SUBMITTED SEPTEMBER 10, 2010 REVISED …€¦ · state of texas strategic and operational plans for...

STATE OF TEXAS STRATEGIC AND OPERATIONAL PLANS FOR STATEWIDE HEALTH INFORMATION EXCHANGE

SUBMITTED SEPTEMBER 10, 2010 REVISED NOVEMBER 17, 2010

Published by

STRATEGIC AND OPERATIONAL PLAN FOR STATEWIDE HIE

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Table of Contents Introduction ........................................................................................................................... 1

Strategic Plan ........................................................................................................................ 2

1. Background ............................................................................................................... 3 "#" $%&'()*!#####################################################################################################################################!+

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2. Environmental Scan: Assessment of Current HIE Implementation and Readiness ................................................................................................................ 13

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3. Gap Analysis ............................................................................................................ 47 +#" K0*27&(.<2!$&*)2&<R<.4!##############################################################################################################!FL

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4. Approach to Statewide HIE Implementation ......................................................... 51 F#" -*.*&/0!C7&/7*4>!#####################################################################################################################!D"

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5. Coordination ............................................................................................................ 80 D#" C7/::<.4!C7&/7*4>!C%''(&7)!A((&5<./7<(.!R*7I**.!66CA!/.5!=6C?!#####################################!NM

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D#N $('%0/7<(.!9.20%)<(.!C7&/7*4>!##################################################################################################!NG

6. EHR Adoption .......................................................................................................... 87 G#" C7&/7*4<2!H&/;*I(&3!:(&!C%''(&7<.4!K6T!?5('7<(.!################################################################!NN

7. Ongoing Expansion of HIE Capacity ..................................................................... 90

Operational Plan .................................................................................................................. 91

8. Introduction ............................................................................................................. 91 N#" O'*&/7<(./0!?''&(/28!/.5!$&(Z*27!$0/.)!################################################################################!J"

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9. Detailed Project Plan ............................................................................................... 97

10. Coordination with ARRA Programs ..................................................................... 102 "M#" A((&5<./7<(.!I<78!X*5<2/<5!69=!$0/..<.4!/.5!O78*&!C7/7*!?4*.2>!69=!9.<7</7<@*)!###############!"M,

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11. Coordination with Other States ........................................................................... 104

12. Domain-Specific Components: Governance ...................................................... 105 ",#" -(@*&./.2*!K.7<7>!#################################################################################################################!"MD

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13. Domain-Specific Components: Finance ............................................................. 108


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14. Domain-Specific Components: Technical Infrastructure .................................. 118 "F#" =*28.<2/0!?))<)7/.2*!#############################################################################################################!""N

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15. Domain-Specific Components: Business and Technical Operations .............. 129 "D#" H(2%)_!?''&(/28_!C7&/7*4<*)!#################################################################################################!",J

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"D#F T<)3!X<7<4/7<(.!C7&/7*4<*)!######################################################################################################!"+D

16. Domain-Specific Components: Legal/Policy ...................................................... 138 "G#" -(/0)!#####################################################################################################################################!"+N


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17. EHR Adoption and Consumer Engagement ....................................................... 142 "L#" $&(@<5*&!?5('7<(.!##################################################################################################################!"F,

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Appendix A. Glossary ......................................................................................... 144

Appendix B. Workgroup Membership ............................................................... 151

Appendix C. Environmental Scan Survey Tool ................................................. 156

Appendix D. Practitioner Survey ........................................................................ 157

Appendix E. Hospital Survey .............................................................................. 162

Appendix F. HIE Functionality Score Card ....................................................... 168

Appendix G. Environmental Scan Summary of Results................................... 170

Appendix H. References and Sources ............................................................... 210

Appendix I. Requirements Crosswalk .............................................................. 211

Appendix J. Letters of Support .......................................................................... 230

Appendix K. Local HIE Grant Program – Request for Application .................. 245


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Introduction The Texas Health and Human Services Commission (HHSC) is pleased to submit the enclosed Strategic and Operational plans for review by the Office of the National Coordinator for Health Information Technology (ONC).

These plans were developed by the Texas Health Services Authority (THSA), an organization created by the Texas Legislature in 2007 to coordinate and catalyze the development of health information exchange (HIE) in Texas. In order to ensure broad stakeholder input in the development of HIE Strategic and Operational plans, the THSA facilitated a transparent, robust, and collaborative stakeholder process between January and August 2010 to solicit input from multi-disciplinary, multi-stakeholder experts. The Strategic and Operational plans address the general and domain-specific requirements established by the ONC under the State HIE Cooperative Agreement Grant Program. These plans also outline and support the implementation of the following three strategies:

! General state-level operations ! Local HIE grant program ! White space coverage

Implementing these three HIE strategies will enable improvements in the quality and efficiency of the Texas health care sector by establishing an HIE infrastructure for the entire state. The Strategic and Operational plans detail the state’s existing HIE capabilities and explain in more detail how the planning process and the identified strategies address the governance, finance, technical infrastructure, business operations, and legal needs of the State of Texas while enabling interoperability with applicable state and federal programs as well as other states.


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Strategic Plan


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1. 1/234&(%.5

1.1 Purpose The purpose of the Strategic and Operational plans is to enable improvements in the quality and efficiency of the Texas health care sector by establishing an electronic HIE infrastructure for the State of Texas. The plans are designed to support the delivery of private, secure, and reliable HIE services to all Texas patients and providers through local HIE networks where the capacity exists and through contracts administered from the state level where it does not.

1.2 General Background Since 2006, several entities have been engaged in health information technology (IT) planning and policy development in Texas at the state level: the Health Information Technology Advisory Committee (HITAC), the Health Care Policy Council (HCPC), the Texas Health Care System Integrity Partnership (THCSIP), and the Texas Health Services Authority (THSA).

1.2.1 Health Information Technology Advisory Committee The Texas HITAC was established in 2005 by the Texas Legislature through Senate Bill 45 and is charged with developing a long-range health IT plan for the state. Over the course of late 2005 and early 2006, the HITAC and its several subcommittees met and developed a state health IT roadmap that included recommendations for state-level health IT action, a template for regional health information exchange (HIE) activity, consumer-level recommendations focused on privacy and consumer engagement, and provider-level recommendations focused on adoption. Among the recommendations for state-level action was the recommendation that a lead entity be identified at the state level to implement certain desirable state-level health IT and HIE functions.

1.2.2 Texas Health Care System Integrity Partnership Subsequently, THCSIP was established through Executive Order RP-61 in late 2006 as a blue-ribbon commission on health care. One of the primary charges to the THCSIP was to identify the governance and finance structures for an entity to operationalize the desirable state-level health IT and HIE functions identified by the HITAC earlier that year. In response, the THCSIP recommended creating a non-profit, public-private partnership focused on promoting and coordinating HIE statewide.

1.2.3 Texas Health Services Authority Based on the recommendations of the THCSIP, the THSA was created by the Texas Legislature in 2007 through House Bill 1066 as a public–private partnership focused on promoting and coordinating HIE statewide, but was never supplied any funding to get started. The THSA was legally structured through its statutory constitution as a nonprofit corporation with a broadly representative board appointed by the Governor with the advice and consent of the Senate. The board was appointed in 2008 and met several times during the course of late 2008 and early 2009 to evaluate opportunities for developing clinical use cases and value propositions around HIE that might allow for a bootstrapped startup and sustainable operations. With the passage of the American Recovery and Reinvestment Act (ARRA), the THSA re-oriented its planning activities around the program that was to eventually emerge from Section 3013.


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The THSA is governed by a 13-member board, the composition of which is outlined in statute. It is required to be a multi-stakeholder group of individuals who represent consumers, clinical laboratories, health benefit plans, hospitals, regional health information exchange initiatives, pharmacies, physicians, and rural health care providers. The Board’s Chair, Ed Marx and THSA’s Chief Executive Officer, Tony Gilman, and his staff oversee the daily operations. The 2010 THSA board members are:

! Edward W. Marx, Chair: Mr. Marx of Colleyville is chief information officer of Texas Health Resources. He served in the U.S. Army and received a bachelor’s degree and a master’s degree from Colorado State University.

! Kathleen K. Mechler, Vice Chair: Ms. Mechler of Fredericksburg is a registered nurse and co-director and chief operating officer of Texas A&M Health Science Center Rural and Community Health Institute. She served in the U.S. Air Force and received a bachelor’s degree and master’s degree in administration from Texas State University.

! Matthew Hamlin, Treasurer: Mr. Hamlin of Argyle is regional vice president of Quest Diagnostics. He received a bachelor’s degree from Ohio Wesleyan University and a master’s of business administration from George Washington University.

Alesha R. Adamson, Secretary: Ms. Adamson of San Antonio is a member of the leadership team at Open Health Tools. She served in the Oregon Army National Guard and received a bachelor’s degree and a master’s degree in computer science and information assurance from Portland State University.

! Fred Buckwold: Dr. Buckwold of Houston is vice president, medical affairs, for Community Health Choice in Houston. He received a medical degree from McMaster University. He is board certified in Internal Medicine, Infectious Diseases, and Quality Assurance and Utilization Review.

! Raymond F. Davis: Mr. Davis of El Paso is employed by Perot Systems Corporation and serves as chief information officer at Sierra Providence Health Network. He received a bachelor’s degree from the University of Texas at El Paso.

! David C. Fleeger: Dr. Fleeger of Austin is a surgeon at the Central Texas Colon and Rectal Clinic. He received a bachelor’s degree from Baylor University and a medical degree from Texas A&M University.

! Donna Montemayor: Ms. Montemayor of San Antonio is senior director of pharmacy corporate operations for H-E-B. She is a member of the Bexar County Pharmacy Association, Texas Pharmacy Association, and University of Texas Pharmacy Alumni Association. She is also a member of the Texas Federation of Drugstores Board of Directors and National Association of Chain Drug Stores, and is chair of the H-E-B Good Living Expo. Ms. Montemayor received a bachelor’s degree from the University of Texas at Austin.

! Judy Powell: Ms. Powell of The Woodlands is a community volunteer and former chair of the Texas State Board of Professional Counselors. She received a bachelor’s degree from Wesleyan College and attended the University of Tennessee for graduate studies.

! J. Darren Rodgers: Mr. Rodgers of Dallas is president of Blue Cross and Blue Shield of Texas. He received a bachelor’s degree from the University of Georgia, a master’s degree in liberal arts from Duke University, a master’s of business administration from Tulane University, and a master’s degree in dispute resolution from Southern Methodist University.


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! Stephen Yurco: Dr. Yurco of Austin is a partner at Clinical Pathology Associates. He received a bachelor’s degree and a medical degree from Northwestern University, and a master’s of business administration from the University of Houston.

! Dee F. Porter: Ms. Porter of Austin is chief operating officer of the Texas Department of State Health Services. She received a bachelor’s degree from the University of Oklahoma and attended the Oklahoma City University Meinders School of Business. She serves as an ex-officio member on the board.

! Adolfo Valadez: Dr. Valadez of Austin is an assistant commissioner of prevention and preparedness services at the Texas Department of State Health Services. He received two bachelor’s degrees from the University of Texas, a medical degree from the University of Texas Medical Branch at Galveston, and a master’s degree in public health from the Harvard University School of Public Health. He serves as an ex-officio member on the board.

1.2.4 Health Care Policy Council Parallel to, and in coordination with, the work of the HITAC, THCSIP, and THSA, the HCPC, an operating unit of the Governor’s Office, has undertaken a series of planning and policy development activities relating to health IT and HIE. In addition to providing the staffing for the HITAC, THCSIP, and THSA, the HCPC has developed several reports on health IT in Texas, including The State of Health IT in Texas, The Value of Health IT in Texas, and The State Health Information Architecture (a link to this report is included in Appendix H, References and Sources).

1.3 Vision In January 2010, the THSA adopted the following vision statement:

To enhance health care quality and effectiveness for all patients, the health care sector should be supported by an infrastructure made up of interoperable, electronic health records composed of standardized, structured data elements that are exchanged among authorized health care organizations and providers across secure regional and statewide networks.

With the knowledge that some sort of HIE activity is underway in many parts of the state, the Texas vision calls for a network of networks, which calls for linking local HIE networks together, linking local HIE networks to state agencies and ultimately linking the state networks among each other and to the National Health Information Network (NHIN). With this approach, local HIE needs will be met, while state needs will be facilitated by and aligned with federal needs. Stakeholder buy-in and sustainability are generated locally, with the THSA in coordination with HHSC, the state’s agency that administers the Medicaid program, providing statewide standards, operational requirements, accountability measures and additional functionalities to ensure coordinated HIE.

The statewide HIE architecture that emerged from the planning process anticipates that local HIE operations will be leveraged where possible, with certain state-level services developed for providers and patients not affiliated with local HIEs. This will ensure that all Texas providers can achieve the types of HIE necessary for meaningful use and that all Texas residents are able to reap the benefits of HIE. Interoperability in areas without a local HIE such as rural areas can be attained by establishing new local HIE networks, through expanded technology and services available through existing local HIE networks, or through the development of new state-level HIE services contracts.

In order to leverage local HIE activity as much as possible, the THSA will work collaboratively with local HIE initiatives underway in the state, during both the planning and operational stages of local/regional


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HIE development to identify mutually beneficial opportunities for promoting and developing HIE statewide. In addition, the Texas HIE effort will be coordinated with broadband capabilities initiated through a $16 million FCC grant administered by the Texas Health Information Network Collaborative and through other grants for broadband services. The state plans to attain desired economies of scale that make such connectivity cost effective, especially for rural areas.

Figure 1 below illustrates the current and proposed future state of HIT and HIE planning and development in Texas.

Figure 1: State-level HIT and HIE planning and development

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1.4 Guiding Principles The planning and policy development relating to health IT and HIE that has occurred in Texas at the state level over the last several years has been guided by some common principles:

! The patient and consumer should be the focus of all other efforts in health IT. Patient control and ownership of personal health information must be protected and patient privacy must be

Current Activities

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State HIE SystemPlanning (THSA)

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State-level HIE

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Future Vision

Medicaid EHRincentive programEHR EHR EHR EHR EHR EHR EHR EHR EHR EHR

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Local HIE Local HIE

RECsProvider Provider Provider Provider Provider ProviderProvider Provider Provider Provider

MedicaidHIE SystemOperations

(MEHIS)

Medicaid HIEOther state-level

data sources


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respected. Health IT has great potential to benefit health outcomes for consumers but not at the risk of violating personal privacy.

! Market-based solutions should be sought whenever possible. In the case of heath IT, there is a large and growing body of research suggesting that there is economic value to be recognized at every stage in the evolution of the electronic health information infrastructure. With respect to health IT, government participation should generally be limited to catalyzing relevant markets, facilitating collaborations, easing regulatory burdens, and assisting in the appropriate alignment of incentives.

! To the maximum extent possible, Texas will leverage existing resources and coordinate with other health IT and HIE initiatives, such as the Medicaid EHR incentive payment program, other state agency HIE initiatives, HIE initiatives developed and administered by private payers, and local/regional HIE initiatives.

! Regional solutions that fit within the statewide framework should be pursued whenever possible. Every region of Texas is different and should be given the freedom to fit into the emerging electronic health information infrastructure in the most appropriate way.

In addition to these long-standing principles that have guided state-level planning and policy development relating to health IT and HIE in Texas over the last several years, several additional concepts emerged as additional guiding principles during the planning process:

! Support the meaningful use of electronic health records by providers.

! Consumers with special needs (e.g., children in foster care, patients in long term care facilities, and clients with mental illness) also need to be considered as part of a privacy and security framework.

! Improved data collection and information sharing for the purpose of transforming the delivery system and providing more efficient, better quality care by producing meaningful information for all parties involved will be a critical catalyst for the effective improvement of care delivery in a community. With stakeholders routinely producing reports regarding their own data, value is created with HIE by producing valuable information across entities. Examples in which HIE can provide unique information are:

! Utilization reporting: high emergency room users, re-admission rates across stakeholders, and unnecessary use of high-cost services. This data can support the development of community-wide care coordination and other programs targeted at reducing high use of emergency rooms (ERs) and providing care for individuals in more appropriate settings.

! Surveillance reports: outbreaks of communicable diseases and immunization patterns. This data supports public health department efforts to address disease outbreaks, reduce health disparities, target disease prevalence, and track prevention through immunization.

! Analytics reports: historical trending, disease prevalence determinations, co-morbidity impact studies, etc. This data can be useful in identifying and addressing community wide gaps and barriers to service, particularly for vulnerable and uninsured populations.

! HIE design must be flexible to allow for changes in how EHRs are constructed, while adhering to national standards that will facilitate information sharing. Future EHRs will likely aggregate data (allowing input from registries and personal health records), applications (allowing calculations to be done by web services), and presentation (allowing physicians to customize their user interface much like customizing a homepage).

! Conduct business in a transparent manner with public input.


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! With the growing concerns about patient privacy and development of data ‘silos’, the need for building trust and adherence to strong privacy standards will be a core objective of statewide HIE.

! The adoption of HIE should improve patient care, emergency preparedness and response, and public health.

Ultimately, the implementation of the Strategic and Operational plans will promote and coordinate the development of a seamless electronic health information infrastructure to improve the quality, safety, and efficiency of the Texas health care sector while protecting individual privacy. Furthermore, the Strategic and Operational plans will facilitate and expand the secure, electronic movement and use of health information among organizations according to nationally recognized standards. The governance, policy, and technical infrastructure supported through these plans will enable standards-based HIE and a high-performance health care system.

The Strategic and Operational plans support a flexible architecture with services delivered through a “network of networks” linking local and regional HIE networks together, linking local and regional HIE networks to state agencies and ultimately linking the state networks amongst each other and to the NHIN. The “network of networks” model will allow the THSA to provide accountability and oversight while allowing the actual delivery of HIE services to take place at the regional level via leveraging THSA chartered/supported pre-existing and emerging HIEs and the work being performed not only by the Regional Extension Centers (RECs) but also related project work through state agency programs (e.g., Medicaid, public health programs, workforce development, etc.).

Accordingly, the proposed flexible architecture and resulting operational plan will be designed to deliver proper services at the proper constituency level. The following model demonstrates how recommended services in the operational plan will ultimately strive to move provider and patient-centered services closest to the point of actual delivery.

Table 1: State, regional, and local services

State-Level Services “Coordinate/Monitor/Standards”

Regional-Level Services “Technical/Operations”

Local-Level Services “Outreach/Connectivity”

! Define, set standards ! Define, charter regions ! Define HIE characteristics and priority services Measure sustainability ! Measure performance Integration at state level ! Legal and policy State HIE governance ! Record locator services White space coverage ! Gateway to NHIN Provider directory services ! Public health reporting

! Regional governance and operations ! Shared technical services ! Record matching services Rules ! EHR integration operationsData routing and translation ! Consent management ! White space coverage ! Data source integration ! Regional aggregated reporting ! Adherence and connection to uniform state standards

! Obtain consent ! Provider adoption ! Consumer engagement ! Outreach ! Education/training ! Recruitment ! Clinical transformation ! System selection


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1.5 Planning and Implementation Framework The Strategic and Operational plans identify the high-level goals and strategic objectives that will guide the implementation of HIE services in the state. The Strategic and Operational plans include goals and objectives for the following domain-specific requirements:

! Governance: Support a governance process that creates trust and consensus on implementation of the approach for statewide HIE implementation, and provides transparency, oversight, and accountability of HIE to protect the public interest.

! Finance: Texas shall pursue financial sustainability models that do not rely on federal or state grants and can be scaled for use at both the state-level and regional/local-levels.

! Technical Infrastructure: The Texas architecture shall provide technical services for HIE in a secure and appropriate manner, and support protocols and technology standards with applicable and appropriate architecture through THSA oversight and governance to ensure statewide and federal program interoperability (including NHIN) and vendor neutrality.

! Business and Technical Operations: Texas shall have clearly defined roles and responsibilities for the THSA, state HIT coordinator, state agency programs, RECs, and other programs and organizations supporting HIT and HIE in Texas.

! Legal/Policy: Texas shall support a framework that addresses privacy and security requirements for system development and use, data sharing agreements, laws, regulations, and multi-state policy harmonization activities. A priority of the Strategic and Operational plans is to support enabling exchange of health information while protecting consumer privacy and security.

1.6 Priority Areas of HIE The ONC directed that HIEs are required to provide services that allow providers to achieve meaningful use across the entire State of Texas. ONC’s vision focuses on providers adopting certified EHRs that when linked to other providers in an efficient and standard way, will deliver value derived from coordinated care. In setting this direction, the THSA has two clear priorities:

! Ensuring that all providers can access the HIE services that will enable them to achieve meaningful use within Texas

! Establishing HIEs that are sustainable and deliver the HIE services required for all providers to achieve meaningful use

Based on the Program Information Notice issued by ONC in July 2010, the Texas state-level HIE planning process will initially focus on enabling the following elements of HIE:

! Electronic prescribing and refill requests: Providing interoperability to enable electronic prescribing and refill requests will be accomplished through the use of industry-standard protocols. It is anticipated that SureScripts and other appropriate providers will participate in enabling this technology for the TSHA HIE.

! Electronic clinical laboratory ordering and results delivery: Providing interoperability to enable clinical laboratory ordering and results delivery will be accomplished through the use of industry-standard protocols.

! Clinical summary exchange: Providing interoperability to enable clinical summary exchange will be accomplished through the use of industry-standard protocols.


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As the Texas HIE landscape matures, and as the additional levels/stages of meaningful use are defined by the Center for Medicare and Medicaid Services (CMS), the scope of HIE services being provided statewide will be expanded.

1.7 Planning Process In March 2010, the HHSC received an award from ONC for funding through the State HIE Cooperative Agreement Program. The purpose of this program, which was created by American Recovery and Reinvestment Act (ARRA), is to fund state planning and implementation of electronic health information networks to support higher quality, safer, and more efficient health care. Texas’ allotment through this program is $28.81 million over the four years of the program. Of this allotment, Texas used $1 million to develop Strategic and Operational plans to guide the establishment and operation of these electronic health information networks. Texas is eligible to access the remaining $27.81 million for implementation following the approval of the state’s Strategic and Operational plans by ONC.

The HHSC is serving as the fiscal agent for this funding and is partnering with the THSA to develop and implement the HIE Strategic and Operational plans for the State of Texas. The THSA conducted an open and participatory planning process that included consideration of the following:

! An environmental scan to assess readiness for HIE implementation and electronic health record adoption

! The development of state-level HIE policies, including privacy and consent policies, to be implemented as funding conditions

! A well-defined vision with goals, objectives, and strategies for achieving HIE capacity and use

! A legal framework for exchange among local, regional, and statewide HIE

! An approach for coordinating with Medicaid, Medicare and other federally funded programs, including other ARRA programs

! Technical support for building and enhancing local and regional HIE capacity

! A communications strategy to ensure that the Texas health care community is informed of HIE activities across the state, such as the availability of tools to assist physicians and other health care providers with HIT adoption and HIE, and the process for receiving Medicaid electronic health record incentive payments

The THSA established four key stakeholder workgroups to provide input into the development of these HIE Strategic and Operational plans:

! Governance and Finance ! Privacy and Security ! Technology Infrastructure ! EHR Adoption and Consumer Engagement

These workgroups, which included a multi-disciplinary volunteer team of over 160 stakeholder experts, held over 22 meetings and webinars since January—eight public meetings were held in Austin, four in Dallas, four in San Antonio, and four in Lubbock. Through these meetings, key stakeholders were able to collect, discuss, analyze, and discern the necessary information to help develop well-vetted and consensus-based options for the THSA to consider. The following table shows the tasks each workgroup was asked to complete:


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Table 2: Workgroup charters

Governance and Finance Privacy and Security

! Develop a governance model ! Develop related roles and responsibilities ! Develop sustainability models ! Develop implementation priorities

! Develop a policy framework ! Develop options for private and secure exchange of personal health information ! Identify rules/laws/regulations gaps and make recommendations

Technology Infrastructure EHR Adoption and Consumer Engagement

! Develop technology standards ! Develop a vendor-neutral model/architecture ! Develop patient-centric HIE services supporting meaningful use ! Develop interoperability standards

! Support provider adoption of EHRs in collaboration with the Regional Extension Centers ! Identify consumer outreach and communication strategies ! Ensure active consumer engagement in THSA governance

The THSA held public meetings in April, June, July, and August to review the options developed by the workgroups and to provide feedback and direction. Additional information on the workgroup and THSA board meetings can be found online at http://www.thsa.org/events.aspx.

1.8 Challenges The most significant challenge that the THSA will have with HIT and HIE adoption is the sheer number of providers spread out across a state as large as Texas. Rural portions of Texas cover approximately 80 percent of the state’s total area, encompassing 213,302 square miles out of 268,581. Key demographic trends for rural Texas include:

! Slow population growth or population loss ! Low population density ! Increased ethnic and racial diversity ! Larger percentage of the population is 65 or older ! Greater than average poverty ! Shrinking number and coverage of local health departments

According to the United States Census Bureau, the population in Texas grew 23 percent between 1990 and 2000 from 16,986,510 to 20,851,820. During the same time period, the population of rural Texas grew by 12 percent from 2,820,852 to 3,159,940.

As of January 1, 2007, Texas has the largest rural population in the nation with 3,296,378 residents. Most of rural Texas’ population growth (69 percent) between 2000 and 2007 has taken place in rural counties with an urban population of 2,500–19,999 that are also adjacent to an urban area.

Challenges and Barriers in Rural Texas Texas needs to implement a strategy to ensure all eligible providers can exchange health information required under the meaningful use rule. This may be a challenge in some areas, particularly in rural Texas, where additional barriers to sustaining a regional/local HIE exist. Among the most common of these barriers cited in the literature are:

! Limited number and size of practices and hospitals; ! Lack of vendor interest in serving these areas;


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! Insufficient access to financing; ! Limited broadband connectivity; and ! Inadequate health IT workforce.


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2. Environmental Scan: Assessment of Current HIE Implementation and Readiness

2.1 Introduction Texas, as the second largest state in terms of geographic area as well as population, with 25.5 million residents, represents a broad range of geographic and cultural (population) diversity which carries forward into health care delivery and ultimately into the progression of HIE development across the state. Perhaps the diversity and regional variation can be better depicted by the understanding that over 50 percent of the 254 counties in Texas meet the federally recognized standards for rural designation and share the characteristics and challenges faced by rural communities elsewhere. On the other hand, five of the major urban Medical Trading Areas (MTAs) meet and/or exceed populations of 25 states across the country. Additionally, Texas shares the longest international border (Mexico) of any state, further differentiating its unique characteristics and diversity as well as adding a level of complexity to development of an optimal HIE solution.

To better understand the HIT landscape in this complex environment, the THSA has conducted an HIE assessment, collaborated with other ARRA HIT award recipients to develop a provider survey, and drawn additional information from other relevant sources. This environmental scan organizes the THSA’s findings into sections on the HIE assessment, physician adoption, and hospital adoption. There is also a section on alignment with the Program Information Notice (PIN) that takes a closer look at the utilization of specific HIE functions.

2.2 Health Services in Texas Texas’ geography and population distribution have contributed to the development of diverse regional health care delivery systems. These systems can be represented in part by the distribution of population and providers, but also through a surprising diversity of referral regions that occasionally divide population centers and extend far beyond the borders of the state.

Texas’ population, providers, and hospitals are concentrated in a few regions around the state including two of the country’s ten most populous metropolitan statistical areas: Dallas–Fort Worth and Houston–Baytown–Huntsville.

Figure two shows that most densely populated counties are located in the eastern and central portions of the state. The vast southern and western regions host several densely-populated counties including parts of the Rio Grande valley, El Paso, Midland–Odessa, Lubbock, Amarillo, and San Angelo. However, unlike the eastern and central population centers, south and west Texas cities may be separated by hundreds of miles of sparsely populated counties.


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The following map shows the population density across the state of Texas.

Figure 2: Population density by county

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Physician and hospital density largely follows the same pattern of distribution as the state’s population. Figure 3 shows that urban counties have a high density of physicians, while 25 counties, all with fewer than 10,000 residents, do not have a physician presence.

Figure 3: Physician density by county

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Hospitals are also concentrated in cities and urban counties, while 65 low-population counties do not have a hospital. The following map shows the density of hospitals across the state of Texas.

Figure 4: Hospital density by county

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