1 st Meeting June 9, 2010 8:30 am – 11:00 am Dial-in:1-866-922-3257; Participant Code 654 032 36#...

1st MeetingJune 9, 2010

8:30 am – 11:00 amDial-in:1-866-922-3257; Participant Code 654 032

36#

North Carolina Health Information Exchange

Governance Workgroup

2

Agenda

Topic Leads Time

Introductions and Objectives Co-Chairs 8:30 - 9:00

Background Manatt 9:00 - 9:20

Workgroup Overview• Workgroup Charter & Work Plan• ONC Statewide Cooperative Agreement Operational

Plan

Co-Chairs & Manatt

9:20 - 9:35

Governance Structure – Public/Private Partnership

Roles and Responsibilities of Governance EntityDiscussion

Co-Chairs & Manatt

9:35 – 10:45

Next Steps & Timeline Co-Chairs & Manatt

10:45 – 10:50

Open Public Comment 10:50 – 11:00

3

Introductions: Co-Chairs, Staff, and Members

Staff

• William Bernstein, Manatt

• Melinda Dutton, Manatt

• Brenda Pawlak, Manatt

• Allison Garcimonde, Manatt

Members

• Connie Bishop, MSN RN, National & State Baldridge Examiner

• Jacquelyn Boyden, Kalish Consulting Group

• Janis Curtis, Duke Health System

• Dana Gibson, Data Link HIE

• Craigan Gray, DHHS DMA

• Mark Gordon, Kerr Drugs

Co-Chairs• Ben Money, NC Community Health Association• Tom Bacon

NC HIE• Alan Hirsch, Interim CEO• Steve Cline, State HIT Coordinator• Anita Massey, State Project Manager

• Don Horton, LabCorp

• Darlyne Menscer, NCMS, Carolinas Healthcare System

• Harry Reynolds, IBM

• Craig Richardville, Carolinas Healthcare System

• Pam Silberman, NC Institute of Medicine

• Sam Spicer, New Hanover Regional Medical Center

• Craig Souza, NC Healthcare Facilities Association

4

Expectations of the NC HIE Workgroups

• Participants have been nominated and invited to participate by the NC HIE governing board co-chaired by Secretary Lanier Cansler and Mr. Charlie Sanders for your expertise in your field and your commitment to improving health care quality, access, and affordability for all North Carolinians.

• Workgroup members are asked to draw on their expertise and perspective from across industries sectors with an eye toward supporting the greater goal of a statewide resource for North Carolina.

• Workgroups are expected to be multi-stakeholder, nonpartisan and all discussions, meetings and decision-making processes to be fully transparent.

• Workgroups are asked to consider multiple stakeholder group perspectives when working toward solutions.

• Workgroups will be asked to make consensus-based recommendations to the NC HIE governing board. In cases where consensus is not reached, the workgroup is expected to put forth a balanced, fair consideration of the pros and cons of an issue.

• Workgroup members are expected to respect the opinions and input of others and to engage in fair meeting conduct to work toward consensus recommendations.

• Workgroup members are strongly encouraged to attend meetings in person whenever possible.

• Public stakeholder input is encouraged.

5

Meeting Objectives:Key Decisions

• Clear Understanding of Our Charge and Tasks

• Confirmation on Public/Private Partnership Model for Governing Entity

• Consensus on Roles and Responsibilities of Governing Entity and recommendations to NC HIE Board

• Understanding of Upcoming Issues Tasked to Workgroup

6

Overview of the Context for Statewide HIE

7Discussion Document – Not for Distribution

7

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

Regional Extension Centers ($640M)

Workforce Training ($80M)

Research and Demonstrations

Medicare & Medicaid incentives for HIT adoption

~$31.5 B to $48.1 B total in expected outlays*

$564 M for Statewide HIE Development

States receive between $4M & $40M

$220 M for “Beacon” Community Program

15 HIEs receiving between $10-$20M

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

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

equipment, including acquisition of HIT systems

New Incentives for Adoption Funding for Health IT

Funding for HIE

Broadband and Telehealth

Community Health Centers

HITECH Funding:HIT & HIE infrastructure

*(North Carolina providers estimated to receive $750 M to $1 B)


8

North Carolina Health IT AwardsARRA:

•State HIE Cooperative Agreement: $12.9 million

•Medicaid Meaningful Use Planning: $2.29 million

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

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

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

•Health IT Curriculum Development: $1.8 million Duke University

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

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

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

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

–Implementing a model electronic health record format for children

9

Meaningful Use Overview Regulatory Definition

In HITECH, Congress specified three types of requirements for meaningful use:

1. use of certified EHR technology in a meaningful manner (e.g. Electronic Prescribing);

2. that the certified EHR technology is connected in a manner that provides for the electronic exchange of health information to improve the quality of care; and

3. that, in using certified EHR technology, the provider submits to the Secretary information on clinical quality measures and such other measures selected by the Secretary.

10

2009 2010 2011 2012 2013 2014 2015 2016 2017….. 2021

Medicare incentives begin Jan 2011 for

non-hospital based physicians

Medicaid: non-hospital basedphysicians no payments after

2021 or more than 5 yrs.

Medicare penalties begin for non-meaningful users

FY15 for hospitalscalendar 2015 for physicians

CMS NPRM and ONC IFC Released

Dec. 30 2009

Medicare (FY2011)incentives begin

Oct. 2010 for hospitals

Medicaid: hospitals that adopt after 2017 not eligible for incentives

Medicaid: non-hospital based physicians1st yr cost

no later than 2016

Medicare incentivesEnd 2016

Medicare phase down incentive payments for physicians

Medicare: Physicians who 1st paymentis after 2014 receive no incentives

MEDICARE

MEDICAID

ONC Final Rule

Meaningful Use: Funding Timeline

Medicaid incentives begin

CMS Final Rule for Incentives

11

CMS Vision for Stages:Requirements Scaling Up Over Time

Stage 1 Stage 2 Stage 3

1. Capturing health information in a coded format

2. Using the information to track key clinical conditions

3. Communicating captured information for care coordination purposes

4. Reporting of clinical quality measures and public health information

1. Disease management, clinical decision support

2. Medication management

3. Support for patient access to their health information

4. Transitions in care

5. Quality measurement

6. Research

7. Bi-directional communication with public health agencies

1. Achieving improvements in quality, safety and efficiency

2. Focusing on decision support for national high priority conditions

3. Patient access to self-management tools

4. Access to comprehensive patient data

5. Improving population health outcomes

For Stage 2, CMS may also consider applying the criteria more broadly to both the inpatient and outpatient hospital settings. CMS expects to propose Stage 2 criteria by the end of 2011.

CMS expects to propose Stage 3 criteria by the end of 2013.

12

Framework of Health Reform: Payment Policy Changes

Reduce Cost of Care

Stimulate Administrative Efficiencies

•HIT Incentives

Limit FFS Payment Updates

•Medicare captures productivity gains

•FFS becomes less attractive

Improve Coordination of Care

Encourage creation of new delivery organizations including:

•Medical Homes, particularly for chronic care populations

•Accountable care organizations

Tie Payments to Broader Units of Service

•Hospital and Physician Payment Bundles

•Episode-Based Payment Bundles

Alter Content of Care

Improving Scientific Basis of Healthcare Decisions

•Based on Comparative Effectiveness Research

Payment Tied to Patient Outcomes

•Based on Quality Measures

13

Health Information Exchange: Changing the Paradigm

Today“One-to-One” Exchange

Today“One-to-One” Exchange

• Human judgment plays a critical role in determining what information is shared and with whom

• Phone conversations between clinicians for purposes of treatment frequently replace the need for physically exchanged information.

• Authentication of requests for information is heavily reliant on relationships between organizations or individuals charged with information sharing.

Tomorrow“Many-to-Many”

Exchange

Tomorrow“Many-to-Many”

Exchange

• In an environment of ubiquitous electronic HIE, data will be gathered or transferred between multiple entities without benefit of the familiar relationships of the old paradigm.

• At the time of collecting the data, verification of the requester and sources will be critical, and may require sophisticated permission and authorization controls.

14

The Health IT / HIE Landscape Is Increasingly Diverse

RHIO

eRx Network Health Plans,

PBMsSpecialists

Primary Care Providers

Labs, X-Rays, etc.

Long Term CareHospitals

Public Health and Other Agencies

Hospital

eRx Network Health Plans,

PBMsSpecialists

Primary Care Providers

Labs, X-Rays, etc.

Long Term CareAffiliated Hospitals

Parent System/Org

RHIOs

A health information organization that brings together health care stakeholders within a defined geographic area and governs health information exchange among them for the purpose of improving health and care in that community*

Personal Health Information Repositories and Exchange

MSFT HealthVault, Epic MyChart, Payer PHRs, etc.

EHR Vendor Networks

Epic Everywhere, eClinicalWorks EHX, etc

PHR

eRx Network

Health Plans, PBMs

Specialists

Primary Care Provider

Labs, X-Rays, etc.

Long Term CareHospitals


EHR

eRx Network

Health Plans, PBMs

Hospital


Labs, X-Rays, etc.

Primary Care ProviderHospital

Specialist

* Source: The National Alliance for Health Information Technology Report to the Office of the National Coordinator for Health Information Technology on Defining Key Health Information Technology Terms, April 28, 2008

HIOs

An organization that oversees and governs the exchange of health-related information among organizations according to nationally recognized standards*

Emerging Private Service Providers and Networks

Surescripts, Availity, Navinet, etc,

Private Networks

eRx Network

Health Plans, PBMs

Hospital


Labs, X-Rays, etc.

Primary Care ProviderHospital

Specialist

15

Multiple Approaches to Patient Engagement

Un-tethered PHRs• Google, Microsoft, Dossia, WebMD• “Life long” – tries to replicate home file system• Requires work to collect data from providers• Traction with wellness, cancer, and chronic

PHR

eRx NetworkHealth Plans, PBMsSpecialists

Primary Care Provider Labs, X-Rays, etc.

Long Term Care

Hospitals


Hospital Providers Pharmacy

Payer Portal

Other HIT Labs Pharmacy

Provider EMR Portal

Tethered to Payer• Insurance providers offer portals to reduce support

cost and for “stickiness”• No longevity, consumer changes insurance every 3 yrs• Comprehensive, all provider data in one place• Predominately used by consumer to understand

healthcare spending for budgeting & HSA

Tethered to Provider• Most major EMRs have a “patient portal”• Larger providers using portal to reduce admin costs and

to drive patient “stickiness”• No integration between providers

16

The NHIN NHIN Direct and NHIN Connect

NHIN Direct NHIN Connect

17

The NHINDetails on NHIN Direct & NHIN Connect

NHIN Connect

A select group of entities that have agreed to

share data across organizations along defined

use cases. The software to accomplish HIE to

HIE exchange (patient look up, retrieval).

• Current Exchange participants

• SSA, MedVA, DoD, Kaiser Permanente,

VA, CDC

• Future potential participants

• Beacon Communities, SSA grantees,

state HIE

NHIN Connect

A select group of entities that have agreed to

share data across organizations along defined

use cases. The software to accomplish HIE to

HIE exchange (patient look up, retrieval).

• Current Exchange participants

• SSA, MedVA, DoD, Kaiser Permanente,

VA, CDC

• Future potential participants

• Beacon Communities, SSA grantees,

state HIE

NHIN Direct

A project to expand the standards and service

definitions that, with a policy framework,

constitute the NHIN. The standards and services

will allow organizations to deliver simple, direct,

secure & scalable transport of health information

over the Internet between known participants in

support of Stage 1 meaningful use.

• Key Deliverables

• standards

• service definitions

• implementation guides

• reference implementations

• associated testing frameworks.

NHIN Direct

A project to expand the standards and service

definitions that, with a policy framework,

constitute the NHIN. The standards and services

will allow organizations to deliver simple, direct,

secure & scalable transport of health information

over the Internet between known participants in

support of Stage 1 meaningful use.

• Key Deliverables

• standards

• service definitions

• implementation guides

• reference implementations

• associated testing frameworks.

18

NHIN Relationship to HIO & HIE

Source: “NHIN 102: Secure and Meaningful Exchange of Health Information over the Internet,” Doug Fridsma, MD, PhD., March 2010.

NHIN Connect envisioned to

support more complex

exchange needs

ONC associates less complex

exchange, such as secure

routing with NHIN Direct

Success is dependent on EMR and HIE vendor adoption of the technologies and standards into their mainstream products

Success is dependent on EMR and HIE vendor adoption of the technologies and standards into their mainstream products

19

Overview of Workgroup Process and Tasks

20




• Consensus on Roles and Responsibilities of Governing Entity and recommendations to NC HIE Board


21

State HIE Cooperative AgreementGoals and Planning Requirements

Domains toAddress

Domains toAddress

RequiredPlans

RequiredPlans

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

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

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

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

verified via Operational Plan process)

- Operational Plan: Detailed explanation, targets, dates for

execution of strategic plan

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

Types of Exchange

Types of Exchange

– Eligibility & claims transactions

– eRx & refill requests– Lab ordering & results

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

coordination & patient engagement

22

Key Strategic Decisions for North Carolina

– How will the NC Statewide HIE relate to regional HIEs? (Governance)

– What State incentives/tools/levers may be used to quickly facilitate significant participation in the statewide HIE? (Governance)

– How will the State ensure that the public interest is protected? (Governance & Legal/Policy)

– What core infrastructure and services will be offered? (Clinical/Technical Operations)

– How will start up and ongoing costs be financed and sustained over time? (Finance)

– What policies will be implemented to protect privacy and security of data and promote trust? (Legal/Policy)

23

State HIE Cooperative Agreement Program: Governance

• The statewide HIE should provide governance, leadership, and accountability around the management of the HIE infrastructure, privacy and security, and a mechanism for consumer and provider participation.

• The Governance Workgroup will– Develop a governance framework that will ensure broad-based stakeholder

collaboration and transparency– Develop and vet governance models to be recommended to the NC HIE

Board

• The Workgroup will be tasked with ensuring a governance framework characterized by: – Alignment with Medicaid and public health programs– The ability to provide oversight and accountability to protect the public

interest– The support of providers statewide to achieve meaningful use

24

State HIE Cooperative Agreement Program: Governance

ONC’s Achievements Expected by 2011

• Governance Structure: Establish a governance structure that achieves broad-based stakeholder collaboration with transparency, buy-in and trust.

• Goals, Objectives, Measures: Set goals, objectives and performance measure for HIE reflecting consensus among stakeholder groups, accomplish statewide coverage of all providers for HIE meaningful use criteria.

• Coordination: Ensure coordination, integration, alignment of efforts with Medicaid and public health programs via efforts with HIT Coordinators.

• Oversight and Accountability: Establish oversight and accountability mechanisms to protect the public interest.

• Alignment with National Governance: Account for the flexibility needed to align with emerging nationwide HIE governance (as specified).


25

Workgroup Deliverables for Operational Plan

Workgroup Deliverables

Governance • Recommendation on public-private partnership structure and functions of the governing body• Recommendation on bylaw-related issues for governing body• Recommendation on approach to statewide HIE• Recommendations to ensure alignment with Medicaid and state programs• Recommendations to ensure alignment with ARRA funded HIT and HIE activities in North Carolina• Components of a consumer engagement and outreach plan

Finance • Environmental data collection / provider landscape • 2-3 financial model scenarios• Payment flow models• Finance section of NC HIE Operational Plan• Workplan for ongoing sustainability effort

Clinical & Technical Operations

• Landscape survey of relevant health IT assets across key stakeholders• Clinical opportunity analysis as relates to NC HIE meaningful use and operational goals• Selected use cases• Straw technical architecture and approach based upon use cases• Description of how the technical architecture will align with NHIN core services and specifications

Legal/Policy • Recommendation on statewide policy framework that protects the privacy and security of health information and that allows for incremental development of polices over time.

• Process to harmonize federal and state legal and policy requirements to support HIE.• Recommendations on operational processes to support privacy and security policies and ensure

implementation and evaluation of policies• Process to develop a consumer and stakeholder outreach, education and engagement plan.• NC state law scan

26




• Consensus on Roles and Responsibilities of Governing Entity

• Recommendations to NC HIE Board


27 27

State-level HIE Governance & Technical Operations

In support of a statewide organizing capacity, state-level efforts serve two important and distinct roles:

• Governance: A primary role to convene health care stakeholders, promote collaboration, develop consensus, coordinate policies and procedures to secure data sharing, and lead and oversee statewide efforts.

• Technical operations: An optional and variable role to manage and operate the technical infrastructure, services, and/or applications to support statewide efforts.

Role Governance Technical Operations

Function Convene Coordinate Operate/Manage

Task • Provide neutral forum for all stakeholders

• Educate constituents & inform HIE policy deliberations

• Advocate for statewide HIE• Serve as an information

resource for local HIE and health IT activities

• Track/assess national HIE and health IT efforts

• Facilitate consumer input

• Develop and lead plan for implementation of statewide solutions for interoperability.

• Promote consistency and effectiveness of statewide HIE policies and practices

• Support integration of HIE efforts with other healthcare goals, objectives, & initiatives

• Facilitate alignment of statewide, interstate, & national HIE strategies

• Serve as central hub for statewide or national data sources and shared services

• Own or contract with vendor(s) for the hardware, software, and/or services to conduct HIE

• Provide administrative support & serve as a technical resource to local HIE efforts

28

Governance: Considerations

• Important distinction between state government and statewide governance, which refers to the process to serve the collective interests in the State.

• Governance occurs at multiple levels: local, regional, statewide, interstate, and federal. States must define the roles, inter-relationships, and obligations within and across these layers.

• Effective governance is built on inclusive and transparent processes that identify and develop practical policies for key decisions.

• Accountability can be achieved through a variety of mechanisms, including statutory, regulatory, contracts, self-enforcement.

• Should the State-level effort be empowered to sanction/accredit other entities (e.g. local health information exchanges, providers, payers) participation in the exchange of data in a state?

29

Potential Functions of a Comprehensive Governance Entity

Administration

Provides operational and financial oversight, as necessary. Likely overseen by an Executive Director and staff that reports to a Board of Directors. Includes oversight of Fiscal processing Legal issues Contracting

Statewide Collaboration Process

Open and transparent stakeholder process to develop statewide policies and procedures around: Health Outcomes Privacy & security Technology Sustainability Evaluation & Accountability

Shared Services

Contract for and manage services to be utilized by all HIEs across the state, for example Core services State-level services Membership Testing Monitoring

Adoption Services

Provides support and assistance with adoption and implementation of Electronic health records (EHRs) Health information exchange (HIE) Electronic prescribing (eRx) Personal health records (PHRs)

Communication and Education

Provides outreach and education tools around HIE activities and its implications to Consumers Providers

30

Governance – Continuum of Statewide Coordination

Market-Driven Approach

State defers to regions

State Designated Entity (SDE)

Independent entity, with state participation

(Public/Private Partnership)

State Led

State government led, supported by

collaborative, multi-stakeholder policy

process

• NV• IN

• AZ• CO• NY

• RI• TN• VT

• MI• MN• WA• DE

• How should HIE be governed in North Carolina?

• What are the State’s and private sector’s roles?

Private Public

31

Governance – Option 1

Option Pros Cons

Market-Driven Approach The State, either directly through a State agency or through a contract with a not-for-profit governance entity, obtains and distributes grant funds through an RFP process to local and regional HIE efforts across the state. Each local or regional HIE effort is responsible for its own policy, governance and operations. Coordination and interoperability across HIEs is dependent upon existing and emerging federal standards.

• Direct• Cost effective• Ensures market

support• Necessarily self-

supported • Most rapid

procurement process

• No defined structure for building consensus or generating widespread mutual trust

• May lack urgency • May leave public health or

policy goals unachieved• Experience to date does not

demonstrate support for a true market-based approach

• Requires mechanism to address coverage gaps

• Risks sub-optimal realization of meaningful use dollars

• Lacks coordinated strategyMarket-Driven Approach




State Led

State government led, supported by collaborative,

multi-stakeholder policy process

32

Governance – Option 2 (A)

Option Pros Cons

Not-for-profit Governance EntityThe State contracts with a not-for-profit governance entity that is responsible for managing the statewide collaboration process, recommending statewide policy and guidance and governing the operations of HIE efforts throughout the state. The not-for-profit governance entity does not operate the HIE directly, but contracts with either one statewide HIE or multiple regional HIEs to provide HIE operations.

• Builds consensus and trust in a multi-stakeholder environment

• May be removed from State political changes

• Multi-stakeholder environment likely improves long-term sustainability

• Allows for flexibility • Voluntary self-

regulation avoids creating a State bureaucratic process

• Facilitates alignment with counties and cities

• Creates a new level of organization that may threaten the independence of existing HIE initiatives

• Requires immediate initial investment in administrative resources

• May require compliance with state procurement law





State Led



33

Governance – Option 2 (B)





State Led



Option Pros Cons

Not-for-profit Governance Entity and Operator

The State contracts with a not-for-profit governance entity that is responsible for managing the statewide collaboration process, recommending statewide policy and guidance and governing the operations of HIE efforts throughout the state. The not-for-profit governance entity is responsible for operating the statewide HIE or shared statewide HIE services.

• Facilitates interoperability among HIEs using State services

• Builds consensus and trust in a multi-stakeholder environment

• May be removed from State political changes

• Multi-stakeholder environment likely improves long-term sustainability

• Allows for flexibility • Voluntary self-regulation

avoids creating a State bureaucratic process

• Facilitates alignment with counties and cities

• May supplant or require significant modification to existing exchanges with the operation of a single statewide exchange or statewide corer services

• Creates a new level of organization that may threaten the independence of existing HIE initiatives

• Requires immediate initial investment in administrative resources

• May require procurement with state procurement law

34

Governance – Option 3

Option Pros Cons

State Led The State, directly through a State agency, is responsible for managing the statewide collaboration process, recommending statewide policy and guidance and governing the operations of HIE efforts throughout the state. The State does not operate the HIE directly, but contracts with either one statewide HIE or multiple regional HIEs to provide HIE operations.

• Elevates priority of State health outcomes

• Prioritizes State HIE goals

• May build on existing State efforts

• Adherence to existing State process and guidelines

• Greater likelihood of alignment with other State initiatives

• The State has experience implementing complex programs

• Creates accountability with the State

• Requires State commitment to administrative funding that does not exist today

• May be less flexible and unable to respond to immediate needs

• State procurement process may lengthen implementation timelines

• Some do not support increasing the size of government





State Led



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36

Governance Workgroup Threshold Issues

Threshold Issue Consensus Recommendations

Unresolved Questions

Governance Model

Roles & Responsibilities

37







38

Key Issues for Discussion in June & July 2010:

• Bylaw-related issues for governing body• Model approaches to statewide HIE• Relationship between public-private partnership

entity and state• Alignment with Medicaid and other state programs • Alignment with ARRA-funded HIT and HIE

programs in state• Components of a consumer outreach and

communications plan

3939

Next Steps

Upcoming Meetings– Board of Directors– June 15th – Workgroup Meeting – June 21st

Questions or Comments? - Contact [email protected]

Discussion Document – Not for Distribution39

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1 st Meeting June 9, 2010 8:30 am – 11:00 am Dial-in:1-866-922-3257; Participant Code 654 032 36#...

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