State Health Information Exchange Cooperative Agreement Program

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1 State Health Information Exchange Cooperative Agreement Program The National Landscape North Dakota HIT Summit November 29, 2011

2 State HIE Program Overview The State HIE Program has provided $548 million in grants to 50 states, the District of Columbia and 5 U.S. territories. Funding is targeted at enabling health data to be exchanged electronically first as simple, secure messaging via and in a more robust way in the future. The resulting data liquidity, coupled with the use of state regulatory and policy levers to encourage electronic data exchange, is targeted at long-term quality improvement and transformation of the health care delivery system in the United States. The Office of the National Coordinator has multiple programs underway to support this effort and meet the objectives of the Health Information Technology for Economic and Clinical Health Act (HITECH) Act. 11/30/2011 Office of the National Coordinator for Health Information Technology 1

3 HITECH: How the Pieces Fit Together Regional Extension Centers Medicaid EHR Program 1 st Year Incentive Workforce Training Medicare and Medicaid EHR Incentive Programs State Grants for Health Information Exchange Medicaid Administrative Funding for HIE Standards & Certification Framework Privacy & Security Framework ADOPTION MEANINGFUL USE EXCHANGE Health IT Practice Research Improved Individual & Population Health Outcomes Increased Transparency & Efficiency Improved Ability to Study & Improve Care Delivery 2

4 Federal Health IT Strategic Plan

5 National Quality Strategy Aims Better Care: Improve quality, by making health care more patient-centered, reliable, accessible, and safe Healthy People and Communities: interventions to address behavioral, social and, environmental determinants of health Affordable Care: Reduce cost of quality health care National Quality Strategy 4

6 National Quality Strategy Six Priorities to help focus community, state and federal efforts: Safer Care: eliminate preventable health careacquired conditions Effective Care Coordination Person- and Family-Centered Care Prevention and Treatment of Leading Causes of Mortality: start with cardiovascular disease Support Better Health in Communities Make Care More Affordable National Quality Strategy 5

7 erx Everywhere States are currently identifying and closing gaps in erx adoption among pharmacies and prescribers by: Leveraging Surescripts data and combining it with other data sources to monitor progress. Increasing erx adoption by pharmacists and prescribers through outreach and incentives. Deploying policy strategies to encourage adoption and use. 11/30/2011 Office of the National Coordinator for Health Information Technology 6

8 Why eprescribe? eprescribing (erx) is safer. It is estimated that a switch to erx could prevent as many as 2 million adverse drug events annually, 130,000 of which are life-threatening. erx could create a cost savings of $2.7 billion a year for physicians in wasted phone time. And, potentially, the U.S. Health Care System could save as much as $27 billion per year. (Source: Agency for Healthcare Research and Quality) 11/30/2011 Office of the National Coordinator for Health Information Technology 7

9 e-prescribing Data Source Surescripts is the leading e- prescription network in the United States. Data on providers and pharmacies are available quarterly. Market presence may vary in certain territories/states. Enabled pharmacy Active pharmacy Connected to the Surescripts network Has processed at least one electronic prescription in the last month 11/30/2011 Office of the National Coordinator for Health Information Technology 8

10 Physicians e-prescribing using an EHR - Nationwide 300,000 *on the Surescripts Network 250, , , , ,000 50,000 4,602 0 Dec-06 Feb-07 Apr-07 Jun-07 Aug-07 Oct-07 Dec-07 Feb-08 Apr-08 Jun-08 Aug-08 Oct-08 Dec-08 Feb-09 Apr-09 Jun-09 Aug-09 Oct-09 Dec-09 Feb-10 Apr-10 Jun-10 Aug-10 Oct-10 Dec-10 Feb-11 Apr-11 Jun-11 Aug-11 Oct-11 Source: Surescripts

11 Office-Based Physicians e-prescribing Using an EHR on the Surescripts Network October *Denominator of office-based physicians from SK&A data, June 2011

12 Pharmacies Enabled to e-prescribe & Actively Processing e-prescriptions Percent Enabled Percent Active Data Source: Surescripts /30/2011 Office of the National Coordinator for Health Information Technology 11

13 Implementation Issues Chain Pharmacies are enabled and active. So what s the problem? Real World Issues Cost barriers for small, independent pharmacies Hardware Transaction Fees Limited Internet Access Concerns about Front of Store sales Technical Interoperability Issues Change to workflow for prescribers and pharmacists Semantic Interoperability (use of a common vocabulary) System-to-System interoperability issues 11/30/2011 Office of the National Coordinator for Health Information Technology 12

14 State Policy Initiatives - California California leveraged Medi-Cal 90/10 administrative funds to support statewide education and outreach. Approaches include focused outreach and technical assistance to independent pharmacies through the Partners in e train-the-trainer program. This program works with California schools of pharmacy and through Regional Extension Centers for collaboration and the deployment of fourth-year pharmacy students trained by the Partners in e program. 11/30/2011 Office of the National Coordinator for Health Information Technology 13

15 State Policy Initiatives - Tennessee In 2008 and 2009, the State of Tennessee awarded approximately $4.68 million in grants to prescribers throughout the state to purchase CCHIT certified e-prescribing software and any necessary hardware. In 2008, Tennessee began a partnership with the Tennessee Pharmacists Research and Education Foundation (TPREF), the educational arm of the Tennessee Pharmacists Association. Through a $675,000 grant to TPREF that remains active to this day, pharmacies are eligible to receive up to $3,500 towards any expense related to e-prescribing. Pharmacies benefiting from the grant must continue to accept e-prescriptions for five years. 11/30/2011 Office of the National Coordinator for Health Information Technology 14

16 State Policy Initiatives - Nebraska Nebraska has an active E-Prescribing Work Group which includes a broad range of stakeholders. The E-Prescribing Work Group is working to foster conversations between pharmacists and prescribers about the e-prescribing process. Better understanding of the process may lead to a reduction in some e- prescribing errors, a reduction in the number of redundant e- prescriptions, and better communication between pharmacists and prescribers. The Nebraska Health Information Initiative (NeHII) is also offering services to pharmacies. Pharmacies currently participating in NeHII are finding that having access to patient health information helps in counseling patients, identifying prescribers with illegible hand writing, updating patient allergy information, entering immunization information, and obtaining documentation for durable medical equipment billing. 11/30/2011 Office of the National Coordinator for Health Information Technology 15

17 What is Direct? Secure Directed Exchange via the Internet The Direct Project specifies a simple, secure, scalable, standards-based transportation mechanism that enables participants to send encrypted health information directly to known, trusted recipients over the Internet. Simple. Connects healthcare stakeholders through universal addressing using simple push of information. Secure. Users can easily verify messages are complete and not tampered with en route. Scalable. Enables Internet scale with no need for central network authority that must provide sophisticated services such as EMPI, distributed query/retrieve, or data storage. Standards-based. Built on well-established Internet standards, commonly used for secure communication; i.e.,. SMTP (or XDR) for transport, S/MIME for encryption, X.509 certificates for identity assurance 16

18 Why is Direct needed? To provide an alternative to legacy mechanisms When current methods of health information exchange are inadequate: Communication of health information among providers and patients still mainly relies on mail or fax Slow, inconvenient, expensive Health information and history is lost or hard to find in paper charts Current forms of electronic communication may not be secure Encryption features of off-the-shelf clients not often used in healthcare communications today Physicians need to transport and share clinical content electronically in order to satisfy Stage 1 Meaningful Use requirements Need to meet physicians where they are now 17

19 Why is Direct needed? To facilitate Meaningful Use Direct Project facilitates the communication of many different kinds of content necessary to fulfill meaningful use requirements. Examples of Meaningful Use Content D I R E C T Being shared through Direct implementations today Patients: Discharge instructions Clinical summaries Reminders Other Health information Public Health: Immunization registries Syndromic surveillance Laboratory Reporting Other Providers/Authorized Entities: Clinical information Labs test results Referrals and other transitions in care summary of care record 18

20 How does Direct fit in with other types of exchange? The Direct Project provides HIEs with a low cost way to enable simple push messaging to their healthcare constituents The Direct Project doesn t replace other ways information is exchanged electronically today, but it might augment them The Direct Project supports simple use cases in order to speed adoption, but other methods of exchange might be suited for other scenarios, e.g., simple provider referrals vs. real-time population health statistics The Direct Project was designed to coexist gracefully with existing protocols for data exchange, e.g., web services, client-server, etc. The Direct Project seeks to replace slow, inconvenient, and expensive methods of exchange (e.g., paper and fax) and provide a future path to advanced interoperability. The Direct Project specifications will be incorporated into the Nationwide Health Information Network Nationwide Health Information Network Exchange Nearby HIE Health information exchange: a puzzle with many pieces Direct Project EMR to EMR (HIE) 19

21 What are the key issues to Challenges think about? Lowered exchange costs may encourage more health systems to go it alone? National exchange participants may compete for simple exchange capabilities? Balancing State HIE goals with FTC Fair Information Practice (FIPs) guidelines? Strengths Offers connectivity for rural providers, local labs, State hospitals, etc. Services offered through state exchange or federated with community and regional exchanges Lowers the cost of providing MU transactions May help support comprehensive state-level interoperability Opportunities Provides standards-based migration paths for providers Fills in the gaps in coverage with national exchange partners The commoditization of secure routing through the Direct Project does not threaten existence/ business case of comprehensive state HIE efforts, as many states have long term plans for comprehensive interoperability solutions that can be layered over Direct Project 20

22 What is needed to implement Direct? Participant Perspective Create an account with a Health Information Services Provider (HISP): Provides a Direct Address, e.g., Obtains and often manages a security certificate (may be provided by an independent Certificate Authority ) Manages HIPAA-level security by, for example: Providing pass-through routing of encrypted documents, or Encrypting documents on participant s behalf, through a business agreement Directed Exchange Participants, e.g., Physicians, Labs, Registries, etc. Use a Direct-enabled client for sending and receiving Direct messages, e.g.,: Direct-enabled client, e.g., Outlook or Webmail Direct-enabled EHR Web portal, often powered by the HISP Obtain the Direct addresses for other healthcare participants with which to exchange clinical data: Participants can be providers, labs, PHRs, state agencies, etc. Obtain Direct address through in-band mechanism (e.g., provider directory) or out of band mechanism (e.g., phone) Provider directories not required but certainly add value Messages between participants must be sent to/from Direct addresses 21

23 What is needed to implement Direct? Healthcare Community Perspective Direct functionality can be enabled for community members through different approaches Healthcare Communities, e.g., States, SDEs, Beacons, etc. 1. Encourage market-based solutions by establishing parameters for trust Create a conducive environment for market-driven solutions through enabling policies, certification criteria, etc. Leverage other HIE services, e.g., directories 2. Offer complete set of services to all community members Can use RFP process or other mechanism to select or set up HISPs and/or Certificate Authorities Need to think through how market-driven solutions can participate 3. Fill in the gaps by providing services to under-served participants, e.g., rural and remote providers and labs Different approaches can be adopted for different components of Health Information Exchange in the same community, including: Meaningful Use objectives, e.g. transitions of care, reporting to public health and immunization registries, etc. HIE architectural components, e.g., HISPs, Certificate Authorities, Provider Directories, etc. 22

24 Where is Direct implemented today? Direct Project is being demonstrated in real-world pilots across the country VisionShare (MN) MedAllies (NY) Rhode Island Quality Institute (RI) Redwood MedNet (CA) Medical Professional Services (CT) VisionShare (OK) CareSpark (TN) 23 Direct Project is architected for rapid adoption by: Thousands of hospitals Hundreds of thousands of physicians Millions of providers Tens (or hundreds?) of millions of patients Many other stakeholders in healthcare

25 Where is Direct implemented today? Example: MN Immunization Registry Objectives: To demonstrate the use of Direct Project communication protocols, security model, and addressing mechanism to securely submit immunization data from providers into a state immunization information system To demonstrate user story: Primary care provider sends patient immunization data to public health Participants: HISP: VisionShare Direct Project Source: Hennepin County Medical Center. Others TBA. Direct Project Destination: Minnesota Department of Health (MDH) Deployment Model: Direct Project Source System: Hospital EHR Direct Project Destination System: Immunization Information System (IIS) Key System Components: Reuse of existing PNHIMS infrastructure Key Milestone: As of January 12, 2011 Hennepin County Medical Center is sending production immunization data to the MDH immunization registry as described above. 24

26 Where is Direct implemented today? Example: NY - Summary Care Records Objectives: To demonstrate Direct Project User Stories, including (but not limited to): Primary care provider refers patient to specialist including summary care record Specialist sends summary care information back to referring provider Hospital sends discharge information to referring provider Provide advanced support to clinicians through enabling of proactive delivery of clinical information to other providers for patient care. Participants: HISP: MedAllies Direct Project Participants (Hudson Valley): Various eclinicalworks practices representing 100s of physician deployments Several larger physician practices utilizing NextGen Half dozen hospitals with disparate inpatient EHRs and HISs Integration Partners: eclinicalworks, Greenway Medical, Siemens, EPIC, Allscripts, NextGen Healthcare, Kryptiq Deployment Model: Messaging mechanism: EHR-to-EHR (Hospital-Provider, Provider-Provider) Key System Components: SMTP backbone, XDR protocol Key Milestone: Aim to support Patient Centered Medical Home by March/April

27 Where is Direct implemented today? Example: Connecticut Heterogeneous IT Environment Objectives: To demonstrate the feasibility of using Direct protocols to connect and securely share clinical information among a diverse group of provider settings with a heterogeneous set of HIT tools To demonstrate five Direct Project User Stories, including: Primary care provider refers patient to specialist including summary care record Primary care provider refers patient to hospital including summary care record Specialist sends summary care information back to referring provider Hospital sends discharge information to referring provider Laboratory sends lab results to ordering provider Participants: HISPs: MedPlus, Microsoft, eclinicalworks, Covisint End-Points: Microsoft HealthVault, Care360, Quest, eclinicalworks, DocSite, Middlesex Hospital Others: The Kibbe Group, American Academy of Family Physicians, Community Health Center Deployment Model: Messaging mechanism: EHR-to-EHR, EHR-to-PHR, EHR-to-Portal, EHR-to- (among practices, hospitals, and labs) Key System Components: DNS for HISP resolution and certificate discovery, SMTP backbone using S/MIME Key Milestone: improve quality of care across a heterogeneous delivery system to support ACO goals and outcomes. 26

28 Q&A Lee Stevens Director, State HIE Policy Office Office of the National Coordinator for HIT 11/30/2011 Office of the National Coordinator for Health Information Technology 27

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