining how much con-trol the individual consumer will have over his or herhealth information in the e-health informationexchange. On the one hand, consumers legitimatelywant control over their own health information andwant the right to choose whether to participate in ahealth information exchange.


On the other hand, seeking consumer consent beforeincluding health information in the e-health informa-tion exchange may mean that an individual consumermay not have the opportunity to consider includinghis or her information before that information isneeded. For example, the person may be in a car acci-dent and treated at an emergency department beforethe person has the opportunity to opt in to the sys-tem, so that person’s information will not yet be avail-able electronically to the emergency care providers. Inaddition, seeking consent of consumers will be anadministratively difficult task and may pose substan-tial expense in implementing the system. Finally, per-mitting consumers control over participation willdiminish the effectiveness of the informationexchange in addressing important public concerns,such as using the information in the exchange forbioterrorism surveillance or to alert healthcareproviders and public health officials to the beginningof a potential pandemic.

There is no easy answer to this challenge. Moreover,the balance between these positions changes, depend-ing on what type of information is included in theexchange, who has access to the information in theexchange, and for what purposes the information willbe available. For example, most consumers may bewilling to include medication information in theexchange without consent, but may want the right toconsent if a full-blown interoperable electronic healthrecord is created. Similarly, some consumers may bewilling to participate in the system if it is accessedonly by physicians and hospitals for treatment pur-poses, but want to authorize access by health plans forpurposes unrelated to paying claims for their health-care.

Weighing the public policy issues above, the e-healthinformation exchange has the following options:

• Seek consumers’ consent to include their healthinformation in the e-health exchange.

• Provide consumers the right to opt out of havingtheir health information in the e-health exchange.

• Include all consumers’ health information in the e-health exchange.

The Legal Analysis Committee will assist in determin-ing the appropriate option for each e-health dataexchange project in the Roadmap.

Challenge 2: How will the e-health informationexchange handle “special” health information that hasgreater confidentiality protection?

Some types of health information have greater confi-dentiality protections than are found in the federalHealth Insurance Portability and Accountability Act(HIPAA) Privacy Rule, which forms the federal“floor” of confidentiality protection. For example,federal and Arizona laws related to communicable dis-ease, genetic testing, mental health, and alcohol andsubstance abuse treatment information permit fewertypes of uses and disclosures of health informationwithout consumer consent than does the HIPAAPrivacy Rule. One of the most challenging decisionsfacing the e-health information exchange will be howto handle this information. The e-health informationexchange has a variety of options:

• The e-health information exchange could excludecommunicable disease, genetic testing, mentalhealth, and alcohol and substance abuse treatmentinformation to provide greater confidentiality pro-tection for that information. However, the exchangemust examine whether this will be workable, giventhat this information (particularly communicabledisease information) is integrated throughout med-ical information held by providers. Moreover, segre-gating that information means that it may not beavailable to healthcare providers, which may com-promise the quality of care provided to the con-sumer.

• The e-health information exchange could includesome sensitive information, but exclude other infor-mation that has the greatest restrictions on use anddisclosure. For example, the e-health informationexchange could include mental health informationand communicable disease information (both ofwhich may be disclosed for treatment, payment,quality improvement, research, and public healthsurveillance), but exclude alcohol and drug abusetreatment information held by federally assistedsubstance abuse treatment programs and genetictesting information (which may not be disclosed forthese purposes without consumer consent). This

Challenge 3: How will the e-health informationexchange handle minors’ health information?

Minors have the right to consent to certain types ofhealthcare in Arizona, such as treatment for sexuallytransmitted diseases, HIV testing, alcohol and drugabuse treatment, and prenatal and other reproductivecare. Minors also have the right to consent to allhealthcare if they are emancipated, have been mar-ried, are homeless, or are in the military. Whileminors have the right to consent to healthcare andactually provide that consent, minors also have theright to control the health information related to thatcare and must authorize disclosure of that informa-tion to their parents or guardians. The e-health infor-mation exchange should determine how to satisfy theparticipants’ legal obligations to protect minors’ rightsto control access to their health information. Theexchange might consider the following options:

• The e-health information exchange might imple-ment a mechanism for providers to flag informationrelated to healthcare to which a minor consented,but that requires the minor’s authorization for dis-closure to parents or guardians.

• The e-health information exchange could excludeminors’ health information from the system if thatinformation relates to healthcare for which theminor has the right to consent (such as substanceabuse treatment, HIV testing, and other types ofspecific healthcare). Excluding that information mayhave negative consequences if that information issignificant to other treatment provided to theminor.

• The e-health information exchange could requestthe Arizona legislature to pass a law granting parentsand guardians the right to see their children’s healthinformation, perhaps with exceptions to protectminors in cases of abuse or other circumstances.However, there are substantial policy reasons thatcounsel against this route, such as discouragingminors from obtaining treatment for sexually trans-mitted diseases or prenatal or reproductive care.


option may be workable, if providers holding genet-ic testing information and substance abuse treat-ment information can store that information sepa-rately from the e-health information exchange.

• The e-health information exchange could includethe special information, but restrict the use of allinformation in the exchange to comply with themost restrictive laws. For example, the laws protect-ing special health information all permit disclosureof the information with consent. The exchangecould seek consent to include an individual’s infor-mation in the exchange, contingent on the individ-ual’s agreement to use and disclose all informationfor certain defined purposes. There are substantialdownsides to seeking affirmative consent to includee-health information in the exchange, as explored inconnection with the first challenge. Moreover, aconsumer may wish all of his or her health informa-tion to be included in the e-health data exchangeexcept alcohol and drug abuse treatment informa-tion; this option would thus force consumers tomake a difficult choice between better quality ofcare and protection of more sensitive information.

• The e-health information exchange could determinea way to flag information that requires more confi-dentiality protection. This would alert providersthat there is additional information in the system,but perhaps not allow access to this informationwithout express authorization from the consumer.

• The e-health information exchange could ask theArizona Legislature to amend laws to facilitate thee-health information exchange. For example,Arizona confidentiality laws might be amended sothat all information is subject only to the restric-tions in the federal HIPAA Privacy Rule. An alter-native might be to reduce the amount of informa-tion subject to greater confidentiality restrictions.For instance, the communicable disease laws—which now protect information on all reportablediseases, including flu, measles, and mumps—mightbe amended to protect only communicable diseasesthat are stigmatizing to individuals, such asHIV/AIDS.


Challenge 4: Who will have access to the e-health infor-mation in the exchange and for what purpose?

For each e-health data exchange project in theRoadmap, the final challenge is to define who hasaccess to the health information for that project andfor what purpose. For example, it must be determinedwhether health plans and employer group healthplans will have access to information in a patienthealth summary. This challenge is closely related toChallenge 1 on whether consumers will have the rightto opt in or opt out of having their health informa-tion included in the e-health information exchange.

These four challenges — among others — aresurmountable, but will require careful considerationbased on the policy goals of the e-health informationexchange, how the exchange is structured, the type ofe-health information to be included, the types of par-ticipants in the exchange, and the reasons participantsaccess the exchange.


VII. Finance

Funding for the Arizona Health-e Connection shouldbe obtained from a variety of sources, depending onthe function. This section considers the funding forHIE, HIT, and a central coordination organization.Each function requires a different approach.Recommendations for each function are listed in thesections below.

It is not necessary to invest large amounts of capitalin a central organization to create a top-down fundingstructure for all Health-e Connection exchange activi-ties. This is consistent with the proposed governanceroles of the central organization. In fact, many proj-ects will be funded on a case-by-case basis at a med-ical trading area level. It is anticipated that start-upfunding efforts and possible sources for these regionalHIE projects could be facilitated by the statewideorganization to gain efficiency.

Finally, it is recommended that ongoing operationalfunding for the core MTA functions and central coor-dination organization applications be value driven, sothat costs for ongoing operations are primarily borneby the organization(s) receiving benefit from the serv-ice. It follows that projects will be addressed when itmakes economic sense to do so. A principal aim ofthe Arizona Health-e Connection is to create a sus-tainable business model with users paying for theproducts and services that they receive — which pre-sumably will be less than what they pay today. Asservices that support information sharing are intro-duced and grow, so too will the required financialresource commitment and the complementary servicerevenues to offset the increased costs.

Costs presented in this section are estimates for theproducts, organization, and implementation envi-sioned for the Arizona Health-e Connection. They arebased on similar products nationwide, research analy-sis, current level of discovery of the Arizona e-healthlandscape, and expert opinion. As the ArizonaHealth-e Connection is implemented, changes inscope will impact costing analysis.

A. Central CoordinationOrganization

A modest budget is recommended for the centralorganization to coordinate, facilitate, and standardizestatewide efforts. As defined in the recommendedgovernance structure for the Arizona Health-eConnection, the central organization is relativelysmall. It will provide staffing, implementation, andsupport for projects and services that benefit allorganizations, making it difficult to assign value tospecific organizations.

Since activities of the central organization aredesigned to promote the common good, fundingshould be obtained from a central source or sources.Options could include grants and donations, statefunds, in-kind donations of staff, and transaction fees.Items such as a secure network, secure messaging,Web portal, clinician directory, and the patient healthsummary application should be funded centrally.The approximate annual amount of central coordina-tion organization funding required is $3 million to$4 million.

B. Health Information Exchange

The first key HIE service to establish a fundingstream is a medical trading area-wide results deliveryservice, which provides physicians with a single sourceto order clinical services, generate and confirm refer-rals, and receive clinical results. The clinical messag-ing service delivers clinical reports to the treatingproviders electronically, thereby reducing costs for thehealthcare data provider and improving efficiency andutility for the recipient. This service is envisioned toa) be free of charge for the ordering physician and the“copy to” physician, and b) require the organizationreceiving the order and sending the result to pay thebulk of the costs to the MTA utility on a monthlybasis for the service its receives. It is assumed thatwhen the service is completely operational that thecurrent more manual, less reliable results delivery andorder processes would be discontinued and that thecosts associated with them would be reduced or elimi-nated. It is further assumed that service levels wouldnoticeably improve for customers and their patients.


The healthcare data providers send clinical reportselectronically; the clinical messaging software convertsthem into a consistent, easy-to-use report format anddelivers them to the treating provider. The intent isfor new, fee-based services to replace paper-basedreports now delivered to physicians by fax, postalmail, or courier. Phone call requests for status track-ing information are reduced. Costs to send andreceive clinical results are reduced (see Appendix F:Business Case for a discussion of benefits realized atSonora Quest Laboratories as a result of implement-ing an electronic system).

Based on cost figures from other results delivery net-works, Arizona can anticipate development costs ofabout $1.5 million to $3 million per one million peo-ple (population) over the first two years.

The proposed fees generated by the clinical resultsdelivery service are critical to support the ongoingoperations of the MTA and provide expansion ofadditional data-exchange services such as the MTAmaster patient index and data transformation (nor-malization). The cost to maintain each results deliverynetwork and provide these expanded data-exchangeservices is about $2.5 million to $4 million per yearper one million people (population), based on figuresfrom other results delivery networks.

Studies to determine primary beneficiaries of a resultsdelivery service have been initiated. It is believed thatinformation source providers such as labs, hospitalinpatient, outpatient and emergency services records,ambulatory surgery centers, imaging centers, etc.,have been identified as beneficiaries of the service inthe early work of the Clinical and Financial TaskGroups. The extent of the benefits and identificationof other beneficiaries will be thoroughly studied infuture phases of each project.

Service fees may be charged to other organizationslegally authorized to receive results on behalf of thepatient, such as personal health record (PHR) entities,chronic care improvement programs (CCIP), and dis-ease management (DM) organizations in or outsidehealth plans, insurers, employers, and associations.Fees may be generated for these services based on thevalue of providing daily batches of information abouttheir patients to their systems (PHR, CCIP, DM) ona per-patient basis.

The patient health summary is a special case as itrelates to the decision to develop and sponsor theservice to clinicians, care coordinators, emergencyphysicians, and other authorized users. The benefici-aries of this service, if built for the medical tradingarea or the central coordination organization, aremost frequently the patients. It serves patients well inmost cases involving their expressed need (a visit or acall) for medical care. Surveys have shown that inmost cases, patients would like to have the clinician asfully aware of their previous conditions and clinicalfindings as possible. Therefore, the patient or thepatient’s financial sponsor or guarantor should fundthe operation of the patient record summary systemthat provides this service. Thus, the costs of the sys-tem that provides the patient health summary, addsnew patients, and provides for the addition and main-tenance of clinical event reports, orders, prescriptions,and other records, and the record matching andintegrity should be paid by those who benefit.

A financing mechanism for such a system includes awide variety of financing approaches and formulas.An example is one that levies a fee for each person onthe database each month and for the addition of moreclinical data and the underlying service support.Thus, a base fee and an index of the degree of valuefor the additional information for each patient couldbe charged each month to the guarantor or sponsor ofthe person/patient. Past proposals have set base fees ofbetween 5 and 10 cents per month, with the indexraising the fee to 25 to 50 cents per patient permonth at that index level.

The proposed strategy to select appropriate earlyapplications that are easy for healthcare providers touse establishes the foundation for building toward amore comprehensive set of functions, thereby facili-tating and expediting the transition of patients,providers, and payers to the benefits that HIT andHIE offer in improving health and healthcare deliveryin Arizona. HIE projects provide support to HITEMRs (interfaces), and HIT EMRs and ePrescribingprovide support to HIE projects as patient healthsummaries are exchanged.


C. Health Information Technology

As envisioned in the HIE section, all clinical practiceswill receive certain free, basic-level HIE services.Some MTA organizations have offered very lowthreshold entry fees when referrals or secure messag-ing services were offered ($10 to $25 per clinician permonth).

Figure X lists the proposed basic-level services for cli-nicians participating in an MTA.

Additional HIT costs should be borne by the organi-zation that is the primary user of any given HIT sys-tem. In most cases this will be the clinical practice.Some HIE projects will most likely provide basic HITextensions to their service offerings to clinicians andother service providers. These extensions can be foundin MTAs like HealthBridge and Taconic’s MedAlliesand includes services such as practice-wide inbox andmessaging, referrals, ePrescribing, dictation/transcrip-tion, basic charting (forms and templates) or progressnotes, patient health summary, and scheduling. Theseservices in many cases are integrated with the HIEsoftware service or interfaced to make it appear seam-less. The fees for these services are usually charged as amonthly subscription with transaction modifiers.

Many clinical practices will opt to fund their owndeployments of HIT systems. According to the mostrecent Health Services Advisory Group (HSAG) sur-vey, about 14 percent of Arizona physician practicesalready have invested in HIT systems and an addi-tional 25 percent plan to invest in the next 12months. Health and hospital corporations were notsurveyed, although their percentage adoption rate ofHIT is believed to be even higher. Incentives (such astax credits, low-cost financing arrangements, andpotentially others) should be explored to encourageadditional HIT adoption.

An alternative approach for clinical practice will be topurchase, via a subscriber financial model, use of acentral system to handle a subset of electronic medicalrecord (EMR) functions. In effect, this is an “EMR-lite” offered through a Web-based system. Thisapproach, commonly used for various business appli-cations via the Internet, is also known as an applica-tion service provider model (ASP). If this approachwere contemplated, collaboration on interface devel-opment and maintenance contracts should be consid-ered, because there are considerable cost and time sav-ings. This approach would also reduce risks of failurefrom collaboration, interface sharing, or joint devel-opment approaches.

The central coordination organization or the MTAscould develop and offer EMR-lite functions. It is alsobelieved that certain vendors would be interested incompeting for this work, if outsourcing the functionis determined to be appropriate. In addition, it is pos-sible that multiple outsource vendors could developEMR-lite applications and market the service to clini-cal practices on a case-by-case basis. For this to occur,outsourced vendors must be required to adhere strict-ly to Arizona Health-e Connection interoperabilitystandards.

Based on a survey of similar services offered nation-wide, it is believed that EMR-lite functions could beoffered to clinical practices on a tiered cost schedule.Figure XI lists an approximate cost schedule for addi-tional EMR-lite functions.

Figure X: Basic-Level Services

Order/receive lab/radiology resultsResults viewing/printingPhysician portal

$0 per month per physician


D. Cost Summary

The following (Figure XII) summarizes cost estimatesfor the Arizona Health-e Connection as presented inthis Roadmap. Ongoing and startup costs for HIE,HIT, and the central coordination organization arepresented.

Intermediate Level of Services Premium Level of Services

Basic services plus: Basic/intermediate services plus:

ePrescribing (price based on number of formularies Referralsneeded)Messaging/task management Charge capture/right codingDrug-to-drug, drug-to-allergy alerts, etc. Decision support (alerts, best clinical practices,

reminders, facilitate diagnoses)Patient education

$30 to $75 per month $100 to $250 perper clinician month per clinician

Figure XI: Costs per Service Levels per Clinician

Startup Costs Ongoing Costs/Year

$3.0 - 4.0 M (year)

$1.5 - 3.0 M (2 years)per 1 million people

(population)

0

$3.0 - 5.0 M*

$2.5 - 4.0 M per1 million people(population)**

$3000/clinician***

Central CoordinationOrganization

HIE

HIT

*

**

***

= partially self funded (Patient Health Summary)

= self funded (Results Delivery)

assumes EMR-lite premium subscription

Figure XII: Summary of Cost Estimates for Arizona Health-e Connection


VIII. Governance

A. Background

Governance is the process by which an organizationestablishes strategic direction, makes major decisions,and remains accountable to its stakeholders. HIEinvolves cooperation, collaboration, and compliancefrom a large number of diverse participants (e.g., cli-nicians, health service providers such as hospitals andlaboratories, employers and purchasers, health plans,health departments, and even patients themselves).Securing the trust and active engagement of stake-holders while achieving the goals of the ArizonaHealth-e Connection Roadmap requires a representa-tive, effective, and resilient governance process.

There is no single correct organizational structure forhealth information exchange efforts. Various modelsinclude government authorities, membership andnon-membership nonprofit organizations, private for-profit firms, cooperatives, and contractual agreementswith an academic institution, among others.

A 2005 survey conducted by the eHealth Initiativefound that health information exchange efforts arematuring and some communities have developedmultiple corporations to accomplish various parts oftheir missions (e.g., adding a wholly owned subsidiarylimited-liability corporation to a nonprofit corpora-tion). For initiatives that have created a formal legalorganizational structure, 70 percent use a nonprofitcorporation model (Figure XIII).2

The survey also shows a clear shift toward leadershipby a neutral, multi-stakeholder entity, with 55 percentof respondents indicating that their initiatives are ledby a multi-stakeholder organization.

Arizona’s model establishes a clear mission, organiza-tional principles, and governance structures to ensuresustainable adoption. One of the most importantaspects of governance is coalition and trust buildingamong the stakeholders.

Figure XIII: Nature of Health InformationExchange Initiatives

B. Getting StartedDiscussions with key stakeholders, SteeringCommittee members, Governance Task Group mem-bers, and public meeting attendees indicated a strongpreference for health information initiatives to be ledby a neutral, diverse, and trusted governing body.Many other successful initiatives have come to thesame conclusion. Given the fragmented and highlycompetitive nature of our healthcare system, buildingtrust among these diverse entities requires a great dealof process and attention.

Although there is need for statewide leadership andcoordination, much of the work will be done at thelocal and regional levels. Most of the day-to-day bene-fits of information exchange accrue inside individualmedical trading areas. This is where stakeholders havethe greatest need for one another’s information andenjoy the trust enabled by face-to-face interaction.From both business case and governance perspectives,early exchanges and innovation are most likely toemerge at the local and regional levels.

Arizona has a good track record in developing suc-cessful and sustainable public-private collaborations,the structure proposed for Arizona’s Health-eConnection initiative. The involvement of consumersis critical to the success the Roadmap implementation.To ensure buy-in, consumers will be integrated intoexisting and planned committees and task forces.

Non-ProfitCorporation Model

Limited LiabilityCompany Model

For-ProfitCorporation Model

No Legal Entity,Formed byContractual

Arrangement

0%

10%

20%

30%

40%

50%

60%

70%

80%


C. Governance Task GroupRecommendations

The following Governance Task Group recommenda-tions are detailed below:

• Mission statement

• Model governance structure for a statewide e-healthinformation infrastructure

• Roles and responsibilities of a governance structure

Mission Statement

“To facilitate the design and implementation ofintegrated statewide health data information systemsthat support the information needs of consumers, healthplans, policymakers, providers, purchasers, andresearchers and that reduce healthcare costs, improvepatient safety, and improve the quality and efficiencyof healthcare and public health services in Arizona.”

Statewide Governance Model

To accomplish the mission of the Arizona Health-eConnection initiative, a governing body is to beestablished that will:

• Include representatives of critical statewide stake-holder interests (e.g., government entities)

• Include representatives of local medicaltrading areas

• Promote interoperability and national standards

• Ensure security and privacy needs are met

• Allow those who contribute data to have a say inhow data is used

• Be positioned to accept and spend both governmentand private funds

• Promote solutions that reach across geographical,demographic, and organizational boundaries

• Effectively attract and retain participants

• Clearly define roles and responsibilities of thepublic-private collaborative

A statewide governance body is needed to develop auniform approach to all aspects of Roadmap imple-mentation. It is recommended that a statewide non-profit Health-e Connection corporation be created toprovide leadership, negotiate standards, and encour-age collaboration. This organization would strategical-ly collect and distribute funding, align financialincentives, develop statewide technical infrastructurewhen needed, and advocate for needed policychanges.

A private-public, nonprofit organization is recom-mended to serve as a coordinating body, to provideleadership and guidance, and to drive collaboration.The organization could also assume key roles in areassuch as providing funding, aligning financial incen-tives, developing technical infrastructure, and drivingneeded policy changes. It is recognized that no cur-rent organization fulfills these requirements. Theadopted governance model is propelled by local andregional initiatives supported by a statewide process.The model consists of a governance board, boardcommittees, full-time supporting staff, a Council ofInitiatives, and technology advisory groups. The pro-posed structure is depicted in Figure XIV.


Governance Board

A board will be established to be the core entity of thegovernance body. It will maintain and refresh thecoherent vision, strategy, and outcome metrics under-pinning the Roadmap. It will provide advocacy andbuild trust, buy-in, and participation of major stake-holders. In addition, the board will assure equitableand ethical approaches in implementing the Roadmap.It may also raise, receive, manage, and distribute state,federal, and private funds. It will prioritize and fosterinteroperability for statewide and sub-state initiatives.Finally, it will implement statewide projects and facili-tate local and sector projects. The concept of a membership dues-driven, nonprofitorganization was considered but discarded because theHealth-e Connection corporation must represent allinterests, regardless of whether individual organiza-tions see fit to participate at any particular time.Instead, a small but committed board must beempowered to act aggressively on behalf of all stateresidents while balancing the interests of critical stake-holders. Similarly, the concept of a para-state organi-zation (such as a government authority) was consid-ered but discarded, given the need to assure substan-tial investment and ownership by both the public andprivate sectors, and the need for agile decisions andactions to implement a complex, ever-changing task.

It is recommended that the governing board consistof 15 to 20 members.

Statewide Stakeholder Representatives

The governance board will contain representativesfrom critical statewide stakeholder interests including:

• Employers

• Health plans/payers

• Healthcare clinicians

• Arizona state government agencies

• Consumers

• Public health

• Laboratories

• Pharmacies

• Hospitals

In some cases, associations can appoint representationof interests statewide. In other cases, it will be neces-sary for the Governor (e.g., government agencies) orexisting board members (e.g., consumers) to selectindividual board members to represent particularstakeholder groups and to ensure that the board rep-resents a diverse cross section of Arizona residents.

StakeholderInterest, e.g.Prof. Assocs.

StakeholderInterest, e.g.

State Government

Health-e Connection Governance Board

StakeholderInterest, e.g.

Payers

MTA(e.g.Tucson)

MTA(e.g.Phoenix)

MTA(e.g.Rural Area)

ConsumerCommittee

PayerCommittee

ClinicianCommittee

EmployerCommittee

Executive,Staff &

Contractors

TechnicalAdvisory/User

Groups

Council ofInitiatives Other eHealth Initiatives

Figure XIV: Proposed Arizona Governance Structure


The bylaws of the Health-e Connection corporationwill need to detail these selection processes. This willinvolve an additional level of detail and would benegotiated by the Transition Team discussed below.

MTA Representatives

Because the participation of statewide and regional(MTA) exchanges is crucial, each MTA health infor-mation exchange would also be represented on theboard. MTA health information exchanges are distin-guished from other types of e-health projects bybeing:

• A single entity for exchange of clinical informationinside a geographic medical trading area on allpatients, regardless of payer or provider system

• Open to all clinicians and service providers inthe MTA who agree to necessary participationconditions

• Committed to collaborating with the Health-eConnections board and other MTA health informa-tion exchanges on statewide information exchange

• Committed to adopting statewide policies andstandards

• Governed by structure that permits participation bylocal clinicians and service providers

• Able to assume the roles and responsibilities detailedin Figure XV

Board Committees

A modestly sized board cannot include representationfrom all important stakeholder groups and contain allthe technical, clinical, legal, and policy expertiserequired. Board committees will be established tobroaden both input into and expertise on the gover-nance process. Each committee will be chaired by aboard member.

Board committees will permit recruitment and inputby an even broader set of stakeholders, as well as con-tent expertise in areas such as clinical problem-solv-ing, technical architecture, standards, finance, andconfidentiality and security concerns. Four standing

committees will represent clinicians, payers, employ-ers, and consumers. In addition, technicaladvisory/user groups and a Council of Initiatives willaddress specific implementation issues confrontinghealth information exchange initiatives.

Full-Time Staff

The Health-e Connection board should be supportedby a full-time executive and supporting staff.Contractors may also be used to supplement the skillsof the full-time employees. The staff would executestrategic, business, and technical plans. Staff wouldalso coordinate day-to-day tasks and deliverables,including establishing contracts and participationwith local and regional initiatives.

Council of Initiatives

Participants of the many e-health initiatives underdevelopment in Arizona (including those operatingon a scale below the MTA level) could join a Councilof Initiatives to help identify obstacles and commonsolutions for future interoperability of informationsystems. The council would send representatives tothe board to contribute expertise and advice. It wouldalso help select representatives to technicaladvisory/user groups.

Technology Advisory Groups

Technology advisory groups will provide MTAs andother interested parties a forum to explore technicalstandards, policies, and solutions to common prob-lems facing multiple MTAs (e.g., user identity man-agement and secure messaging). From these discus-sions, standards, policies, and solutions will be pro-posed to the governance board. In addition, the advi-sory groups will be a forum to openly share knowl-edge and solutions across projects and the largerHealth-e Connections community.


Roles and Responsibilities of ProposedGovernance Structure

The following (Figure XV) summarizes the responsi-bilities of each entity in the above diagram.

Governance Role Responsibility

• Develop vision, strategy, outcome metrics, and technical and business plans• Build trust, buy-in, and participation of major stakeholders• Assure equitable and ethical approaches• Approve statewide policies, standards, and agreements• Balance interests and referee or resolve disputes• Raise, receive, manage, and distribute state, Federal, and private funds• Foster interoperability for statewide and sub-state initiatives• Implement statewide projects and facilitate local/sector projects• Provide financial and legal accountability, compliance, and risk management• Educate and market• Be credible representatives of their sectors • Offer needed participation in decisions and projects • Offer expertise and advice• Serve as subset of e-health projects working toward exchange, including all

willing participants in a geographic area• Recruit and build trust, buy-in, and participation of project participants;

implement projects• Send credible representatives to the Statewide Board• Select representatives to technical advisory/user groups• Provide financial and legal accountability, compliance, and risk management

for their initiatives• Broaden the number of stakeholder representatives involved • Provide content expertise in specific areas of concern to the board• Serve as standing committees representing clinicians, payers, employers, and

consumers • Execute strategic, business, and technical plans• Coordinate day-to-day tasks and deliverables • Establish contracts and other relationships with local and sector initiatives• Provide industry knowledge • Measure and report meaningful outcomes• Establish participation agreements• Provide fiduciary and compliance accountability• Serve as meeting place for all interested e-health projects, including those

with a more limited scale than MTAs• Offer shared learning and recruitment into projects serving Health-e

Connection goals• Select one or more representatives to Statewide Board to contribute expertise

and advice• Help select representatives to technical advisory/user groups• Serve as forums to explore and propose technical standards, policies, and

solutions to common problems facing multiple MTAs (e.g., user identity management and secure messaging)

• Propose standards, policies, and solutions to Statewide Board• Openly share knowledge and solutions across projects and larger Health-e

Connections community

Governance Board

Statewide Stakeholder Representatives

Medical Trading Area (MTA) Representatives

Board Committees

Executive, Staff, and Contractors

Council of Initiatives

Technical Advisory/User Groups

Figure XV: Roles and Responsibilities of Proposed Governance Structure


IX. Transition Plan

The transition plan explains how the Roadmap willbegin to be implemented during the first 12 months.It lays out the process for establishing the statewidegovernance organization, implementing early stages ofthe HIE infrastructure, and partnering with strategicHIT systems or initiatives. The transition alsorequires activities of the AzHISPC organization deal-ing with privacy, security, and legal questions inimplementing the Roadmap. For more informationabout AzHISPC and its activities, see the section onPrivacy and Security.

The first activity during transition is to finalize thetransition structure, which includes selecting interimleaders, obtaining commitments from the partici-pants, identifying interim funding requirements, andobtaining the funding. Obtaining commitments fromparticipants should take no more than one month.Identifying interim funding requirements and secur-ing the funds must then occur to avoid a vicious cycleof inactivity and discouragement. Transition partici-pants will focus on:

• Establishing the governance corporation, draftstrategic and business plans, and model participa-tion agreements

• Developing a practical strategy for statewide andMTA engagement in the Health-e Connection effort

• Implementing early statewide HIE infrastructure(e.g., the secure portal)

• Identifying and coordinating with current ArizonaHIT initiatives

• Developing a marketing and education plan forRoadmap implementation

Statewide Governance Organization

Critical transition activities are to incorporate anddefine bylaws for the governance body and ensurethat core board members are recruited and appointed.It may also be necessary to position the board tooperate effectively by arranging for interim executivestaff and required contractors.

Once the governance body is established, it will devel-op a detailed strategic and business plan. The businessmodel needs to be flexible enough to evolve to sup-port changes in the healthcare industry (e.g., pay forperformance) and changes in the local community(e.g., local business leadership changes as the initiativegains momentum). It is impossible on day one oreven in year one to say what the sustainable modelwill be. The Health-e Connection approach is to plan,implement, and continuously evaluate and refine themodel.

Another early task for the governance body is todevelop model participation agreements to governhow the individuals or entities granted access to the e-health information exchange may access, use, andrelease the data in the exchange. These agreementswill need to address a host of issues, such as authenti-cation of users, security requirements for participatingsystems to ensure confidentiality of the information,the reasons participating individuals and entities mayaccess data in the exchange, who has the right togrant access to consumers, and who has the right toamend information in the exchange. The agreementsalso will need to address the difficult issue of allocat-ing risk and liability through indemnification andinsurance provisions, and how participants will besanctioned or disciplined for misuse of the system.The development and negotiation of these participa-tion agreements will be time intensive because theymust reflect participant consensus on a wide variety ofissues. Final agreements will be developed as the e-health data exchange projects are refined.

Strategy for Statewide Engagement

It is important to engage various regions and audi-ences in Arizona to implement the Roadmap. One ofthe first activities is establishing an Arizona map ofmedical trading areas (MTAs), including demographicinformation (population, numbers of providers of var-ious types, etc.) and taking account of cross-jurisdic-tional questions (e.g., Mexico, Nevada, California,etc.). The map will also include overlays of demo-graphic information, such as the HHS Indian HealthService, the U.S. Department of Veterans Affairs, andprofessional association membership. The maps willbecome a part of the communication plan and willalso be posted on the state portal. The goals are tohelp everyone recognize the scale of what is happen-


ing, establish the base for a full licensee/providerdirectory over time, and demonstrate progress.

Once the MTAs are identified and described by theoverlay maps, the transition team will identify a viableapproach for engaging MTAs, including a template ofrequirements to establish a formal informationexchange. The transition team will approach groupsthat are currently organized and assist them in estab-lishing a formal data exchange within their MTA.

HIE Initiatives

An important objective of the transition plan is tomaintain the momentum that Governor Napolitanocreated when she asked for the creation of theRoadmap. Part of the strategy is to quickly implementsome of the early HIE initiatives, including the devel-opment of a secure communications infrastructure.The activities for establishing a secure communica-tions infrastructure include:

• Setting up a participation structure (e.g., hospitals,labs, payers, and other organizations that will ben-efit) and developing consensus about overall tech-nical approach

• Identifying potential suppliers for the technicalapproach

• Developing technical designs

• Selecting project approaches for viable technicaldesigns, including cost projections and fundingpossibilities

• Developing a Web portal strategy. Activities associ-ated with creating the strategy include:

- Identifying potential suppliers- Developing a conceptual design- Developing a project approach- Identify portal operation support - Obtaining funding - Implementing the portal

Perhaps one of the more challenging HIE initiativesduring the transition phase is developing an MTAresults delivery strategy. This includes identifyingguidelines for regional governance, oversight

mechanisms, and results reporting. It will also includefunding strategies and a guidebook to establish theservice.

HIT Initiatives

An important strategy to implement the Roadmap isto leverage strategic HIT systems. During theRoadmap development process, some HIT systemswere identified as having potential strategic impor-tance to the Roadmap. There may be additional HITsystems that could be leveraged. Therefore, an earlyHIT strategy is to identify and work with HIT sys-tems that will help move the goals of the Roadmapforward. Activities related to this effort include:

• Conducting an HIT/HIE survey or inventory

• Determining information to publish on the portalfor HIT adoption

• Establishing ongoing liaison with identified HITprojects

• Obtaining funding and staffing as necessary

Marketing and Education Plan

The following marketing and education items are theresponsibility of the transition structure for theArizona Health-e Connection. These responsibilitieswill most likely be absorbed into the permanent gov-ernance structure after it is established.

The responsibilities listed are critical to maintain proj-ect momentum and to generate additional enthusiasmat local and regional levels. In addition, it is critical tomaintain resources to respond to public inquiries andpublic relations opportunities.

Activities to be listed in the marketing plan include:

• Developing standard presentations

• Advocating key implementation components(when needed)

• Establishing and training a speakers bureau

• Establishing media contacts


• Developing a media plan

• Distributing a quarterly newsletter

• Assisting the Governor’s office (as requested) in therelease of the Roadmap

• Reaching out to key stakeholders(especially rural constituencies)

• Maintaining a contact database

• Partnering with existing groups such as Doctor’sOffice Quality–Information Technology (DOQ-IT), Health Information and Management SystemsSociety (HIMSS), and Arizona Health InformationTechnology Accelerator (AHITA) for additionalmarketing coverage

In addition to the marketing plan, an education planneeds to be developed to give specifics for participat-ing in the initiative. Activities related to an educationplan include:

• Organizing workshops for initial projects(such as results delivery)

• Assisting in coordinating grant and funding oppor-tunities with statewide, regional, and localorganizations

• Continuing to develop talent to serve asimplementation leaders

• Supporting and exchanging industry knowledgesuch as lessons learned and best practices

• Assisting statewide, regional, and local organizationsin obtaining assistance from national experts

• Advocating key implementation components(when needed)

• Developing materials to help communities andregions get started

• Expanding education opportunities by partneringwith existing groups such as Doctor’s OfficeQuality–Information Technology (DOQ-IT),Health Information and Management SystemsSociety (HIMSS), and Arizona Health InformationTechnology Accelerator (AHITA) for additionaleducational resources


X. Project Timeline

Figure XVI: Project Timeline

YR1

MTA

MTA

Statewide Web PortalStatewide Patient Health Summary

Secure Infrastructure ComponentsSecure Messaging

Results DeliveryProvider DirectoryMaster Patient Index (MPI)Data Normalization

YR2 YR3 YR4 YR5

Public Health Functions

Transition Plan

Statewide Governance

Model Data Use/Sharing Agreements

Other Functions (e.g., Oral Health, Other Professionals)

Statewide Patient Record Locator(Enhanced) Patient Health SummaryStatewide Personal Health Record

Additional - Results Delivery, Provider Directory, MPIs, & Data Normalization

Privacy Policy & Procedures

Encourage HIT Adoption

Marketing & Education

Baseline DataCollection

Process & OutcomeMeasures

Evaluation Process & Reports

Roadmap implementation involves accomplishing many activities concurrently. In addition, some activitiesdepend heavily on others. The following diagram (Figure XVI) provides a picture of the timing of activitiesin relationship to each other.


XI. ImplementationSummary

The Roadmap contains actionable items that willenable Arizona to reach critical milestones on theroad to fully sharing healthcare information through-out the state. Many specific activities will take place

over the next five years to enable Arizona to exchangehealthcare data statewide. The diagram on the preced-ing page shows a timeline of the most critical activi-ties. The following chart (Figure XVII) highlightsthose same activities by year. Full implementation ofthese activities will enable Arizona to realize the bene-fits of electronic health data exchange and to be rec-ognized as a national leader for its efforts to establisha virtually connected healthcare environment.

Year Milestones/Activities

• Establish Health-e Connection governance body• Develop statewide business plans• Develop model participation agreements• Identify and establish baseline measures of Health-e Connection outcomes• Identify and approach Arizona MTAs • Establish the first MTA information exchange with a results delivery service - Develop a provider directory - Begin a master patient index (MPI) - Begin data transformation• Develop Arizona’s statewide Web portal with security infrastructure

components• Pilot a basic patient health summary• Establish HIT adoption plan• Market and educate the healthcare community about Health-e Connection• Provide guidance to first MTA information exchange for enhanced services• Establish other MTA information exchanges with results delivery services

(including provider directories, master patient indexes, and data transformation)

• Implement secured messaging• Obtain Health-e Connection outcome measurements• Encourage HIT adoption• Establish and provide guidance to MTA information exchanges with results

delivery services (including provider directories, master patient indexes, and data transformation)

• Enhance the patient health summary with data from MTAs• Enhance public health functions• Obtain Health-e Connection outcome measurements• Encourage HIT adoption• Establish and provide guidance to MTA information exchanges with results

delivery services (including provider directories, master patient indexes, and data transformation)

• Enhance the patient health summary with data from MTAs• Implement statewide patient locator • Develop statewide personal health record access • Obtain Health-e Connection outcome measurements• Encourage HIT adoption• Enhance the patient health summary with data from MTAs• Add functions for oral health and other healthcare professions• Obtain Health-e Connection outcome measurements• Encourage HIT adoption

1

2

3

4

5

Figure XVII: Implementation Milestones by Year


XII. Acknowledgements

Creation of the Arizona Health-e Connection Roadmap would not have been possible without the contributionsof the following individuals. Their knowledge, input, assistance, and spirit of dedication and teamwork wereessential to successful completion of Governor Napolitano’s Executive Order. The content presented in thisRoadmap is a direct result of literally thousands of hours of volunteered time.

Steering Committee

Co-Chairs:

Chris Cummiskey Government Information Technology Agency

Beth Schermer University of Arizona College of Medicine

Members:

Joe Anderson Schaller Anderson

Reg Ballantyne Vanguard/Abrazo Health Care

Betsey Bayless Maricopa Health District

Bill Bell Arizona Department Of Administration

Bruce Bethancourt, M.D. Banner Health

Richard Boals Blue Cross Blue Shield

Leslie Bromberg Bromberg Consulting Inc.

Joe Coatsworth Arizona Association of Community Health Centers

Benton Davis United Health Care

Crane Davis Arizona Pharmacy Association

Don Davis Indian Health Service Plans

Jack E. Davis Arizona Public Service

Mark El-Tawil Healthnet

John Fears U.S. Department of Veterans Affairs

Peter Fine Banner Health

Susan Gerard Arizona Department of Health Services

Bernard Glossy Delta Dental

Wyllstyne Hill Raytheon

Roger Hughes St. Luke's Health Initiatives

Linda Hunt St. Joseph's Hospital & Medical Center

Mark James Honeywell Aerospace

Jack B. Jewett TMC HealthCare

David Landrith Arizona Medical Association


Celeste Null Intel

Kathleen Oestreich University Family Care/University Physicians Healthcare Group

Kathleen Pagels Arizona Health Care Association

Sethuramen Panchanathan Arizona State University School of Computer Science

Greg Pivirotto University Medical Center Corporation

Rick Potter Health Services Advisory Group

Patt Rehn, R.N. Arizona Nurses Association

John Rivers Arizona Hospital and Healthcare Association

Anthony D. Rodgers Arizona Health Care Cost Containment System

Phyllis Rowe Arizona Consumers Council

Michael Sherman Salt River Project*

Richard Silverman Salt River Project

Jim Sinek Verde Valley Medical Center

Christina Urias Arizona Department of Insurance

Wendy Vittori Motorola

Michael Warden Banner Health*

Amanda Weaver Arizona Osteopathic Medical Association

Ronald S. Weinstein, M.D. University of Arizona College of Medicine

Gerald Wissink BHHS Legacy Foundation

*Substitute member

Executive Leadership Team

Chris Cummiskey Government Information Technology Agency

Roger Hughes St. Luke's Health Initiatives

Anthony Rodgers Arizona Health Care Cost Containment System

Beth Schermer University of Arizona College of Medicine

Anne Winter Governor Napolitano’s Office


Task Group Leadership Team

Clinical Task Group

Chair: Bruce Bethancount, M.D.

Facilitator: Seth Foldy, M.D.

Staff: Andy Miller/Chris Muir

Technical Task Group

Chair: Eric Dean

Facilitator: Paul Biondich, M.D.

Staff: Chris Muir

Financial Task Group

Chair: Rick Potter

Facilitator: Jay McCutcheon

Staff: Elizabeth McNamee

Legal Task Group

Chair: Kristen Rosati

Facilitator: Bill Braithwaite, M.D.

Staff: Andy Miller

Governance Task Group

Chair: David Landrith

Facilitator: Seth Foldy, M.D.

Staff: Lorie Mayer

eHealth Initiative and Partners

Paul Biondich, M.D.Bill Braithwaite, M.D.Seth Foldy, M.D.Janet MarchibrodaJay McCutcheonKatie SawyerEmily Welebob

Project Management Team

David EngelthalerLorie MayerElizabeth McNameeAndy MillerChris MuirKristen RosatiHarvey ShrednickEmily Welebob

Task Group Membership

Nancy AbellRichard AdamsKen Adler, M.D.Rep. Amanda AguirreDesh AhujaDeniz AkincSheena AlbrightSarah AllenAnna AlonzoJason AttakaiWade BannisterLeila BarrazaMary Jean (MJ) BarrettTim BarrettKevin BassoLaura BazzillScott BeattyLori BedfordMary BenhaseWendy BenzMona BerkowitzIra BerkowitzBruce Bethancourt, M.D.Tom BetlachJack BeveridgeMark Bezjian


Kalyanramon BharathanPaul Biondich, M.D.Rick BlankinshipKen BobisWilliam Bonfield, M.D., M.P.H.Bill Braithwaite, M.D.John BraswellJohn Brimm, M.D.Tom BrinkLeslie BrombergKathy ByrneAndrea CabreraLaura CarpenterMichael CarterBarry Cassidy, M.D.Pete CerchiaraGordon ChagrinRicardo ChavezDavid ClarkSusan CobbBarbara CohenDaniel CohenDarrell ContrerasJoshura CorkVan CosbyJim CramerBradford Croft, D.O.Chris CronbergRobert CrossleySandra DavidsonByron DaviesJack DavisMary Davis DoyleEric DeanDjango DegreeLinda DeileyDeborah DennisMatt DevlinKevin DolanRobert DowdRoger DowneyAndy DraperPaula DunnJudith EffkenMark EmeryScott Endsley, M.D.Dave EngertEdie FaustBill FinkAngela Fischer

Sharon Flanagan-HydeJeff FlickSeth Foldy, M.D.Chris FonnerBrian FosterDon FosterRichard FoxRobin Furlong Rita GangiMargaret GarciaAmy Gelliffe, M.D.Sue GerardDenice GibsonKaty GilbertMichael GleasonMichal GoforthNathan GoldbergDavid Gregg GordonJanet Gordon KennedyLouis GormanMartin Goslar, Ph.D.Kimiko Gosney, M.S.Alan Grobman, M.D.Julie HaleFrancine HardawayPhil HarringtonKim Harris-SalamoneEric HedlundPatricia HenriksonBarbara HessMichelle HindmanJoyce HospodarJim Houtz John HoytAlison HughesBecky HullMinu IpeCarol IversonDoug JaegerBruce JamesonKaren JiggensBill JohnsonDana JohnsonJulie JohnsonMary Beth JoublancJack Keane Michael KeelingKenneth KelleyDavid KempsonLeonard Kirschner, M.D.


Jeremy KlagesGlen KlineerPenny KnochenhauerSharon KocherKen KomatsuMary KoppUday KulkarniConnie LagneauxDavid LandrithWilliam LarkinMary Jo LaufenbergJim LauvesChuck LehnMarc Leib, M.D.Lee LemelsonSteve LieberDenise LinkThomas LitesNicki LovejoyKathy MallochJeannie MarinoLorie MayerJoel McAldruffBrian McAnallenMark McCourtLisa McCoySue McCoy, R.N.Jay McCutcheonMike McHaleTed McKeverElizabeth McNameeTerry McPetersJ. McVeyThomas McWilliams, D.O.Manjula MellacheruvuLinda MeltonLaura MeyerChris MeyersJoe MigliettaSamuel MillerAndy MillerDarrell MillsBevey MinerMark MoehlingSusan MorleyZach MortensenBruce MortensonChris MuirAnita MurckoTina Naugle

John NelsonDebbie NixonSusan NoackRichard NollLaura NorquistCeleste NullMichael O’HaraChristopher OliverJosh PadnickKathleen PagelsNorma PealGregory PendergrassStan PersonBonnie PettersonBill PikeDebi PomeroyRichard PorterRadi Ann Porter, R.N.Tracy PostRick PotterDeborah ProkopMichael PrudenceSally ReelPatt Rehn, R.N.Jay ResioChuck RevenewBart Rippenger, D.P.M.John RiversTony RodgersAnne RomerKristen RosatiDavid RuntMary Rybka, R.H.I.T.Scott SadlerRuss SavageKatie SawyerSandra SchindlerChristopher SedorEnrique SernaPaul ShannonBen ShaoJohn SheldonMichael ShermanHarvey ShrednickJenn SimmonCynthia SmithSteve SmithJulie Smith DavidMarshall Smith, M.D., Ph.D.Jared Smout


Dan SouleSydney StandifirdMike StearnsChristine SteigerwaldSteven SteinbergSylvia StockRandy StonePam StottLinsy StraitJohn SwagartHolly SwensonDave SypossMatt TaylorLiz Temple M.P.A., J.D.Marilyn TeplitzRoy TeramotoKay ThompsonMicheal ToomeyGail UlanPeach UnrastTom Updike, M.D.Iris VillarrealGeoffrey WaltonJim WangTodd WatkinsRita WeatherholtAmanda WeaverJack Weiss, M.D.Emily WelebobKathy WellsBruce Werber, D.P.M.Liddy WestDavid WoodcockJoe YelanichLon YoPing ZhangJudy Zimmet


XIII. Appendices

Appendix A:Governor’s Executive Order


Appendix B:Organization Structure forRoadmap Creation

The organization structure used to create the ArizonaHealth-e Connection Roadmap consists of a SteeringCommittee and supporting task groups. The processis aided by an Executive Leadership Team, TaskGroup Leadership Team, and a Project ManagementTeam. A listing of all Roadmap participants is in theAcknowledgments section of the Roadmap.

The Steering Committee is charged to comprehen-sively review issues surrounding the creation of an e-health infrastructure in Arizona and develop guidancefor the users of such infrastructure. The SteeringCommittee is also charged to explore funding optionsfor creation of the infrastructure. There are 42 mem-bers on the Steering Committee, including two co-chairs.

Representation on the Steering Committee is broadbased and includes membership from the followingorganizations/sectors:

• Major employers

• Health plans

• Physician community

• Hospitals and hospital systems

• Healthcare foundations and organizations involvedin e-health information

• Healthcare associations

• Arizona Health Care Cost Containment System

• Arizona Department of Health Services

• Arizona Department of Administration

• Arizona Department of Insurance

• Arizona universities

• Health information, privacy, and securitycontent experts

Task groups were created to support the SteeringCommittee and to provide specific recommendationsfor Steering Committee consideration.

The five task groups established were:

• Clinical

• Technical

• Financial

• Legal

• Governance *

* The Governance Task Group is a subcommittee ofthe Steering Committee

Participation on the Clinical, Technical, Financial,and Legal task groups was open to all. An inclusiveapproach to task group membership provided a vehi-cle for all interested individuals and organizations tobe represented. This approach proved successful andprovided a rich variety of viewpoints and ideas. About250 people signed up for task group participation.

Each task group was assigned a chairperson and afacilitator. The chairperson is an Arizona leader (andpreferably a member of the Steering Committee). Thefacilitator is a nationally based expert obtained via anengagement with the eHealth Initiative.(www.eHealthInitiative.org).

An Executive Leadership Team provided day-to-dayleadership of the project. The Executive LeadershipTeam, consisting of five members of the SteeringCommittee, provided guidance and support for theproject staff on an as-needed basis. The team providesa channel between the Governor and the SteeringCommittee and is the Steering Committee’s voice tothe community. The team also ensures that theSteering Committee and task groups have appropriateresources.

The Task Group Leadership Team provided a keyvenue to continuously align progress and direction ofeach individual task group with the direction of theoverall project. The Task Group Leadership team con-sisted of the chairperson, facilitator, and staff for eachtask group.

A Project Management Team orchestrated schedul-ing, logistics, and compilation of presentation materi-als for the entire process. The Project ManagementTeam reports to the Executive Leadership Team.


Appendix C:Process to Create the Roadmap

This appendix discusses the process used to createthe Roadmap.

The process was kicked off October 5, 2005, at theGovernor’s Call to Action Summit. About 300 peopleattended the summit. Attendees were encouraged tovolunteer for one or more of the task groups at thesummit. Formation of the Steering Committee wascompleted about a month after the summit. Theprocess to create the Roadmap was discussed at theinitial Steering Committee meeting.

The seven key steps in the process are below.

A more detailed description of each step in theprocess follows.

Step 1. Steering Committee sets goals, objectives,principles, and policy.

The Steering Committee is responsible for establish-ing the direction of the Roadmap. It developed andapproved several documents instrumental in movingthe project forward. The documents include theArizona Health-e Connection Briefing Paper, a Valuesand Guiding Principles document, a MissionStatement, and charges for each of the five taskgroups.

The Arizona Health-e Connection Briefing Paper is astarting point for creation of the Roadmap. It providesa baseline of the e-health landscape from a nationalperspective and an Arizona perspective. Of specialinterest is a section that summarizes responses from agroup of 27 Arizona leaders on the state of e-health inArizona. The paper is available athttp://www.azgita.gov/tech_news/2005/ehealth/Briefing.pdf.

The Steering Committee also provided a MissionStatement and a Values and Guiding Principles docu-ment for the Roadmap. These documents are inFigures XVIII and XIX.

Finally, the Steering Committee provided a TaskGroup Charge for each of the five task groups. TheTask Group Charge document provides specific direc-tion for deliverables from each group. The chargescorrelate to the Governor’s Executive Order and arelisted in Figure XX.

Figure XVIII: Mission Statement

1. Steering Committee sets goals, objectives,principles, and policy.

2. Task groups make recommendations forthe Roadmap.

3. Steering Committee reviews recommendations.

4. Executive Leadership and Project ManagementTeams synthesize recommendations into a ohesive document.

5. Draft Roadmap is presented to the SteeringCommittee for review and approval.

6. Once approved, the Roadmap is presented tothe Governor.

7. Upon the Governor’s direction, the Roadmapis implemented.

“Facilitate the design and implementation of integratedstatewide health data information systems that sup-port the information needs of consumers, healthplans, policymakers, providers, purchasers, andresearchers and that reduce healthcare costs, improvepatient safety, and improve the quality and efficiencyof healthcare and public health services in Arizona.”


Figure XIX: Values and Guiding Principles


Figure XX: Task Group Charges


Figure XX: Task Group Charges (continued)

63


Arizona Health-e Connection Roadmap


Step 2. Task groups make recommendationsfor the Roadmap.

Each task group was responsible for making recom-mendations to the Steering Committee based on itscharge (see Figure XX). To accomplish this task, eachtask group conducted a series of meetings to discussits charge, priorities, and alternatives and to reachgeneral consensus.

By design, the Clinical Task Group was the leadgroup. It was the responsibility of the Clinical TaskGroup to determine priorities for the Roadmap basedon urgency (see the Roadmap section on FundamentalConcept #2: Urgency Balanced by FeasibilityDetermines Timing of Roadmap Inclusion).

It was noted that the Clinical Task Group representedpayers, providers, and patients in their deliberationsof priorities. Although representation of providers inthe task group was prevalent, it is believed the urgentpriorities from the perspective of patients and payerswere effectively represented.

The top priorities identified by the Clinical TaskGroup were:

• Create shared information access betweenprofessionals to

- Support quality systems- Support continuity of care and access- Improve cost efficiency - Improve safety

• Add processes and interfaces for patient informa-tion access and communication (next priority),public health functions (next priority), research,and other functions (later priority)

These priorities were translated into urgent producttypes and presented to the Financial, Technical, andLegal Task Groups for feasibility analysis. The urgentproduct types determined by the Clinical Task Groupare:

Initial Product:

• Historical, assembled view of a patient's high-valueinformation from across all providers (continuity ofcare information)

– Positive impact on all four top clusters (quality,safety, continuity of information, andcost efficiency)

– Patient’s high-value information includesmedications prescribed, medications dispensed,allergies, immunizations, lab results and trends,other providers caring for patient (and contactinfo), cumulative medical problem list (frombilling and/or EMRs), insurance/eligibility andbasic demographic information of patient, andhospital and emergency department dischargeinformation.

Other Products of Interest:

• ePrescribe

• Secure communication between users(providers initially)

• Decision support

In considering feasibility, it was the responsibility ofthe Technical, Legal, and Financial Task Groups todetermine, “What needs to happen to implement theClinical Task Group product-type priorities?” In con-sidering this question, the task groups needed to bal-ance factors such as:

• Were any prerequisite technical activities/projects required?

• Importance of establishing early wins to maintainproject momentum

• How would startup capital and sustainable fundingbe obtained?

Initiatives such as a results delivery service and theWeb portal were determined critical during this phaseof roadmap construction. These initiatives, for exam-ple, are both prerequisites for establishment of apatient health summary.

Regular meetings of the Task Group Leadership Teamwere conducted to maintain synchronization amongthe task groups. The meetings also served as a forumto vet conclusions and recommendations before theywere forwarded to the Steering Committee.


The Clinical Task Group conducted five meetings,the Legal Task Group conducted two meetings, theTechnical Task Group conducted three meetings, theFinancial Task Group conducted three meetings,and the Governance Task Group conductedfour meetings.

Step 3. Steering Committee reviewsrecommendations.

The Steering Committee approved high-levelrecommendations from the five task groups on March 8, 2006.

Step 4. Executive Leadership and ProjectManagement Teams synthesize recommendationsinto a cohesive document.

The process of creating the Roadmap commencedMarch 8, 2006, upon approval of high-level recom-mendations by the Steering Committee and was com-pleted April 3, 2006.

Step 5. Draft Roadmap is presented to the SteeringCommittee for review and approval.

A draft copy of the Roadmap was delivered to theSteering Committee March 28, 2006.

Step 6. Once approved, the Roadmap is presentedto the Governor.

The Steering Committee approved the Roadmap onApril 4, 2006.

Step 7. Upon Governor’s direction, the Roadmapis implemented.


Appendix D:HIT Support Organizations

Doctors Office Quality-Information TechnologyInitiative (DOQ-IT)

The Doctors Office Quality-Information TechnologyInitiative (DOQ-IT) is a three-year national initiativeof the Centers for Medicare & Medicaid Services(CMS) to promote adoption and effective use ofinformation technologies in small- to medium-sizedprimary care practices. The national aim is to increaseadoption of electronic health records by 5 to 6 per-cent within three years. At the state level, the QualityImprovement Organization (QIO) provides coordina-tion of technical assistance activities of the DOQ-ITinitiative. In Arizona, the Health Services AdvisoryGroup (HSAG) is the state QIO responsible forDOQ-IT. HSAG is partnering with the ArizonaMedical Board, the Arizona Medical Association(ARMA), the Arizona Academy of Family Physicians(AAFP), the Arizona chapter of the American Collegeof Physicians (ACP), and the American Academy ofPediatrics (AAP) to promote EHR adoption. TheArizona DOQ-IT Web site is www.azdoqit.org.

The following recommendations were provided byDOQ-IT for implementing the HIT portion ofthe Roadmap:

• Convene health plans to establish a grant pool thatcould be managed by an HIT foundation

• Convene the banking and lending industry to estab-lish common practices for lending for HIT

• Create state loan guarantees for HIT smallpractice loans

• Co-sponsor EHR University. Include the Universityof Arizona College of Medicine and the ArizonaState University Bioinformatics Institute

• Organize statewide purchasing cooperative forsmall- to medium-sized practices

• Sponsor a speakers’ bureau

• Sponsor town halls to introduce Roadmap andpromote HIT adoption

Healthcare Information and Management SystemsSociety (HIMSS)

HIMSS is the healthcare industry's membershiporganization exclusively focused on providing leader-ship for the optimal use of healthcare informationtechnology and management systems for the better-ment of human health.

HIMSS supports HIT adoption and standards with awide variety of educational events, conferences,Webinars, advocacy, and standards. Here is a listing:

CCHIT

HIMSS, AHIMA (American Health InformationManagement Association), and The Alliance (former-ly National Alliance for Health InformationTechnology) have joined forces to launch theCertification Commission for Healthcare InformationTechnology (CCHIT). These three associations havecommitted funding and staff to support the commis-sion during its organizational phase. CCHIT’s mis-sion is to accelerate the adoption of robust, interoper-able HIT throughout the U.S. healthcare system bycreating an efficient, credible, sustainable mechanismfor the certification of HIT products.

Advocacy

As a partner of the Capitol Hill Telehealth andHealthcare Informatics Series, HIMSS convenes regu-lar luncheon programs on Capitol Hill. Held onbehalf of the Capitol Hill Steering Committee onTelehealth and Healthcare Informatics, it is designedto inform federally elected officials and their stafferson topics pertinent to HIT.

Standards

HIMSS has been assigned the role as secretariat toISO TC/215, the technical committee of theInternational Organization for Standardization (ISO)for healthcare informatics, and other activities.

Physicians Adopting Computer Technology (PACT)

These are a series of conferences addressing thechallenges and successes of EMR implementationheld around the country for the independentphysician practice.


Integrating the Healthcare Enterprise (IHE)

Integrating the Healthcare Enterprise (IHE) is a mul-tiyear initiative that creates the framework for passingvital health information seamlessly—from applicationto application, system to system, and setting to set-ting—across the entire healthcare enterprise.

RHIO Federation

To begin supporting the development of regionalhealth information organizations (RHIOs) and healthinformation exchanges (HIE), HIMSS has launchedthe RHIO Federation to focus on three key areas ofcollaboration: chain of trust, business rules, and har-monization.

The HIMSS RHIO Federation’s goal is to help fosterthe RHIO/HIE industry through education, out-reach, and advocacy activities at the local, state, andfederal levels. All Federation activities will be support-ed by 43 regional chapters through the RHIOFederation Chapter Liaison program. Federationliaisons and HIMSS’ staff and membership of subjectmatter experts will be made available to RHIO/HIEinitiatives nationwide to help them plan, develop, andmaintain their business plans by connecting them tothe right resources at the right time.

Arizona Health IT Accelerator (AHITA)

AHITA is a nonprofit organization that bringstogether technologists and physicians dedicated tohelping other physicians select, implement, andfinance EHRs. AHITA helps physicians by:

• Understanding the business of practicing medicine

• Understanding the technology

• Knowing how to facilitate beneficial change

• Being vendor neutral

A major part of AHITA’s work is education. Workingwith Arizona DOQ-IT and Arizona medical associa-tions (AAFP, AAP, ACP, Arizona Osteopathic MedicalAssociation, and ARMA), AHITA is helping physi-cians get ready for electronic health records.


Appendix E:Sample HIT Adoption Strategies

The following is a list of potential approaches toencourage HIT adoption for consideration by thestatewide governance organization. The list was devel-oped by the task groups and the Task GroupLeadership Team. There is no implied order or priori-ty of the listed approaches.

PLANNING

• General assistance

• Standards, CCHIT, CDA, HL7, coding

• Arizona guidelines and materials

• Vendor and product ratings with comparisonsand reports

• Pricing information

• Example RFPs and contracts

• Interregional network for information sharing

FINANCING

• ROI studies

• HIT tax credits, including credits for specialpopulations and credits for utilization

• Low-interest loans

• Reimbursement for HIT integration with statewideHIE program

• HIT ASP services

• EMRs and other products as part of the HIE

• Grants from governments, foundations, andother sources

• Hospital HIT foundation

IMPLEMENTATION

• General assistance

• Example implementation plans

• Example network plans

• Example interface specifications

• Work process analysis templates

• Example procedures (e.g., change management)

• Network infrastructure

• Hardware procurement/replacement

• Design assistance

• User groups and chat rooms

• QIO staff support

• Joint ventures of HIT implementations

• HIT “Peace Corps”

EDUCATION AND ADOPTION

• EMR subsidies for medical schools

• Training programs (e.g., through communitycolleges and technical and medical schools)

• HIT education with CME credits

• Readiness assessment templates

• Training manuals

• SuperUser Network


Appendix F:Business Case for ElectronicOrders and Results for Laboratory

Business Case for Electronic Orders and Resultsfor Laboratory

The business case enabling referring physicians toorder laboratory tests and receive their results elec-tronically is a compelling one. Without the electronicorders and results system, the reliance on paper docu-ments caused numerous errors and delays in testing.The paper documents were incomplete and inaccuratebecause of illegible writing. In addition, vague orderswere given, resulting in the wrong tests being per-formed. The ordering physician’s office was impactedbecause this task was handled manually and relied onthe office staff to provide the laboratory with all rele-vant information, including patient demographics,medical history, diagnosis, and medical necessity. Ifthe information was not complete, the office or thepatient had to be contacted directly for the requiredinformation. The manual paper process could causedelays in testing and require rework for the physician.The patient was inconvenienced by the need to com-plete missing data, by being billed incorrectly and, inworst cases, by having to return to the laboratory fora redraw. All data entry in the laboratory to initiatetesting was manual, creating another possible errorpoint, and costly to perform. Results were sent tophysicians via courier, fax, or remote printing.

With the implementation of electronic orders andresults, the laboratory receives accurate data from theordering physician. The system has all requirementsinherent in the system and prompts the staff for alldemographics and testing information. The medicalnecessity logic is in the system, preventing billingerrors and delays. The physician’s office staff has anelectronic record of the ordered tests for follow-upand the patient’s demographics are the same as in theoffice system. The order is received by the laboratorydirectly into its system, which reduces manual dataentry and errors due to inaccurate test requests orspecimen requirements. Once the testing is reported,the results are immediately available electronically forthe physician’s office. There is no need to wait forcourier delivery, faxes, or remote printing.

Overall, the electronic orders and results processreduces cost for both the ordering physicians and thelaboratory because the orders are validated in the sys-tem and screened for errors, reducing rework andphone calls to clients. Quality improvements are seenin the laboratory because the correct tests and speci-men requirements are adhered to; orders are electroni-cally received, reducing data entry errors and improv-ing turnaround time for testing. Results are sentdirectly to the physician’s system electronically and areavailable for immediate review. This also reduces costsfor courier delivery. Patients benefit because theirorders are received correctly with all required data,reducing the number of redraws and requests for cor-rect demographic information. The whole cycle, fromtest ordered to result to billing, is reduced throughthe electronic process.

The following two pages provide a view of the envi-ronment before and after implementation of an auto-mated lab system.


XIV. Glossary

Application Service Provider (ASP)—A businessthat provides computer-based services to customersover a network. The most limited sense of this busi-ness is that of providing access to a particular applica-tion program (such as medical billing) using a stan-dard protocol such as HTTP.

Arizona Department of Health Services (ADHS)—State department involved in a wide array of activitiesdesigned to promote and protect the health ofArizona citizens. Some of the services overseen byADHS are the state’s Mental Health program,Assistance and Licensure offices, community and fam-ily health, epidemiology and disease control, andOffice of Vital Records.

Arizona Health Care Cost Containment System(AHCCCS)—Arizona’s Medicaid program. AHCCCScontracts with health plans and other program con-tractors, paying them a monthly capitation amountprospectively for each enrolled member. The plan orcontractor is then “at risk” to deliver the necessaryservices within that amount. AHCCCS receives feder-al, state, and county funds to operate, including somemoney from Arizona’s tobacco tax.

Arizona Health Information Security and PrivacyCollaboration (AzHISPC)—The Arizona entry forfunding from the national Agency for HealthcareResearch and Quality (U.S. Department of Healthand Human Services) to 1) assess variations in organi-zation-level business policies and state laws that affecthealth information exchange; 2) identify and proposepractical solutions, while preserving the privacy andsecurity requirements in applicable state and federallaws; and 3) develop detailed plans to implementsolutions.

Arizona Health IT Accelerator (AHITA)—A non-profit organization that brings together technologistsand physicians dedicated to helping other physiciansselect, implement, and finance EHRs.

Arizona Health Query (AzHQ)—An integrateddatabase of medical records from public and privatedata partners in Maricopa County. A joint project ofSt. Luke’s Health Initiatives and Arizona State

University, its purpose is to monitor the performanceof the local healthcare system in terms of access, qual-ity, and cost, and to conduct research that improvessystem performance over time.

Arizona Technology Council (ATC)—The largesttechnology association in Arizona, serving all tech sec-tors across the state. A member-driven association,ATC represents the interests of technology companies,their support firms, educational institutions, andstatewide economic development groups that collec-tively form Arizona’s technology community.

Arizona Telecommunications and InformationCouncil (ATIC)—An economic development foun-dation under the Governor's Strategic Partnership ForEconomic Development (GSPED). The ATIC mis-sion is to promote and support the adoption of effec-tive public policies for the state of Arizona and localcommunities that encourage investment and deploy-ment of information technologies and telecommuni-cation services to enable continued educationaladvancement, enhanced quality of life, and economicprosperity for the Arizona community.

Broadband—Refers to an increased ability of a userto view content across the Internet that includes largefiles, such as video, audio, and three-dimensional(3D). A user's broadband capability is typically gov-erned by the last mile issue, the connection betweenthe Internet service provider and the user.

Certification Commission for HealthcareInformation Technology (CCHIT)—The mission ofCCHIT is to accelerate the adoption of robust, inter-operable HIT throughout the U.S. healthcare systemby creating an efficient, credible, sustainable mecha-nism for the certification of HIT products.

Centers for Medicare and MedicaidServices (CMS)—U.S. Department of Health andHuman Services agency that seeks to protect andimprove beneficiary health and satisfaction; fosterappropriate and predictable payments and high-quali-ty care; promote understanding of CMS programsamong beneficiaries, the healthcare community, andthe public; promote the fiscal integrity of CMS pro-grams and be an accountable steward of public funds;foster excellence in the design and administration ofCMS programs; and provide leadership in the broaderhealthcare marketplace to improve health.


Chronic Care Management—Process used to admin-ister care for high-cost beneficiaries to control costs.

Clinical Document Architecture (CDA)—TheCDA, until recently known as the Patient RecordArchitecture (PRA), provides an exchange model forclinical documents (such as discharge summaries andprogress notes) and brings the healthcare industrycloser to the realization of an electronic medicalrecord. The CDA Standard is expected to be pub-lished as an ANSI-approved standard by the end of2006. (See Health Level 7.)

Continuity of Care Record (CCR)—A type ofpatient health summary. CCR is a way to createflexible documents that contain the most relevant andtimely core health information about a patient and tosend them electronically from one caregiver to anoth-er. It contains various sections—such as patientdemographics, insurance information, diagnosis andproblem lists, medications, allergies, and care plan—that represent a snapshot of a patient’s health datathat can be useful, even lifesaving, if available whenthe patient has his or her next clinical encounter.

Disease Management—A system of coordinatedhealthcare interventions and communications forpopulations with conditions in which patient self-careefforts are significant. Disease management supportsthe physician- or practitioner-patient relationship andplan of care, emphasizes prevention of exacerbationsand complications using evidence-based practiceguidelines and patient empowerment strategies, andevaluates clinical, humanistic, and economic out-comes on an ongoing basis with the goal of improv-ing overall health.

Doctor's Office Quality–Information Technology(DOQ-IT)—Promotes the adoption of electronichealth record (EHR) systems and information tech-nology (IT) in small- to medium-sized physicianoffices with a vision of enhancing access to patientinformation, decision support, and reference data, aswell as improving patient-clinician communications.

Electronic Health Record (EHR)—Generic term forall electronic patient care systems. It is a real-timepatient health record with access to evidence-baseddecision support tools that can be used to aid clini-cians in decision-making. The EHR can automate

and streamline a clinician's workflow, ensuring thatall clinical information is communicated. It can alsoprevent delays in response that result in gaps in care.The EHR can also support the collection of data foruses other than clinical care, such as billing, qualitymanagement, outcome reporting, and public healthdisease surveillance and reporting.

Electronic Medical Record (EMR)—Electronicrecord with full interoperability within an enterprise(hospital, clinic, or practice).

ePrescribing—A type of computer technology inwhich physicians use handheld or personal computerdevices to review drug and formulary coverage andtransmit prescriptions to a printer or a local pharma-cy. ePrescribing software can be integrated into exist-ing clinical information systems to allow the physi-cian access to patient-specific information to screenfor drug interactions and allergies.

Government Information TechnologyAgency (GITA)—The agency responsible forstatewide information technology (IT) planning,coordinating, and consulting. The GITA directorserves as the chief information officer for state govern-ment. GITA is responsible for administering thestate's Executive Branch IT resources.

Governor's Council on Innovation andTechnology (GCIT)—Formed by executive order,the council consists of 32 members appointed by theGovernor and serves without compensation at thepleasure of the Governor.

Greater Arizona eLearning Association (GAZEL)—GAZEL initiatives help eLearning companies developnew business opportunities and advanced technolo-gies and services. GAZEL helps enhance businesspractices, develop strategic partnerships, and identifysources of business financing. It also provides oppor-tunities to network with consumers and othereLearning professionals, and to engage in professionaldevelopment opportunities to export client technolo-gies and services nationally and internationally.

Health Information Exchange (HIE)—The mobi-lization of healthcare information electronically acrossorganizations within a region or community. HIEprovides the capability to electronically move clinical


information between disparate healthcare informationsystems while maintaining the meaning of the infor-mation being exchanged. The goal of HIE is to facili-tate access to and retrieval of clinical data to providesafer, more timely, efficient, effective, equitable,patient-centered care.

Health Information Technology (HIT)—The appli-cation of information processing involving both com-puter hardware and software that deals with the stor-age, retrieval, sharing, and use of healthcare informa-tion, data, and knowledge for communication anddecision-making.

Health Services Advisory Group (HSAG)—Founded by a group of medical professionals in 1979,HSAG is one of most experienced quality improve-ment organizations in the nation. The mission of theorganization is to positively affect the quality ofhealthcare by providing information and expertiseto those who deliver and those who receivehealth services.

Healthcare Information and Management SystemsSociety (HIMSS)—The healthcare industry's mem-bership organization exclusively focused on providingleadership for the optimal use of healthcare informa-tion technology and management systems for the bet-terment of human health.

Health Insurance Portability and AccountabilityAct (HIPAA)—Enacted by the U.S. Congress in1996. According to the Centers for Medicare andMedicaid Services, Title I of HIPAA protects healthinsurance coverage for workers and their familieswhen they change or lose their jobs. Title II ofHIPAA, the Administrative Simplification provisions,requires the establishment of national standards forelectronic healthcare transactions and national identi-fiers for providers, health insurance plans, andemployers.

Health Level Seven (HL7)—One of severalAmerican National Standards Institute (ANSI) -accredited standards developing organizations (SDOs)operating in the healthcare arena. Most SDOs pro-duce standards (sometimes called specifications orprotocols) for a particular healthcare domain such aspharmacy, medical devices, imaging, or insurance(claims processing) transactions. Health Level Seven’sdomain is clinical and administrative data.

ICD-9 (International Classification of Disease,9th Revision)—The 1972 revision of the interna-tional disease classification system developed by theWorld Health Organization (WHO). TheInternational Statistical Classification of Diseases andRelated Health Problems (commonly known by theabbreviation ICD) is a detailed description of knowndiseases and injuries. Published by WHO, it is usedworldwide for morbidity and mortality statistics,reimbursement systems, and automated decision sup-port in medicine. The ICD is a core classification ofthe WHO Family of International Classifications.

Indian Health Service (IHS)—An agency of theU.S. Department of Health and Human Servicesresponsible for providing federal health services toAmerican Indians and Alaska Natives. IHS is theprincipal federal healthcare provider and health advo-cate for Indian people, and its goal is to raise theirhealth status to the highest possible level. IHS pro-vides health services to approximately 1.5 millionAmerican Indians and Alaska Natives who belong tomore than 557 federally recognized tribes in 35 states.

Institute of Medicine (IOM)—A nonprofit organi-zation specifically created for this purpose as well asan honorific membership organization, IOM waschartered in 1970 as a component of the NationalAcademy of Sciences. IOM's mission is to serve asadviser to the nation to improve health. It providesunbiased, evidence-based, and authoritative informa-tion and advice on health and science policy to poli-cymakers, professionals, leaders in every sector of soci-ety, and the public at large.

Master Patient Index (MPI)—A software databaseprogram that collects a patient's various hospital iden-tification numbers, perhaps from the blood lab, radi-ology, admission and so on, and keeps them under asingle, enterprise-wide identification number.

Medical Trading Area (MTA)—An MTAs is usuallya geographic area defined by where a population clus-ter receives its medical services. It is an area in whichgroups of physicians, hospitals, labs, and otherproviders work together to serve a population of con-sumers.

Normalization—The process of redefining clinicaldata based on some predefined rules. The values areredefined based on a specific formula or technique.


Office of the National Coordinator for HealthInformation Technology (ONC)—U.S. Departmentof Health and Human Services office that providesleadership for the development and nationwideimplementation of an interoperable health informa-tion technology infrastructure to improve the qualityand efficiency of healthcare and the ability of con-sumers to manage their care and safety.

Pandemic—An epidemic (outbreak of an infectiousdisease) that spreads worldwide, or at least across alarge region.

Patient Health Summary—Historical, assembledview of a patient's high-value information from acrossall providers (continuity of care information). High-priority items identified in the Roadmap creationprocess include medications prescribed, medications dispensed, allergies, immunizations, labresults and trends, other providers caring for patient(and contact information), cumulative medical prob-lem list (from billing and/or EMRs), insurance/eligi-bility and basic demographic information on patient,and hospital and emergency department dischargecare summary

Patient Record Locator—An electronic health recordlocator that would help patients and their clinicianslocate test results, medical history, and prescriptiondata from a variety of sources. For example, physi-cians could use the locator to find out which otherphysicians have information on patients they are see-ing. A record locator would act as a secure healthinformation search tool.

Personal Health Record (PHR)—An electronicapplication through which individuals can maintainand manage their health information (and that ofothers for whom they are authorized) in a private,secure, and confidential environment.

Pima Community Access Program (PCAP)—Anot-for-profit organization that provides access toprofessional healthcare at discounted prices that theuninsured adult can afford. PCAP links low-income,uninsured residents of Pima County with an afford-able, comprehensive, and coordinated network ofhealthcare providers.

Practice Management System (PMS)—Part of themedical office record. It carries the financial, demo-graphic, and non-medical information about patients.This information frequently includes patient's name,patient's federal identification number, date of birth,telephone numbers, emergency contact person, alter-nate names for the patient, insurance company orentities financially responsible for payment, subscriberinformation for an insurance company, employerinformation, information to verify insurance eligibili-ty, information to qualify for lower fees based on fam-ily size and income, and provider numbers to processmedical claims.

Quality Improvement Organization (QIO)—Medicare QIOs work with consumers, physicians,hospitals, and other caregivers to refine care deliverysystems to make sure patients get the right care at theright time, particularly among underserved popula-tions. The program also safeguards the integrity of theMedicare trust fund by ensuring payment is madeonly for medically necessary services, and investigatesbeneficiary complaints about quality of care. Underthe direction of the Centers for Medicare & MedicaidServices (CMS), the program consists of a nationalnetwork of 53 QIOs responsible for each U.S. state,territory, and the District of Columbia. (See HealthServices Advisory Group.)

Results Delivery Service—Service that delivers clini-cal results from labs to the ordering clinician in theformats they require. Examples of results includeblood tests, immunology, pathology reports, X-ray,CAT scan, mammography, and transcribed reports.The service will deliver those results to the orderingphysicians and to anyone else requiring a copy.

Request for Proposal (RFP)—An invitation for sup-pliers, through a tender process, to bid on a specificproduct or service. An RFP typically involves morethan the price. Other requested information mayinclude basic corporate information and history,financial information (whether the company candeliver without risk of bankruptcy), technical capabil-ity (used on major procurements of services, wherethe item has not previously been made or where therequirement could be met by varying technicalmeans), product information such as stock availabilityand estimated completion period, and customerreferences that can be checked to determine acompany's suitability.


Regional Health Information Organization(RHIO)—Multi-stakeholder organizations expectedto be responsible for motivating and causing integra-tion and information exchange in the nation’srevamped healthcare system. Generally these stake-holders are developing RHIOs to affect the safety,quality, and efficiency of healthcare as well as accessto healthcare as the result of health information tech-nology. (Note: The Roadmap uses the term and defi-nition of medical trading area (MTA) instead ofRHIO).

Secure Integrated Response Electronic Notification(SIREN)—Arizona Department of Health Servicessystem that supports disease surveillance and publichealth response efforts statewide, provides a securegateway to public health systems, has alerting capabil-ities and online collaboration tools, and is based onnational standards for information sharing.

Southern Arizona Tech Council (SATC)—A non-profit organization formed in August 2000 whosemission is to promote and implement high-techindustry economic development and competitivenessin Tucson and Southern Arizona.

SureScripts—Founded in 2001 by the NationalAssociation of Chain Drug Stores (NACDS) and theNational Community Pharmacists Association(NCPA) to improve the quality, safety, and efficiencyof the overall prescribing process. The SureScriptsElectronic Prescribing Network is the largest networkto link electronic communications between pharma-cies and physicians, allowing the electronic exchangeof prescription information.

Veterans Affairs, U.S. Department of (VA)—estab-lished on March 15, 1989, succeeding the VeteransAdministration. It is responsible for providing federalbenefits to veterans and their families. Headed by thesecretary of Veterans Affairs, VA is the second largestof the 15 Cabinet departments and operates nation-wide programs for healthcare, financial assistance, andburial benefits.


XV. Contact Information

For more information on the report contact:

Chris MuirStrategic Projects ManagerGovernment Information Technology [email protected]

Produced by Health2 Resourceswww.health2resources.com

Funded by St. Luke’s Health Initiativesand BHHS Legacy Foundation

With support and assistance by eHealth Initiative

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