strategic planning session. - 2 - new hampshire health information organization © nhhio. all rights...

Strategic Planning Session

- 2 -New Hampshire Health Information Organization © NHHIO. All rights reserved.

Today’s Goals

Get Educated

Get Inspired

Get Connected

Get Involved


Agenda

Welcome and Introductions – Denise Purington, Board Chair, NHHO - Jeff Loughlin,

NHHIO Executive Director

The State Perspective – William Baggeroer, Chief Information Officer, NH DHHS

Where did we start from – How far have we come? – Mark Belanger, Director of

Strategic Advisory Services, Massachusetts eHealth Collaborative

Legislative Issues and Concerns – Denise Purington, Board Chair, NHHIO

Current State of NHHIO – Jeff Loughlin, NHHIO Executive Director

Future of Health Information Exchange – Micky Tripathi, President & CEO,

Massachusetts eHealth Collaborative

HIE Adoption and Use Case Review – Mary Beth Eldredge, Board Vice Chair, NHHIO

Participant Discussion

Getting Involved, Getting Connected – Jackie Baldaro, Project Manager, NHHIO

Q& A - Closing Remarks


Introductions - NHHIO Board of Directors

Board Member Representation Board Member Representation

Denise Purington CIO Elliot Hospital

NHHIO Chair Board Member at LargeHospitals

David BridenCIO Exeter Hospital

NH Hospital AssociationLarge Hospitals

Mary Beth EldredgeIT DirectorDartmouth Hitchcock

NHHIO Vice Chair Board Member at LargeHospitals

Patricia WitthausIT DirectorValley Regional Hospital

NH Hospital AssociationCritical Access Hospitals

Kirsten PlatteCHAN

NHHIO Secretary Bi-State Primary Care Association

Dr. Richard Lafleur Anthem BC/BS

Board Member at Large Health Plans

Carol LaCrossCFO - Retired

NHHIO Treasurer Board Member at Large

Michael Lehrman Catholic Charities

Board Member at LargeNH Health Care Assoc.

Deb MullenConcord VNA

Home Care Association Mark GuptillCommunity Partners

NH Behavioral Health Association

Dr. Daniel WaszkowskiDerry Medical Center

NH Medical Society David Querusio Harvard Pilgrim Healthcare


William BaggeroerDHHS

Board Member at LargeDHHS

Dr. Christine Rosenwasser Dartmouth Hitchcock Pediatrics

Board Member at Large Physicians

Victor St. PierreConsumer Advocate

Board Member at Large Consumers

Lorraine NicholsIT Consultant

Board Member at Large

Vacant Retail Pharmacy


Introductions – NH Team

NHHIO Staff:

Jeff Loughlin – Executive Director

Jackie Baldaro – Project Manager

Micky Tripathi – Senior Advisor

NHHIO Partners:

Mark Belanger – Strategic Advisor

Nancy Fennell – Regional Extension Center (REC) Director

Jaime Dupuis – EHR/HIE Consultant

Len Levine – EHR/HIE Consultant

Gary Tomlinson – Hospital Consultant

Jennifer Monahan – Program Coordinator


Introductions

Orion Health Partners:

Nick Yarker

Project Manager

Lisa Sherwin

Regional VP, Professional Services Group


Introductions

Large Hospitals and providers

Critical Access Hospitals and providers

Private practices

Home health care, VNA, and hospice

Long term care or rehabilitation facilities

Behavioral Health

NH State entities

Surgical centers

Legislators

Professional Associations

Members of the press

Anyone I missed?















Agenda

- 10 -Massachusetts eHealth Collaborative

Health Information Exchange in New Hampshire

Where did we start from – How far have we come?

September 20, 2013

- 11 -- 11 -Massachusetts eHealth Collaborative

In 2010 we collectively established a high degree of consensus around five strategies

1. Establish a sustainable organizational, governance, and technical foundation for achievement of long term statewide health information goals

2. Level-set individual providers’ abilities to meet Stage 1 Meaningful Use criteria by facilitating e-Prescribing, lab results delivery, and patient care summary exchange across the state

3. Catalyze the efforts of programs focused on HIT adoption

4. Expand availability of HIE services to providers that do not currently have access to robust capabilities for health information exchange

5. Collaborate with Legislators to define the future policy governing HIE purpose and participants


NH DHHS, NHHIO, the REC of NH, and many committed volunteers have made steady progress ever since

Major accomplishments to date:• The New Hampshire Health Information Organization (NHHIO) is now in place

• The NHHIO Board of Directors has been established, has set bylaws, has elected officers, and has formed committees

• The Executive Director has been selected and NHHIO has been staffed for operations

• The Technical services provider, Orion Health, has been selected and is on board

• The contract with NH DHHS has been executed to transfer duties and funding to NHHIO

• The Participation Agreement, Policies & Procedures, and pricing has all been finalized and is being used with new members

• Technical services have been configured and NHHIO has moved forward with 4 pilot sites (Exeter, Seacoast Mental Health, Elliot, and DPH)

• The Legislature has passed legislation allowing public health to participate in NHHIO and for PH reports to be sent via NHHIO – There is recent progress to align the HIE law with HIPAA

• Alongside NHHIO and NH DHHS, the REC of NH has helped many of the state’s providers and critical access hospitals implement and use EHRs.

• 26 organizations have kicked off with NHHIO and 10+ more are in the pipeline


Where do we stand?eRx in NH - 2012

% of new and renewal prescriptions e-prescribed (SS)

% of physicians actively using an electronic health record to e-prescribe via SS network (SS)

% of physicians actively e-prescribing via Surescripts network (SS)

% of pharmacies participating in e-prescribing (Surescripts)

64%

76%

83%

96%

eRx in NH - 2012


Where do we stand?Lab order/result exchange in NH - 2012

% of hospitals sharing laboratory results electronically with hospitals outside their system (AHA)

% of labs electronically sending structured lab results to providers outside their organization (UNH)

% of ambulatory providers able to send lab orders electronically (NAMCS)

% of hospitals sharing laboratory results electronically with ambulatory providers outside their system (AHA)

% of ambulatory providers able to view lab results electronically (NAMCS)

28%

45%

63%

73%

77%

Lab order/result exchange in NH - 2012


Where do we stand?Care summary exchange in NH - 2012

% of hospitals sharing electronic care summaries with hospitals outside their system (AHA)

% of ambulatory providers electronically sharing care summaries with other providers (NAMCS)

% of hospitals sharing electronic care summaries with ambulatory providers outside their system

(AHA)

0% 20%

40%

60%

80%

100%

20%

22%

27%

Care summary exchange in NH - 2012


Where do we stand? Care summary exchange with Patients in NH - 2012

% of ambulatory providers able to provide patients with clinical summaries for each visit (NAMCS)

% of hospitals capable of providing patients with an electronic copy of their health information (AHA)

0% 20%

40%

60%

80%

100%

59%

84%

Care summary exchange with Patients in NH - 2012


What other “pain points” should we keep an eye on?

1. Focus first on those gaps we identified originally such as facilitating medication reconciliation and transfers of care

2. Need to stay aligned with and support Accountable Care and Stage 2 Meaningful Use

3. Admission/Discharge/Transfer (ADT) transport and support of real time notifications and alerting.

4. Stay out front with privacy & security issues

5. Help providers avoid building infrastructure and/or interfaces twice

6. Interstate connectivity

7. Address the needs of provider types that were left out of Meaningful Use

8. Facilitate administrative transactions such as prior authorizations, claims eligibility, and claims status

9. Provide translation services (e.g., RxNorm, LOINC mapping)

10.Stay cognizant of market consolidation and adjust accordingly


What organization types should be prioritized for connection? Importance of exchanging data with stakeholder types (June 2013 survey results n=20)

Out of State Providers

Imaging Centers

Pharmacies

Payers

Patients

Laboratories

Veteran's Administration

Case Managers

Quality Data Reporting

LTC/SNF

Home Health

Public Health Agencies

Physician Practices

Hospitals

0 2 4 6 8 10 12 14 16 18 20

5

9

10

5

7

7

12

6

8

12

9

12

4

5

4

5

4

9

7

8

3

9

8

6

9

6

15

15

medium priority

high priority


What are the reasons to join NHHIO? Reasons to Join NHHIO (June 2013 survey results n=17)

Receive lab results from labs outside of my organization

Send and receive event notifications

Reduce staff time, effort, and cost spent on medical records management

Send lab orders to labs outside of my organization

Reduce (consolidate) interfaces my organization has with other organizations

Send required reports to the Department of Public Health

Support Accountable Care Organization information sharing needs

Support Patient Centered Medical Home information sharing needs

Provide clinicians with a means to more easily access critical patient information from providers outside my organization

Improve care transitions through sending and receiving patient care summaries with outside providers

Satisfy meaningful use requirements

0 2 4 6 8 10 12 14 16

8

9

9

10

10

11

11

12

14

14

14

- 20 -Massachusetts eHealth Collaborative

Thank you!

Mark BelangerDirector of Advisory Services

Massachusetts eHealth Collaborative860 Winter Street, Waltham, MA 02451

[email protected] Tel: 781.434.7889

Mobile: 339.223.2051

mailto:[email protected]















Agenda

Legislative UpdatesDenise Purington

Board ChairCIO Elliot Hospital

New Hampshire Health Information Organization


Our Changing Environment

HB489Creates NHHIOJul 2011

SB288DHHS ReportingJun 2012

ONC ApprovesSOPSep 2010

Pioneer ACODec 2011

ACA SignedMar 2010

NH ACOPilotsJun 2010

DHHS beginsHIE developmentNov 2009

PCMH, P4P, ACO2012

Stage 1 MU2011

ARRA SignedFeb 2009

2009 2010 2013+2011 2012

Stage 2 MU2013

RSA 332:I PHI Use2009


Healthcare Improvement Goals

Better Care

Patient Safety Quality Patient Experience

Reduce Per Capita Cost

Reduce unnecessary and unjustified medical cost Reduce administrative cost thru process simplification

Improve Population Health

Decrease health disparities Improve chronic care management and outcome Improve community health status


Health Information Technology Drivers

Meaningful Use and CMS EHR Incentive Program

Maximizes use of electronic data exchange for efficiency and safety Requires care coordination and patient engagement Requires HIPAA compliant transactions

Patient Centered Medical Home

Develops closed-loop electronic referral system Encourages patient engagement and participation Maximizes care coordination to eliminate redundancy and waste

Accountable Care Organizations

Requires effective care coordination and care management Maximizes clinical efficiency and decreases costs Requires HIPAA compliant transactions


NHHIO Legislative Updates

Update Definitions to Fully Align with HIPAA

Undefined terms leads to ambiguity and misinterpretation of meaning “Healthcare Services” is not defined in provider definition “Treatment” is not defined under use and disclosure

Update Use and Disclosure to Fully Align with HIPAA

Variability of transmission methods drives inconsistency and increased cost

Allow all parties currently receiving and reviewing PHI to do so using safe, secure and auditable methods

Patient engagement increases self-management, self-regulation, and informed decision making process for clinical and cost effectiveness


NH HIE Facts: (RSA 332-I:2)

A health care provider or business associate may disclose an individual's PHI and information about the location of an individual's medical records to a HIE – allows for Electronic Master Person Index (EMPI) (Phase 2)

Individual must be given an opportunity to opt out of sharing his/her name, address, and PHI through a HIE – information not sent to HIE, does not prevent public health reporting

Only a health care provider, for purposes of treatment, may access PHI in a HIE – does not include patients or payors

A HIE must maintain an audit log of health care providers who access PHI – central site will maintain transmission logs

When federal certification standards are established, a HIE must be certified to be in compliance with nationally accepted interoperability standards and practices – NHHIO is using Direct standards for message transport

SB288 – Authorized reporting to Department of Health and Human Services (DHHS) – AHEDD, Cancer Registry, Immunization Registry


Legal Language Updates

II. In this chapter:

(a) The following terms have the same meaning as given in the regulations under sections 160, 262 and 264 of the Health Insurance Portability and Accountability Act of 1996 (HIPAA):

(1) Business associate;

(2) Use;

(3) Disclosure; and

(4) Protected health information; and

(5) Health care provider

(b) "Health care provider'' means any person, corporation, facility, or institution either licensed by this state or otherwise lawfully providing health care services, including, but not limited to, a physician, hospital, office, clinic, health center or other health care facility, dentist, nurse, optometrist, pharmacist, podiatrist, physical therapist, or mental health professional, and any officer, employee, or agent of such provider acting in the course and scope of employment or agency related to or supportive of health care services.



Comment:

The current law uses an undefined term of “health care services” in order to define a health care provider. In order to alleviate any ambiguity, and to ensure consistency of interstate communication capabilities with other organizations, we suggest using the standard HIPAA definition of a Health care provider. Section 160 of HIPAA contains the definition of Health care provider.

“Health care provider” has the meaning given such term in section 160.103 of title 45, Code of Federal Regulations: Provider of services (as defined in section 1861(u) of the [Social Security] Act, 42 U.S.C. 1395x(u)), a provider of medical or health services (as defined in section 1861(s) of the Act, 42 U.S.C. 1395x(s)), and any other person or organization who furnishes, bills, or is paid for health care in the normal course of business.



332-I:3 Use and Disclosure of Protected Health Information; Health Information Exchange. –

I. Except as provided in paragraph VI, a health care provider, or a business associate of a health care provider, or patient, may transmit an individual's protected health information through the health information organization. Only a health care provider, for purposes of treatment, may have access to Except as provided in section 332-I:4, protected health information transmitted through the health information organization., may only be used and disclosed in accordance with the Health Insurance Portability and Accountability Act of 1996 (HIPAA).



Comment:

1. The current language prevents the transmission to, or the receipt of information from patients that may be required by a variety of clinical improvement and home monitoring programs.

2. By limiting the transmission of data for treatment purposes only, which is also an undefined term, providers will be required to build a variety of alternative conduits for data transmission for care coordination and accountable care reporting.

3. By allowing the data to be utilized in accordance with HIPAA, organizations may utilize the data for care coordination purposes, or it may be de-identified for use by NH Medicaid Manage care plans for population reporting and management activities that are critical for cost saving programs.

4. These changes retain all the original limitations on use of the data for marketing and fundraising activities.


Questions and Comments















Agenda

Jeff LoughlinExecutive Director


American Recovery and Reinvestment Act (ARRA)

HITECH: Catalyst for Transformation

Pre 2009 2009 2014A system plagued by inefficiencies

EHR Incentive Program and 62 Regional Extension Centers

Widespread adoption & meaningful use of EHRs

Three-Part Aim:Better Healthcare Better Health Reduced Costs

Paper Records HITECH Act EHRs & HIE

Transforming Healthcare

Medicare and Medicaid Incentives and Penalties

Improved Individual & Population HealthOutcomes

IncreasedTransparency & Efficiency

ImprovedAbility to Study &Improve Care Delivery

ADOPTIONADOPTION

EXCHANGEEXCHANGE

State Grants forHealth Information Exchange

Standards & Certification Framework

Privacy & Security Framework

Regional Extension Centers

Workforce Training

MEANINGFUL USEMEANINGFUL USE

37

Health Information Technology for Economic and Clinical Health (HITECH) - Framework

HITECH Framework in New Hampshire

ADOPTIONADOPTION

EXCHANGEEXCHANGE

MEANINGFUL USEMEANINGFUL USE

Improved Individual & Population HealthOutcomes

IncreasedTransparency & Efficiency

ImprovedAbility to Study &Improve Care Delivery


New Hampshire Health Information Exchange Plan

June 2010 created multi-stakeholder groups

The plan is the result of collaborative planning among over 80 stakeholders

380 stakeholder comments were addressed in the current version

The plan continues to evolve as we refine the strategy, obtain broader stakeholder input, and incorporate updated use cases from the field

Current strategic plan is posted at http://www.dhhs.nh.gov/hie/strategic.htm

http://www.dhhs.nh.gov/hie/strategic.htm


HB #489 (July 2011) created the New Hampshire Health Information Organization (NHHIO)

NHHIO Governed by a broad community based multi-stakeholder Board of Directors

Seven (7) seats named by statute with 10 at-large members

501(c)(3) Public Charity organization status received August 2012

Establishing Governance


NHHIO Board of Directors

Board Member Representation Board Member Representation

Denise Purington CIO Elliot Hospital

NHHIO Chair Board Member at LargeHospitals

David BridenCIO Exeter Hospital

NH Hospital AssociationLarge Hospitals

Mary Beth EldredgeIT DirectorDartmouth Hitchcock

NHHIO Vice Chair Board Member at LargeHospitals

Patricia WitthausIT DirectorValley Regional Hospital

NH Hospital AssociationCritical Access Hospitals

Kirsten PlatteCHAN

NHHIO Secretary Bi-State Primary Care Association

Dr. Richard Lafleur Anthem BC/BS


Carol LaCrossCFO - Retired

NHHIO Treasurer Board Member at Large

Michael Lehrman Catholic Charities

Board Member at LargeNH Health Care Assoc.

Deb MullenConcord VNA

Home Care Association Mark GuptillCommunity Partners

NH Behavioral Health Association

Dr. Daniel WaszkowskiDerry Medical Center

NH Medical Society David Querusio Harvard Pilgrim Healthcare


William BaggeroerDHHS

Board Member at LargeDHHS

Dr. Christine Rosenwasser Dartmouth Hitchcock Pediatrics

Board Member at Large Physicians

Victor St. PierreConsumer Advocate

Board Member at Large Consumers

Lorraine NicholsIT Consultant

Board Member at Large

Vacant Retail Pharmacy


NHHIO Architecture and Services

NH Statewide Network – “Backbone”

CHAN

Provider Practices

Hospital

Public Health (DHHS)

SecurityNode

addressingProvider

addressingAudit

MDMD MD

Record Locator Service (EMPI)

Long-term care

SNFs

Phase I:

• Direct Secure Messaging

• Inter-state gateway

Phase II:

• Relationship Listing Service (RLS) - Electronic Master Person Index (EMPI)

Health Centers

Behavioral Health

Diagnostic testing

NH Hospital

VNA / Homecare

MDMD

ASCC

Inter-state communications


Electronic Health Record (EHR) Integration

Provider directory

Certificate repository

DIRECT gateway

Web portal mailbox

HIE ServicesUser types

3 methods of accessing HIE services

EHR connects directly

Browser access to webmail inbox

Physician practice

Hospital

Long-term careOther providersPublic healthHealth plans

EHR connects through LAND Appliance


Gateway to access HIEs Across New England

RI

NY

CT

MA

ME

NH

VT


Participant ScheduleParticipant

ImplementationStatus

Messages current/planned September 2013 October 2013 November 2013

2-Sep 9-Sep 16-Sep 23-Sep 30-Sep 7-Oct 14-Oct 21-Oct 28-Oct 4-Nov 11-Nov 18-Nov 25-Nov

Elliot Hospital Production AHEDD, ELR data

Exeter Hospital Testing Hospital Discharge Summaries

Seacoast Mental Health Center Testing Medical Summary

State of New Hampshire Department Public Health Production Recieving AHEDD, ELR

Dartmouth Hitchcock Medical Center On boarding AHEDD, ELR data

State of New Hampshire Cancer Registry On boarding Receiving Cancer Registry data

Cheshire Medical Center On boarding AHEDD data

Valley Regional Hospital (CAH) On boarding AHEDD data

Pemi Baker On boarding Provider Orders, MedicalSummary

Androscoggin On boarding AHEDD data, Medical Summary

Cornerstone VNA On boarding Medical Summary

Central VNA & Hospice On boarding Medical Summary

COOS County On boarding Medical summary

Catholic Medical Center On boarding Medical Summary

Franklin VNA & Hospice On boarding Medical Summary

Midstate Health On boarding Medical Summary

Community Health Access Network (CHAN) On boarding Medical Summary

Frisbie Memorial On boarding AHEDD data, DischargeSummary

Cottage Hospital On boarding AHEDD data, ELR data, MedicalSummary

Derry Medical On boarding Medical Summary

Speare Memorial On boarding AHEDD data, ELR data,Discharge/Medical Summary

Home Health & Hospice On boarding Medical Summary

Monadnock Family Services Scheduled Medical Summary

Access Sports Medicine Scheduled Medical Summary

Weeks Medical Center Scheduled AHEDD data, Medical Summary

Huggins Hospital Scheduled AHEDD data, Medical Summary

Mental Health Center of Greater Nashua Scheduled Medical Summary

VNA & Hospice of Northern Carroll County Scheduled Medical Summary

Mental Health Center of Greater Manchester Scheduled Medical Summary

Gastroenterology PA (GASPA) Scheduled Medical Summary

Stage 2 M

eaningful U

se


Participant Schedule

ParticipantImplementation

StatusMessages current/planned September 2013

2-Sep 9-Sep 16-Sep 23-Sep 30-SepHomemakers Health Services Pending Schedule Memorial Hospital Pending Schedule St. Josephs Hospital Pending Schedule Southern New Hampshire Medical Center Pending Schedule Southern New Hampshire Internal Medicine Pending Schedule Concord Hospital Pending Schedule Concord VNA Pending Schedule Franklin Regional Hospital Pending Schedule Littleton Regional Pending Schedule Northern Human Services Pending Schedule New London Hospital Pending Schedule Ammonoosuc Community Health Center Pending Schedule West Central Behavioral Health Pending Schedule Wentworth-Douglass Pending Schedule

Legend: Status:Implementing Testing Production


Can I query the HIE for available records and request the information?

Currently, NHHIO does not provide a centralized data repository of patient records for querying and retrieving functions, but is creating a platform for electronic directed secure messaging (DSM). However, through the Relationship List Service (RLS) in phase II, NHHIO providers will be able to see a list of organizations where the patients have some type of record associated and the date of the last encounter. Providers may then reach out to the organization through traditional methods associated with the encounter and request the information to be sent to them. NHHIO will also provide a Healthcare Provider Directory (HPD) of all participating providers and organizations.


What is the Healthcare Provider Director (HPD) used for?

NHHIO is establishing a payload agnostic platform to allow organizations to transmit any type of message, file or document that relates to patient treatment. The message is encrypted and transmitted based on the HPD information available to the HIE. This “To” and “From” addressing information can be manually embedded into the file name of the message, ie. FromAddress..ToAddress[##UniqueIdentifier][#Filename], or as an example,

[email protected]@receivingOrganizations.com##20130212#JoeBloggs.pdf

Or, the “To” and “From” information may also be embedded into the C32 CCD , or CDA document, HL7 or XML message depending on vendor capabilities. The ability to include this information into a local provider directory in your EHR or other source system, or not, will help determine our integration methods with each source system.

mailto:[email protected]@receivingOrganizations.com








LAND Appliance

Device Next Unit of Computing Kit

Processor Intel Celeron 847 (1.10 GHz)

RAM 8GB RAM (2ea 4GB DDR3 SDRAM)

Hard Drive 120 GB SSD (Intel SSD 525)

Dimensions 4.59”x4.41”x1.55”


LAND Appliance

Deployment Facility

LAND Appliance

Orion Health Direct Secure

Messaging

EMR/Interface

Engine

Messaging

Administration

Orion Health Monitoring

HISP Services

NHHIO Participant NHHIO Central Site

• HIE Gateway – message packaging, transmission, encryption• LAND Appliance uses outbound communication only• Centrally managed and remotely supported• Communicates “up” status to central site• Local “hot-swap” appliances available


How does the LAND appliance communicate?

The LAND appliance periodically pings the central site in order to determine if messages are waiting for retrieval. Communications are outbound only directed to a single IP address through a single Port on the local firewall. Once messages are identified, they are then pulled into the LAND, unencrypted, then delivered to destination. Communication between the participant and the LAND appliance is un-secure. http://www.nhhio.org/sites/nhhio.org/files/media/NHHIO%20Solution%20Diagram.pdf

Where is the best placement of the LAND appliance: Local Network vs. DMZ?

Since communication between the LAND appliance and your sources systems is not encrypted, we recommend the appliance is placed on your network behind your Firewall which provides continuous security of PHI. Messages are encrypted by the LAND appliance, and remain encrypted until they are received on the Receiver’s appliance, at which point they are safely decrypted.

http://www.nhhio.org/sites/nhhio.org/files/media/NHHIO%20Solution%20Diagram.pdf


How is data in transit secured and encrypted?

Data is sent through Orion HISP, following Direct ( http://www.healthit.gov/policy-researchers-implementers/direct-project ) standards, using TLS version 1 transport protocols with PKI certificates, encrypted using AES256 algorithm. Encryption/Decryption takes place within the LAND appliance and messages are not opened or deposited at the central site.Where is the Central Site?

System is securely hosted by LogicWorks in a hybrid cloud environment, http://www.logicworks.net/, (SSAE16 certified) with separate database and server instances for NHHIO protected by Cisco ASA5520 firewalls with redundant communication ports and full anti-virus and intrusion detection software.

What type of network connectivity is required?

NHHIO relies upon participant’s commercial internet connectivity and does not utilize any private networks or dedicated circuits.

http://www.healthit.gov/policy-researchers-implementers/direct-project

http://www.logicworks.net/

LAND Appliance Integration MethodsDescription Sending Receiving

Directory InterfacesSimplified File Exchange Drop a specially named file into a directory to send the file. ✔ ✖

Simplified CDA Documents Exchange

Drop a specially named CDA document into a directory to send the file. Information is extracted from the CDA document and included as metadata for the message.

✔ ✖

Document Exchange using the SendDocuments format

The sender creates a specially formatted XML document that contains metadata information and either the file to send, or the name of the file to send.

✔ ✔

Web Service InterfaceSimplified CDA Documents Exchange

Uses a web service to send a CDA document. Information is extracted from the CDA document and included as metadata for the message

✔ ✖

Document Exchange using the SendDocuments format

Use a web service and a specially formatted XML document with embedded attachment(s) to send a message.

✔ ✔

HTTP Interface SendDocuments format Uses an HTTP Post and a specially formatted XML document with

embedded attachment(s) to send a message.✔ ✔

IHE XDR InterfaceIHE XDR Interface Uses the IHE XDR web service to send messages. This interface is

appropriate for systems with full XDR implementations.✔ ✔

FTP Client InterfaceDocument Exchange using the SendDocuments Format

Use an external FTP server and a specially formatted XML document with embedded attachment(s) to send/receive messages.

✔ ✔


How do I select an appropriate integration method?

With support and guidance from NHHIO and the Orion teams, each participant will need to work with their EHR vendor(s) to determine the best integration method based on the export functions of their system, the ability to include HPD information, and the trigger events for the release of information such as:

• Medical Summary / Continuity of Care Document (CCD) / (CDA)

• Transfer of Care Summary (TOC)

• Progress / SOAP notes

• Referral requests / Referral letters















Agenda

HIE Trends

September 20, 2013

Context

1997 – Healthbridge HIE

1999 – New England Health Exchange Network

2001 – Rhode Island Quality Institute

2003 – Indiana Health Information Exchange

2005 – Vermont Information Technology Leaders

2005 – YouTube

2006 – Maine HealthInfoNet

2006 – Facebook

2006 – Accountable care

2007 – Twitter

2007 – Mad Men

2008 – Breaking Bad

2008 – Android

2009 – Modern Family

2009 – HITECH (Meaningful Use)

2010 – Obamacare

2010 – iPad

2011 – NHHIO

HIE is maturing

• Focused on “the noun”

• Trying to solve “market failures”

• Multi-entity governance, but often driven by third-party entities

• Strived to solve wide variety of rich use cases through comprehensive interoperability

• Complex legal, business, and technical requirements to support rich array of use cases

• Tried to tackle policy issues to enable business practices and technology solutions

HIE 1.0 hie 2.0• Focused on “the verb”

• Demand-driven -- trying to meet market needs

• More tactically focused to meet immediate interoperability needs

• Led by any organization that has business need and ability to marshal financial, technical, and organizational resources

• Designed to fit within existing legal, business, and technical constraints – technology out ahead of policy in some areas

What is driving this transition?

Limited successes of the prior model

Bottom-up demand -- systems are not interoperable because not enough customers asked for interoperability

• Meaningful Use incentives

• Value-based purchasing

• Market expectations about standards of care

• Younger provider expectations about use of technology

• Consumer expectations about use of technology

Supply-side

• EHR certification requirements – common denominator important in a fragmented industry

• Technology advancements in cloud services, mobile, broadband, storage, patient-matching capability, etc

Industry changing rapidly

0%

10%

20%

30%

40%

50%

60%

70%

2008 2009 2010 2011 2012

National

NH

Massachusetts

Vermont

Maine

EHR Adoption

0%

10%

20%

30%

40%

50%

60%

70%

80%

2008 2009 2010 2011 2012

ME

MA

National

NH

VT

eRX Use

- 61 -Massachusetts eHealth Collaborative © MAeHC. All rights reserved.

National-level HIOs are most comprehensive HIE implementations, but still quite thin

• Over 20 participants (4 federal) as of September 2011

• Over 90,000 transactions conducted

• HIE solution based on NHIN standards enabling send/receive and query/retrieve

• DURSA covering complete set of exchange patterns

• Five provider organizations (Geisinger, Kaiser, Mayo, Intermountain, Group Health)

• Complete solution based on NHIN standards enabling send/receive and query/retrieve


EHR vendors with high penetration generating large amount of vendor-specific HIE traffic

• Large majority of customers (200+) participating in query-based exchanges

• Currently CCD/CDA query-based exchange is ~2.2 million records for ~385K unique patients per month

• Volume doubled over previous year

• Does not include HL7 directed exchange transactions

• 16,743 providers using query-based exchange

• ~2.5 million new CCD records made available on query exchange hubs or sent directly to referral providers per month

• Processed over 75+ million lab result records in 2012

• ~1.5 million query-based exchanges per month

• ~58.5 million directed exchange transactions per month (including HL7 lab result delivery)

Source: January 2013 -- Epic, eClinicalWorks, Cerner


Some vendors teaming to standardize cross-vendor HIE capabilities

• Nascent collaboration effort among some leading EHR vendors

• Creating common infrastructure for directed query capability facilitated by:

• Record locator service

• EMPI

• Patient-controlled consent management

What will drive HIE in the future?

MU Stage 1 – get everyone electronic, push transactions that already work (labs, eRX)

MU Stage 2 – establish new “push” transactions (provider-to-provider)

MU Stage 3 – establish new “query” transactions

MU Stage 4? 5? 6?

Accountable care?

Market forces?

HIE Functional Needs Vary With Business Goals

Independent actors

IDNAccountable care entities

IPA/PHO

Enterprise Integration & Management

• Business integration

Measurement & Reporting & CDS

Population, Risk, and Financial Management

Measurement & Reporting & CDS

Population, Risk, and Financial Management

• Business alignment• Team-based care• Patient engagement

EHR functions

Message & document delivery

EHR functions


EHR functions


EHR functions

Message & document delivery • Become electronic

• Fill in gaps in care transitions

Registries & Repositories

Cross-system query


Cross-system query


• Performance mgmt• Population mgmt• Utilization mgmt• Case facilitation

Cross-system query

Case management & patient access



Cross-system query


Massachusetts HIE Plan

Patient name Local name Institution MRN Last visit date # visits

Jones, Jennifer L Jones, Jennifer Hospital A 1234 Dec 3, 2012 3Jones, Jennifer L Jones, Jenny PCP 5678 Jul 8, 2010 12

Record Locator Service

Specialist Hospital A

Jennifer L Jones

PCP

Y YN

1. Consent to Publish Provider Relationships

2. Send demographics to RLS

Hospital B

Jennifer L Jones

3. Consent to Search or Retrieve

Y

5. Request patient record

6. Send patient record

4. View Patient Relationships (constrained to patients with established relationships)


Massachusetts HIE Plan – Possible Patient Access Options

Specialist Hospital A

Jennifer L Jones

PCP

Y YN

1. Consent

Patient Directory

2. Lookup Patient Address

Jennifer L Jones

3a. Send Record

Patient name Local name Institution MRN Direct address Certificate

Jones, Jennifer L Jones, Jennifer Hospital A [email protected] 34X&)VX

Jones, Jennifer L Jones, Jenny PCP 5678 [email protected]&)VX

3b. View RLS or RLS Audit Log or Manage Consent?

3c. Notification of RLS Change



Conclusions

HIE activity is starting to flourish….just not in the way we expected a few years ago

Heterogeneity will be the hallmark of HIE activity in the coming years

There will not be a “National HIE” – but there are already many of them…

Multi-layered HIE modes developing as business practices mature

• “B2B”-style patterns to move documents around with light centralized coordination – Direct and Directed Query

• “Supply-chain” style patterns with deep integration among very closely aligned entities seeking centralized orchestration for rich applications to support complex uses

Most state-level HIEs will not survive, and the survivors will be the ones who:

• Focus on customer needs

• Tackle the problems that only they can solve

• Remain flexible to market changes















Agenda

HIE Use CasesMary Beth Eldredge

Board Vice ChairDH Director of Regional IT Systems



New Care Team Model Extends the Reach and Need for Data

Patient & Families

PCP

Home Health /

LTC

eHealth Portals

Mobile Technology

Diagnostic Testing

Specialty Care

Acute Care

ACO

PQRS

eRX

MU & CQM


EP Meaningful Use – Stage 2

Core Objective: Summary of Care record sent with transitions of care and referrals (CCD)

Measure:

1. Sent for more than 50% of transitions of care and referrals

2. 10% sent electronically in Direct compliant format

a) Transmitted using CEHRT

- Or -

b) Transmitted via NwHIN participating exchange or ONC established governance mechanism (NHHIO)

3. Conduct exchange test

a) Different EHR

- Or -

b) CMS-designated test EHR


EP Meaningful Use – Stage 2 (cont)

Core Objective: Submit immunization data (Dependent on NHDPH)

Measure: Submit data

Other related Objectives:

1. Core: Secure messaging

2. Core: Patient ability to View, Download, Transmit health information

3. Core: Structured lab data >40%

4. Menu: Syndromic Surveillance data

5. Menu: Cancer and other registries

6. Menu: Imaging results


Value Propositions

Increases care coordination efforts by transmitting structured data elements in care summaries, discharge notes, lab results, history and physicals, etc.

Replaces traditional point-to-point communications (unsecure fax, mail, etc.) with electronic directed exchange streamlining workflow in the practice setting

Provides consistent method for private, secure and auditable transmissions of protected health information (PHI)

Streamlines Public Health reporting to the State with connections for AHEDD, electronic lab reporting, cancer care registry and immunization registry

Uses national standards to allow providers and hospitals to comply with multiple incentive and quality programs

Eliminates the creation and management of multiple point-to-point connections for results delivery and information sharing


Dartmouth Hitchcock Use Cases

Replacing Faxing between sites

DH to DH providers

DH to non-DH providers

Delivering Lab results to ordering providers

Referral Requests / Referral Information from referring providers

NCCC Outreach Clinics – dual documentation in local record and DH record New London Hospital, Valley Regional Hospital, Catholic Medical Center,

Weeks Medical Center, Littleton Regional Hospital, Cottage Hospital, St. Joseph Hospital

CHaD Outreach Clinics – dual documentation in local record and DH record CHaD @Wentworth Douglass, Elliot Hospital

Discharges to Home Health agencies and SNF/LTC

40% of DHMC discharges go to post-acute care sites

Discharge summaries from local hospitals to DH Clinics

Manchester, Nashua, Concord

Interstate communication of all the above information

Vermont, Massachusetts, Maine


What are your use cases?















Agenda

Getting ConnectedJackie Baldaro

Project Manager


www.nhhio.org

NHHIO Resources

http://www.nhhio.org/


On-Boarding Documentation

NHHIO On-Boarding Document (~5 week on-boarding project plan)

Appendix A – Readiness Questionnaire (updated to identify multiple systems)

Appendix B - LAND Form (technical contacts and integration method(s))

Appendix C – Provider Directory Upload File Format (.CSV file to be updated)

Appendix D – LAND Appliance Documentation (specifications and integration)

NHHIO Solution Diagram (description of technical infrastructure and communications)

Available at www.nhhio.org



HIE Technology Grant Program

Reduce barriers to implementation and adoption

Financial support for hardware purchases

Financial support for software upgrades

Financial support for additional staffing needs

Award amount based on need justification in application

Workflow assistance and guidance from the Regional Extension Center of New Hampshire


In-Kind “Donation” Tracking

NHHIO is responsible for a 25% match against all Federal dollars spent

In order to keep participant fees low, NHHIO requests tracking of resources spent by the participants:

Internal staff time – meetings, staff training, education & outreach Hardware, software purchases External consulting/integration services

Documentation in NHHIO tracking form

Participant retains auditable receipts


Week 2-3: NHHIO – Orion – Participant Kick-off Call• Orion reviews systems and architecture for preliminary guidance• Orion completes LAND form with Participation for NHHIO approval (PKI)• Orion configures/delivers LAND Appliance

Week 1: Participant completes documentation• NHHIO Participation agreement and associated addendums •Technical architecture information – Integration Engine• Identify system connections• LAND Form contact information• HPD CSV file

Week 3-4: LAND Appliance installation and HIE connection• Participant installs LAND Appliance on LAN• Configure firewall with IP / Port information• Particpant/Orion test connectivity with central site

On-Boarding Process (i) ~ 5 weeks


LAND Appliance Integration Process

8) Participant Integration - EHR to LAND Appliance

Participant, with assistance and guidance from NHHIO, will need to work with their EHR vendor(s) or internal IT team to develop a process to transport, test and validate messages from EHR system(s) to LAND Appliance. Depending upon the Participant’s integration method, additional network directory set-up work may be required to support file exchange.


Week 4-5: System testing• Participant creates test messages for transmission• NHHIO will facilitate receiving participant• Orion validates connectivity• Participant validates results – acceptance testing

Week 5: Move to production• Complete acceptance testing• Review support / help desk methods• NHHIO dues payment (quarterly)

Week 3-4: LAND Appliance Integration• Participant establishes system(s) to LAND Appliance integration method(s)• Participant establish initial use case(s) for export• Integration engine / EHR system(s) configuration needs• Network security / file share configuration (directory method)• EHR vendor or other IT resources/programming may be required• NHHIO / RECNH can provide integration management assistance

On-Boarding Process (ii) ~ 5 weeks


Project Contact Information

Jeff Loughlin Executive Director c: (508) 326-3944 o: (781) 434-7751 [email protected]

Jackie Baldaro Project Manager c: (339) 223-0888 o: (781) 434-7553 [email protected]

















Agenda

Conclusion


Today’s Goals

Get Educated

Visit www.nhhio.org for updated information

Email [email protected] to get on our distribution

Get Inspired

Contact us with use cases and leads

Get Connected

Download our agreements

Contact Jackie to set up a kick-off meeting

Get Involved

Contact your legislators to support HIE expansion

Check out our calendar for committee meetings

Join us for webinar series and discussions




Thank You!

Thank you for partnering with the New Hampshire

Health Information Organization (NHHIO) as we take

this important next step in the evolution of health care

delivery in the Granite State.

strategic planning session. - 2 - new hampshire health information organization © nhhio. all rights...

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