An Examination of Policy Approaches and Alternatives for the Sustainability of Public Health Information Exchange As State-Level Health Information Exchanges (SLHIEs) seek a path towards sustainability, data transformation may hold the key by Jeffery R. L. Smith ABSTRACT: HITECH was a watershed moment for the promotion of health information exchange (HIE) in the United States. But it was also a 100-year event, in terms of funding. Three years later, Congress is intensely focused on debt and deficit cutting, and states are not anticipating any out-year funding for their HIE efforts. At the same time, HIO performance vis-à-vis cost savings, clinical outcomes and public health improvement will soon come under heavy scrutiny – by legislators, but also by current and potential HIO participants. The need to prove value will be paramount, and as most of the HITECH grants were front-end loaded, time is running short. Nearly half of the sand has fallen through to the bottom of the hour glass. In the end, there are a few basic concepts that will unlock sustainability: data saturation, interoperability and data transformation. With the first two tasks being supported by healthcare system-wide changes, the accomplishment of the third may make or break many statewide efforts. Issue for Analysis Sustainable business models continue to elude most publicly- funded health information exchanges (HIEs). This paper will examine prevalent revenue drivers among five State-Level Health Information Exchanges (SLHIEs) and explore the challenges that lie ahead for health information organizations as the nation’s health information infrastructure matures.
Transcript
An Examination of Policy Approaches and Alternatives for the Sustainability of Public Health Information ExchangeAs State-Level Health Information Exchanges (SLHIEs) seek a path towards sustainability, data transformation may hold the key
by Jeffery R. L. Smith
ABSTRACT: HITECH was a watershed moment for the promotion of health information exchange (HIE) in the United States. But it was also a 100-year event, in terms of funding. Three years later, Congress is intensely focused on debt and deficit cutting, and states are not anticipating any out-year funding for their HIE efforts. At the same time, HIO performance vis-à-vis cost savings, clinical outcomes and public health improvement will soon come under heavy scrutiny – by legislators, but also by current and potential HIO participants. The need to prove value will be paramount, and as most of the HITECH grants were front-end loaded, time is running short. Nearly half of the sand has fallen through to the bottom of the hour glass. In the end, there are a few basic concepts that will unlock sustainability: data saturation, interoperability and data transformation. With the first two tasks being supported by healthcare system-wide changes, the accomplishment of the third may make or break many statewide efforts.
Issue for Analysis
Sustainable business models continue to elude most publicly-funded health information
exchanges (HIEs). This paper will examine prevalent revenue drivers among five State-Level
Health Information Exchanges (SLHIEs) and explore the challenges that lie ahead for health
information organizations as the nation’s health information infrastructure matures.
Background
Health information exchange in the United States has a storied and acronymed history.
From the early community health information networks (CHINs) of the 1990s to the regional
health information exchanges (RHIOs) of the mid and late-2000s, health information
professionals have sought for ways to communicate clinical data across space and time. Today,
these networks prefer the simple designation of health information exchange (HIE) or health
information organization (HIO). HIOs are often referred to as the noun, whereas HIE is the verb.
For our purposes, we can differentiate by saying, HIOs are the legal entities that have been
established to allow secure, integrated sharing of clinical information among numerous
stakeholders, including clinical partners and public health, through a health information
exchange. The purpose of such exchange is to ensure patient data can accompany them to any
care setting in the country – securely and accurately – so that better health, better healthcare and
lower costs can be achieved. The Department of Health and Human Service’s Office of the
National Coordinator for Health Information Technology (ONC) envisions independent HIEs
will serve as “nodes” in a “network of networks.”1 The resulting Nationwide Health Information
Network (NwHIN) “is a set of standards, services and policies that enable secure health
information exchange over the Internet.”2
Historically, HIOs have struggled with business models that allow them to be financially
sustainable after grant money or seed funding is expended. Dr. Julia Adler-Milstein has
chronicled the financial challenges of HIOs since 2007 with the help of the eHealth Initiative – a
non-profit organization that surveys and tracks health IT infrastructure and is recognized as an
authority on health information exchange. According to Dr. Adler-Milstein, failure rates for
HIEs in 2007 and 2008 were about one-in-four and one-in-five respectively.3 Although the 2008
report found more operational HIOs (131) than in 2007 (83), they had made little progress in
expanding the types of data being exchanged, leading the author to conclude that HIOs’ “scope
remains limited and their viability uncertain.”4
A number of challenges were identified in the 2007 / 08 reports including a lack of
funding, privacy and security concerns of stakeholders, legal or regulatory challenges, concerns
about competitiveness and technical architecture or infrastructure challenges. Funding ranked
the highest concern for HIOs in 2008 and Adler-Milstein’s research suggests that about 17
percent of HIOs had sustainable financing in 2008. Since this time, however, the world of health
information technology and health information exchange has changed dramatically.
ONC and other agencies of the federal government have invested hundreds of millions of
dollars over the last four years to establish a framework that could facilitate both local and
national health information exchange. In 2009, as part of the American Recovery and
Reinvestment Act, the Health Information Technology for Economic and Clinical Health
(HITECH) Act contained $548 million in grant money for exchange. Fifty-six states, territories
and state designated entities (SDEs) received grants ranging from $4 million to $38 million
through the State Health Information Exchange Cooperative Agreement Program. The
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Cooperative Agreement is a four-year program that requires states to submit operational and
strategic plans to the ONC, including yearly reporting requirements on financial status and
program progress. State awardees must also match federal funds at increasingly higher rates
during the four-year period, beginning with 1 percent in year two and ending at 33 percent by
year four.5 ONC had originally required each state to file a sustainability report by February
2011, but the requirement was removed and a new deadline has not been set.
Also part of the HITECH Act – and a significant driver of current health information
technology adoption – is the Medicare and Medicaid Electronic Health Records Incentive
Payments Program. Upwards of $19 billion in federal reimbursement funds is available to
eligible hospitals and eligible professionals who demonstrate the “meaningful use” of electronic
health records (EHRs). The meaningful use policy platform is a multi-year program seeking to
modernize health information technology through increased adoption of standardized and
certified EHRs. Meaningful Use is a base-line requirement for receiving incentive payments
from Medicare and Medicaid, and if a hospital or doctor has not become a meaningful user of
EHRs by 2015, their reimbursement rates will be cut. In addition to components of the policy
that encourage certain uses of technology, some objectives require the exchange of health
information. And as the program moves into its second and third stages (2014 and 2016,
respectively) it is expected that increasingly robust exchange will be required to qualify as a
meaningful user.
Mapping the Current HIO Landscape
As explained by the ONC’s “Federal Health Information Technology Strategic Plan 2011
– 2015,” the federal government’s health information exchange strategy, “focuses on first
fostering exchange that is already happening today, supporting exchange where it is not taking
place, and creating means for exchange between local initiatives.” When considered alongside
the benchmark reports by Dr. Adler-Milstein, two reports in 2011 can help us better understand
the HIO landscape and give us an indication of how federal policy is affecting that landscape.
HIO Data Points
According to various authorities on HIE, between 228 and 255 HIEs / HIOs currently
exist. The aforementioned eHealth Initiative (eHI) found in their 2011 annual survey that 255
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“initiatives” are underway across the country and that 12 percent of survey respondents (24)
indicated they had sustainable business models.6 A common understanding of what constitutes a
sustainable business model is articulated by the University of Maryland’s Center for Health
Information and Decision Systems (CHIDS):
“A sustainable HIE reflects a situation where all the costs of the HIE operations are funded based on the value generated from HIE (e.g. transaction fees, subscriptions, 3rd party reimbursements) instead of other sources external to the direct value chain (e.g. government grants and subsidies).” 7
This percentage of sustainable HIOs is slightly below the 2008 findings by Dr. Adler-
Milstein who indicated roughly 23 of 131 HIOs surveyed were able to “cover operating costs
with revenue from entities participating in data exchange.” In fact, an eHI survey found that only
18 of the 234 HIOs (8 percent) were sustainable in 2010. While it is important to note the self-
reporting nature of the eHI and Adler-Milstein reports, it would seem that sustainability rates
have been rising the last two years, from 8 to 12 percent. However, these numbers are well short
of the 17 percent estimate of 2008 HIOs.
Another data point that can be compared over time between the eHI and Adler-Milstein
reports is the percentage of HIOs who were previously pursuing HIE, but no longer pursuing HIE
– a failure rate. According to Adler-Milstein, 26 percent of identified organizations fell into this
category in 2007 and 20 percent in 2008. eHI has tracked a similar measure, finding that HIOs
no longer pursuing HIE between 2010 and 2011 represented a 4 percent failure rate.
A different kind of survey surfaced in 2011, one more focused on the vendor market
surrounding HIE solutions, but it gives us another important view of the landscape. A July 2011
survey of HIEs by KLAS, a research firm specializing in monitoring and reporting on the
performance of healthcare vendors, categorized their analysis into public and private HIEs.
“Public” HIEs are defined by KLAS to be those efforts that receive a substantial portion of their
funding from government programs and are obliged to receive financial and organizational
oversight from governmental entities. KLAS found the number of operational public HIEs grew
from 37 in 2010 to 67 in 2011. Meanwhile, the number of operational private HIEs rose from 52
to 161 over the same period.8 This report highlights the amount of growth in health information
exchange over the last year, and much of it can be tied back to federal policies that financially
and organizationally support HIE. Through the Cooperative Agreement, public HIOs have risen
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over 80 percent. And one can argue that private sector growth (in excess of 200 percent) over the
last year can be tied to meaningful use requirements. Anther explanation for such high levels of
growth can be tied to federal programs associated with parts of the Patient Protection and
Affordable Care Act (PPACA) of 2010. Bundled payments, accountable care organizations,
patient centered medical homes, all components of PPACA, require clinical data and claims data
exchange across different settings of care.
Sustainability in the Shifting Healthcare Landscape
Started under HITECH and bolstered by PPACA, health information technology adoption
and health information exchange have seen massive monetary support from the federal
government. In all, close to $30 billion has been made available for health IT-related programs
throughout the federal government. Activities in both the public and private sector reflect a
shifting landscape between fee-for-service and pay-for-performance in Medicare and Medicaid.
This shift in payment model will impact health information technology (HIT) adoption and HIE
use – something policymakers have acknowledged. Regulators and lawmakers at all levels of
government have sought to make new programs enablers of HIT and HIE, not inhibitors. And
with many federal programs well underway, states are increasingly trying to align their HIT
strategies with federal program funds.
All states that received HIE Cooperative Agreement grants must submit and implement
ONC-approved operational and strategic plans. Most states had some kind of HIT strategy in
place prior to HITECH, however, only a handful had dedicated legislation and funds to
implement that strategy. With the implementation of HITECH and PPACA, state-level strategies
have been accelerated, but most – if not all – are moving forward without clearly defined
business models for financial sustainability.
To understand how HIO sustainability fits within the context of federal HIT activities,
and to serve as a foundation for recommendations, I will examine plans submitted by five states,
focusing on their visions for a sustainable statewide exchange program: California, Maine,
Maryland, Ohio and Colorado. Two factors of sustainability that warrant inspection are the
HIO’s technical architectural and service offerings. Indeed, these two factors are contingent
upon several other organizational and environmental factors, such as HIE participant mix,
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governance model, privacy model and physical (broadband) connectivity. However, these two
factors should be resultant from the latter list of factors: participants and their views will make
decisions on a preferred privacy model, which will dictate the technical architecture. Service
offerings will be based, again on participant mix and privacy expectations, but also broadband
penetration – or connectivity. See Figure 1 in the Appendix for a visualization of these
relationships.
Service Offerings
Although an HIO’s service offerings and technical architecture present a “chicken and
egg” paradigm, emerging best practices suggest a thorough understanding of service needs and
wants should come before choosing a preferred technical architecture. Many HIOs are
delineating between “value-add” and “core” services, and there are a set of offerings that are
required for the ONC Cooperative grants. Some of the services are offered by necessity, such as
a record locator service (RLS), and other services, like computerized physician order entry
(CPOE) or EHR-lite, are seen as a way to attract participation in exchange. Other services, like
electronic prescribing (eRx) are considered a value-add service, but ONC has put an emphasis on
eRx through its Cooperative Agreement program, requiring states to outline an eRx-specific
strategy. It should also be noted the eRx is itself part of an incentive program the pre-dates
HITECH. Appendix B contains a list of core and value-add services offered by the five
aforementioned states and will be discussed in further detail below.
Technical Architecture
When discussing a state’s planned technical architecture for HIE, I am referring to the
organization of the state’s technology that will facilitate clinical data exchange. There is a host
of considerations that accompany an HIO’s technical architecture, including data storage,
common terminology definitions and messaging and document standards. HIOs have choices
when deciding on their technical architecture, but a large portion of that final decision rests on
HIO’s participant mix and their stakeholders’ physical connectivity. And in conjunction with the
HIOs privacy policies, these factors determine the needed technical architecture to facilitate the
desired service offerings.
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Data storage is the prime determinant, from a policy perspective, for how the HIO will
operate. Questions around data ownership, patient privacy and data use depend largely on where
and who stores the data. Three main data storage models have emerged through policy and
technical breakthroughs in the last several years: Centralized, Federated (also known as
decentralized) and Hybrid (See Figure 2 for a visualization and Figure 3 for a list of pros and
cons). A guide published recently for hospital chief information officers and other healthcare IT
leaders outlined the characteristics of each model.9 According to the CHIME and eHI “HIE
Guide for CIOs,”
A centralized approach uses one repository to collect all clinical information. The centralized entity manages and performs the exchange of clinical and administrative data among all the participants in the exchange. In A decentralized (federated) approach, the HIO acts mostly as a coordinator and collaboration facilitator to enable the exchange of information; no actual data is held by the entity serving as the HIO. Healthcare organizations make copies of their clinical information on patients available, storing them on “edge servers” that are accessible to other organizations but protected by firewalls to prevent access to their core data storage systems. With a hybrid approach, elements of both the centralized and decentralized models are combined, and services can be handled centrally by one or more HIOs in an area. Often, the hybrid approach takes the form of a central repository of information with “edge servers” utilized for data storage. These edge servers can be located at stakeholder sites or within the central repository, but are notable for the control that providers maintain over their data.
An examination of current trends reveals that most public HIOs are using a hybrid
approach based on their stakeholders’ needs and projected revenue streams.10 All the states
examined in this paper use hybrid models, combining elements of centralized, but predominantly
federated data storage, except Maine.
State Sustainability Strategies
States looking towards long-term sustainability are examining a range of financing
mechanisms that include transaction fees, subscription or membership fees, general purpose
revenues / taxes, and fees per covered life. All of these have corresponding pros and cons and
every state will have to decide what mix and what level of these mechanisms to employ so that
participation is not hindered. However, states have also developed unique policies, apart from
the simple calculations of price structure.
OHIO
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The Ohio Health Information Partnership (OHIP) is the state’s designated entity and is
one of three major HIOs in the state. OHIP utilizes a hybrid approach to exchange information
and its sustainability strategy is predicated on a three-tiered revenue model: Meaningful Use
Revenue Tier, Administrative Revenue Tier and Data Revenue Tier.11 The state first intends to
offer services according to what the EHR Incentive Program requires for meaningful use of
EHRs; then it will offer eligibility verification, coordination of benefits, real‐time claims
adjudication and real‐time payment. In its third stage, the HIO plans to incorporate users of
secondary data, such as state agencies, into its participant mix. OHIP predicts that, along with
payers and employers, state agencies will pay for aggregated data made available through the
exchange. By 2015, OHIP estimates this approach can achieve sustainability with expected
revenues to cover costs by just under $1.5 million.
MAINE
Earlier this year, the National eHealth Collaborative (NeHC) profiled twelve fully
operational HIEs that demonstrate a self-sustaining business strategy to identify common
“success factors.”12 The NeHC report finds that only one of the HIEs profiled used a centralized
data storage approach – HealthInfoNet of Bangor, Maine. HealthInfoNet is Maine’s official
statewide HIO and its primary reason for centralization is aggregated data. Because Maine has a
centralized architecture, it has built a “patient centered clinical database” that HealthInfoNet
leaders believe will supplement future changes in healthcare policy. A monthly subscription fee
allows HealthInfoNet to offer four bundles of services: (1) view; (2) basic HIE; (3) core HIE and
(4) Core HIE + Quality Measure reporting.13 One stakeholder that Maine has yet to successfully
integrate into the participant mix is payers, which could solidify Maine’s self-sustaining status in
the coming years.
MARYLAND
Maryland has been fairly proactive in recent years in its policies to adopt health IT. The
state has had since the late 1970’s a unique all-payor hospital rate setting system that seeks cost
containment in healthcare through rate regulation. According to one estimate, this system has
saved Maryland $45 billion since its inception.14 Through the rate regulation system, Maryland
committed $10 million in funding for the implementation of a statewide HIE, and in May of
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2009 established its own EHR incentive program funded by the state’s six largest health
insurers.15 Maryland has tasked the Chesapeake Regional Information System for our Patients
(CRISP) to be its official HIO, and so far, CRISP has secured letters of intent (LOI) from all
forty-eight of the state’s hospitals to participate in the hybrid model HIE. Like other states,
Maryland has identified “use case” services they believe will be needed and valued by HIE
participants. Specifically, the MD HIE State Plan says the “HIE will use secondary data…to
provide clear societal benefits and benefits to various local, state, and national public health
agencies for the purposes of early identification of communicable diseases and acute or long-
term population health threats.”16 The state plan does not speculate how much revenue can be
raised by each use case, but collectively, Maryland believes the use cases will yield just shy of $6
million in subscription fee revenue in 2013. This is about $1 million short of what the HIO
expects operating costs to be that same year.
COLORADO
Colorado is the only state in the country that has a Chief Data Officer who reports to the
state CIO and is in charge of taking a statewide view of how data is used, spanning programs
from juvenile justice and education to healthcare.17 The state selected the Colorado Regional
Health Information Organization (CORHIO) to serve as the state’s designated HIO. CORHIO
will use a hybrid technical architecture that interfaces closely with a broadband initiative called
the Colorado Telehealth Network. According to the state plan, “The availability of broadband
access is an underpinning to the success of our Statewide Health Information Exchange,” and the
state’s HIE plan is tied to the sustainability of its broadband plan.18 Colorado is also aggressively
charting a course to develop an “Interagency Data Exchange Model” for all health-related IT
programs across the state government. This model foresees a close relationship with CORHIO
and would supplement their service offering sometime in the future.
In September 2011, CORHIO announced a repackaging of its fee schedule that gave
participants a choice of an “integrated” package that allows practices that use EHRs to have HIE
data route seamlessly into their system and the “standard” package, for practices that do not have
an EHR, or they have an EHR but would prefer to access HIE data from a stand-alone Web
portal. Specific estimates for HIE costs and revenues were not available, but the plan foresees
financial sustainability by 2015.
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CALIFORNIA
Predictably, California’s geography and population present major challenges to statewide
health information exchange. Where most states have one to three HIEs operating within their
borders, California has thirteen. As such, California has designated Cal eConnect as the HIO
responsible for tying the other HIEs together as one interoperable network. This will cost
between $1 billion and $2 billion per year, according to California’s projections. The state has
identified a number of financing mechanism to make HIE sustainable in an interim report
outlining pros and cons alongside each of the potential participants.19 The state’s HIE plan was
submitted to ONC in March 2010, where it acknowledged, “The most viable sustainable model
for HIOs is to have broad based participation where stakeholders are charged fees or dues
commensurate with the value they derive from the HIO combined with their ability to pay
relative to other stakeholders.”20 It also went on to say, “In the course of doing business, Cal
eConnect will develop a useful knowledge base, and will consider providing contracted services,
either to the State or to HIE participants such as health systems.” It was with this last statement
in mind that Cal eConnect’s Business Advisory Group in October 2011 unveiled a framework of
service offerings around governance, coordination and technical assistance to the state’s HIEs
and their participants. Cal eConnect envisions that they could “become the Trusted Entity for
policy and standards oversight,” help create a “common technical architecture” and help other
HIEs with financial management, performance measurement and facilitate “relationships with
other Federal and State entities.”21
Common Challenges, Diverse Approaches
Administrative simplification, telehealth coordination, aggregated data, and HIE expertise
– these are parts of the suggested solutions to the “sustainability question.” Were more HIOs
examined as part of this analysis, it is probable that other solutions would emerge, but they
would likely be variants of these themes. With just over two years left in the program, many
HIOs’ sustainability strategy has not yet been put to the test – federal and state-matching grants
are still covering the bills. Subscription fees and phased service unveilings are the predominant
strategy for those HIOs analyzed in this report and are likely to be the same in other states.
10 | Policy Approaches and Alternatives for the Sustainability of Public HIE
Line-item projections about specific revenue drivers aside, there are some common trends
that can be both cause for optimism and grounds for worry. It is likely that historical challenges
that lead to HIO failure – low levels of data volume and diversity; lack of standards and few
reasons to track quality measures – may become irrelevant in today’s health policy world.
According to a November 2011 Center for Disease Control and Prevention (CDC) report, 34
percent of the nation’s office-based physicians used basic EHRs – this number is up from 10.5 in
2006.22 Further, the report notes that 52 percent of physicians intend to apply for meaningful use
incentives, up 41 percent in 2010. A similar survey on meaningful use intention, conducted by
the College of Healthcare Information Management Executives indicates that 93 percent of
hospital CIOs believe their facilities will qualify for stage 1 meaningful use by 2015.23
Clearly a wave of new health data in the form of standardized electronic health records
has and will continue to enter the US health IT infrastructure. Likewise, federal policies continue
to spur health information exchange.
Subsequent criteria under meaningful use will require more robust health information
exchange, for transitions of care and for public health use. Stage 2 meaningful use criteria will
soon be available and recommendations to “raise the bar” for health information exchange have
already been submitted to the ONC.24 Additional programs developed as part of the PPACA –
ACOs, Value Based Payments and Bundled Payments, among them – will also require robust
exchange, of both clinical and claims data, for quality measurements.
Despite the amounts of money being spent to develop HIOs, the 2008 Adler-Milstein
report found that money upfront may actually be detrimental to long-term success. She found
that while grants and large cash infusions helped HIOs develop their infrastructure, it also
allowed them to circumvent stakeholders and potential participants.25 This exclusion problem
may well be exacerbated by the tremendous dollar amounts available to HIOs through HITECH.
Additionally, the structure of these grants may be a source of concern. The Cooperative
Agreements encourage large, upfront spending, lest the state be stuck with a sizable matching
amount in the third and fourth years of the program. And the ONC’s decision to omit and forget
about a requirement that every state submit a financial sustainability report is somewhat curious.
Implications
11 | Policy Approaches and Alternatives for the Sustainability of Public HIE
From the small survey of HIOs above, it’s clear that most of them will look to capitalize
on the growing saturation, standardization and interoperability of health data. All of the states
surveyed are either aligning services to coincide with meaningful use requirements, or at least
considering a phased approach that will meet participants’ most basic needs first. This approach
is likely repeated by other states. But will other states strive, as these will, to make data
transformation a core competency, to give all the data they handle value? A common theme
throughout these varied state HIO strategies includes a reliance on “big data” – aggregated pools
of patient data for claims, for clinical outcomes and for disease reporting. While most states’
HIOs may not be working with zettabytes of data, the ones analyzed above foresee a future in
which huge amounts of patient data can: help pay insurers and providers in near real-time (Ohio);
gather and submit quality reports (Calif., Colo., Maine, Md., Ohio ); communicate in real-time
with state public health agencies (Calif., Colo., Maine, Md.). It is not clear that these states, or
others planning to offer the same kinds of services, will be capable of delivering. A 2011
continuation of the studies done by Dr. Julia Adler-Milstein concludes, “Only 13 RHIOs in the
country seem capable of supporting stage 1 meaningful use criteria,” and “Of greater concern, we
found no organizations that support the robust data exchange that is probably required to realize
the projected quality and efficiency gains from HIE.”26
Recommendations
The ONC should re-initiate plans to require financial sustainability reports from
HIOs receiving federal funds through the Cooperative Agreements.
It is highly likely that the ONC has a close watch on HIO financials that either reflect or
refute the state plans submitted by HIOs in 2009/10. But by omitting the process of organizing
and submitting a financial report, as a requirement to receive funds, the ONC may very well have
committed a sizable oversight. The act of convening diverse stakeholders in an open forum to
submit federal reports can go a long way towards ensuring its feasibility. Strategic and
operational plans for projects such as HIE are understandably fluid, but having information on
sustainability for each state would be beneficial for individual HIOs and the overall national
effort.
HIOs need to be realistic in their service capabilities and delivery timelines.
12 | Policy Approaches and Alternatives for the Sustainability of Public HIE
Finding ways to derive value from clinical, claims and public health data will prove a
worthwhile endeavor, but HIOs need to be realistic in their timelines and capabilities. There is a
looming problem in promoting a service that requires a multifaceted technical solution not
currently in place. There is a definite problem in identifying that service as a core competency,
intended to help make your business sustainable. Most state HIEs are using hybrid architectures,
but hybrid architectures make producing the reports and data composites envisioned by these
HIOs more difficult.
Appendix AFigure 1
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14 | Policy Approaches and Alternatives for the Sustainability of Public HIE
(Source: Compiled from CHIME, eHI “HIE Guide for CIOs”)
Appendix B The following charts were compiled using criteria outlined in eHI’s Health Information Exchange: Sustainable HIE in a Changing Landscape and compiled with author’s analysis of state HIE plans.
MaineHIE or SDE: HealthInfoNetTechnical Architecture: Centralized
HIE Services
Core Services Value-Add
X Master Patient Index X Medication Reconciliation
X Master Provider Index Computerized Physician Order Entry
X Record Locator Services EMR-Lite
X Clinical Messaging X ePrescribing
X Clinical Data Routing X Care Coordination Modules
X Longitudinal Patient Record Viewer Administrative Services
X HIE to HIE Interoperability X Patient Management Tools
X HIE-Related Meaningful Use Support X Quality Reporting
13 / 16 HIE Services
MarylandHIE or SDE: CRISP Technical Architecture: Hybrid
HIE Services Core Services Value-Add
X Master Patient Index X Medication Reconciliation
X Master Provider Index X Computerized Physician Order Entry
X Record Locator Services EMR-Lite
X Clinical Messaging X ePrescribing
X Clinical Data Routing X Care Coordination Modules
15 | Policy Approaches and Alternatives for the Sustainability of Public HIE
1 Office of the National Coordinator for Health IT, Summary of the NHIN Prototype Architecture Contracts, 31 May 2007 http://1.usa.gov/tLvhIw (accessed 16 November 2011).2 Office of the National Coordinator for Health IT, The Nationwide Health Information Network, Direct Project, and CONNECT Software, http://bit.ly/sVtyhw (accessed 19 November 2011)3 Adler-Milstein, J., Bates, D., Jha K., “U.S. Regional Health Information Organizations: Progress And Challenges” Health Affairs, 28, no. 2 (2009): 483-4924 Ibid.5 Office of the National Coordinator for Health IT, State Health Information Exchange Cooperative Agreement Program Funding Opportunity Announcement http://bit.ly/tPATqz (accessed 3 November 2011)6 eHealth Initiative, Health Information Exchange: Sustainable HIE in a Changing Landscape, Oct. 2011 7 Agarwal, R., Crowley, K., Ramos-Johnson, D., “CHIDS Evaluation Framework for Sustainable Health Information Exchange: DC RHIO Current Progress and the Road Ahead,” Robert H. Smith School of Business, UMD, Sept. 20108 KLAS, Health Information Exchanges: Rapid Growth in an Evolving Market, July 20119 College of Healthcare Information Management Executives (CHIME) and eHealth Initiative, The HIE Guide for CIOs, Nov. 2011 available online at http://www.cio-chime.org/hieguide/ (accessed 25 November 2011)10 Prestigiacomo, J., “A Hybrid Approach” Health Informatics, August 2011 http://bit.ly/ndOBnT (accessed 13 November 2011)11 Ohio Health Information Partnership (OHIP) Ohio State HIE Plan: Strategic and operational plans for a statewide health information exchange, 2010 http://bit.ly/vz1HuJ (accessed 20 October 2011)12 National eHealth Collaborative ”Secrets of HIE Success Revealed: Lessons from the Leaders” July 2011 http://bit.ly/tbFMnn (accessed 12 November 2011)13 HealthInfoNet Maine Statewide Health Information Exchange Strategic and Operational Plans: A Strategy to Create an Infrastructure that Preserves and Improves the Health of Maine People July 2010 http://1.usa.gov/uIY9fl (accessed 12 November 2011)14 Buntin, J., “Maryland’s All-Payer Answer” Governing March 22, 2011 http://bit.ly/v1Nmf1 (accessed 25 November 2011)15 Maryland General Assembly House Bill 706 (HB706) “HR Electronic Health Records - Regulation and Reimbursement” 2009 http://bit.ly/u0hszw (accessed 25 November 2011)16 Maryland Health Care Commission, Health Information Technology State Plan FY2010 – FY2013, 2009 http://1.usa.gov/uDSnEE (accessed 25 November 2011)17 Smith, J. “Moving Mountains: Sharing data on both sides of the Continental Divide” CivSource, March 31, 2009 http://bit.ly/cprfCi (accessed 20 November 2011)18 CORHIO Colorado’s State Health Information Exchange Strategic Plan, October 2009 http://bit.ly/sShh0v (accessed 20 November 2011)19 Cal eConnect, California’s HIE Sustainability Development Plan: Interim Report to California Health and Human Services (CHHS), April 2011 http://bit.ly/rQvDvF (accessed 13 November 2011)20 Cal eConnect, California Health Information Exchange Strategic and Operational Plans March 2010 http://bit.ly/sEfSOT (accessed 13 November 2011)21 Cal eConnect, Business Advisory Group Meeting Presentation HIE Services October 5, 2011 http://bit.ly/tbUoVO (accessed 13 November 2011)22 US Dept. of Health and Human Services, Centers for Disease Control and Prevention, Electronic Health Record Systems and Intent to Apply for Meaningful Use Incentives Among Office-based Physician Practices: United States, 2001–2011, Nov. 2011 http://1.usa.gov/t1fc00 (accessed 30 November 2011)23 College of Healthcare Information Management Executives, “CHIME Member Meaningful Use Readiness Quarterly Update” October 2011 http://bit.ly/sicEBX (accessed 30 November 2011)24 ONC Health IT Policy Federal Advisory Committee, Stage 2 Meaningful Use Matrix http://bit.ly/sgtEVu (accessed 30 November 2011)25 Adler-Milstein, J., Bates, D., Jha K., “U.S. Regional Health Information Organizations: Progress And Challenges” Health Affairs, 28, no. 2 (2009): 483-49226 Adler-Milstein, J., Bates, D., Jha, A., “A Survey of Health Information Exchange Organizations in the United States: Implications for Meaningful Use,” Annals of Internal Medicine, (2011) 154: 666-671
