citizens health initiative · • incremental steps, not big-bang approach • openness and...
TRANSCRIPT
John K. Evans and Camilla Hull Brown
HIE HIT Work GroupJuly 9, 2008
CITIZENS HEALTH INITIATIVE
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Interview Feedback• Interviewed 8 people so far; comments
reflect 5 of them• Exciting opportunities• Time for action• Should emphasize HIT and HIE equally• Need health system buy-in• Benefit in getting different initiatives to work
together• More focus on the consumer
Vermont Information Technology Leaders, Inc.
Secure sharing of electronic medical records between
doctors, hospitals, and patients
Gregory Farnum, PresidentJuly 9, 2008
Presented to NH Citizens Health Initiative
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What Is VITL?• A non-profit public-private partnership
located in Montpelier, Vt.• Designated in statute to operate the
Vermont Health Information Exchange • It exists to serve multiple stakeholders,
including patients, practitioners, hospitals and other health care facilities, payers, employers, and state agencies.
5
Mission and Vision• Our Mission: To facilitate the implementation of
electronic health records and health information exchange in Vermont.
Our Vision: Our vision is for a healthier Vermont, where shared health information is a critical tool for improving the overall performance of the health care system. The health care community will work together to achieve new efficiencies through the use of information technology in order to deliver better overall value and care to our citizens.
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How VITL Came to Be
• Started as a project within the Vermont Association of Hospitals and Health Systems
• Founded on the principle that improved data leads to better care, controlled costs
• Vermont’s health care reform effort is another driving force
• Spun off as independent entity in July 2005
6
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VITL Funding• Vermont General Assembly
– $3 million appropriated FY06-FY09• Non-State Grants
– $475,000 RTI privacy and security– $470,000 HRSA federal– $500,000 Community Grant Foundation
• Hosting and Data Services– $600,000/yr. Vermont Dept. of Health– $150,000/yr. Medication History Service
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Stakeholder Engagement
• Emphasized benefits of data exchange• All stakeholders given a seat at the table• Consensus approach to decision-making• Hospitals willing to participate because they
have much to gain, little to lose (Vermont has low competitive environment among hospitals)
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9
Governance
• 21-member board representing stakeholder groups– Hospitals, Physicians, Insurers,
Employers/Payers, Consumers, and State agencies
• Now converting “start-up phase” board to smaller, more strategic “implementation phase” board.
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Operating Principles
• Incremental steps, not big-bang approach
• Openness and Transparency• Use of national standards (HITSP, IHE
Profiles)
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Issues Trying to Solve
• Relieve physician data pain points• Bend the cost curve downward• Reduce duplication, drive out waste and
inefficiencies• Increase effectiveness and quality of
care• Lower barriers to EHR adoption
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Vermont’s Strategic Health Information Technology Plan
• Outlines vision, identifies key stakeholders, strategies and objectives
• Puts forth standards for health information exchange in Vermont
• Provides technology architecture overview
• Privacy and security framework
• Public education plan
• Funding, governance, and next steps
13
VITL’s Projects• Statewide Health Information Exchange
Network• Infrastructure for Vermont Dept. of
Health’s Clinical Information System• Electronic health record pilot• Medication history service
Geographic DiversityOf VITL’s Projects
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Health Information Exchange• Links hospitals, physicians, and other
stakeholders • Built to national standards• Core components are ready • Allows practitioners to share data• VITL now adding data sources,
connecting users for Phase I -- lab and radiology results delivery to physician EHRs
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HIE Phases
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Core Components
Basic Legal Agreements
Connectivity w/ sitesInterfaces & Security
Phase I
SecureResultsMessaging & BlueprintSupport Core Components
Basic Legal Agreements
Connectivity w/ sitesInterfaces & Security
Phase II
Advanced Legal Agreements
Specific Privacy Policies
Connectivity w/ sitesInterfaces & Security
Advanced Functionality(EMPI, XDS, Security) Public
Health &Research
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Medication History Project• Initiated to relieve #1 pain point: lack of good
medication history
• Piloted at two hospitals
• More than 20,000 medication lists generated from pharmacy claims data delivered to emergency physicians since April 2007
• Payers providing data through PBMs (including BCBSVT, MVP, VT Medicaid)
• Already tangible quality improvements
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Medication History Pilot Results
• On average, 90% of patients give consent
• Matches produced for 70% of consenting patients, on average
• 10% of medication lists showed medications patient did not mention
• Positive anecdotal feedback from providers: faster treatment; better information to base decisions on
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EHR Pilot Project• Project authorized by Vermont Legislature in Act
70 of 2007 session, funded by $1 million in voluntary contributions from payers
• Independent primary care practices serving low-income populations eligible
• Selected physicians to receive financial and technical assistance – Grants for 75% of cost, up to $45,000 per provider
FTE (18 providers being helped in pilot)
– Physicians to pay no more than 25% of cost 19
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VITL Pre-Screened EHRs
• Allscripts HealthMatics• Allscripts TouchWorks• eClinicalWorks• GE Healthcare Centricity• McKesson Practice Partner• NextGen
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EHR Pilot Project Grantees
• Mt. Anthony Primary Care, Bennington• Bennington Family Practice, Bennington• Mad River Integrative Medicine,
Waitsfield• Brookside Pediatrics & Adolescent
Medicine, Bennington• Northern Tier Center for Health,
Richford
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EHR Pilot Outcomes
• Clinical workflow transformation• Full use of all EHR features
– E-prescribing– Clinical decision support– Clinical messaging– Patient population management
• Data sharing through HIE
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Vermont Health IT FundApproved by the Vermont Legislature
Insurers to pay 0.199% fee on all medical claims
Fee expected to raise $32 million over 7 years
First payments into the fund will be in Oct. 2008
VITL developing plans to expand EHR grant program to assist more independent primary care practices, and to implement next phase of HIE
Information about grant program will be sent to practices as it becomes available.
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New England Telehealth Consortium
• Private broadband network• Funded by $25 million FCC grant• Connecting health care providers in ME,
NH, and VT• 64 sites participating in Vermont
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Working With N.H.
• Vermont and N.H. share an academic medical center, other providers see patients from both states
• Developing similar privacy/security policies would reduce confusion, lower barriers to data exchange
• VITL can provide successful models on medication history, EHR adoption, developing HIE built to national standards
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State Level HIE Consensus Project – May 1, 2008
• Continued expansion and evolution in state-level HIE efforts
• 75% of states have established state-level HIE initiatives/governance entities
• Advanced state-level efforts poised to begin data exchange
• Health care reform, privacy rights and confidentiality protections are drivers
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Independent private/public partnership incorporated (Aug 2005 - Aug 2006)
Independent private/public partnership incorporated (before Aug 2005)
Independent private/public partnership incorporated (after August 2006)
HIE Privacy and Security (HISPC) Initiatives
Last Updated: October 2, 2007
State level HIECurrent trends across statesState-level Census Project:
Current Trends
In New England (National):
1. Early planning: NH (15)
2. Foundational: CT (12)
3. Early Implementation: ME, VT, RI (13)
4. Operating: MA (5)
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Trends and Models across the United States
• Two distinct and key organizational roles at the state level:
• Governance: convening, coordination• Technical operations: owned and/or managed
• State-level HIE governance role is primary:• Ensure HIE develops as a public good• Serves all statewide stakeholders and data needs• Reduces technology investments and other costs
for all participants• Mechanism for coordination of HIE
policies/practices
2929 29
State-level HIE Functions and RolesSLHIE
roleGovernance Technical
Operations
Function Convening Coordination OperatingTasks • Organizational leadership
and structure• Neutral venue for diverse stakeholder collaboration• Support board/business operations for non-profit org
• Information resource for stakeholders and HIE development (Resource Center concept)
•Advocacy for HIE adoption
• Facilitate statewide HIE implementation
•Facilitate alignment with local, interstate, regional, and national strategies
• Promote consistent application of effective statewide HIE policies and practices
• Facilitate collaborative development of public policy options and ongoing health care reform efforts
• Infrastructure -> statewide MPI, RLS• Applications -> clinical messaging, EHR via ASP • Services -> Implementation guides, clinical data standardization, central
3030
Scope of State-wide HIE Efforts
DelawareVermontMaineCalifornia
TechnicalOperations
In-Between
Michigan Connecticut New York
KansasArkansas
Governance: Convene & Coordinate
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Trends and Models across the United States
• State-level HIE governance entity is a public-private partnershipentity:
• Role between state government and the health sector and industry
• Involves state government, but independent of state government
• State governments play important roles:• Designating authority to a state-level HIE governance entity• Providing resources: start-up and ongoing• Leveraging public programs, policy levers to create incentives
for HIE
• Statewide technical approaches can vary and will likely evolve:• Size, market characteristics, resources• Stages of development
32323232
3 Prevailing Organization 3 Prevailing Organization Models:Models:
1. State government leads with involvement of public/private sector
2. State-level HIE is an independent PPP focused exclusively on the Governance Role
3. State-level HIE is an independent PPP focused on Governance and Technical Operations roles
3333
State-level HIE Organizational Frameworks and Functions 1/2008
Governance Technical & Governance
State State Government Led
Independent Public/Private Partnership
Independent Operating
MAMINYCAINMEVTRIFLKYWA
XXX
XXX
XXXXX
X = currently operating X = foundational/early implementer
34343434
State Health Information State Health Information Network Network –– New YorkNew York
(SHIN(SHIN--NY)NY)
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State Health Information Network – NY (SHIN-NY)
• Key Principles:• HIT itself will not result in value: alignment with
clinical practice redesign; support services for clinicians; new models of prevention, quality-based reimbursement and patient engagement strategies
• Clinical, quality and public health priorities must drive HIT adoption and common actions among public and private health care sectors
• Major HIE building blocks – organizational, clinical/quality, technical – must co-evolve and advance together in order to realize value
• Cross-sectional interoperability needed to support policy alignment, value realization for clinicians and sustainable transformation
3636
State Health Information Network – NY (SHIN-NY)
• Organizational Strategy:• Regional Health Information Organizations (RHIOs)• Community Health Information Technology Adoption
Collaborations (CHITAs): community collaboration of ambulatory care clinicians and affiliated providers defined as acare coordination zone with a mission to advance adoption and use of HIT tools, especially EHRs, for clinicians at the point of care
• New York eHealth Collaborative (NYeC): public-private partnership collaborating to: drive consensus on HIT policies and standard implementation approaches; provide technical assistance and provide governance and policy framework
• HITEC: a multi-institutional collaborative among institutions in NY state charged with providing evaluation services for awardees: Cornell, Columbia, Univ of Rochester, SUNY Buffalo and SUNY Albany
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State Health Information Network – NY (SHIN-NY)
• Funding:• 2005: $52 million to 26 grantees• 2008: $106 million to 19 grantees
• 19 projects ranging from $1-10 million each
• Awards for technical infrastructure:• Statewide Health Information for NY: 8• Clinical Informatics Services: 3• Electronic Health Records 8
• Awards for clinical priorities:• Implementing EHRs linked to Medicaid: 12• Public Health: 10• Connecting New Yorkers to their clinicians: 5• Quality Reporting: 4• Clinical Decision Support: 2
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Michigan Health Michigan Health InformaionInformaionNetwork (Network (MiHINMiHIN))
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HIE Priorities in Michigan• Medical Trading Area (MTA) driven• Conduit to Care report• Health Information Security and Privacy Collaborative
(HISPC)• HIT Commission• HIE related grants: FCC Rural Health Pilot; Medicaid
Transformation
• 2007/2008 funding:• $ 6.4 million• Seven initiatives: 5 planning and 2 implementation• $ 1 million to MSU and MPHI for HIE Resource
Center• $ 2.0 million for new planning or implementation
efforts
4040
Michigan’s Regional HIEs
Marquette General (Implementation)
North Central Council of the MHA
Alliance for Health
Central Michigan University
Greater Flint Health Coalition
Capital Area Health Alliance (Implementation)
SE Michigan
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Core of MIHIN Roadmap
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National: The trend of statewide efforts is to closely integrate regional initiatives with the statewide HIE initiative. Large and complex states are not starting with a statewide HIE approach.
Regional HIE Approach: Michigan is the 8th largest state, so one HIE for the entire state will not work or be accepted. Therefore, the regional emphasis is a critical aspect of any Michigan approach.
Statewide HIE Approach: Michigan will be comprised of multiple Regional HIE initiatives that may have different architectures and capabilities. A state-level organization can facilitate exchange of data between the Regional HIEs.
Future State of MI Health Information Network (MiHIN)
43434343
Delaware Health Information Delaware Health Information Network (DHIN)Network (DHIN)
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State of Delaware (DHIN)• Population of Delaware – 875,000• Medical Society of Delaware – 1800 physicians• HIE org effort over 10 year period• Governance
• Statewide HIT infrastructure; multi-stakeholder• More to fill in
• Functionality• Clinical messaging and results delivery• Next stage is inquiry of data across orgs (snap shot)
• First state-wide infrastructure to exchange data
45457/9/2008 HIE 5
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Delaware Health Information Network Milestones
• Funding:• Launch $5M
• 2005 – Delaware Health Care Commission awarded a 5 year Federal Contract from the Agency for Healthcare Research and Quality
• 2006 – Augmented with $2M from the State of Delaware Bond and Capital Improvements Budgets
• 2006 – State funds matched with $2.1M from community based partners. Key Partners
• Christiana Care Health System• Beebe Medical Center• Bayhealth Medical Center• Labcorp• Delaware Physician participants (No utilization fee to physicians)
• October 2006 – Vendor award to Medicity and Perot Systems with implementation in 2007
Agenda #4
NH Report on HIT Status (Patrick) – 25 minHospital Association and UNH Surveys ePrescribing Statistics Telehealth UsageDiscussion Barriers to HIT (Camilla and John)
• Funding• Knowledge Transfer
Hospital Association and UNH Surveys
New Hampshire Hospitals’ Use of
Information Technology
Kathy A. BizarroExecutive Vice President
New Hampshire Hospital Association
49
Survey of Hospital IT Use
Survey conducted in summer of 2005AHA (American Hospital Association) Survey on Hospital Adoption and Procurement of Health Information Technology was used.National results are excerpted from AHA’sfinal report “Forward Momentum: Hospital Use of Information Technology” (2005)
50
Hospital Participation
19 of the 26 acute care community hospitals participated in the New Hampshire survey.More than 900 hospitals participated in the American Hospital Association survey (19%).Representative sample of all hospitals by size and location.
51
IT Areas ReviewedIT AdoptionTypes of IT UsedElectronic Health Records (EHRs)Computerized Physician Order Entry Systems (CPOE)Users of EHRs and CPOELocal/Regional sharing of patient informationCapital and Operating investment in ITBarriers to IT Implementation
52
IT AdoptionNH Hospitals are actively considering, testing
and using IT for Clinical Purposes100% 100%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Yes
Critical Access Hospitals (9) Urban Hospitals (10)
53
IT Adoption
NH Hospitals have adopted IT in Non-Clinical Areas
100%
89% 89%
67%
100%
90%
80% 80%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Patient Accounts Patient Scheduling Pharmacy Supply Mgt Medical-Surgical Supply Mgt
Critical Access Hospitals (9) Urban Hospitals (10)
54
Types of IT-Bar CodingNH Hospitals that have Fully or Partially Implemented
Bar Coding
78%
33%
11%
33%
0%
60%
30% 30% 30%
60%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
a. laboratory specimens b. trackingpharmaceuticals
c. pharmaceuticaladministration
d. supply chainmanagement
e. patient ID
Critical Access Hospitals (9) Urban Hospitals (10)
55
Types of IT-Bar CodingNH Hospitals that are Considering
Bar Coding
11%
56%
78%
44%
89%
30%
50% 50%
60%
30%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
a. laboratory specimens b. trackingpharmaceuticals
c. pharmaceuticaladministration
d. supply chainmanagement
e. patient ID
Critical Access Hospitals (9) Urban Hospitals (10)
56
Other Types of IT
NH Hospitals that have Fully or Partially ImplementedOther Technologies
22%
0%
11%
38%
0%
36%
0%10%
20%30%40%50%
60%70%80%
90%100%
a. Use of Telemedicine b. Use of Radio Frequency ID C. Physician Use of PDA
Critical Access Hospitals (9) Urban Hospitals (10)
57
Other Types of IT
NH Hospitals that are Considering Other Technologies
56%44%
33%
13%
100%
27%
0%10%20%30%40%50%60%70%80%90%
100%
a. Use of Telemedicine b. Use of Radio Frequency ID C. Physician Use of PDA
Critical Access Hospitals (9) Urban Hospitals (10)
58
EHRsNH Hospitals that have Fully or Partially Implemented
Electronic Health Records
33% 33%
0%
67%
80% 80%
50%
90%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
a. Access to current medicalrecords
b. Access to medical history c. Access to patient f lowsheets
d. Access to patientdemographics
Critical Access Hospitals (9) Urban Hospitals (10)
59
EHRsNH Hospitals that have Fully or Partially Implemented
Electronic Health Records
33%
22%
78%
44% 44%50%
60%
100%
80% 80%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
e. Clinical – guidelines &pathw ays
f. Access to PACS g Order entry – Lab h. Order entry – Radiology i. Order entry – Pharmacy
Critical Access Hospitals (9) Urban Hospitals (10)
60
EHRsNH Hospitals that have Fully or Partially Implemented
Electronic Health Records
33%
78%
56%
22% 22%
11%
90% 90% 90%
60%70%
20%
0%10%20%
30%40%50%60%70%
80%90%
100%
j. Results review –Consultant Report
k. Results review –Lab
l. Results review –Radiology Report
m. Results review –Radiology Image
n. Results review –Other
o. Patient supportthrough home-
monitoring, self-testing, and interactive
patient education
Critical Access Hospitals (9) Urban Hospitals (10)
61
Users of EHRsNH Hospitals with 50% or greater staff use of EHR functions
22% 22%
33%
80%
90%
60%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
a. Physicians b. Nurses c. Other clinical staff
Critical Access Hospitals (9) Urban Hospitals (10)
62
CPOENH Hospitals that have Fully or Partially Implemented
Computerized Physician Order Entry functions
11% 11%
33%
11%
40% 40%
50%
30%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
a. Access to current medicalrecords
b. Access to patient flowsheets
c. Access to patientdemographics
d. Real time Drug interactionalerts
Critical Access Hospitals (9) Urban Hospitals (10)
63
CPOENH Hospitals that have Fully or Partially Implemented
Computerized Physician Order Entry Functions
0%
22%
11% 11%
0%
50%
30%
40%
30%
50%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
e. Back end Druginteraction alerts
f. Order entry –Pharmacy
g Order entry – Lab h. Order entry –Radiology
i. Report review – imagereview
Critical Access Hospitals (9) Urban Hospitals (10)
64
CPOENH Hospitals that have Fully or Partially Implemented
Computerized Physician Order Entry Functions
22% 22%
11%
0%
50% 50% 50%
30%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
j. Results review – Consultantreport
k. Results review – Lab k. Results review – Other o. Patient support throughhome-monitoring, self-testing,
and interactive patienteducation
Critical Access Hospitals (9) Urban Hospitals (10)
65
Users of CPOENH Hospitals with 50% or greater staff use of
Computerized Physician Order Entry functions
11% 11% 11%
30% 30% 30%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
a. Physicians b. Nurses c. Other clinical staff
Critical Access Hospitals (9) Urban Hospitals (10)
66
Local/Regional SharingNH Hospitals participate in local/regional arrangements
to share electronic patient specific healthcare information
78%
70%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Critical Access Hospitals (9) Urban Hospitals (10)
67
SharingNH Hospitals participation in local/regional arrangements
to share electronic patient specific healthcare information
33% 33%
0% 0% 0%
60%
30%
0% 0%
20%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Private practice physicianoff ices
Laboratories Free-standing imagingcenters
Retail pharmacies Long-term care facilities
Critical Access Hospitals (9) Urban Hospitals (10)
68
SharingNH Hospitals participation in local/regional arrangements
to share electronic patient specific healthcare information
11%
0%
33%
22%
0% 0%
30%
0%
20%
40%
10%
20%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Public HealthDepartment
School Clinics Other Hospitals Payers Pharmacy BenefitManagers
Other:
Critical Access Hospitals (9) Urban Hospitals (10)
69
Funding Sources for ITNH Hospitals Use Multiple Sources
for Funding of Health Information Technology Systems
89%
100%
11% 11%
22%
80%
100%
20% 20% 20%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Operations Budget Capital Budget Grants Loans Bonds
Critical Access Hospitals (9) Urban Hospitals (10)
70
Capital Investment-last yearPercent of Capital Expenses devoted to Health Information
Technology by NH Hospitals in past year
3%
15%
59%
4%
30%
60%
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
CAH - Low
CAH - Median
CAH - High
Urban - Low
Urban - Median
Urban - High
71
Capital Investment-next 3 yearsPercent of Capital Expenses devoted to Health Information
Technology Investment over the next three years
10%
25%
45%
5%
30%
50%
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
CAH - Low
CAH - Median
CAH - High
Urban - Low
Urban - Median
Urban - High
72
Operating Expenses-last yearPercent of Expenses allocated to Health Information
Technology in the past year by NH Hospitals
0.60%
1.25%
2.00%
1.50%
2.25%
2.90%
0.00% 0.50% 1.00% 1.50% 2.00% 2.50% 3.00% 3.50%
CAH - Low
CAH - Median
CAH - High
Urban - Low
Urban - Median
Urban - High
73
Operating Expenses-next 3 yrsPercent of expenses to be spent on hospital IT operations
0.7%
1.7%
2.0%
1.5%
2.7%
3.1%
0.0% 0.5% 1.0% 1.5% 2.0% 2.5% 3.0% 3.5%
CAH - Low
CAH - Median
CAH - High
Urban - Low
Urban - Median
Urban - High
74
Significant Barriers to Hospital IT Adoption
0%
0%
8%
8%
17%
0%
8%
17%
8%
8%
0%
0%
0%
0%
33%
33%
0%
33%
33%
44%
0% 5% 10% 15% 20% 25% 30% 35% 40% 45% 50%
Other barriers:
Inability to cost-effectivelymaintain HIPAA compliance
Legal barriers to investment anddevelopment
Fear that technology will becomeobsolete too quickly
Acceptance of technology byclinical Staff
Availability of well-trained IT staff
Inability of technologies to meetneeds
Interoperability of hardware andsoftware with current systems
Ability to support ongoing costsof hardware and software
Initial cost of IT investment
Urban Hospitals (10) Critical Access Hospitals (9)
75
Items Considered Somewhat of a Barrier to Hospital IT Adoption
23%
25%
8%
17%
17%
42%
42%
42%
58%
75%
19%
33%
22%
67%
22%
33%
56%
56%
67%
56%
0% 10% 20% 30% 40% 50% 60% 70% 80%
Other barriers:
Inability to cost-effectivelymaintain HIPAA compliance
Legal barriers to investment anddevelopment
Fear that technology will becomeobsolete too quickly
Acceptance of technology byclinical Staff
Availability of well-trained IT staff
Inability of technologies to meetneeds
Interoperability of hardware andsoftware with current systems
Ability to support ongoing costsof hardware and software
Initial cost of IT investment
Urban Hospitals (10) Critical Access Hospitals (9)
76
Key FindingsHospitals in NH are committed to ITWide variation between hospitalsCapital and operating expenditures may prove to be a barrierTraining of clinicians and other staff needs to be reviewedOverall, NH is on par or exceeds national trends for IT adoptionStill more to be done!
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Kathy A. Bizarro, FACHE
Executive Vice President / Federal Relations
New Hampshire Hospital Association
(603) 225-0900
78Stepping Up to the FutureNH CITIZENS HEALTH INITIATIVE
NH Clinical Use of Technology Survey
• Mixed mode (web & mail) survey of physicians and other health care professional in NH
• Questionnaire replicates other surveys conducted in Florida and Vermont
• Worked with Governor’s Office, professional societies, and insurers to contact potential respondents to encourage response
• 600+ completed surveys in 2006
79Stepping Up to the FutureNH CITIZENS HEALTH INITIATIVE
Sample Demographics
• Type of Professional– Primary Care: 23%– Pediatrics: 8%– OB/GYN: 10%– Specialty: 25%– Allied Health Care Professional: 12%– Other: 21%
• 52% male, 47% female• Average age - 49• 13% in solo practice, 72% 2-25 clinicians, 15%
25+
80Stepping Up to the FutureNH CITIZENS HEALTH INITIATIVE
Overall Findings
• Doctors and other health care professionals are technologically sophisticated personally, but have not fully implemented current technology into their practices.– Particularly hesitant to use e-mail with patients
• Electronic Health Records (EHR) are being used by less than half (46%) of doctors and other patient care givers– Biggest barrier to increased use is cost.
81Stepping Up to the FutureNH CITIZENS HEALTH INITIATIVE
Overall Findings
– Biggest barrier to increased use and adoption is cost
– Of providers who use an EMR, 45% have used them for 3 years or less.
82Stepping Up to the FutureNH CITIZENS HEALTH INITIATIVE
Use of Computers / Technology
98% 97%92%
99% 97%
55%46%
16%
0%
20%
40%
60%
80%
100%
Have accessto computer
at office
Internetaccess at
office
Other staffuse
computers
Computersused in scope
of practice
Have accessto computerwhen needed
Have website forpatients
Use EMR Use Registryor Disease
ManagementSoftware
83Stepping Up to the FutureNH CITIZENS HEALTH INITIATIVE
Functions of Technology
77%
64%57%
39%30%
0%
20%
40%
60%
80%
100%
Billing ChargeCapture
Drug Interactions Claims Submission e-Prescribing Electronic OrderEntry
84Stepping Up to the FutureNH CITIZENS HEALTH INITIATIVE
How Sophisticated a Computer User Are You?
14%
37%34%
13%
2%
-10%
10%
30%
50%
VerySophisticated
Sophisticated Neutral Unsophisticated VeryUnsophisticated
85Stepping Up to the FutureNH CITIZENS HEALTH INITIATIVE
Satisfaction with Office Computerization
36%39%
11% 11%
3%
-10%
10%
30%
50%
Very Satisfied SomewhatSatisfied
Neutral SomewhatDissatisfied
VeryDissatisfied
86Stepping Up to the FutureNH CITIZENS HEALTH INITIATIVE
Use e-mail to communicate with patients?
Yes; 30%
No; 70%
87Stepping Up to the FutureNH CITIZENS HEALTH INITIATIVE
Should Patients have Access to Own Electronic Medical Records?
Yes, Definitely; 16%
Yes, Probably; 42%
No; 42%
88Stepping Up to the FutureNH CITIZENS HEALTH INITIATIVE
New Hampshire Connects for HealthStatewide Assessment Project
• Conducted 34 key informant interviews with New Hampshire health care stakeholders in April and May of 2006
• Interviewed stakeholders from state government, hospitals, physician groups, community health centers, mental health, home health, public health, health plans, employers, and academic medical centers
• UNH/eHI documented assessment and incorporated into the briefing paper with feedback from the steering committee
89Stepping Up to the FutureNH CITIZENS HEALTH INITIATIVE
Assessment Project: “What We Heard”
• Project Goals and Approach– Lack of understanding of health information exchange
(HIE) among participants
– Reported HIE to be a collaborative effort based on comprehensive, standards-driven data to reduce error, enhance safety, and promote quality
Implication: Need for further dialogue and discussion between stakeholder groups in order to gain a greater understanding and knowledge of HIE and its implications, values and benefits.
90Stepping Up to the FutureNH CITIZENS HEALTH INITIATIVE
“What We Heard”• Leadership and Vision
– HIT viewed as important vehicle towards solution of health care issues such as patient safety, quality of care, access and cost
– Participants strongly stated the need for a statewide infrastructure, one that would allow interconnectivity with a national health information exchange
91Stepping Up to the FutureNH CITIZENS HEALTH INITIATIVE
– Public/Private Collaboration with multi-stakeholder representation to provide oversight and guidance
• Citizen’s Health Initiative (CHI) viewed as leadership body for spearheading discussions and facilitating development of strategic plan in the near term
“What We Heard”
Implication: Development of statewide vision and infrastructure design necessary to provide guidance, continuity and consistency towards achieving the maximum level of interconnectivity across the state.
92Stepping Up to the FutureNH CITIZENS HEALTH INITIATIVE
“What We Heard”• Barriers to Adoption and Implementation of
Health Information Technology and Health Information Exchange1. Interoperability
> Lack of common standards and terminology allowing the communication and exchange of information between various stakeholders and systems> Difference in software utilization
“A number of organizations have already committed to certain technology for some time, true HIT infrastructure refers to adherence to standards what are they going to be? What will be the safeguards?”
93Stepping Up to the FutureNH CITIZENS HEALTH INITIATIVE
2. Access to the Internet> Lack of availability and limited access to
broadband in Northern NH
“Level of technology by community is widely different.”
“Regional collaboration will be critical.”
“What We Heard”
94Stepping Up to the FutureNH CITIZENS HEALTH INITIATIVE
3. Financing> Leaders cited capital investment, staff training,
and cost of program maintenance and patient awareness as areas of concern
“Money is not the be all or end all.”
“What We Heard”
95Stepping Up to the FutureNH CITIZENS HEALTH INITIATIVE
4. Privacy and Security> Variation in interpretation of HIPAA specifically in
regards to what information can be shared> Exchange of data between various providers and
facilities of concern
“Why should providers spend money on this when nobody has answered the privacy concerns?”
“What We Heard”
Implications: Common standards and terminology are essential forcommunication and exchange of information between various stakeholders and systems. Sustainability and viability of health information exchange analysis is needed. Work from RTI subcontract will have major impact on privacy and security concerns.
96Stepping Up to the FutureNH CITIZENS HEALTH INITIATIVE
Conclusions (cont)
• Barriers can be resolved, but have to be mindful of and leverage existing regional initiatives and HIT implementations – do not want to “recreate the wheel”
• Regional collaboration will be critical to a statewide process.
• There is variability of technology across NH –we need to dig deeper in access issues and available technologies.
ePrescribing Statistics
Core Components
ePrescribing has three core quality improvement and efficiency components:
• Medication history. This information may come from a variety of sources, including electronic medical records, pharmacy claims data, or from prescriber-to-pharmacy transactions.
• Drug-to-drug interaction and allergy alerts. These provide decision support rules at the point of prescribing and combine this information with health insurance formularies and pharmacy benefit plans to assist the prescriber in their drug selection.
• Bi-directional pharmacy communication. This allows the prescribing practitioner to electronically write the prescription and transmit it to the pharmacy. Additionally, the pharmacy may request refills electronically without needing to fax or call the prescriber.
NH’s Progress to Date
~50% of clinicians have an EMR with some level of electronic prescribing; “eRx Lite”; the base is largely in place
79% of our pharmacies are ready to accept fully electronic prescriptions (June 23, 2008 – 179 chain & 47 independent)
Significant payer connectivity to RxHub or SureScripts
Solutions Being Led By Payers – Providers –Employers
Payer Connectivity is at 70+% of NH Residents
RxHubAnthem
SureScriptsNH MedicaidRxhub (majority)National Part D PlansNoneHarvard Pilgrim
RxHubCigna
RxHub Ranking 2007
Source: SureScripts
5957264VT
722729489388RI
1261273123NH
2232224214ME
4505441426571635MA
67762516359CT
Active PrescribersActive PrescribersActive PrescribersActive Prescribers
January 2008200720062005
Prescribers Active on the SureScripts Pharmacy Health Information Exchange, January 2005-January 2008
1MAShare1LightHouse2PracticePartner2NewCropRX3Medinotes4RxNT4EHS4DrFirst5SOAPWare5iScribe6ZixCorp6McKessonPrescriber7NetSmart8eClinicalWorks
13eMD22Emdeon42A4 Allscripts48Allscripts
Count of PrescribersSolution Provider
•183 Prescribers on SureScriptsNetwork as of May 2008
• 57 added since January 2008(46% increase)
1Wolfeboro3Somersworth
1Plaistow3New London
1Pembroke3Amherst
1Northwood4Suncook
1Newington4Colebrook
1Milford5Laconia
1Methuen, MA (Salem practice)5Exeter
1Hampton Falls5Derry
1Enfield6Merrimack
1East Hampstead6Keene
1Chesterfield6Dover
1Center Tuftonboro5Concord
2Wolfeboro7Manchester
2Peterborough7Claremont
2North Hampton10Salem
2Newport13Plymouth
2Littleton14Bedford
2Lebanon15Portsmouth
2Hopkinton16Nashua
2Hampstead18Londonderry
Count of ePrescribersTownCount of ePrescribersTown
Telehealth Usage
Funded by the Endowment for Health and the NH Funded by the Endowment for Health and the NH Charitable FoundationCharitable Foundation
Lou Kazal MD, Director NHTPLou Kazal MD, Director [email protected]@dartmouth.edu
David Price, CoDavid Price, Co--Director NHTPDirector [email protected]@verizon.net
603 444 1626 (Office)603 444 1626 (Office)
107107
"Imagine a world where no matter who you "Imagine a world where no matter who you are or where you are, you can get the are or where you are, you can get the health care you need when you need it."health care you need when you need it."
-- Office of Advancement of Telehealth (HRSA) Office of Advancement of Telehealth (HRSA) websitewebsite
108108
NHCFNH Network of Child Advocacy Centers
Child Abuse Medical Assesments(Telecam)
Labor / HHS9 Non Profit sites
NH Community Health Centers
Labor/HHSManchester 25 Sites
Elliot Hospital/VNARemote Monitoring
$268000 USDA Rural Development Rural Utilities
New London HospitalSoftware Integration to implement a telemedicine program .
Dept of Health and Human Services Rural Health Outreach
RegionalThe Caring Community Network of the Twin Rivers
Chronic disease, telehealth
Hanover, NHNew Hampshire Area Health Education Center Program -Darmouth College
Continuing Education, Professional Devel.
$327,100. USDA Rural Development
Keene NHVNA at HCS Inc.Real Time Home Monitoring
Health Services Resources Administration (HRSA)
10 CountiesNorthern New Hampshire AHEC
Distance Learning, telemedicine
Dept of Health and Human Services Rural Health Outreach
Rural Swestern NH
Home Healthcare, Hospice and Community Services Inc.
Telehealth technology for chronic disease management
Dept of Health and Human Services Rural Health Outreach
5Northern Human Services 87 Washington St.Conway,NH
The Northern Tele-psychiatry Initiative
Funding SourceSitesEntityProgram
109109
$236,898 USDA Rural Dev.
Belknap, Carroll, Coos, Grafton, Merrimack, Rockingham and Sullivan Counties
Dartmouth CollegeContinuing Education and Professional Dev.
$499,996. RUS.Rockingham County
Timberlane Regional School District; Plaistow, NH
Timberlane Regional School District will utilize RUS grant funds to implement adistance learning and telemedicine project
$499,965. USDA Rural devel.
Hillsborough, Sullivan, & Strafford Counties
Southeastern Regional Education Service Center, Inc
Installation of video conference system for raining purposes
$499,330. USDA Rural Development
Carroll, Stafford, Rockingham Counties in New Hampshire; Orleans County in Vermont
Exeter Region Cooperative School District
IP-based video equipment
$10000. Grant from Northway Bank
Franklin Regional Hospital (Genesis Behavioral Health )
Twenty-four-hour emergency psychiatric care
Rural Development fundsCoos, GraftonWeeks Medical CenterObstetrical telemedicine
U.S. Department of Agriculture CogswellBenevolent Trust Agnes Lindsey Foundation
Weeks Medical CenterFetal Monitoring (CALM System)
Funding SourceSitesEntityProgram
Agenda #5
NH Data on HIE (Patrick) – 20 minNorth Country Survey ResultsCare Migrating Out of StateCare Migrating Within State
North Country Survey Result HighlightsFebruary 2008
112
Provider Interviews
n/a1 (NHS)Behavioral Healthn/a1 (DHMC)Tertiary Hospitals
2 (NCHHHA - Littleton, PBHHH - Plymouth)
0Home Health Agencies
1 (TMH - Conway)6 (AVH, CH, LRH, SMH,UCVH, WMH)
CAHs
1 (GCNH - W. Stewartstown)
2 (GCNH, CCNH)County Nursing Homes
1 (WMCHS - Conway)4 (ACHS, CCFHS, ISHC, MSHC)
FQHCs/RHCs
PendingCompleteType
113
Summary – Interviews Not exactly sure what defines the N. Country (ie, Plymouth, Concord, Manchester, Lebanon, Maine Medical have roles too)
Significant amount of health information exchange taking place today (ie, point-to-point and view access as primary mediums)
Recognition that longitudinal health record is the end pointDesire to be more efficientDesire to improve clinical qualityDesire to move beyond point-to-point and view access exchange
114
Summary - View Access
Significant number of organizations providing views access into other systems
DHMC CISCAHs and FQHCs for EMR, PACS, IP Clinical
Typically “one-way”High cost of licensesPrivacy and securityMultiple applications for providers to learn
115
Summary – EMR/EHREMR/EHRs are installed in at least:
100% of the FQHCs1 Nursing Home5 Critical Access Hospitals1 Tertiary Hospital2 Home Health Agencies
116
Summary – IP Clinical Apps.Availability of Clinical Applications across CAHs varies, but includes:
PACSLabSchedulingIP ClinicaleRx
117
LaboratoryRadiologyProblem lists, meds and allergies
Admission, discharge, or transferDemographicQuality improvement
N. Country Exchange Priorities
UniversallyTop 3
UniversallyBottom 3
118
Summary - Technical Architecture
Federated or hybrid model most desiredWill need to be developed further
119
Summary - GovernanceMany options floated:
N. Country goes it alone either as a full region or a sub-regionN. Country partners with DHMCDHMC becomes the exchangeDHHS becomes the exchangeIndependent entity developedPartnership with ME, VT, MAOther……….
120
Summary - GovernanceUniversal support for an impartial, 3rd party as the governor of the exchangePartnering with other exchanges was considered favorablyQuestions about DHHS as exchangeConcern over DHMC given market shareConnectivity to statewide effort importantGovernance is linked to sustainability
121
Summary - Financing
IT spending ranked extremely high as overall organization prioritiesThe HIE needs to show some level of ROI, but non-tangible benefits are also understoodDesire for grants or state seed fundingBusiness model for sustainability needs clarityPartnering with other states may make sound fiscal senseMuch benefit accrues to payer; how to involve them
Care Migrating Out of State
123
Commercial Claims Medical Care Expenditures for NH Residents by State All Types
of Service w/ Pharmacy REMOVED CY 2006
NH, 83%
VT, 1%MA, 10%ME, 1%
Other, 4%
124
Commercial Claims Medical Care Expenditures for NH Residents by State
Inpatient Type of Service w/ Pharmacy Removed CY 2006
NH, 73%
VT, 1%MA, 20%
ME, 2%
Other, 4%
125
Commercial Claims Medical Care Expenditures for NH Residents by State
Outpatient Type of Service w/ Pharmacy Removed CY 2006
NH, 89%
VT, 1%MA, 8%ME, 1%
Other, 1%
126
Commercial Claims Medical Care Expenditures for NH Residents by State
Professional Type of Service w/ Pharmacy Removed CY 2006
NH, 86%
VT, 1%MA, 7%ME, 1%
Other, 5%
Care Migrating In State
Methodology
2006 commercial insurance claims representing 525,000 covered lives; all commercial lines of business; no Medicaid or Medicare
Medical claims (inpatient and outpatient); no pharmacy claimsHealth Analysis Areas were developed by NH DHHS; 22 total
areasLimitations:
Not all southern NH residents in datasetProvider billing zip code used as location for provider provision of servicesNot broken out by type of service
22 Health Analysis Areas
Source: NH DHHS
847127283 80354 4982253 31139070Rochester
75363119,8847,1684745541161Portsmouth
12,1931662,374862681737,21375020Plymouth
3613,7825206942425,0419275Peterborough
1,913611217461845473247282North Conway
2274,383982,6851,86711,1774,120277516Nashua
1,0945,2643538,7321,82635,61341,8362120461Manchester
15437291430267012713299Littleton
1,1201,536765841152369,444718,6179Lebanon
202929141230645641,205Lancaster
109,1184156,7173571,15947323,208193132Laconia
84126,09576761361771,46651,3304Keene
14,44216118,69612721533618,95716728Franklin
16635017143,50213,40911,2892,883233411Exeter
5171602615,999109,0853741,7331059Dover
159479749,41651698,0492,81421195Derry
8,1922,9753,5282,8633,9253,792379,456671,23455Concord
272371650242644,9690587Colebrook
361,7114561112549528,6970Claremont
164577347149550511227,627Berlin
LaconiaKeeneFranklinExeterDoverDerryConcordColebrookClaremontBerlin
Patient Health Analysis Areaof Residence
Health Analysis Area of Service Encounter Location:
37%18,7866,925Woodsville
41%85,40834,962Wolfeboro
32%164,43652,424Rochester
53%134,96472,020Portsmouth
50%95,26847,621Plymouth
50%110,08955,581Peterborough
68%65,52544,825North Conway
70%588,062409,106Nashua
66%716,863471,444Manchester
63%45,29728,549Littleton
68%259,940176,599Lebanon
52%22,66011,673Lancaster
60%182,116109,118Laconia
71%177,539126,095Keene
29%64,90318,696Franklin
44%323,830143,502Exeter
46%235,453109,085Dover
43%230,56598,049Derry
69%549,777379,456Concord
48%10,2784,969Colebrook
51%56,07328,697Claremont
70%39,28727,627Berlin
% Care Within Resident HAA
Total Encounters Resident HAA
Encounters Within Resident HAA
Member Health Analysis Areaof Residence
Encounters by Health Analysis Area (HAA) For Residents of Four HAAsCY2006 Data With Pharmacy Removed
0
50,000
100,000
150,000
200,000
250,000
300,000
350,000
400,000
Berli
n
Cla
rem
ont
Col
ebro
ok
Con
cord
Der
ry
Dov
er
Exet
er
Fran
klin
Kee
ne
Laco
nia
Lanc
aste
r
Leba
non
Littl
eton
Man
ches
ter
Nas
hua
Nor
th C
onw
ay
Pet
erbo
roug
h
Plym
outh
Por
tsm
outh
Roc
hest
er
Wol
febo
ro
Woo
dsvi
lle
Oth
er N
H Z
ip
Pro
vide
r in
MA
Prov
ider
in M
aine
Pro
vide
r in
VT
Prov
ider
in O
ther
Sta
te
HAA Where Care Received
# of
Enc
ount
ers
Exeter HAAConcord HAAPlymouth HAALebanon HAA
379K(69%)
22K(4%)
51K(9%)
16K(3%)
33K(6%)
133133
NHCHI Discussion on Operational Mission & Vision
For a State-level HIT HIE Initiative
Topic Areas:• The underlying problem• The emergence of network neighborhoods• Operational Mission
134134
The Underlying Problem• Lack of coordinated care exists despite the best
intensions of care providers• Mrs. Jones is 83 and in a county nursing home where she falls
and breaks a hip.• She is transferred to a local acute care hospital for surgery that
uses a paper chart.• She is then transferred to a regional rehabilitation facility in a
different health system that doesn’t communicate electronically outside of its system.
• She is then transferred back to the county nursing home• When she returns to the nursing home, the clinicians have an
incomplete medical record of her treatment including medications and lab and radiology results.
• Coordinated care would dramatically improve if electronic data were exchanged across systems.
135135
6/28/2008 Event Name 2
Network Neighbors in a Health Information Exchange
136136
Emergence of Network Neighbors
• More network neighborhoods than in the past due to rise of:• Integrated health systems• Physician networks• Clinic networks• Many other provider exchanges
• More network neighbors able to participate as a result of investments in HIT
• Goal• Allow network neighborhoods to thrive; they drive innovation• Enable data to be exchanged across network neighborhoods to
follow patient flow• Make sure all physicians can participate in HIT HIE regardless of
economic resources, not just those in network neighborhoods
137137
How to Listen
• How does this entity distinguish itself from other HIT HIE initiatives?
• In what way does this entity contribute to the growth of other HIT HIE initiatives?
• What are examples of this?• Where is there role confusion with other
entities?
138138
Operational MissionState-level HIT HIE Initiative
• Key healthcare stakeholders in New Hampshire are using the HIT HIE Strategic Planning Process to serve as a primary resource to achieve coordinated care using electronic tools (HIT) and health information exchange (HIE) to significantly improve the quality and value of care for citizens living in New Hampshire and for patients who receive care in New Hampshire
139139
We Do This by:1. Establishing an HIT strategy that ensures that
all providers have access to electronic toolsirrespective of income and geographic location.
2. Establishing an HIE infrastructure that enables providers serving patients to use electronic tool to exchange data across organizations.
3. Serving as a state-level convener and coordinator.
140140
1. Establishing an HIT Strategy…
• Encouraging physician adoption of electronic tools (e.g. EMR, eRX, registries)
• Establishing base level low cost e-tools• Working in collaboration with other HIT
initiatives (e.g. telemedicine)• Identifying and obtaining funding• Facilitating alignment of other major
investments that impact HIT and HIE (e.g. FCC)
141141
2. Establishing an HIE Infrastructure…
• Ensuring that HIE does not compete or replaceexisting network neighborhoods and investments.
• Providing services to support patient-centric care• Achieving critical mass of users/data sources• Meeting standards for interoperability, privacy &
security.• Driving investment in certified EHRs.• Identifying and funding pilot opportunities that
can demonstrate value.
142142
3. Serving as State-level Convener and Coordinator
• Ensuring activities are consistent with NHCHI HIT HIE Vision and Principles.
• Establishing an over all state-level direction.• Setting state-wide standards – Interop. P&S• Coordinating HIT HIE efforts.• Interacting with other state HIEs for common
solutions and potential opportunities to leverage/share infrastructure.
• Identifying and finding ways to address gaps in services.
• Recommending legislative changes needed.