Rhode Island Health Information Exchange Strategic and Operational Plans

Transcription

1 Rhode Island Health Information Exchange Strategic and s Approved by the Rhode Island Quality Institute Board of Directors on July 7, 2010 Submitted to the Office National Coordinator July 9, 2010 Modified and resubmitted August 6, 2010 Modified and revised on November 18, in Response to ONC Comments dated September 24, 2010

2 Table of Figures... 6 Executive Summary... 7 Strategic Plan Introduction Environmental Scan Clinical Network Readiness Administrative Readiness E-Prescribing Readiness Other Statewide Readiness Health Information Exchange (HIE) Development and Adoption HIE Mission, Vision, Goals and Objectives HIE Development and Adoption Strategies Strategy for Continuous Quality Improvement of Care Coordination and Meaningful Use of HIT Health Information Technology Adoption EHR Adoption E-Prescribing Adoption Coordination with State Government Coordination with Public Health, Medicaid and other State and Federally Funded Programs Public Health Collaboration Medicaid Collaboration Other Government-Funded Programs: Participation with Federal Care Delivery Organizations Coordination with other ARRA and ONC Programs Governance Building a History of Collaborative Governance Governance Model: Membership Representation and Structure Governance Model: Decision Making Authority Alignment with Emerging NHIN Governance Rhode Island HIT Coordinator Transparency Applicable Policies November 18, 2010 Page 2

3 Interoperability Standards Community Involvement Accountability Finance Management of Resources Sustainability Challenges for Sustainability Technical Infrastructure Technical Architecture / Approach Business Overview Technology Overview Detailed view of Data Submission and Retrieval Future Vision Technology Overview Interoperability Meaningful Use Business and Technical Operations Implementation Project Management Leveraging Existing HIE Capacities and Services Legal/Policy Analysis of State and Federal Law Privacy and Security Framework Ongoing Compliance and Legal Review Oversight of Information Exchange and Enforcement Introduction Coordination with ARRA Programs Rhode Island Regional Extension Center (RI REC) Workforce Development Availability of Broadband Coordination with Other States Environmental Scan Project Management Project Management Methodology November 18, 2010 Page 3

4 2.6 Risk Assessment Governance Stakeholder Representation Finance Sustainability Cost Estimates and Staffing Plans Controls and Reporting Community Outreach and Marketing Technical Infrastructure Standards and Certifications Modularity, Data Portability, Reuse, and Vendor Transitions Architecture and Approach Technology Deployment Business and Technical Operations Leveraging Current HIE Capacities Enrollment and Recruitment Using State-Level Shared Services and Repositories Standard Operating Procedures for HIE Resource Management Legal/Policy Established requirements Privacy and Security Coordination Attachments A. Gap Analysis and Strategy B. Clinical Laboratory Survey Summary C. CHC HIE Survey Summary D. Hospital HIE Survey Summary E. Business Case for HIE F. Physician HIT Survey Summary G. RI Governor s Letter for SDE H. Letters of Support I. currentcare Funding Model J. HIE Act of November 18, 2010 Page 4

5 K. RIQI Policies Inventory L. Technical Roadmap N. Meaningful Use Coordination Template O. NHIN Direct Pilot Solution Architecture P. NHIN Direct Pilot Requirements November 18, 2010 Page 5

6 Table of Figures Figure 1 - Meaningful Use Measures Figure 2 Savings Impacts Figure 3 - AHRQ Funding Figure 4 - MTG Funding Figure 5 HIE Timeline Figure 6 - RIQI Governance Committees Figure 7 - Stakeholders Figure 8 - Current RIQI Policies Figure 9 - Value Creation Estimates Figure 10 - Allocation of Value Figure 11 - Sources of Funding Figure 12 - HIE Programs Figure 13 - Key Implemented Components Figure 14 - Data Submission Figure 15 - Data Retrieval Figure 16 - Future Vision Figure 17 - NHIN Direct Pilot Solution Architecture - Point-to-Point Use Case Figure 18 - NHIN Direct Pilot Solution Architecture - System-to-System Use Case Figure 19 - Results Delivery Options... Error! Bookmark not defined. Figure 20 - Provider Directory Project Mapping Figure 21 - Vendor Partners Figure 22 - Status Report Template Figure 23 - Requirements Template Figure 24 - Federal Law Analysis Figure 25 - State Law Analysis Figure 26 - Privacy Framework Crosswalk Figure 27 Broadband Availability Figure 28 - Escalation Paths Figure 29 - Risk Assessment Figure 30 - Stakeholder Participation Figure 31 - Key Committees and Governing Entity Roles Figure 32 - Budget Summary Figure 33 - Personnel Costs... Error! Bookmark not defined. Figure 34 - Operating Dimensions Figure 35 - Organizational Chart November 18, 2010 Page 6

7 Executive Summary By all accounts, the U.S. health care system is facing unprecedented challenges. In a 2000 World Health Organization study, the U.S. health care system ranked 37 out of 191 nations in health system performance, placing us behind Costa Rica and just ahead of Slovenia. The U.S. spends more than twice per capita than any industrialized nation, yet our outcomes do not justify the expenditure. Many ideas for reform of the system are being advanced nationally such as the Patient- Centered Medical Home model of primary care delivery, public reporting of outcomes, application of evidence-based medicine, and pay-for-performance systems. Yet, virtually none of these reforms can reach their full potential as long as health care remains mired in a paperbased system and decades behind other industries in the effective use of information technology. The Economist magazine ranked health care second only to mining in lack of capital expenditures devoted to information technology ( While health IT alone isn t the answer to the problems in health care, it is an essential foundation for almost all other promising reforms. Health information technology s real value is as a key enabler in the improvement of health care quality, safety, and value. Rhode Island sees tremendous opportunity in assuring that health information is available where it s needed, and when it s needed to produce the most benefit for the individual and the population as a whole. We have committed to work together to do whatever is necessary to bring this vision into reality. The fragmentation of the health care industry creates significant difficulties in the effort to deliver safe, high quality and cost-effective care. Patient information must be obtained from multiple sources, which are not easily accessible to the provider or to the patient due to a lack of a clear and comprehensive record that is electronically available. Enabling the change to create exchange of information first requires that providers implement and can meaningfully use electronic health records (EHRS) and secondly requires that the information can be shared and utilized across systems to better care for both the individual patient and the larger patient population. Rhode Island s approach to health information exchange focuses first on leveraging exchanges that promote Meaningful Use and improve care at the point of service such as laboratory results delivery, electronic prescribing and clinical summary exchange. Concurrently, currentcare, the state s Health Information Exchange (HIE) will organize the health information of the state s population in an information hub, reducing the fragmentation of health information in the state and promoting improved health and healthcare delivery. By facilitating the authorized exchange of clinical data, currentcare supports the nation s goals of safe, timely, efficient, effective, equitable, patient-centered care. The Operational plan will integrate the foundational strategies for both of these activities that will permit the benefits of the HIE be fully recognized. November 18, 2010 Page 7

8 The many benefits of implementing a health information exchange include Referral visits and emergent care will be conducted with relevant information in hand. Patients with chronic conditions who visit multiple providers will benefit from the availability of their health information across their care continuum. Records will electronically follow patients who move from place to place. Quality of health care, together with cost savings, will be improved. Many medical errors resulting from a lack of access to patient information will be avoided. Cost saving due to avoidance of duplicative testing and medical procedures A life-long longitudinal record of clinical data will be constructed for all Rhode Island citizens who agree to participate in the HIE. Consumers will have access to information they need to better manage their health With patient permission and the approval of the RI Department of Health, data can be used to improve the performance of the health care system and to conduct research that serves the public s interest. In Rhode Island, the Rhode Island Quality Institute (RIQI) was officially designated as RI s Regional Health Information Organization (RHIO) by the state government and is the ARRA State-Designated Entity (SDE) for the statewide HIE to coordinate and expand HIE activities across the state. RIQI has also been awarded both the Regional Extension Center and the Beacon Communities grants. RIQI has previously engaged in the leadership and coordination of large-scale HIE initiatives i.e., the Agency for Healthcare Research and Quality State and Regional Demonstrations in HIE project as well as efforts to support and accelerate healthcare providers efforts to adopt and effectively use Electronic Health Records (EHRs). RIQI is well-positioned to continue to advance all of these initiatives. This document represents the Strategic and Operational plans which represent the blueprint for the state s efforts to achieve the mission of significantly improving the quality, safety, and value of healthcare in Rhode Island. November 18, 2010 Page 8

9 Strategic Plan 1.1 Introduction Founded in 2001, the Rhode Island Quality Institute (RIQI) is a collaboration of leaders in the Rhode Island (RI) community who share a vision of a transformed healthcare system in the state. The collaboration includes consumers, consumer advocacy groups, integrated delivery systems and community hospitals, health insurers, physicians, professional associations, the Medicare Quality Improvement Organization, behavioral health professionals, community health centers, skilled nursing and long term care facilities, employers, academia, and RI state government, including past and present Lt. Governors, Medicaid, Human Services, Public Health and the RI Health Insurance Commissioner. RIQI s mission is to significantly improve the quality, safety, and value of healthcare in Rhode Island. The organization is comprised of people with very different viewpoints some even fierce competitors, yet we consistently reach consensus on some very tough issues. It is RIQI s belief that only by embracing different interests and working together can we significantly improve health care in the state. RIQI represents every constituency of health-care leadership, as well as health insurance, consumer and public interest. RIQI works collaboratively, comes up with innovative solutions, champions changes throughout the organization, and dedicates time, money, and expertise to improve the quality of health care in Rhode Island. Envisioning the value of a health information exchange (HIE) and its powerful impact on healthcare delivery, in 2004 RIQI asked the RI Department of Health (HEALTH) to take the lead in an application for federal funding for HIE. HEALTH, in collaboration with RIQI, applied and received funding from the Agency for Healthcare Research and Quality (AHRQ) on behalf of the RI community. RI became one of six states nationally to be awarded a $5 million, six-year State and Regional demonstration project in Health information technology contract to integrate patient health data from various healthcare organizations and make it accessible to authorized healthcare providers. In 2007, through a competitive bid process by the state of Rhode Island, RIQI won the official designation as the single Regional Health Information Organization (RHIO) for RI. Having been successful with the operational, governance and financial responsibility per the original AHRQ contract RIQI was also designated to be RI s HIE beyond the demonstration project. During the AHRQ project, RIQI, HEALTH, and community leaders worked highly collaboratively to manage this project and to design and build the business, policy and technical infrastructure for currentcare. The demonstration project, originally scheduled to close in June 2010 has been extended to June HEALTH and RIQI worked closely together to transition the November 18, 2010 Page 9

10 technical infrastructure developed as part of the AHRQ grant to RIQI and on September 30, 2010 RIQI assumed all accountability for completion of the technical build and implementation of the HIE and the infrastructure beyond the demonstration scope, expanding it as the platform supporting the transformation of healthcare in RI. This plan will build on the significant progress that has been made in developing RI s HIE. Several project components have been planned and executed successfully, such as governance, community and consumer engagement, regulatory and policy development (including a consumer oriented opt-in approach which permits patients to actively choose whether to enroll in the HIE, as well as designate who can access their data), marketing strategies to enroll Rhode Islanders, and long term sustainability. RIQI will continue to work collaboratively with key stakeholders to strengthen and integrate multiple existing and developing initiatives for the advancement of HIT. November 18, 2010 Page 10

11 1.2 Environmental Scan The environmental scan is an assessment of HIE readiness within the State of Rhode Island. The scan discusses the readiness of the clinical network, currentcare s support of clinical information exchange, clinical laboratory ordering and results delivery, public health reporting (i.e., immunizations), e-prescribing, quality reporting and the readiness of the administrative network to support eligibility, and claims transactions. Health IT resources that are currently being used in Rhode Island are discussed in the HIT Adoption section of the Strategic Plan. The results of the environmental scan have been used to create a gap analysis which includes the development of a strategy and work plan to address the gaps in HIE capabilities. The Gap Analysis can be found in Attachment A. Specifically, the following measures have been included in the assessment and will be addressed in the appropriate section of the environmental scan. % pharmacies accepting electronic prescribing and refill requests % clinical laboratories sending results electronically % health plans supporting electronic eligibility and claims transactions % health departments receiving immunizations, syndromic surveillance, and notifiable laboratory results There are a variety of surveys that RIQI or other key stakeholders have conducted prior to this plan and as a result of this plan. The need for these were identified by the governing body of RIQI and its stakeholders and results are openly shared with RIQI s stakeholders including but not limited to those responsible for Medicaid, Medicare, Department of Health and other federal and state program leaders Clinical Network Readiness Laboratories Electronic clinical laboratory ordering and results delivery in RI is becoming increasingly available to physicians and providers in RI. Several clinical laboratories in the state are actively supporting electronic clinical laboratory ordering and results delivery as a subset of HIE activity. Others are beginning to implement these services. One of the state s largest private clinical laboratories provides EHR interfaces, as well as a laboratory results web viewer for providers without EHRs. Laboratories operated by several of the state s hospitals and hospital systems have also implemented interfaces with numerous EHRs, and they support web viewers for affiliated providers to access its patient records. Additionally, HEALTH s Laboratory has implemented electronic laboratory ordering and results delivery to this hospital network, and will be interfacing with the newly implemented EHR at the Department of Corrections. While the multiple interfaces have been necessary prior to a functional HIE in Rhode Island, many November 18, 2010 Page 11

12 recognize the expense and duplication associated with this proliferation and look to the HIE to address this in the short and long term. A survey of state licensed and hospital clinical laboratories in RI revealed that 50% of laboratories are able to receive orders electronically and 50% are able to electronically transmit results (70% response rate; 12/17). 80% (5/12) of the large labs were able to transmit results electronically with only one of all the labs offering a standards-based interface. A full summary report can be found in Attachment B. A separate survey, of 13 out of 15 hospitals in RI, (i.e., 7 of 9 hospital systems) shows that none of the hospitals are able to handle orders at this time, although 69% anticipate having the ability to handle orders in the near future. In contrast, 54% of hospitals are fully implemented to send laboratory results electronically and 31% of the hospitals are partially implemented [see Attachment D Hospital HIE Survey Summary]. The larger systems hospitals still need to focus on transmitting results outside their systems. There is a need to identify solutions that facilitate direct receipt of clinical laboratory results into the structured data fields in the clinicians EHR. Specifically, there is a greater need for this type of point to point delivery in smaller practices that are not part of a larger system. Existing HIE currentcare Supported by the AHRQ HIT demonstration contract funding awarded to HEALTH, the technical infrastructure for the statewide HIE currentcare has been developed. currentcare supports a broad range of clinical and administrative data types (both structured and unstructured data), integrates information from data sharing partners (DSPs), and will enable population-based analyses for purposes of accomplishing select public health and other appropriate quality improvement and health services research objectives, as permitted by consumers and HEALTH. The Physician Advisory Panel (now integrated into the Health Information Technology Physician Advisory Council (HIT-PAC)) was asked to prioritize the sequence in which data types are made available in currentcare. The Panel ranked laboratory and medication history data as priority. This data set aligned well with the clinical focus of the AHRQ contract requirements and immediate needs of the provider community at large. The next phase of the project includes expansion to new DSPs and inclusion of additional data types. Enrollment in currentcare has begun with over 100,000 individuals enrolled in the HIE as of the September It is expected that over 100,000 individuals will be enrolled when the system goes into production which is anticipated to be no later than the first quarter of LEAP Additionally, RIQI has gone live with another proof of concept pilot to capture and exchange clinical summary data, aggregated from electronic health records (EHRs) in individual providers offices. This pilot, the Limited EHR Aggregator Project (LEAP) includes a community health center and a community hospital; a patient portal may be developed in the next phase of the EHR aggregation work. EHR aggregators will provide additional data types for the HIE and will support Meaningful Use as defined by CMS. Current exchange between the EHR and the November 18, 2010 Page 12

13 aggregator support the Continuity of Care Record (CCR) current medications, medical history, allergies, surgical history, hospitalizations, family history, social history, vitals, assessments marked into Problem Lists, reviewed labs, reviewed diagnostic imaging, immunizations, procedure codes, and patient demographics. Immunizations and Reportable Diseases Electronic public health reporting (immunizations, notifiable laboratory results) varies across HEALTH. HEALTH s nationally known integrated child health information system, KIDSNET links data from eight separate child public health programs (vital records, developmental newborn screening, newborn hearing screening, newborn metabolic screening, early intervention, home visiting and lead screening, and a childhood immunization registry), and provides the information to providers through a web viewer. KIDSNET receives approximately 50% of childhood immunization records electronically through billing data or interfaces with EHRs. Currently, 99.5% of RI physicians who provide immunizations for children are participating in KIDSNET. Immunizations are currently the only electronic submission that HEALTH is able to obtain. HEALTH is in the very early planning stages for implementing electronic reporting of communicable diseases from provider offices directly to HEALTH. Electronic syndromic surveillance is available in 9 of 11 hospitals. HEALTH has worked with the Health Center Controlled Network to electronically report symptoms of influenza and other conditions from an EHR, thus enabling early recognition of health related issues. This capability is in the EHR but does not yet support electronic transmission, nor is it available in all ambulatory settings. However, the department realizes the value of this reporting and its ability to influence education and treatment options and will continue to explore options to allow electronic syndromic surveillance. HEALTH was also able to use retail pharmacy medication data as an additional surveillance tool which helped them monitor potential outbreak area and educate clinicians regarding appropriate treatment options. The HIE has the capacity to combine both types of data for even stronger surveillance and reporting capability. Community Health Centers As a part of Rhode Island s environmental scan a survey was sent to all Community Health Centers (CHC) to assess their level of adoption and HIE capacity. The survey was sent to the Chief Information Officers (CIO) or similar executive level positions at the health center. The response rate was 91% with ten of eleven CHCs responding. One center has nine sites, five Centers have 2-4 sites and four are just one site. Of note, responses received indicate that all CHCs have either implemented an EHR or plan to implement an EHR (already purchased). While EHRs are in place, only a small percentage of CHC respondents are exchanging information via an interface; most exchange to and from external hospitals and specialists consultants is still occurring via fax. It is anticipated that coordination of efforts with the RI Regional Extension November 18, 2010 Page 13

14 Center will facilitate the centers in moving towards full exchange. The high level of EHR deployment and planned deployment demonstrates the commitment and forward thinking of the CHCs in Rhode Island. A full summary of results can be found in Attachment C CHC HIE Survey Summary. Hospital Systems A similar survey was sent to all hospital systems CIOs to assess each hospital s level of adoption and HIE capacity. To date, 78% of surveys sent were returned covering 87% of the RI hospitals. Of those responding, 77% of the hospitals have a fully implemented EHR and 8% are partially implemented. In regards to electronic health information exchange with referring physician affiliates, 54% of RI hospitals responding have implemented outbound electronic interfaces to distribute diagnostic test results to external EHR systems operated by practices of affiliated physicians not employed by the hospital. A full report of the findings can be found in Attachment D Hospital HIE Survey Summary. For comparison of RI hospital EHR adoption rates to national peers, a review of the Q1/2010 Health Information Management Systems Society (HIMSS) Analytics EMR Adoption Model (EMRAM) report by state reveals a mean EMRAM score of for Rhode Island s 11 hospitals that were evaluated. This compares favorably to the mean EMRAM score of for the entire New England Region and the national mean EMRAM score of for all US hospitals in the same time period. Two hospitals in RI have achieved Stage 6 EMRAM score. RI will continue to pursue obtaining data from those who have not yet responded and use this combined data to inform their marketing and planning as they move forward to implement the HIE to determine where risks and or benefits to facilitate the process can be gained Administrative Readiness As the SDE for HIE, RIQI intends to support healthcare providers in achieving administrative and revenue cycle efficiencies. Electronic eligibility and claims transactions from public and private health insurers in the state are being planned for the future. The RI Department of Human Services (DHS) has developed a data warehouse, called the Human Services Data Warehouse, within the Medicaid Management Information System that will include claims data and beneficiary assessment tied into service delivery care plans. As statewide business priorities dictate, the DHS Data Warehouse will also serve as a DSP with the HIE. A plan is being developed to use a vendor to aggregate data from private insurers and provide it to the HIE. Rhode Island has a public reporting law that permits HEALTH to see to it that private insurer claims data can be aggregated, as well (see Section 1.2.4). The RI Health Commissioner has recently identified several commercial payers (e.g., United, BCBS, Tufts & Neighborhood Health Plan) in addition to Medicaid and Medicare that support electronic eligibility for 66% of RI s population. The RIQI plans to work with Office of the Health Insurance Commissioner to implement a survey that will assess insurers and determine the November 18, 2010 Page 14

15 exact percentage of insurers that can support electronic eligibility and claims transactions. Additionally, this survey will assess the percentage of claims that are electronically submitted to commercial insurers E-Prescribing Readiness RIQI will continue to promote e-prescribing adoption. Electronic prescribing and refill requests in RI continue to increase every year through the adoption of EHRs and web-based electronic prescribing tools. RIQI launched electronic prescribing in RI as Surescripts beta test site in The RIQI s e-prescribing Committee is chaired by the Director of HEALTH and has achieved significant success through its outreach to the physician and pharmacy community. The Governor has also been a strong promoter of electronic prescribing and has worked with HEALTH and RIQI to host provider events, where peer to peer learning and mentoring has been provided. As of December 2009, 67.5% of RI prescribers were using electronic tools for new prescriptions and refill requests; 33.5% of all RI prescriptions were filled electronically (Dec 2009 Surescripts); and 100% of RI retail pharmacies are capable of electronic prescribing (since October 2009). In each of the past three years, RI has received a Surescripts Safe Rx award for being one of the country s top two electronic prescribing states in the nation. RIQI will continue to drive RI s e- prescribing campaign in 2010 and Surescripts is among the first data sharing partners in currentcare. According to the 2010 HIT Physician Summary Report, at least 46.6% of RI physicians are utilizing health information exchange services that are relevant to Meaningful Use and necessary for care coordination. This estimate is based on only those providers who are electronic prescribing through an EHR and who are exchanging health-related information among organizations according to nationally recognized standards. This statistic is based on sample data provided by Surescripts. Additional exchange is occurring between providers who are prescribing with hand-held devices, point-to-point exchange between providers and laboratories and between physicians and hospitals and the aggregator that is currently under development through the LEAP. RIQI has participated in advancing e-prescribing at the national level, providing invited testimony a subcommittee of the Senate Judiciary Committee on the issues caused by prohibition of the e-prescribing of controlled substances Other Statewide Readiness Quality Reporting The need for and benefits of a complete and consistent solution for quality reporting in the state is driven by a number of primary considerations: November 18, 2010 Page 15

16 1. State regulation Health Care Quality Program (HCQP) - General Law requires that the state deliver regular reports on patient satisfaction and clinical performance 2. Patient-Centered Medical Home initiatives within Rhode Island that have existing multi-practice reporting solutions but lack the ability to deliver population- and patient-level reporting 3. Federal Meaningful Use requirements for attestation and electronic reporting as established in the applicable final rule of the American Recovery and Reinvestment Act 4. currentcare s role a potential information source for consented patient data to drive population- and patient-level reporting State Regulation The State s Healthcare Quality Program (HCQP) was initiated in 1998, when Rhode Island passed a law (Rhode Island General Law ) that requires the public release of information about the quality of care in all licensed healthcare facilities. This law includes releasing information about patient satisfaction and clinical performance or outcomes. Since the law s passage, the Department of Health has reported information on health plans, hospitals, home health agencies, nursing homes, and most recently, physicians (specifically use of EHRs and electronic prescribing). A consolidated source for population-level quality reporting will enable the state to provide additional reporting capabilities and increase the efficiency of delivering those capabilities. Patient-Centered Medical Home (PCMH) Initiatives RIQI is collaborating with a number of PCMH initiatives across the state. Each of these initiatives has its own form of quality reporting so that it can accurately model patient outcomes and ensure proper utilization. Each has different data requirements and quality reporting outputs that will be considered in the development of the RIQI Quality Reporting solution. The intent is not to replace existing practice-level solutions, but to augment these with statewide population- and patient-level reporting that cannot be driven by a single practice or small subset of practices. Details of each major PCMH initiative in the state are described below: Rhode Island Chronic Care Sustainability Initiative (CSI-RI) In 2008, the Commissioner of the State s Office of Health Insurance convened CSI-RI, a multi-payer pilot of the Patient-Centered Medical Home to develop a sustainable model of primary care. CSI-RI will improve the care of chronic disease and lead to better overall health outcomes for Rhode Islanders. Initial funding from the Center for Healthcare November 18, 2010 Page 16

17 Strategies and extension funding from all insurers and the Rhode Island Foundation has expanded the initiative to include more than sixty-six providers at thirteen practice sites and covers 46, 000 covered lives 74% commercial, 15% Medicaid managed care and 11% Medicare Advantage. The initiative provides additional revenue to the practices from insurers, onsite nurse care manager services, medical home implementation support. The initiative emphasizes improving care for diabetes, coronary artery disease and depression and on reducing ER admissions, hospitalization and readmissions through improved care management, transition planning, co-location of services, disease registries and tracking of quality measures. Most importantly significant focus has been put on standardized, consistent, public contract terms, reporting requirements and quality measures for all providers and payers. Each practice has an EHR and data is extracted from the EHR, aggregated by CSI and given back to the practice for common quality reporting measures. This project is also feeding practices into and coordinating efforts to facilitate use of health information exchange with the Beacon Community efforts. Rhode Island Chronic Care Collaborative (RI CCC) RI CCC developed one of the first PCMH programs in the state. Through this breakthrough collaborative the RI Health Centers have initiated several PCMH activities within their environment. In 1999 the RICCC grew out of a partnering of the Rhode Island Department of Health Diabetes Prevention & Control Program (HEALTH DPCP) and the Thundermist Health Center in the Bureau of Primary Care s Health Disparities Collaborative for diabetes. Between 2000 and 2002 HEALTH DPCP created an in state collaborative with the addition of ten community health centers and one hospital-based practice. In 2003 HEALTH DPCP and Quality Partners of Rhode Island (QPRI) received a grant from the Robert Wood Johnson Foundation s Improving Chronic Illness Care program to train physician practice teams based on the Bureau s Collaborative model. The RICCC has continued to use the Learning Model from the Institute for Healthcare Improvement to train participating teams in the implementation of the Chronic Care and Improvement Models. In September 2008, the RICCC Planning Team was designated as the training arm for the new Patient Centered Medical Home Project-The Chronic Sustainability Initiative RI (CSI RI) in addition to its sustaining work. As of May 2010, the RICCC Planning Team reverted to its work with health centers, hospital based practices, and small private practices to move toward the Patient Centered Medical Home Model using the conditions of diabetes, asthma, heart disease and colorectal cancer screening. Blue Cross Blue Shield Medical Home Program BCBSRI has developed a Medical Home program for its practices which aims to improve health outcomes and reduce medical costs for BCBSRI members/patients while November 18, 2010 Page 17

18 increasing coordination between providers, facilities, and other care providers. It will develop care partnerships between BCBSRI and local physicians to improve patient experiences and drive participation in activities and behaviors that improve patient health. It also aims to align reimbursements across the system and to create a program that allows practices to build their capabilities over time. Meaningful Use Centralization will enable not only population health measures and comparative quality benchmarking for practices but also will provide the infrastructure needed for some smaller practices to achieve Meaningful Use. Some smaller practices won t have the scale, resources, or wherewithal to implement quality reporting and analytics capabilities locally. Measure Category Baseline Data Goal 2011 Frequency of Reporting % pharmacies accepting electronic prescribing and refill requests % of providers in RI using e- prescribing % of total prescriptions routed electronically e- prescribing e- prescribing e- prescribing 100% 100% Quarterly 28.5% (2010) and 23.9% (2009) 39% Yearly 33.5% 41.3% Quarterly % clinical laboratories sending results electronically % of clinicians with an EHR who have the capability to place laboratory orders electronically % of clinicians in RI who have the capability to place laboratory orders electronically % of clinicians in RI who use functionality to place laboratory orders electronically % of clinicians with an EHR who are able to receive laboratory test results via electronic interface % of clinicians in RI who are able to receive laboratory test results via electronic interface % clinicians in RI who use functionality to receive laboratory test results via electronic interface Lab Results 50% 70% TBD Lab Results 72.1% 85.0% Yearly Lab Results 30.8% 45.0% Yearly Lab Results 25.1% 45.0% Yearly Lab Results 80.9% 90.0% Yearly Lab Results 34.7% 55.0% Yearly Lab Results 32.0% 50.0% Yearly November 18, 2010 Page 18

19 Measure Category Baseline Data Goal 2011 Frequency of Reporting % of clinicians with an EHR who have the capability to generate an electronic clinical summary % of clinicians in RI who have the capability to generate an electronic clinical summary. % of clinicians in RI who use functionality to generate an electronic clinical summary Clinical Summary Clinical Summary Clinical Summary 80.9% 90.0% Yearly 34.6% 55.0% Yearly 28.3% 50.0% Yearly Number of health plans supporting electronic eligibility and claims transactions ; % of population/lives covered currentcare registrations as a percent of program through 2010 Plan Eligibility and Claims HIE Enrollment 6 major TBD; 75% insurers covering 66% of the RI population 60% 100% (250,000 targeted enrollees) Yearly Monthly % of Health Departments electronically receiving data (only one department in the state) Public Reporting 100% 100% Yearly % pediatric immunizations received electronically Immunizations 50% 60% Yearly % of hospitals submitting syndromic surveillance electronically Syndromic Reporting 81% 90% Yearly % of notifiable laboratory results received electronically (influenza and pertussis) Notifiable Results <25% (currently one hospital; 2 tests) Figure 1 - Meaningful Use Measures 25% Yearly RIQI is incorporating this information in its plans to help Rhode Island healthcare providers demonstrate Meaningful Use of health IT, potentially incorporating data already captured in currentcare, providing support services and technology via RI Regional Extension Center, and initiation of a quality reporting project as part of the Beacon Community program. currentcare as source for Quality Reporting data currentcare presents a unique resource in the state for population- and patient-level quality reporting. The infrastructure for collecting, normalizing, matching, and storing data in November 18, 2010 Page 19

20 currentcare from any number of sources --will be leveraged to collect data for statewide quality reporting that includes primary care, inpatient, medication, and laboratory clinical data. No other sources exist for collecting statewide data. For additional details on the implementation plans for the RIQI Quality Reporting solution, see Section Resources RIQI s designation as the HIE SDE for Rhode Island and as RI s Regional Extension Center will clearly require additional resources which have been built into the financial model. However, the current RIQI staff that can be dedicated to the development of the Rhode Island HIE and the HIT Regional Center includes the President/CEO, COO/CIO, Director of Technology/Chief Security Officer, Health IT Adoption Manager, Regional Extension Center Program Manager, Director of currentcare Marketing, currentcare enrollment staff, customer service agents and data entry staff. Part time availability for the HIE work includes legal counsel, human resources, and administrative support. Other part time resources include consultants and community stakeholders from the public and private sectors of healthcare [see section Governance Model: Membership Representation and Structure]. RIQI staff has a history of success developing HIE functionality, collaborating with major stakeholders in the private sector of healthcare delivery, and working closely with the Department of Health within the State. RIQI has achieved much of the progress that has been made through literally thousands of hours of in-kind contributions over the past 6 years of HIE work that do not appear to be on the decline. November 18, 2010 Page 20

21 1.3 Health Information Exchange (HIE) Development and Adoption HIE Mission, Vision, Goals and Objectives The Rhode Island Quality Institute s mission is to improve the safety, quality, and value of healthcare in RI. The Rhode Island HIE vision is to build a statewide health care information exchange and interoperability and ensure the adoption of EHRs as the foundation for continual improvement in the quality of care. RIQI will use information technology with privacy and confidentiality protections to support the authorized exchange of electronic health information to improve the quality, safety, and value of healthcare provided in the state. To that end, Rhode Island will create and sustain a statewide secure health information system that will: 1. Allow individuals seeking care in Rhode Island to authorize their health services providers, and others whom they designate, to have access to their health information, solely for approved purposes, when and where it is needed; 2. Adhere to sound policies, design principles, and interoperability requirements to support the exchange of information in a meaningful, lawful, and efficient manner; and 3. Maximize the effective use of technology by patients, providers, policymakers, and researchers to realize significant and continuous improvements in the quality and outcomes of healthcare delivery in the state. (November 30, 2005) The goal of the HIE program is to significantly improve the safety, quality, and value of healthcare in RI by engaging consumers, providers, and the community in general, connecting entities that gather and generate clinical data, amassing the data, sharing data with authorized health care users (primary care providers, specialists, patients, community caregivers) who serve broad populations of people with a variety of needs, using the data for authorized purposes and ensuring privacy and security of all data. The objectives and project success criteria outlined in the original proposal remain appropriate with a more specific focus on the strategies to achieve Meaningful Use Stage 1 priorities of e- prescribing, receipt of structured lab results and exchange of clinical summaries as required by the ONC-HIE-PIN-00 released on July 6, The objectives of the HIE program over the next four years are as follows (not in order of priority): November 18, 2010 Page 21

22 To achieve an enrollment target of 50% of the population of the state of Rhode Island in the HIE. To integrate discharge summaries, administrative, patient-generated measures, medications, radiology, cardiology, pathology, immunizations, and behavioral health, Medicare/Medicaid data, problem lists, allergies, ADT/registration, medication, clinical care summaries, and advance directives data sources into the HIE (supports clinical summaries and e-prescribing) To facilitate options that allow providers to receive structured lab results. To implement statewide EHR aggregator(s) as part of the HIE that gathers data from a myriad of individual sites operating EHRs. To build an analytics warehouse that is used to promote improved health and healthcare in accordance with state and federal laws. To enable a connection to the Nationwide Health Information Network (NHIN) and NHIN Direct. The project success criteria identified are closely aligned with the strategy. Additional success criteria include the following: All of the project objectives have been met and are complete. 50% of certified EHRs in the state are connected to the HIE, and physicians using these EHRs are able to demonstrate meaningful use. Specifically, there is one option to allow receipt of structured lab results and exchange of clinical summaries. The RHIO is financially self-sustaining. The HIE capability has been shared with physicians, elementary school nurses, correctional institutions, long term care facilities, and individuals within their homes who are managing their health and the health of their families. Consumers in RI have registered to view and perhaps update their data via a patient portal. 75% of prescriptions (new and refills) in RI are being submitted to pharmacies electronically HIE Development and Adoption Strategies RI is a coastal community (1,214 square miles) with just over one million residents 1,050,000 (US Census Bureau). Rhode Island s size presents a tremendous advantage in enabling face-toface program outreach across the state, shorter timelines, and faster turn-around than larger states. The goal is for every RI provider (100%) to be involved in currentcare. This includes all 6,531 of the practicing providers (licensed M.D.s, D.O.s, Midwives, N.P.s, P.A.s, and Podiatrists in all provider practices and all provider facilities) including small and large practices, community health centers (the safety net providers and Health Center Controlled Network), clinics, visiting nurses, social workers, behavioral health providers, school nurses, long-term care facilities, and primary and tertiary hospitals. The RI REC is a resource for both priority November 18, 2010 Page 22

23 primary care providers as defined and funded by the ONC and specialists who may purchase the services. Rhode Island s HIE Strategic Plan builds upon strategies developed in the RIQI Business Case for Health Information Exchange completed in December The Business Case provides an economic model of the net value of a health information exchange for Rhode Island. It includes an estimate of how the HIE can create value over time, scenarios for key interdependencies and uncertainties, an assessment of how this value will accrue to various stakeholders and provided transparency regarding assumptions and sources and was structured for easy modification as additional information is collected in future. Since that time the financial plan and prioritization details have evolved and been updated but the underlying elements remain relevant and initial priorities are unchanged. Specifically, this is the Annual Value Creation [Figure 9] and Allocation of Value by Stakeholder [Figure 10] discussed in the Finance Sustainability in Section Based on a recently released article "The Value from Investments in Health Information Technology at the U.S. Department of Veterans Affairs" by Byrne, Colene M., et al., in Health Affairs 29.4 (2010) the Estimates of Annual Value Creation will be updated. The full Business Case for HIE can be found in Attachment E. In general, strategies will be used to assist the community in understanding 1) the annual value creation that can be achieved 2) the value allocated by stakeholders 3) impact of adoption and type of savings [Error! Reference source not found.] and 4) engaging physicians in the process. Figure 2 Savings Impacts November 18, 2010 Page 23

24 To accomplish this some specific strategies include: RIQI as the designated REC, HIE, and Beacon Community leader will drive quality improvement efforts though the integration and coordination of multiple projects and facilitate activities to promote Meaningful Use while minimizing duplicative efforts. Utilize the members of the HIT Physician Advisory Council (HIT-PAC), who will continue to assist in prioritizing the sequence in which data types are made available in currentcare. Laboratory and pharmacy data has been prioritized by providers as part of the AHRQ demonstration project based on financial analysis that recognizes significant gains through the reduction of redundant testing. This is consistent with priorities identified in the Business Case. The Roadmap has been prioritized based on national direction and quality initiative along with input from the Physician HIT Advisory Council composed of end users of the system and the Consumer Advisory Committee. Broad based marketing of currentcare to all physicians is promoting engagement and coordination of care between primary and specialty care providers and enhance enrollment efforts. is already in existence as a physician peer to peer EHR web site for physicians and their staff adopting HIT. Implementation of NHIN for point to point clinical messaging between providers will promote exchange between providers and other entities providing care to patients as well as providers and patients and may also provide the mechanism to move data from EHRs into currentcare Implementation of Delaware Health Information Network (or similar product) to allow the exchange of structured lab results. Note that due to the currentcare patient opt-in model structured lab resulting will occur outside of currentcare. Continue implementation of EHR aggregators to capture and exchange clinical summary data, pulled from electronic health records (EHRs) in individual providers offices. EHR aggregators provide additional data types for the HIE and will support Meaningful Use. RIQI recognizes two major challenges 1) the policy and procedures consistent with the RI HIE Act of 2008 provide for a consumer opt-in-model, which is stricter than federal requirements, will provide challenges but can be mitigated through effective marketing 2) the HIE is only as effective as the data in the exchange. Physician and patient activities that support data transactions can facilitate coordination of care and improvements to quality and efficiency. The Technical roadmap found in the Technical Architecture Section outlines the specific implementation of additional providers, patients, and data to support the HIE. The Operational Plan will address this in Business and Technical Operations, Section 2.7.5, Project Risks and Mitigation. November 18, 2010 Page 24

25 1.3.3 Strategy for Continuous Quality Improvement of Care Coordination and Meaningful Use of HIT Background Quality reporting capabilities within the HIE are being planned to maximize the effective use of technology by patients, providers, policymakers, and researchers and realize significant and continuous improvements in the quality and outcomes of healthcare delivery in the state. RIQI has and will continue to lever statewide quality reporting. The State s Healthcare Quality Program (HCQP) was initiated in 1998, when Rhode Island passed a law (Rhode Island General Law ) that requires the public release, or public reporting, of information about the quality of care in all licensed healthcare facilities. This law includes releasing information about patient satisfaction and clinical performance or outcomes. Since the law s passage, HEALTH has reported information on the health plans, hospitals, home health agencies, nursing homes, and most recently, physicians (specifically use of EHRs and electronic prescribing.) HEALTH s publically reported Physician Health Information Technology (HIT) Survey asks physicians how they are using computers to help care for their patients. Survey responses are required from all physicians in RI who care for patients. During 2009, RI was the first state in the nation to report individual-level measures of health information technology adoption for all licensed physicians. Publically reported information that is collected is posted on the HEALTH web site in order to help consumers compare healthcare providers and organizations. Potentially the HIE could be expanded to include the provision of metrics for quality reporting and support the state s efforts to improve public health. RIQI, Health, and Medicaid are currently in discussions to determine an approach to leverage the survey to assist with Meaningful Use implementation. RIQI has a strong capability in leading quality improvement efforts. The RIQI is the principal investigator on the RI ICU Collaborative, lead in conjunction with Quality Partners of Rhode Island (RI s QIO), the Hospital Association of RI, and RI hospitals. This project involves every adult in every hospital in the state and is now entering into its sixth year. The results have been a reduction in central line-related blood stream infections by more than 60%. Sepsis mortality was also reduced by 31% through the program. The decrease in mortality and suffering has been significant, and at an estimated expense of $35K per infection, the cost savings have been significant as well. It is RIQI s intention to apply the same principles and tools of quality improvement once sufficient data is available through the HIE and in accordance with all applicable state and federal laws. Regional Extension Center and Beacon Community A major thrust of RIQI s strategy for continuous quality improvement and achievement of Meaningful Use can be seen in its REC program and in the Beacon Communities initiative. The REC program has provisions for preparing providers to link to currentcare. For the Beacon Communities work, RIQI and its partners have joined together to drive positive change in the November 18, 2010 Page 25

26 quality, cost efficiency and population health outcomes through HIT by focusing on two primary objectives: 1) Supporting RI s transition to the Patient-Centered Medical Home (PCMH) model for delivering healthcare by developing needed foundational capabilities through HIT 2) Improving RI s ability to see and act on the quality and efficacy of the healthcare system by providing foundational capabilities in quality reporting and public reporting, in aggregate and at the practice level. To achieve these two primary objectives, the RI Beacon Community plan is to: Lever the substantial infrastructure upon which the statewide Health Information Exchange (HIE) was built over the last five years through both a $5 MM CMS HIE Demonstration project grant and more than $9.5MM in private funding, which will be extended through the pending ARRA HIE grant of $5.28 MM. Build upon ongoing work to implement and interconnect EHRs in select RI Community Health Centers (the Health Center Controlled Network), funded through $2.65 MM in Health Research and Services Administration (HRSA) grants. Further the adoption of EHRs in the state by extending RI Regional Extension Center (REC) services to specialists and other providers not currently eligible for direct assistance with implementation and achievement of Meaningful Use through the ARRA. Partner with on-going initiatives to implement Patient-Centered Medical Homes (PCMHs) including the Chronic Care Sustainability Initiative (CSI-RI), RI s Medicare Patient Centered Medical Home initiative, the Blue Cross & Blue Shield of RI Patient Centered Medical Home project, the RI Veteran s Administration Patient Centered Medical Home initiative, and the Community Health Center Patient Centered Medical Home initiative. Build upon RI s mandatory public reporting efforts, which began with first-in-the-nation legislation in 1998 requiring public reporting that has been expanded incrementally since that time. Improvement of clinical quality metrics through HIT enabled quality improvement efforts. Specifically, the Beacon Community program is responsible for moving the following outcomes: Diabetes o Reduce the percentage of diabetic patients in RI with poorly controlled disease to below 20% o Increase the percentage of diabetic patients with well controlled blood pressure to over 40% o Increase the percentage of diabetic patients with well controlled LDL cholesterol levels to over 50% Smoking Cessation o Increase the percentage of smokers who received a smoking cessation intervention to 75% November 18, 2010 Page 26

27 Depression Screening o Increase the percent of eligible patients screened annually for depression, using a standardized screening tool (PHQ-2 or PHQ-9), to 60% Transitions of Care o Reduce the hospital admission rate for ambulatory care sensitive (ASC) conditions by 4% per year over 3 years in the Beacon target population, for a total of a 12% decrease o o o o Reduce all hospital admissions by 2% per year in the Beacon target population, for a total of a 6% decrease Reduce preventable/avoidable emergency department visits by 4% per year in the Beacon target population, for a total 12% decrease Reduce overall emergency department visits by 2% per year in the Beacon target population, for a total 6% decrease Reduce the overall 30 day hospital readmission rate by 4% per year in the Beacon target population, for a total 12% decrease To demonstrate movement in the identified clinical outcomes practices will need to utilize e-prescribing, receive laboratory results as structured data and share clinical summary information with other providers/hospitals. The planned initiatives combined with the medical home construct will support and encourage meeting the desired objectives through meaningful use activities. Quality Reporting as a Mechanism for Quality Improvement Performance evaluation at the patient level is critical for driving improvement because it enables staff, providers, and the care team to see both successes and opportunities for improvement. Practices should be able to identify opportunities for improvement in planning, processes, and documentation of care. Pursuant to the national agenda of quality improvement, physicians need to be able to generate or access aggregate reporting for their communities, organizational reporting for their practices, exception reports and other forms of physician-targeted feedback, and analytics to benchmark themselves against their peers. RIQI plans significant effort, through the Regional Extension Center and the Beacon Community Program, to support Meaningful Use of HIT within Rhode Island, as documented above. One core facet of RIQI s strategy to address Meaningful Use is development and provision of a quality reporting capability that meets the needs of care teams across the state. The Beaconfunded quality reporting platform will enable practices to access feedback and auditing mechanisms on their performance against the community objective measures. Beacon leadership will drive cross-practice pollination of best practices and lessons learned through benchmarking and community facilitation. November 18, 2010 Page 27

28 Quality reporting will enable practices to document the data capture processes required as part of Meaningful Use. It will also inform strategies and interventions at both the practice level and the community level to improve quality outcomes. Providers, however, will not all have the capability or the interest in developing quality reporting infrastructure within their own organizations. Smaller practices that run locally-managed EHRs may struggle with the challenges of installing and managing additional software platforms. Larger practices may opt to use (or build) quality reporting capabilities atop their EHR platforms, but will still be unable to compare their measures against peer groups or against statewide benchmarks. Role of the Statewide Health Information Exchange Quality reporting will play an integral role in driving quality improvement and Meaningful Use within the state, and RIQI aims to use currentcare as a central building block to this strategy. The statewide HIE is uniquely positioned to provide the baseline data collection and analytical infrastructure for quality reporting. Through the Beacon Community Program, RIQI will fund development of a centralized data warehouse that enables aggregate reporting for communities (including the Beacon Community) and peer benchmarking across providers and practices. RIQI aims to prove out several technical approaches to aggregating clinical data from providers into this warehouse. Clinical data sets from currentcare, stored and optimized for quality reporting, will help RIQI and Rhode Island providers to produce Meaningful Use reporting, quality outcome reporting, and benchmarking for all participating practices. Providers will gain real-time access to quality data, enabling self-monitoring and continuous improvement. Stakeholders within the community will gain the ability to see reports on practice and provider performance against quality metrics, track quality metrics within specific panels, and benchmark quality performance. RIQI will offer this as a service to providers and to the community. As discussed in Section 1.2.4, the HIE Advisory Commission and the Director of Health will be key stakeholders in defining how HIE data will contribute to this strategy. The Department of Health will be a direct beneficiary of quality reporting efforts constructed atop currentcare, as it will enhance the State s ability to inform public health reporting and policymaking. Policy Considerations for Quality Reporting While currentcare presents significant opportunities for quality reporting, legal and policy issues associated with HIE in RI must be considered. All data collection through the HIE must be done within the regulations of the Health Information Exchange Act of 2008 (R.I. Gen. Laws ). D esigned to ensure the security and privacy of health information shared through the statewide HIE, the Act requires consumers to opt-in for participation (more detailed information on the Act can be found in Section ). The current opt-in consent model governing currentcare will restrict quality measures to only those patients who have consented to have their health information stored in currentcare. November 18, 2010 Page 28

29 Furthermore, the use of data in currentcare is limited to coordination of care, public health purposes and administration of the HIE. Use of data for other purposes and/or for the definition of some public health reporting use can only be done with approval from the Department of Health. Per statute, an HIE Advisory Commission will advise the Department of Health in making these decisions. Beacon Community Quality Reporting In order to meeting the requirements described above, a Quality Reporting and Registry project is being kicked off under the auspices of the Rhode Island Beacon Community. The Beacon Community Quality Reporting initiative will provide a mechanism to assess Beacon project quality metrics including practice and physician-level benchmarking and patient-level exception reporting. It will include the design and creation of reports, creation of patient registries where needed, a recommended process for utilization, and training of staff and physicians to use the reports. The target architecture for this solution will be to collect data from practice-based EHRs through system-to-system messaging via NHIN/Direct. Patient-level data will be processed by currentcare via existing MPI, matching, normalization, and deduplication functionality. Through ETL, data for quality reporting will be extracted into a data warehouse optimized for analytics. Regardless of the final technical solutions, the project has been structured around the goal of making quality reporting and comparative performance functionality available as soon as possible to meet Meaningful Use in The project is currently in the initiation phase, and will soon release an RFP for an implementation partner, who will further define the approach, design and implement technical solutions, and coordinate rollout to the broader community. November 18, 2010 Page 29

30 1.4 Health Information Technology Adoption EHR Adoption Assessment of EHR Adoption/Use In 2009, RI was the first state in the nation to report individual-level measures of health information technology adoption through public reporting as required by HEALTH. The latest survey administered in January 2010 to licensed physicians in RI in active practice had a 57.8% response rate and found that 74.1%of the respondents are already using EHRs (42.8% of all physicians) and that 18.5% of the respondents (10.7% of all physicians) are using qualified EHRs. Qualified EHRs include specific clinical documentation, reporting, results management, decision support, and e-prescribing functions and have been certified by CCHIT. Based on physicians responding 70% of the Community Health Centers are using an EHR. For the full survey results see the Physician HIT Survey Summary in Attachment F. In addition, the RIQI EHR Adoption Committee recognized the challenge of disseminating information to physicians so that they understand, believe, and take steps to adopt EHRs. To address this issue RIQI created a strategy that utilizes proven theories of diffusion of innovations and social networking, and developed tactics to spread positive messaging about EHRs, as well as information to lower barriers to adoption through its innovative study on the Application of Social Networking Theory to EHR Adoption in RI. The creation of a physician peer-to-peer website mobilizes the physician community to become educated about health IT and adopt EHRs by disseminating positive messages through multiple channels within social networks. This important and powerful website drew upon the research done by Everett Rogers and others that focuses on diffusion of innovation. Rather than a single entity broadly promoting EHR adoption across all audiences, this project applied the diffusion of innovations (or Tipping Point ) theories about how to speed adoption of an innovation across a social system. Impersonal marketing methods like advertising and media stories may spread information about new innovations, but once the community s early adopters and thought leaders have adopted the innovation, it is conversations with these leaders that cause them to be adopted by the early majority, late majority and even those Rogers referred to as laggards. When considering adopting a new innovation such as EHRs, physicians look to others to share their experience and mitigate the potential risk of changing their established practices. If a respected peer has had a positive and observable experience, a physician will be much more likely to try the innovation herself/himself. Once the decision to November 18, 2010 Page 30

31 try a new innovation has occurred, these peers can also positively or negatively reinforce other physicians personal experiences Using a specially designed survey tool with 3,500 RI physicians, quantitative baseline data was collected and analyzed. This research process resulted in the identification of peer-nominated opinion leaders or physician leaders who are viewed as the innovators by the physician community. The findings also revealed where physicians were positioned on the spectrum of adoption by geographic location and specialty. Qualitative research was then completed to learn about barriers and drivers of adoption and EHR best practices. is built to support messaging through key opinion leaders to their physician peers in RI who have not yet adopted EHRs. EHR Adoption Initiatives Individual organizations, small and large, are purchasing and implementing a range of electronic medical record (EHR) applications and enterprise-level integrated health information systems with a focus on enhancing organizational capacity for electronic health information management. A few notable examples include: RI s Health Insurance Commissioner, having regulatory authority over the commercial health plans in RI, established The Health Insurance Advisory Council of the Office of the Health Insurance Commissioner. This Council has promulgated Affordability Priorities for Commercial Health Insurers in Rhode Island that mandate that health plans will improve the affordability of health care in Rhode Island by focusing their efforts upon provider payment reform, beginning with primary care. Provider Payment Reform efforts are intended to address weaknesses in the current payment mechanisms by promoting improved population health and improved medical care quality and efficiency and the activities that produce those results. Commercial insurers must meet these standards by investing a percentage of their medical spend on the focus areas noted above, including investments in EHR adoption incentives. The financial resources that must be devoted to achievement of these Affordability Standards over the next 5 years are very substantial. Rhode Island Primary Care Physician Corporation developed and operates an EHR system and is expanding its use among a network of Rhode Island providers. EHR of Rhode Island (EHRRI) is an exclusive distributer of a nationally-known EHR in Rhode Island, offering group purchase agreements to subsidize EHR system pricing for providers. Blue Cross Blue Shield of Rhode Island offers a pay-for-performance program as an incentive for EHR adoption and also mandates EHR adoption as a qualifier for participation in their Patient Centered Medical Home program that includes innovative payment structures based on quality metrics. Care New England, a large integrated delivery network (IDN), has implemented an integrated EHR system across its several hospitals and employed physician practices. It is working to expand on-line physician documentation and order management in all its care settings. November 18, 2010 Page 31

32 ConnectCare program of the RI Department of Human Services (DHS) offers an increased rate for its providers who utilize EHR s. Quality Partners of Rhode Island (QPRI), the state s QIO, administered the CMS DOQ-IT project, which provided technical assistance to providers interested in purchasing an EHR. They continue to support small physician practices as they adopt EHRs and have extensive experience assisting practices to implement change in their practice Lifespan, a large IDN which operates a lifetime electronic clinical record system and e- prescribing (erx) solution is implementing standardized lab data exchange capability with local and national lab partners. Surescripts, an electronic prescribing (erx) network operator, is expanding its medication history exchange capability in Rhode Island (and other states). East Side Clinical Laboratory, a regional laboratory services provider, is extending its webbased electronic interface for lab reporting to its customers. Community Health Centers which provide care to 12% of the state s population have either implemented or initiated contracts for EHRs. This has been made possible through both strategic leadership and federal and Neighborhood Health Plan Rhode Island financing. The echc Network applied for and received the HRSA EHR Implementation Grant (H2KIT08590), and the ARRA HRSA Health IT Innovations Grant (H2LIT16862) in The grants supported the ability to implement a shared Practice Management System, Electronic Medical Records and Electronic Dental Records at four community health centers in Rhode Island with the aim to improve the effectiveness and efficiency of care delivery at each participating health center, as well as improving patient safety and performance on specific quality indicators. The Network has successfully implemented the shared Practice Management System (PMS) and Electronic Medical Records (EHR), to three centers with roll-out of Electronic Dental Records (EDR) in progress E-Prescribing Adoption Through the efforts of RIQI s e-prescribing Committee, 100% of RI s pharmacies are linked into the e-prescribing network. RIQI has hosted provider events, where peer to peer learning and mentoring has been provided. As of December 2009, 67.5% of RI prescribers were using electronic tools for new prescriptions and refill requests; 33.5% of all RI prescriptions were filled electronically (December 2009, Surescripts); and 100% of RI pharmacies are capable of electronic prescribing (since October 2009). Over the past three years, RI has received a Surescripts Safe Rx award for being one of the country s top two electronic prescribing states. Despite this ranking, in the February 2010 RI Physician HIT Survey, 28.5% of the physicians in RI utilize e-prescribing (a 4.6% increase from 2009). RIQI will use the e-prescribing Committees campaign to drive RI s e-prescribing rates to a higher level in Surescripts is among the first data sharing partners in currentcare and is actively engaged in helping to promote these activities in Rhode Island. November 18, 2010 Page 32

33 1.5 Coordination with State Government The Rhode Island Department of Health (HEALTH) was one of the first State Departments of Health in the nation to become actively engaged in advancing Health Information Technology through the development of a statewide health information exchange. HEALTH, in collaboration with the Rhode Island Quality Institute (RIQI) and stakeholders across the State, was the recipient of AHRQ s state and regional demonstration (SRD) project for HIT. The goal of this initial project was to design and deploy an interconnected statewide health information system that uses a master patient index to link patient-specific health information from disparate sources to help provide the right information to clinicians and their patients when and where it is needed. currentcare is intended to evolve into a broadly interconnected statewide health information network to improve the quality, safety, and value of healthcare services and to support critical public health needs that can improve population health for Rhode Island residents and the surrounding region. In addition to HEALTH s direct involvement in the development of a statewide HIE system, the department has also been involved in promoting the adoption of EHRs and e-prescribing, and in the growing ability to have HIT support public health business processes and functions in the areas of tracking children s preventive health services, disease reporting, syndromic surveillance, and laboratory testing (laboratory ordering and results delivery) and public reporting. Approach to Work with State Medicaid RIQI has worked with the state Medicaid agency, the Executive Office of Health and Human Services (EOHHS) /Department of Human Services (DHS), since the spring of 2005 in developing Rhode Island's HIE currentcare system. DHS has the responsibility to administer the state's Medicaid Management Information System (MMIS). The Secretary of the Executive Office of Health and Human Services is a member of the RIQI Board. RIQI is aware of a major Medicaid Information Technology Architecture (MITA) planning effort that EOHHS/DHS will begin in mid-2010, entitled "Global Waiver and MITA IT Planning." Guided by the CMS MITA framework document, the planning effort places great emphasis on structured MMIS business processes. However, MITA is also relevant to the EHR initiative in its focus on data exchange via hubs for stakeholders both internal and external to the Medicaid enterprise. Note that the EOHHS/DHS efforts are in the planning stage, so implementation efforts are scheduled to follow the year-long planning effort, after approvals are granted and federal/state funding is obtained. Medicaid is working with RIQI to come to a mutual understanding of the other s capabilities, to reach conclusions on those shared services and technical services that each organization may utilize. One such effort is a Memorandum of Understanding with the New England States Consortium Systems Organization (NESCSO) to explore a collaboration of Medicaid programs in November 18, 2010 Page 33

34 the New England region with the intent to explore options for shared services such as a regional provider directory. On March 8, 2010, EOHHS/DHS received an approval from CMS to plan an incentive program to distribute 100% federal money to eligible Rhode Island providers and hospitals that adopt implement, or upgrade EHRs. In conjunction with the Department of Health and RIQI, Medicaid is considering incorporating incentives in the EHR incentives distribution program. At the very least, Medicaid s EHR outreach efforts will promote currentcare. Medicaid will work with the RI Regional Extension Center to plan future potential incentive arrangements such as pay for performance and encouraging additional provider types as it completes its plan and addresses first those priority providers. Overall, Medicaid must perform two significant tasks: Plan how it will implement an EHR incentive program for Medicaid-eligible providers & hospitals and Encourage EHR adoption for Medicaid-eligible providers & hospitals. Medicaid is working on its State Medicaid HIT Plan (SMHP) for Medicaid beneficiaries while RIQI is creating the State HIE Strategic Plan for the entire state of Rhode Island. There are a number of parallels in the two planning initiatives, and given the level of collaboration in the state for many years, DHS is working closely with RIQI and HEALTH. All three organizations have had a close working relationship for many years on the RI HIE and are now involved in EHR planning and implementation. Medicaid will continue collaborating under a together we stand, divided we fall philosophy. The DHS business vision can be summarized with three principles: 1) Increase access to care, 2) Increase quality of care, and 3) Contain costs. DHS believes that EHR adoption in Rhode Island will directly impact all three principles. Constituencies There is one type of hospital that Rhode Island Medicaid incentives will cover: acute care hospitals with a 10% Medicaid volume. The State must also cover five Medicaid-eligible professional constituencies for incentive distribution: 1. Physician 2. Dentist 3. Certified Nurse-Midwife 4. Nurse Practitioner 5. Physician Assistant practicing in a FQHC or Rural Health Clinic that is also led by a physician assistant. DHS has been working closely with HEALTH and RIQI due to their shared business goals. RIQI, in particular, shares many business goals and covers similar outreach constituencies with November 18, 2010 Page 34

35 Medicaid such as hospitals and physicians. However RIQI does not currently cover #2-5 above dentists, certified nurse midwives, nurse practitioners, and certain physician assistants. Outreach Medicaid intends to collaborate with RIQI to outreach to the constituencies they share. Medicaid is in the early planning phases and will be able to later describe how they will cover the constituencies not covered by RIQI. It may be that RIQI s outreach assistance might be leveraged for Medicaid s other four constituencies. Planning may reveal that other means are necessary, but DHS intends to first work with RIQI to forge an integrated approach. Collaborating on Meaningful Use (MU) CMS offers a broad definition of the MU phrase: Meaningful Use is a term defined by CMS and describes the use of HIT that furthers the goals of information exchange among healthcare professionals. CMS and ONC released the final rulings of requirements needed to meet MU in July The key elements are listed below along with Medicaid s collaboration plans with RIQI, the Dept. of Health, and many Medicaid incentive-eligible providers and hospitals in the state. Clinical quality measures. Paraphrasing the CMS regulations, the goal is to capture the needed data fields and calculate the clinical quality measure results. DHS will work closely with RIQI to achieve this goal for its subset of people in Rhode Island the Medicaid beneficiaries. E-prescribing. Rhode Island has had a statewide plan in place since 2003 with Surescripts. 100% of pharmacies statewide are capable of e-prescribing. DHS s MMIS IT system now supports e-prescribing for Medicaid beneficiaries. DHS intends to support future advancement of the system in the future. Immunization reporting. The RI Dept. of Health KIDSNET program has tracked immunization data for some time. DHS s goal is to both contribute to, and receive information from KIDSNET to increase the quality of care for Medicaid beneficiaries. Continuity of care. The purpose is to coordinate care for a Medicaid beneficiary over time and across various healthcare providers. DHS will work with RIQI and the various EHR systems at Eligible Providers and hospitals to improve the quality of care for Medicaid beneficiaries and by promoting more integrated beneficiary data from a variety of relevant sources. Registry and quality reporting. DHS expects to collaborate with RIQI and the Dept. of Health to run reports to assist in its quality goals in support of Medicaid beneficiaries. Lab results. The ability for providers to a view coordinated lab results is expected to benefit Medicaid clients care quality and costs. DHS will continue to collaborate with RIQI and the Dept. of Health to achieve the advantages offered by more information organized centrally. Patient clinical summaries. DHS has envisioned web-based beneficiary report cards for all beneficiaries to help individuals keep track of health outcomes, including the compilation of disparate data. In collaborating to bring integrated EHR systems into November 18, 2010 Page 35

36 being, DHS stands to gain since a more complete data set could be made available to its beneficiaries. PHI privacy and security. DHS plans to cooperate with the various statewide entities to ensure beneficiary data is secure. Security and Privacy Rhode Island has been in the forefront on issues regarding security and privacy related to HIE including a deep level assessment conducted during their involvement in the Health Information Security and Privacy Collaborative (HISPC) in 2005 to This work influenced how the state addressed issues of security and privacy in the resulting Health Information Exchange Act of 2008, R.I. Gen. Laws et seq ( the Act ) - designed to ensure the security and privacy of health information shared through the statewide HIE through an opt-inmodel (more detailed information on each of these can be found in Security and Privacy). While the ACT only applies to the information in currentcare, Medicaid is aligned with the opt-in model and therefore does not require, but strongly encourages its beneficiaries to enroll in currentcare to encourage sharing of medical information and coordination of care. Architectural Collaboration Rhode Island Medicaid has collaborated and continues to collaborate with RIQI in the architecture of IT health care systems. HEALTH, through its authorization permit capacity over RIQI, also participates in the collaborative architectural analysis and design. Regional Master Patient Index work is now being done in concert with NESCSO (New England States Consortium Systems Organization. NESCSO is in the early stages of work with key stakeholders, including Medicaid, RIQI, and DOH, from the 6 New England states and New York. The job is to determine those business needs that can be best met via regional coordination. We plan to follow that up with collaboration on the technical architecture. currentcare Medicaid has worked with DOH since 2005 from the early stages of the HIE analysis to the immanent implementation of the HIE (aka currentcare) system. RIQI has become more involved in the last several years and now runs currentcare, benefiting from the substantial contributions of the early architectural design contributors like DOH, DoIT, and Medicaid. Medicaid and RIQI both attended CMS s Medicaid Incentive conference in early 2010 covering the 100% federal monies being made to encourage the usage of EHR s by eligible Medicaid providers and hospitals. All-Payer Claims Database Medicaid recently attended a Utah Conference on All-Payer Claims Databases (APCD), along with DOH and RIQI designated personnel. RIQI will implement the APCD as part of their Beacon project. Medicaid is planning to submit data to the APCD, so it intends to stay abreast of progress and to contribute to the design to maximize its usefulness of the system and to make the data more useful for all stakeholders. November 18, 2010 Page 36

37 Global Waiver and MITA IT Planning Medicaid recently embarked on a major year-long Global Waiver and MITA IT Planning project that will do substantive business and IT planning across the Medicaid enterprise. Medicaid has now contracted with Public Consulting Group (PCG) to assist the State in the analysis and IT design of federally-required new system functionality. A major thrust of MITA is the secure exchange of Medicaid data to external entities such as the APCD, so Medicaid will coordinate its planning efforts with RIQI and DOH. Regular Interactions DHS (Medicaid), DOH, and RIQI have a regular venue to continue collaboration via high level monthly meetings held in Providence. The meetings include the State HIE Coordinator, Dr. David Gifford of HIE, and high-level management from all three organizations. The meetings invariably bring up issues germane to the organizations resulting in a more coordinated approach to issues. November 18, 2010 Page 37

38 1.6 Coordination with Public Health, Medicaid and other State and Federally Funded Programs The successful expansion and continued development of the statewide HIE requires coordination with other state and federally funded programs. The statewide HIE has utilized many of the resources and tools developed by previous federal and state grants including: AHRQ State and Regional Health Information Transformation Demonstration applied for and won by HEALTH to implement statewide health information exchange, with an initial goal of sharing lab data and medication histories Medicaid Transformation Grant- begun during the AHRQ Demonstration project, the MTG aimed to expand the software and hardware capabilities of health information exchange as well as drive the enrollment of long term care patients in currentcare Via these grants and various local grants, the bulk of the required infrastructure, policies, and operations were established. HEALTH managed the work to design and implement the technology. HEALTH and RIQI partnered to drive policy development and the definition of a consent model through a community-based governance structure executed by RIQI. HEALTH also contracted with RIQI to design and build the operations underlying the HIE and to carry out the campaign to enroll Rhode Islanders in the HIE. Acceptance testing was interrupted by the floods in March 2010 and is now resuming, but is now being managed by RIQI. Per contract terms, RIQI took responsibility for all aspects of the HIE in June of At that point, HEALTH assumed regulatory authority over RIQI. Since that point RIQI has driven the work to recover from the impact of the flood, including the selection and contracting with a new data center (with DR capabilities), installation of upgraded equipment, and reinstallation of software. The interrupted acceptance testing will resume in December 2010; the initial production release capturing lab data and medications histories will be live in Q RIQI continues to work collaboratively with the DOH and the State Medicaid Agency to align HIE activities with the State Medicaid HIT Plan (SMHP). Regular interactions with the ONC and other federal agencies drive the coordination of care though health information exchange in the state. November 18, 2010 Page 38

39 1.6.1 Public Health Collaboration RIQI has a long history of collaboration on public health issues with both HHS and HEALTH in the state, notably in the planning and execution of the statewide e-prescribing and the ICU collaborative programs. Public health requirements are one of the key drivers for the implementation of currentcare, and a state defined acceptable use of the HIE. Looking forward, public health benefits such as electronic transport of immunization records via NHIN Direct to a central location should be realized. RIQI was an early collaborator with public health entities and has now assumed responsibility for the AHRQ grant, described in detail below. AHRQ State and Regional Health Information Technology Demonstration Initiation The Rhode Island Department of Health (HEALTH) applied for and received the SRD contract from AHRQ on behalf of stakeholders across the State. The goal of the grant was to develop the statewide health information exchange, (currentcare), under the jurisdiction of HEALTH. The project's goals were to design, develop, test, deploy, and evaluate an initial health information network to support the secure and reliable exchange of health information, beginning with laboratory results and medication history information. The system would link longitudinal patient-level information from source data systems using an MPI, provide a Web-accessible viewer to authorized users in provider settings, and interface with electronic health record systems. The contract has and continues to support the initial design, development and testing of a complex technical infrastructure which supports a robust patient consent model. The SRD contract funds intended to: Build and acceptance test the currentcare technical platform as the future foundation Prepare, issue and review a technical vendor RFP to build the statewide HIE system Purchase a limited data sharing license for Healthshare (Intersystems HIE product) Fund Hewlett-Packard (formerly known as EDS) as the prime vendor to work as a systems integrator Purchase the other required software licenses (Appelon, Quadrmed, Open SSO, hardware) Interface development Data center and hosting services System modifications and enhancements needed to meet the consent model. An implementation interruption was caused by floods in March 2010, as the team was completing Acceptance Testing. Since June 2010, the oversight of and responsibility for the AHRQ grant have been transitioned to RIQI, per the HEALTH contract. After the ongoing November 18, 2010 Page 39

40 implementation of new data center, installation of upgraded equipment, and reinstallation of software us complete, the interrupted acceptance testing will resume in December The initial production release capturing lab data and medications histories will be live in Q Use of AHRQ Funds The following describes how AHRQ funds were distributed via different mechanisms to achieve the various goals of the AHRQ grant. Amount Mechanism Timeframe Results Status Provider Oct COMPLETE engagement Sept 2009 $343,000 Consumer engagement $164,000 Evaluation $531,000 Technical development HEALTH subcontracted to QPRI HEALTH subcontracted to the Clarendon group HEALTH subcontract to Brown university HEALTH sub contract to HP Oct Sept 2008 Oct Sept 2010 Convened and staffed monthly provider advisory committee Educated providers about HIE Obtained input of providers in design and development of HIE including priorities of data elements to be shared, system requirements, policy development Conduct initial consumer focus groups to understand consumer perspectives re the HIE, concerns, identify what value statements resonated with public, Convened and staffed consumer advisory committee which provided input into development of all policies and on matters related to privacy etc and on legislation Conducted second setoff focus groups to get perspectives on naming hie, and on authorization form Developed communication plan marketing materials and tag line, logo, etc. developed multilingual educational video. Developed evaluation plan Collected baseline data for potential use cases Conducted evaluation of enrollment in LTc and conducted policy based eval using focus groups of stakeholders Development of functional requirements, detail design, COMPLETE COMPLETE November 18, 2010 Page 40

41 $1,682,000 Governance and HIE capacity building and operations $177,000 HIE/ Development and Operations $520,000 (EDS) HEALTH subcontract to riqi Health subcontract to RIQI July 2005 Sept 2010 Oct June 2011 security plan, technical architecture, hardware purchase and installation in data center, customization/ configuration and systems integration of the HIE/Healthshare product, development of participation gateway, and interfaces with data sharing partners,,mapping of system for lab values Design and development of custom code Design and development of consent model and algorithms Selection and implementation of additional vendor relationships Quadramed, Apelon, etc Establish governance structure with committees, steering committee etc Provide governance and decision making in collaboration with Health Incrementally accept responsibility and build capacity for HIE operations including hiring a technical director Complete the development of the initial HIE build to share labs and medication history, ( was supposed to be completed by HP) Upgrade to healthshare Restart and complete user acceptance testing Develop interface with surescripts for medication history Conduct a security audit of new data center Develop security monitoring and log management services for new data center Develop and implement enhancement required by data submitting partners to audit log transactions sent to currentcare COMPLETE Initial work through 2 contractstransition of management to RIQI has occurred see next contract to address completion of HIE. In progress November 18, 2010 Page 41

42 Project management $600,000 Current State Health Subcontract to RPM inc March present Provide project management support and assistance throughout project period including but not limited to: o developing and maintaining detailed project plan o documenting project progress, staffing several project committees o writing RFP for technical vendor o staffing RFP review of technical vendor proposals o developing user acceptance testing tools and conducting user acceptance testing o developing project reports Figure 3 - AHRQ Funding For a variety of reasons including the March floods which impacted the AHRQ contract project schedule, the AHRQ contract has been extended into spring HEALTH has issued another contract with RIQI to use unspent AHRQ funds that would have been spent if the flood hadn t happened to complete the testing and turnover to production for initial production release. This will allow the first phase of current care to go live with laboratory data from at least two laboratories being sent to currentcare and the ability for currentcare to access medication history from Surescripts on a request basis. Lessons Learned Many lessons have been learned over the past 6 years while carrying out the AHRQ SRD project. Some of the key lessons include: 1. The realization that engaging a community and building consensus takes time 2. Market forces and business needs of individual organizations need to be considered as they will influence the outcome of the project and its potential sustainability plan 3. Identifying the consent model/guiding principles impacts the technical structure, and if it is not clear or changes are made once a technical model has been developed, it can cause the need for significant alterations to original plan 4. Engaging the consumer in the process can ease acceptance and hopefully positively impact enrollment. There are some concerns that the opt-in model can make it difficult to maximally implement HIE. It is hoped that the time spent on complicated consent models may eliminate future privacy and security issues down the road. The SRD project has also informed the development of the State HIT plan. November 18, 2010 Page 42

43 1.6.2 Medicaid Collaboration Medicaid Transformation Grant Initiation Collaboration between RIQI and the state s Medicaid program and the development of a statewide HIE began during the development of the AHRQ project and have continued as evidenced by RI s Executive Office of Health and Human Services being awarded by CMS a Medicaid Transformation Grant in 2007 that provided additional funding to support and expand the statewide HIE. Overall Activities The MTG funding has been used to expand upon the SRD grant by providing the funds to: Move to an unlimited software license for data sharing within currentcare (AHRQ funds only supported a data sharing license for two data types) Expanding the hardware design Enrolling Medicaid beneficiaries into currentcare including developing multilingual materials and an educational video Enabling long term care facilities to participate in currentcare. Long Term Care Activities More specifically regarding Long Term Care, efforts have and continue to be underway to work with long term care (LTC) facilities to: Enroll their residents in currentcare To identify those long term care facilities that do not have computers accessible to their clinical staff, and provide them with the necessary technology to have their health care providers be able to access currentcare. Initially 54 LTC facilities were targeted but this was reduced to 37 once assessments realized that there were larger gaps in technology hardware and understanding to provide adequate services and resources to all 54. Medicaid collaborated with Quality Partners RI, the states QIO who coordinated technology assessments, guidance on purchase, installation and use of computers and trained staff on the value and use of currentcare in caring for their patients. This initiative is still ongoing and is being further supported by the Beacon Community Grant to reach beyond the 37 LTC facilities currently targeted. An evaluation of currentcare enrollment successes and challenges with long term care facilities has been conducted by Brown University and the outcome of that evaluation will inform the process for the ongoing work with the November 18, 2010 Page 43

44 nursing homes. The MTG grant runs through March 31, An additional contract has been issued with HEALTH to RIQI to use secondary MTG funds to drive enrollment of the Medicaid population. Use of MTG Funds Amount Mechanism Timeframe Results Status LTC and ED July COMPLETE engagement sept 2010 $160,000 HEALTH subcontracted to QPRI Worked with 8 pilot LTC sites to educate them on currentcare; develop and implement processes to enroll LTC residents, Assist approximately 20 LTCs identify the need for a computer for clinical staff to use currentcare and if so provide TA around purchasing and installing the computer ( funded directly by the state via MTG funds) Educate EDS on currentcare and determine workflow issues related to implementation of currentcare enrollment in ED. (initial group) currentcare Consumer Engagement and Enrollment (targeted to Mediciad beneficiaries) $269,000 HIE Development and Operations $625,000 HEALTH subcontract to RIQI Health subcontract to RIQI July sept 2010 Oct June 2011 Assume responsibilities for convening and staffing consumer advisory committee Assume responsibilities for obtaining consumer input in hie policies, hire an enrollment specialist to coordinate enrollment activities including: o outreach and training to enrollment sites o distribution of enrollment materials o develop and maintain a consumer call line to respond to questions update and reprint enrollment,materials target enrollment efforts to Medicaid beneficiaries, Complete the development of the initial HIE build to share labs and medication history, ( was supposed to be completed by HP) Upgrade to healthshare COMPLETE IN PROGRESS November 18, 2010 Page 44

45 Restart and complete user acceptance testing Develop interface with surescripts for medication history Conduct a security audit of new data center Develop security monitoring and log management services for new data center Develop and implement enhancement required by data submitting partners to audit log transactions sent to currentcare Figure 4 - MTG Funding Other Government-Funded Programs: Tracking of Children s Preventive Services including Immunizations The Rhode Island Department of Health has served as a national leader for achieving high immunization rates for its children and adult populations and for developing an integrated child health information system known as KIDSNET. KIDSNET, first implemented in 1997, facilitates the collection and appropriate sharing of health data with healthcare providers, maternal and child health programs, and other child service providers to assist with the provision of timely and appropriate preventive health services and follow up. These goals make KIDSNET a valuable tool across a variety of initiatives. KIDSNET links individual child data from vital records, developmental newborn screening, newborn hearing screening, newborn metabolic screening, early intervention, home visiting, lead screening, and immunizations. In actuality, Rhode Island was ahead of the nation by developing a health information exchange system for children prior to the current emphasis on EHR and HIEs for broader data exchange. KIDSNET has a web front end through which healthcare providers can view individual preventive health information on their patients as well as run reports for their practice to identify children in need of follow-up services (behind on immunizations, in need of a lead screening test, etc.). In developing the statewide HIE, KIDSNET was identified early on as a critical data sharing partner for the HIE since KIDSNET already has a significant amount of linked individual pediatric patient data accessible to providers via the web. By allowing KIDSNET to serve as a data source for currentcare, a provider will be able to access a child s immunization history through currentcare, along with other relevant clinical data such as labs tests and medication histories. Given KIDSNET s success, HEALTH is interested in expanding it to include adult immunization data, making KIDSNET a lifelong registry. This would include both having the current KIDSNET childhood population as well as capturing immunizations administered to adults. currentcare provides an avenue to advance this effort and provide the basis upon which adult immunization November 18, 2010 Page 45

46 data can be individually captured and sent to a life-long immunization registry. The data also could be used in aggregate to identify any existing gaps or disparities for immunization rates among the state s population leading to strategies for increasing adult immunizations rates throughout the state. The long term plan is that immunization data flow bi-directionally between KIDSNET and currentcare. The vision is to have KIDSNET serve as a federated data source to currentcare. This will allow KIDSNET data to be integrated with other currentcare health data and viewable at the point of service. currentcare will also be able to leverage the KIDSNET childhood immunization decision support algorithm already in place, which takes into account RI s universal vaccine program and immunization requirements, support the development of consistent decision support algorithms for adult immunizations, and the Department of Health s ability to monitor and improve immunization rates across the state. The vision also includes having the HIE be a data source for KIDSNET. To date childhood immunization data has been captured through a variety of methods including provider billing data files, hand data entry from encounter forms, and some EHR interfaces. Currently KIDSNET receives approximately 50% of childhood immunization records electronically through billing data or interfaces with EHRs, and importantly 99.5% of physicians who provide immunizations for children are participating in KIDSNET. HEALTH along with the community would like to streamline the data collections process by increasing EHR data populating KIDSNET. Several constraints, including consent requirements of the HIE (opt-in) versus those for KIDSNET (no consent required) prohibit this from immediately occurring. KIDSNET as a public health tool collects information on the entire population, whereas currentcare can only collect information on enrolled individuals. The consent implications need to be analyzed and considered in developing the technical approaches to capturing immunization data for KIDSNET. While the above analysis and overarching technical approach for electronically capturing immunization data (both currentcare and KIDSNET) are being determined, HEALTH will continue to work with healthcare providers to obtain immunization data electronically. As part of this overall plan, HEALTH is proposing a pilot with NHIN Direct to provide the needed connectivity to send immunization data from the provider s and hospital s EHR systems to KIDSNET. If timing is such that this is not permissible, then the HEALTH plans to pursue establishing direct interfaces with proposed EHR aggregators, all in an attempt to reduce the number EHR interfaces to KIDSNET. These same strategies will be used to help build the adult immunization registry even prior to a fully operational HIE (currentcare). The NHIN Direct or interfaces with the EHR aggregators can also be used for transmitting other necessary data to the Department of Health such as reportable diseases and syndromic surveillance conditions. Electronic clinical laboratory ordering and results delivery Electronic clinical laboratory ordering and results delivery has become increasingly available to physicians and providers in RI. Several clinical laboratories in the state are actively supporting electronic clinical laboratory ordering and results delivery. Others are beginning to implement November 18, 2010 Page 46

47 these services. One of the state s largest private clinical laboratories provides EHR interfaces, as well as lab results web viewer for providers without EHRs. Several of the state s hospitals and hospital systems have implemented interfaces with numerous EHRs in affiliated physician offices, and several support a web viewer for affiliated providers to look at patient records. The Rhode Island Department of Health Laboratory has been heavily invested in the establishment of an electronic process for receiving lab test orders and sending results. In 2005, the HEALTH Laboratory completed its first interface between its own Cerner Millennium Laboratory Information system (LIMS) and the Information Management System at Lifespan, the state s largest integrated delivery network. Lifespan includes 3 hospitals: Rhode Island Hospital (RIH), the largest hospital in the state located in Providence, about 2 miles from the Health Laboratory, the Miriam Hospital, also in Providence, and Newport Hospital (Newport, RI). Establishment of this LIMS interface initially allowed bidirectional ordering and resulting of laboratory test information for f culture and PCR testing; it was then expanded to include influenza testing. HEALTH would like to expand electronic test ordering and resulting capability to cover all tests and at all RI hospitals. Similar to the plan for immunization data collection, HEALTH is considering the ability to pilot the NHIN Direct to provide connectivity between the hospitals and health centers to the State Health Laboratory. If timing is such that this is not permissible then HEALTH will pursue establishing direct interfaces with each Hospital in order to achieve the desired outcome and to allow hospitals to meet Meaningful Use criteria. HEALTH s laboratory has also been working on establishing a bidirectional interface with the NextGen Electronic Medical Records (EHR) system that has been implemented at the Rhode Island Adult Correctional Institution (ACI) for which the HEALTH laboratory performs a variety of tests but specifically target HIV and other STDs. While a direct interface is under development, there has also been some discussions about having the ACI participate with the RI s Health Center Controlled Network, which has implemented NextGen in three of Rhode Island s community health centers and is planning to implement NextGen s HIE product, Community Health Solutions, to serve as an EHR aggregator to currentcare. Electronic Disease Reporting (National Electronic Disease Surveillance System, NEDSS) While many of the reportable diseases that HEALTH needs to be notified about (and then report to CDC) may result from laboratory work performed in the state laboratory, there are other labs and providers that need to be able to notify HEALTH of a reportable disease. These efforts are largely paper based at this time. HEALTH is working to electronically send laboratory results from its LIMS system into its NEDSS system and then to CDC. HEALTH is also developing a plan to implement the capability to accept reportable disease data directly from providers. This will support providers ability to meet Meaningful Use. Once again, HEALTH will work with RIQI to determine the options for using currentcare to pass along this information without violating the HIE law and consent policies. HEALTH in partnership with RIQI will be determining if the NHIN Direct can be leveraged to assist with these public health needs. Rhode Island Chronic Care Collaborative (RICCC) A healthcare collaborative is defined as a gathering of healthcare teams committed to a 12- November 18, 2010 Page 47

48 month period of rapid change in the delivery of primary care. Developed by the Institute for Healthcare Improvement (IHI), collaboratives are being carried out in a variety of settings and topic areas including diabetes, depression, and coronary artery disease. The RICCC uses electronic disease tracking programs, rapid change cycles, and a team approach to disease management to make improvements in healthcare delivery. The RI-Diabetes and Prevention Control Program (RI-DPCP) began the Collaborative initiative modeled on the Health Resources and Services Administration s Bureau of Primary Healthcare s (BPHC) successful Diabetes Collaborative Initiative. RI-DPCP staff is trained in the Chronic Care and Improvement Models. This Initiative promotes the adoption and use of practice guidelines by building an infrastructure for diabetes quality assurance in health sites including centers and sites that principally serve uninsured and underinsured persons with diabetes. Initially, the RI- DPCP took the initiative and created Boston Public Health Commission look-alikes called Community Health Improvement Programs (CHIP) in 11 community health centers and one primary care center (St. Joseph s). In 2002, RI-DPCP was awarded funds from the Robert Wood Johnson Foundation s (RWJ) Improving Chronic Care Illness Care program and expanded its collaboration to Quality Partners of Rhode Island. From this partnership and the RWJ grant funds the Rhode Island Chronic Care Collaborative (RICCC) was established to improve the quality of diabetes care in primary care settings through accelerated learning, innovation, registries, and change models. Additional partnering agencies joined the RICCC planning committee including Neighborhood Health Plan of RI, Blue Cross/Blue Shield of RI, and United Healthcare of New England, Brown Medical School, and RI Health Center Association. Twenty-six teams are participating private physician offices, hospital-based practices, and community health centers. Additional partnering agencies include Neighborhood Health Plan of RI, Blue Cross/Blue Shield of RI, United Healthcare of New England, Brown Medical School, and RI Health Center Association. The RICCC has over 6,500 people with diabetes (10% of the state s diagnosed persons with diabetes) enrolled in the RICCC registries. Over the past three years, the health plans have contributed $245,000 as payment for process and performance to the new and sustaining teams. The RICCC has spread its influence and is the training arm of the first five teams in the new Chronic Sustainability Initiative-RI (CSI-RI) which seeks to align payer support with quality of care for diabetes, depression, and coronary artery disease. This Patient Centered Medical home approach is being piloted in five primary care practices with 26 physicians and 26,000 patients with health plans paying the teams $1.2 million for process and performance. Medicare Quality Improvement Program The President and Chief Executive Officer of Quality Partners of RI (QPRI), the RI Medicare Quality Improvement Organization (QIO), is a member of the RIQI Board of Directors. Current projects include: The QIO Chronic Kidney Disease Project results will be further supported, to improve the Diabetes metrics, by the HIE and ARRA Beacon Community funding. November 18, 2010 Page 48

49 The QIO Safe Transitions Project results will be further supported, to improve the 30-day re-hospitalizations and emergency department metrics, by the HIE ARRA Beacon Community funding. QPRI is a stakeholder and participant in the RI Beacon Community. November 18, 2010 Page 49

50 1.7 Participation with Federal Care Delivery Organizations There are multiple Initiatives at Federal Care Delivery organizations that are positioned to be incorporated and stand to benefit from coordination with the HIE. These include the following: Veterans Administration Data from the VA will be integrated with the RI HIE through the NHIN when the RI VA to NHIN linkage is available. Additional ARRA Beacon Community funding will also facilitate capabilities to be extended to the VA Medical Homes where possible. Department of Defense Virtual Lifetime Electronic Records will be integrated with the RI HIE through the NHIN when it becomes available. Rural, Long-Term Care and Indian Health Services The RIQI understands that individuals served by these means have unique needs and thus RIQI has reached out to representatives of these segments of the population to be members of the RIQI Board of Directors, Committees, and Workgroups. Representatives from long-term care facilities actively participate in these bodies to ensure that their interests and needs are addressed. A previously stated, through the state s Medicaid Transformation Grant, efforts are under way to work with long term care (LTC) facilities to assure that they are able to utilize currentcare the state s HIE system. There is currently no planned coordination with Indian Health Services. November 18, 2010 Page 50

51 1.8 Coordination with other ARRA and ONC Programs Regional Extension Center Rhode Island Quality Institute is responsible for the execution of the RI Regional Extension Center, Beacon Community, and RI Health Information Exchange. Many RIQI staff members have responsibilities across the three ARRA-funded initiatives and those that do not are already working together. Teams are coordinating EHR adoption with HIE expansion efforts, thus enabling primary care practitioners to implement EHRs to maximize their opportunities to demonstrate Meaningful Use of summary document exchange, e-prescribing, care coordination, and public health participation through HIE. In addition, RI has a Health Center Controlled Network (HRSA and ARRA Capital Improvement grants) which has extensive experience with EHR aggregation, EHR adoption, clinical feedback, and performance monitoring. The HCCN is a stakeholder and participant in the RI Beacon Community. The Rhode Island Regional Extension Center is led by the same executive staff that will lead the HIE project. The RI REC initiative involves staff who also participates in the technical and governance functions of currentcare. RI-REC staff will support Meaningful Use of EHRs by performing outreach, education, and providing a qualified vendor marketplace. More specifically, the Rhode Island Regional Extension Center (RI REC) is a local, vendor-neutral service provided by the Rhode Island Quality Institute. Offering no cost services for identified Priority Primary Care Providers, the Regional Extension Center provides valuable assistance to healthcare providers as they transform their practice through the Meaningful Use of Electronic Health Records (EHRs). Key Tenets of the RI REC: 1. Provides objective one-on-one support through a designated Process Manager. The Process Manager guides and coaches providers on the journey to EHR adoption, practice workflow redesign, and optimization for Meaningful Use. 2. Creates a qualified vendor marketplace. The Regional Extension Center provides practices with a pre-approved list of vendors who RIQI knows have the ability to provide the services providers need. This eases the vendor selection process; standardizes services; promotes transparency for pricing and interface development; assists with reporting needs, saves time, and minimizes disruption to the practice. 3. Helps providers qualify for federal, state, and payer incentives and positions providers to be eligible for future funding opportunities. 4. Decreases the costs and risks of implementing an EHR. Working with experienced implementation consultants and vendors to coordinate services, data sets, interfaces, and resolve issues quickly helps the practice to achieve their goals. November 18, 2010 Page 51

52 5. Shares best practices for using technology to support care processes. Benefit from documented best practices and learn from peers to expedite EHR adoption and integration. Because the RI REC and RI HIE staff already work together, the teams will coordinate EHR adoption with HIE expansion efforts thus enabling primary care practitioners implementing EHRs will maximize their opportunities to demonstrate Meaningful Use of summary document exchange, e-prescribing, care coordination, and public health participation through HIE. The Beacon Community Program As noted in Section 1.3.3, RIQI and its partners have been designated as a Beacon Community. The Community will drive positive change in the quality, cost efficiency, and population health outcomes through HIT by focusing on two primary goals: Supporting RI s transition to the Patient-Centered Medical Home (PCMH) model for delivering healthcare by developing needed foundational capabilities through HIT (i.e. registries and standardized reporting). Improving RI s ability to see and act on the quality and efficacy of the healthcare system by providing foundational capabilities in quality reporting and public reporting, in the aggregate and practice levels. Multiple community stakeholders beyond those named in the Beacon Community will be engaged and benefit from this initiative. As such, the Community has put in place a set of intermediate objectives to help drive the larger efforts supporting their goals. These intermediate objectives are: Enhance the quality of care provided to chronic disease patients, as defined by adherence to recognized evidence based guidelines. Decrease overall healthcare costs by reducing preventable hospital and emergency department use. Reduce the impact of tobacco use on the health of the population of Rhode Island. Reduce the impact of undiagnosed and untreated depression through increased screening. The success of these community objectives largely relies on the HIE. Because the RI Beacon Team and RI HIE staff already work together, the teams will coordinate HIE expansion to ensure the success of the Beacon Community objectives. These community objectives represent an opportunity to leverage the health IT infrastructure in RI to reduce costs, and improve population health. NHIN Direct RIQI is adopting NHIN Direct as the primary transport mechanism for directed exchange of health information in Rhode Island, including: November 18, 2010 Page 52

53 Point-to-point exchange between providers who are coordinating care for a patient a key component of Meaningful Use requirements in 2011 Automated system-to-system exchange of health information for the purpose of aggregating health data for clinical, public health, and/or quality uses. This includes pushing data from EHRs for statewide coordination of care work without building customized interfaces for all combinations of systems in the state Triggering interventions such as notifying providers when their patients are admitted to or discharged from the ER or hospital. RIQI has participated in the NHIN Direct Implementation Group from inception, with active participation in a number of the workgroups including Implementation Geographies and Best Practices. RIQI is also leading one of the NHIN Direct Pilots underway and scheduled for completion in Q For more information on the RIQI NHIN Direct Pilot, see Section Future Vision Technology Overview NHIN Exchange and the NHIN Direct Pilot. November 18, 2010 Page 53

54 1.9 Governance Building a History of Collaborative Governance RIQI is the officially designated RHIO for RI and the ARRA State-Designated Entity (SDE) for the statewide HIE [see Attachment G RI Governor s Letter for SDE]. The board and its committees are responsible for assuring the HIE is developed and implemented in a way to meet the needs of RI and with alignment to federal standard, specifically NHIN. RIQI has an established broad governance structure that has been in place since prior to incorporation in 2002 and which was expanded upon as part of the AHRQ SRD contract and assures input from a wide range of community stakeholders. Community oversight of HIE activities is a key responsibility of the RIQI Board, which is comprised of 24 CEO-level, visionary, and influential leaders in the RI healthcare community, including consumers, providers, employers, health insurers, state government, and the Medicare QIO. In turn, a diverse offset of individuals serve on board and working group committees representing stakeholders from all facets of the community provide input, advocate, execute, and monitor all aspects of HIE development. The implementation and execution of this governance structure has been in place from the inception of early HIE tasks [Error! Reference source not found.] and was effective for the AHRQ HIE Demonstration Project contract to address the initial development and implementation of the HIE. November 18, 2010 Page 54

55 HIE Timeline Oct: RIQI introduces the Rhode Island Health Improvement Initiative (RIHII), a vision to use health information exchange and EMRs to improve the quality, safety and value of health care in Rhode Island. Nov: Exploration of the business and clinical case for health information exchange (HIE) begins Dec: RIQI plans to proceed with implementation of RIHII initiative and develops a grant application to submit to the Agency for Healthcare Research and Quality. Mar: RI/AHRQ HIT Steering Committee convened Jul: DOH awards RIQI single source contract to provide governance for AHRQ/HIE and to QPRI for provider engagement Oct: HIE architecture design agreed upon by stakeholders Dec: RFP for technical vendor released Mar: RIHII early plans include wiring an entire community within RI with EMRs and health information exchange as a pilot. However, after community input, it was decided that the infrastructure was needed statewide and we should work to implement health IT statewide. May: Responding to a request by the RIQI Board, preparations begin with DOH to respond to the AHRQ State and Regional Demonstrations in Health IT Request for Proposal (RFP) Jun: DOH submits a response to AHRQ s RFP for HIE contract Oct: DOH receives $5M AHRQ contract to build HIE demonstration system (minimum requirement to share lab results and medication history) Mar: RIQI convenes Consumer Advisory Committee Apr: Start discussions with providers and consumers regarding the HIE consent model. Initially propose allowing data to flow to HIE, assuming opt-in consent at viewing level May: DOH receives HHS award Health Information Privacy and Security (HISPC) contract Aug: Analysis of laws related to sensitive data conducted through HISPC Oct: EDS receives tentative notice of award as technical vendor; First draft of RIQI/HIE business plan developed 1 HIE Timeline (2) Feb: HIE Joint committee meeting results stipulate that no data can leave source (i.e., flow to the HIE) unless consented. Required changes to authorization policy and technical model Jul: EDS contract to build HIE technical infrastructure officially begins (partnering with InterSystems Corporation); RI Department of Administration issues Request for Proposal (RFP) to officially designate RI s Regional Health Information Organization (RHIO) Oct: The stakeholders agree upon functional requirements for technical solutions to implement the authorization policy; referred to as the HIE participation service and gateway Nov: RIQI receives tentative notice of award for RHIO RFP Dec: CVS awards RIQI $2.5M to support HIE and EHR adoption work; RIQI receives an $862K congressional appropriation for HIE Jan: Begin contract negotiations with RIQI for RHIO designation and HIE Operations February: Beginning development of HIE transition plan; begin to develop the HIE Operations contract May: Begin to draft EDS contract modification language Jun: RI s HIE branded as currentcare ; RI Health Information Exchange Act of 2008 signed into law by Governor June to present: Review and negotiate EDS contract modification Jul: Contract with RIQI for RHIO and HIE Operations signed; some transition from the State to RIQI begins; State modifies EDS contract to include additional technical components needed to implement RI s consent model Aug: RHIO/HIE strategic and operational plan updated Oct: Boston Consulting Group (BCG) engaged to develop HIE business case Dec: HIE business case finalized and approved by the RIQI Board 2 November 18, 2010 Page 55

56 HIE Timeline (3) Mar: ARRA HITECH Act passes; Warwick enrollment strategy begins; Apr: Boston Consulting Group (BCG) engaged to assist with develop of long-term funding (sustainability) model for HIE May: Public hearing for HIE regulations held Jun: RIQI Board votes to approve a sustainability model involving an assessment on health care claims Jul: HIE technical system testing underway with EDS Aug: HIE and Regional Extension Center RFPs announced by the Office of the National Coordinator for Health IT (ONC) Sep: Governor officially names RIQI as RI s State Designated Entity for ARRA Statewide HIE grant; RIQI submits application for ARRA HIE grant; Limited EHR Aggregation Pilot (LEAP) begun with Thundermist, Landmark Hospital and eclinical Works ehx aggregator Oct: RIQI submits application to the ONC for ARRA funding to become RI s Regional Extension Center (REC) Nov: currentcare sign-ups exceeds the goal of 30,000 enrollees in 2009; RIQI ramps up implementation of long-term funding approach Jan: New goal of 100,000 additional currentcare sign-ups set for 2010 Feb: RIQI awarded $5.2M in ARRA funding for statewide HIE; RIQI awarded $6M in ARRA funding as RI s Regional Extension Center for assisting providers with EHR adoption and meaningful use Mar: RIQI Board votes to suspend efforts to pass legislation to execute the long-term funding model in 2010; RIQI submits an application for a Congressional appropriation in the amount of $740K, entitled, RI Community Hospitals Integration with the Statewide HIE ; EDS data center in Warwick flooded HIE hardware systems destroyed; LEAP production environment in place and security audit begun Apr: Process to update statewide HIE plan begins; RIQI becomes involved in the development of the Nationwide Health Information Network (NHIN) Direct project ($1.8M earmarked by ONC in RI HIE grant for connection to NHIN/regional efforts) May: RIQI awarded $15.9M in ARRA funding for Beacon Communities grant, which includes provisions for HIE 3 Figure 5 HIE Timeline Governance Model: Membership Representation and Structure RIQI Governance Committees Figure 6 - RIQI Governance Committees A complete listing of the HIE related Board and Working Group committees and a description of their roles can be found in Figure 31 in Section 2.7 of the. The RIQI Board represents state government, hospitals, employers, providers, payers, academia, the state November 18, 2010 Page 56

57 Quality Improvement Organization and consumers. The proportion of the governing organization (RIQI Board of Directors) that is represented by public stakeholders is 12%. The proportion of the RIQI Board that is represented by private sector stakeholders is 87%. Stakeholder Representation by entity can be found in Figure 7. The state Medicaid agency has a designated governance role in the organization. The Director of the DHS is an ex officio member of the RIQI Board. In addition, Work-group sub-committees are comprised of community members in addition to board members supporting the ability to engage stakeholders. ACP Board of Regents, RIMS American Association of Retired Persons (AARP) Astro-Med, Inc. Blackstone Valley Community Health Center Blue Cross & Blue Shield of Rhode Island Cameron & Mittleman Care New England Health System Center for Gerontology and Healthcare Research, Brown University Comprehensive Community Action Program CVS Caremark Division of Geriatrics in the Department of Medicine Donoghue Barrett & Singal East Side Clinical Laboratory Former Rhode Island Lieutenant Governor Gateway Healthcare, Inc. Greater Providence Chamber of Commerce Hasbro Children s Hospital Health Care Consumer Health Insurance Commissioner for the State of Rhode Island Hospital Association of Rhode Island Lifespan Mental Health Association of Rhode Island National Association of Social Workers, Rhode Island Chapter Neighborhood Health Plan of Rhode Island NetCenergy Nixon Peabody LLP Normand Law, Ltd. OSHEAN Providence Community Health Centers Quality Partners of Rhode Island Rhode Island Coalition Against Domestic Violence Rhode Island Council of Community Mental Health Organizations Rhode Island Department of Administration Rhode Island Department of Health Rhode Island Department of Hospitals (MHRH) Rhode Island Department of Human Services Rhode Island Department of the Attorney General Rhode Island Disability Law Center (RIDLC) Figure 7 - Stakeholders Rhode Island Distribution National Grid Rhode Island Division of Information Technology Rhode Island Health Care Association Rhode Island Medical Society Rhode Island Parent Information Network Rhode Island Partnership for Home Care Rhode Island Primary Care Rhode Island Quality Institute Saint Joseph Hospital Senate Health Policy Advisor South County Hospital South County Internal Medicine, Inc. Staff of Senator Sheldon Whitehouse State of Rhode Island and Providence Plantations Sullivan & Company SureScripts Thundermist Health Center Tufts Health Plan United Healthcare of New England, Inc. UnitedHealth Networks University of Rhode Island The Westerly Hospital Governance Model: Decision Making Authority RIQI recognizes that in order to modernize health information infrastructure, address the complexities of medicine and patient privacy, and avoid multiple parties working at crosspurposes with each other, community involvement is crucial. RIQI s communication approach is intended to guide discussion, investigation, and experimentation in meetings that are open to the public with participation encouraged. The RIQI Board is ultimately responsible for HIE activities and has specified the RHIO Oversight Committee of the RIQI Board to monitor November 18, 2010 Page 57

58 performance (along with the Audit and Compliance Committee of the RIQI Board). The HIT Leadership Team was created to facilitate the need for increased accountability and coordination of daily activities given the expanded responsibilities under the three new grants and thus includes RIQI s CEO and COO/CIO and is accountable to the RHIO Oversight Committee. Relevant Work-group sub-committees provide advice and guidance to the HIT Leadership Team Alignment with Emerging NHIN Governance RIQI has been involved with the NHIN Direct projects since the initiation of the project, and has built an internal governance and implementation structure that strongly aligns with the emerging national model. RIQI has followed and is in alignment with the Tiger Team s recommendations on privacy, security, and consent. RIQI s COO/CIO is a member of the NHIN Direct Implementation Group, and has been an active member of a number of workgroups including Implementation Geographies and Best Practices. As part of RIQI s involvement in the Best Practices workgroup, we are helping to shape the guidelines and principles governing NHIN Direct. All of the Best Practices are being implemented as part of our pilot, including the optional (but supported) practice of RIQI acting as a Trust Anchor and potential certifying body for HISPs within the state. The project team overseeing Rhode Island s pilot project for NHIN Direct is heavily involved in proving out specific user stories developed by the NHIN Direct community specifically those to demonstrate point-to-point secure health information exchange, and the transparent feed of clinical information from the EHR to the state HIE, currentcare. The project team overseeing this pilot is heavily involved with all aspects of NHIN Direct governance and has driven the community in a number of ways, in particular the development of best practices for HISPs and Security/Trust, and technical leadership for components of the Reference Implementations Rhode Island HIT Coordinator The Governor of RI has appointed the Director of Health (David Gifford, M.D, MPH) to serve as the State s HIT Coordinator. The Director of Health is a cabinet level position, which directly reports to the Governor. HEALTH has and continues to provide local and national leadership in the promotion of health information technology. HEALTH is well suited to manage the coordination of HIT across the state having served as the recipient, on behalf of the RIQI and the Rhode Island community, of the AHRQ state and regional demonstration project contract to build a statewide Health information Exchange system, as well as actively promoting and publically reporting the adoption of EHRs and e-prescribing. HEALTH has an Office of Health Information Technology, which will provide staff support to the State HIT Coordinator. The role of the State HIT Coordinator will be to provide overall strategic planning and policy direction for HIT activities throughout the state and to assure the November 18, 2010 Page 58

59 coordination of HIT initiatives undertaken within the state (both private and public sectors) to leverage existing efforts and achieve synergy in 1) the adoption of EHRs including providers ability meet Meaningful Use and 2) the implementation and use of the HIE Transparency Applicable Policies RIQI policies aim to ensure privacy and security of a patient s medical records as well as a patient s right to audit who is viewing his/her health information. Policies have been designed to ensure that providers are legally accountable for how and when they access patient information. In addition to an opt-in consent model, patient information is further restricted by break the glass policies - requiring that providers identify why they need to access a record. All access information is reportable and auditable throughout the system, while privacy officers conduct periodic assessments to evaluate potential instances of inappropriate access. In the event that breaches should occur despite stringent controls, RI legislation mandates that these breaches in security are transparent and made public. RI makes transparent to the public privacy and security programs by publishing all of the policies and procedures public via the RIQI website 1. Similarly, enrollment materials and other collateral reference the availability of this information. Current policies include: Policy currentcare Notification of Breach Policy currentcare Response to Breach Policy RI HIE Enrollment Policy RI HIE Complaints Policy RI HIE Temporary Authorization Policy Description This policy establishes the process by which the RHIO will determine the appropriate level of notification to consumers and users if a security breach of currentcare occurs. The purpose of this policy is to establish a process used by the RHIO to respond to any breach of security and/or confidentiality of protected health information in currentcare. This policy describes the consumer's choice to enroll or terminate participation in currentcare, and the procedure by which the consumer can express that choice. This policy describes the process in which complaints on a range of issues are handled and processed by a currentcare user organization, the RHIO, or the Department of Health. The purpose of this policy is to set the rules and resposibilities for any authenticated individual currentcare user to gain temporary authorization to access patient information through the HIE for a limited time in unanticipated or unscheduled situations. 1 November 18, 2010 Page 59

60 RI HIE Role-Based Permissions Policy Revocation of Authorization for Enrollment Policy Patient's Rights The purpose of this policy is to establish permission/ authorization to users for accessing functions and information within currentcare. This procedure describes the consumer's choice to terminate participation in currentcare. This policy describes the Rules and Regulations Pertaining to the Regional Health Information Organization and Health Information Exchange Figure 8 - Current RIQI Policies Interoperability Standards RIQI continues to support the development and implementation of national interoperability standards, including support for NHIN Exchange and NHIN Direct. These standards support both individual privacy and counter-party trust for health information exchange, allowing for the establishment of transparent, uniform links between heterogeneous systems ranging from state and national entities (currentcare, VA, etc ) to individual provider offices (via NHIN Direct). For more information RIQI s support for these interoperability standards, see Section Community Involvement To support transparency, RIQI Board meetings are open to the public. The schedule of meetings, agendas, and minutes are distributed electronically and posted on the website at RIQI also maintains transparency by encouraging public feedback on HIE operating policies and procedures. To ensure that a broad population has visibility/input RIQI regularly engages a diverse set of community entities as new policies are developed. (Figure 7) Accountability RIQI understands the value and importance of deep stakeholder involvement and accountability. Engaged stakeholders contribute to the success of community initiatives. To strengthen HIE Governance activities RIQI has established the following committees: 1. Technical Advisory Group provides expertise and guidance regarding technical standards and implementation 2. Consumer Advisory Committee provides guidance on a wide variety of issues that benefit from strong consumer participation and input, specifically how patients/consumers control access to their health information 3. RHIO Oversight Committee RIQI board of directors committee that provides oversight of all statewide HIE activities undertaken by RIQI 4. RIQI Operations Oversight Committee RIQI Board of Directors committee that provides oversight of all operational aspects of the Institute, including Financials, HR, Infrastructure, Operations, Audit/Compliance, and Programs November 18, 2010 Page 60

61 5. HIT Leadership Team assist in strengthening management functions and accountability, including regular oversight of project execution delivery 6. Health IT Physicians Advisory Council informs the RHIO oversight committee and its subcommittees on physician perspectives on use of HIT and advises and makes recommendations regarding the development of strategies related to HIT initiatives to improve quality of care The full RIQI Board of Directors meets monthly. The RHIO Oversight Committee provides direct oversight for the statewide HIE network. The RI HIE team follows an established process for status reporting on HIE development to the Board and stakeholders. RIQI recognizes the need for clear communication with the community and employs a variety of mechanisms for doing so, including listservs, websites, and wide distribution of Board materials including the monthly CEO letter to the Board. For operational details on Key Committees and Governing Entities, see Section November 18, 2010 Page 61

62 1.10 Finance Management of Resources As a not-for-profit organization, RIQI currently receives revenue from both public and private organizations. In 2009, the portion of funding to advance statewide HIE that was obtained from federal assistance was 38%, State assistance through subcontracting of federal grants/contracts was 9%, other charitable contributions was 51%, and revenue from HIE services was 0%. In 2010, the portion of funding to advance statewide HIE that will be obtained from federal assistance is 0% (other than ARRA), State assistance is 10% (through subcontracting of federal grants), other charitable contributions is 89%, and revenue from HIE services is 0%. Of these charitable contributions, in 2009, 51% of funding came from a charitable trust and two major health plans. In 2010, 89% of funding came from a charitable trust and two major health plans. RIQI has a business plan that includes a financial sustainability plan that targets new legislation and is described in Section Sustainability. RIQI has developed and implemented financial policies and procedures consistent with state and federal requirements. The RIQI Board, the RIQI Operations Oversight Committee, and the RHIO Oversight Committee review plan versus actual financials on at least a quarterly basis. Reports to the Board on financial status are delivered monthly. RIQI will comply with the Single Audit requirements of OMB. RIQI is executing a financial plan to secure a revenue stream to support sustainable business operations throughout and beyond the performance period Sustainability Importance of Sustainability From the outset, the RIQI Board and the community of HIE stakeholders have recognized the importance of building a sustainable business model for health information technology programs in the state of Rhode Island, in particular those programs that support coordination of care. To this end, a series of studies to assess the value of and options for sustaining health IT programs have been completed. Phase 1: Assessing value and a building a Business Case (Attachment E) The RIQI Board engaged Boston Consulting Group (BCG), to work with RIQI and the healthcare community in Rhode Island to develop a business case for HIE in RI. RIQI instructed BCG to be conservative in their calculations, stipulating that any savings from the following sources NOT be include the following value creation: 1. quality improvement activities enabled by the HIE November 18, 2010 Page 62

63 2. Potential value to RI s research / biosciences / biotech economy 3. Improvements in public health 4. Worker s compensation care improvements. The return on investment was calculated on 2004 dollars and not inflated to 2008 dollars. National estimates were for 6-7% growth over that time period [see Attachment for details on additional measures to ensure a conservative estimate]. The intent was to understand only the value created from coordination of care. Even with these strong efforts not to overstate the value of the HIE, the analysis still suggested an approximate annual return to Rhode Island s public and private stakeholders of $108M on a $5-10M sustainability cost. Figure 9 - Value Creation Estimates The initial analysis of value creation potential of an HIE done in 2008remains accurate but but should be reviewed as part of the February 2011 sustainability plan based on the most recent literature from the Center for Information and Technology Leadership, Byrne, Colene M., et al., The Value from investments in Health Information Technology at the U.S. Department of Veterans Affairs. Health Affairs 29.4 (2010). Once the overall value of HIE was understood, the next question to answer which stakeholders accrued value. The BCG analysis gave credence to the concept that HIE benefits a community November 18, 2010 Page 63

64 in a way similar to a public utility. There was no sector that garnered a sufficient share of the savings (Federal receiving the most at 26%) to warrant placing the burden of financing the HIE on them and not other stakeholders who are also receiving benefit. Per the figure below, benefit is spread relatively evenly across sectors if one sector had received a large proportion of benefit, it would follow that that section should bear a larger proportion of costs. This fact helped to guide the formation of the long-term funding model, which seeks to distribute the burden of financing the HIE as fairly as possible over the groups receiving financial benefit. Figure 10 - Allocation of Value Phase 2: Developing a Funding Model (Attachment I) The RIQI Board again engaged BCG in early 2009 to help with the development of the long-term financing model guided by the findings of the business case analysis. A comprehensive analysis of potential funding models was conducted and presented to the RIQI Board of Directors. The evaluation criteria used to assess models included the ability to be modifiable and flexible, stable and predictable, as well as simple and transparent. The ideal funding model would emphasize ease of implementation, fair distribution of cost, and reinforcement of organizational focus on value creation. It was important that the funding model be stable and predictable, avoid disagreements among stakeholders regarding how the value of the HIE would be allocated, be inclusive of self-insured employers, and deliver matching requirements of the state for federal funding opportunities. As part of that work, BCG completed a comprehensive environmental scan of various funding models and the leading edge approaches throughout the country. (See Figures 11 and 12). After a review of approaches in other states, analysis of the RI community, and projections of November 18, 2010 Page 64

65 HIE-related costs, the RIQI Board voted to pursue legislation that will create an assessment on claims of the commercial insurers and the self-insured, similar to the strategy adopted in Vermont by Vermont Information Technology Leaders. It was recognized that the funding model should be appropriate for the stage of the business life cycle of the HIE and the assessment model best fit the current growth stage of RI s use of health information exchange. A key transition point will occur in 2016 (year five of the seven year program), as the HIE transitions from the growth phase to the maturity phase. At this checkpoint, a complete analysis will be undertaken to evaluate alternative funding models that more directly align the actual value being delivered. Once mature, the HIE should be able to create value, demonstrate that value, and therefore find ways to fund its needs by capturing some of the value as a reward through fee models. Figure 11 - Sources of Funding November 18, 2010 Page 65

66 Figure 12 - HIE Programs Long Term Sustainability via a Payer Assessment Model Phase 2 of the BCG study proposed an assessment model using healthcare claims as a basis for allocating the assessment for the growth phase of the HIE. This model will be in place until such time when significant data sharing partners and data points are implemented so as to increase value, sun-setting in a maximum of 7 years. Under the proposed model, an assessment fee of 0.13% would be applied to the claims of the privately insured and also to those of the self-insured. This equates to roughly $9.94 per employee per year. Given that the average cost of a lab test in Rhode Island is $24 and the average hospitalization is $11,700, a fee of less than $10 per employee per year would likely be easily recouped. Provider and Medicaid Contributions to Long Term Sustainability RIQI does not see a case where providers would be expected to provide monetary contribution to support the HIE. The analysis of value distribution shows providers receiving only 2% of the overall benefit. Based on the already overwhelming financial and operational burdens faced by providers (particularly primary care physicians), they are unwilling to pay additional fees or take on additional administrative tasks for minimal quality of care or financial benefit. This barrier may be altered as health information technology programs begin to demonstrate concrete November 18, 2010 Page 66

67 value and/or as payment reforms (PCMH, ACOs) are instituted in the state making the technology more attractive. The State of Rhode Island (and thus Medicaid) act as an employer and will contribute in this capacity. RIQI and stakeholders from state agencies are working in regular collaboration, meeting regularly to evaluate long term plans and funding strategies. As HEALTH s MITA reengineering strategic plan is developed and finalized, long term contributions from the state are being evaluated as a part of that plan due to be completed in February A key transition point will occur in 2016 (year five of the seven year program), as the funding plan enters the maturity phase. At this checkpoint, a complete analysis will be undertaken to evaluate alternative funding models that will be based on the value produced and the recipients return on investment. With this value demonstrated, the long-term sustainability could be realized by a continuation of the straight assessment on claims if the benefit remains evenly distributed, and/or the introduction of specific fees if certain stakeholders are realizing new and disproportionate benefits. Legislative Support for Assessment Funding Model Having received the support of all of the private insurers in RI, the Smaller Business Association of New England and the RI Business Group on Health, RIQI initially planned to seek support in the legislature during the 2010 session. However, given the dynamics of an election year, the state s budget deficit, a decision was made to hold off attempting to pass legislation in Given that RIQI received funding from all three major HIT grants (HIE, REC and Beacon Communities), there is even more impetus for pursuing the long-term funding strategy in 2011, as Rhode Island has a significantly higher level of health IT investment to protect and has much more to build upon and leverage, which bodes well for the effort to secure the funding. RIQI s strategic plan for long-term sustainability with support from legislative action will be executed by the RIQI Public Affairs Committee, with oversight from the RIQI Board. Specific tactics have been defined and are currently being executed as outlined in the detailed HIE Task Timeline in Attachment M. RIQI is working with a legislative advocacy firm to execute the optimal approach for ensuring a positive outcome with the Legislature. In addition, the Board is exploring alternative approaches and contingencies should the Legislature not support the proposed assessment. These will be addressed in the updated sustainability plan to be completed and submitted to ONC in February Challenges for Sustainability Truly evidence-based economic and outcome research on HIE is in the infancy stage (as opposed to theoretical business cases, of which there are many). Research is being presented as this document is written and will need to be incorporated into existing financial modeling on a regular basis. Futher updates to the financial model will be based on the prioritization of November 18, 2010 Page 67

68 needs to the community and additional state and federal requirements that present themselves. The challenges to RIQI s long-term funding model include: 1. Potential inability to pass state legislation Legislation was determined to be necessary in this funding model to ensure that all beneficiaries of the statewide HIE contribute appropriately to its financial support, eliminating the problem of free riders. A risk analysis of sustainability funding was conducted through the BCG engagement which includes risks to public funding; potential mitigations for risk to the legislative process, and a potential contingency plan if the proposed model does not move forward. This contingency plan would be to create a fee on claims for insured lives through the regulatory mechanism and couple with on-going contributions from large self-insured organizations (especially, e.g., state, municipalities, largest employers such as hospitals). Transition to fees as HIE reached critical mass would also be an option for further exploration. 2. Availability of funds to health information technology programs even as legislation is passed, the dedication of funds exclusively to sustain health IT programs could be at risk as other funding requirements arise. As a mitigation, draft language for legislation calls for a Restricted Receipt Account which helps assure that the money will be used only for the RHIO s HIT programs. Additionally, a mechanism will be proposed that assures that the money will be dispersed monthly, so as to minimize the build-up of funds in the account, keeping it unattractive for other uses. 3. Unclear value delivery of HIE at year 5 checkpoint The 5-year checkpoint will begin to determine what long-term funding strategy should be pursued after the 7 year sunset of the legislation. The legislature could decide the system needs more investment and extend the legislative action beyond 7 years, or if it is the case that health information technology fails to deliver sufficient results, money might not be spent further until a concrete plan to increase real value can be established. November 18, 2010 Page 68

69 1.11 Technical Infrastructure Technical Architecture / Approach The technical strategy for currentcare builds on other successful solutions that meet similar requirements. The solution integrates best-of-breed commercial off-the-shelf (COTS) packages from vendors including InterSystems, Quadramed, Apelon, eclinicalworks, and NextGen, to develop a flexible, expandable, scalable, and standards-based health information exchange system; this ensures that currentcare will remain sustainable and relevant over time. At the same time, this solution is very closely attuned to Rhode Island s requirements: it supports the specific privacy and patient consent policies that are legally mandated in Rhode Island, and leverages current technical capabilities for EHR aggregation in the Rhode Island provider community. The technical architecture is comprised of two elements: an integration framework using products based on a service-oriented architecture (SOA) and integration standards, and a suite of functional components that provide the required services. The architecture of the system is based on an Enterprise Master Patient Index (EMPI) combined with Data Registries and Data Domain Repositories to create a longitudinal health record for each patient. The architecture provides the platform that will ultimately support a broad range of available clinical data about a patient from a variety of source systems. The technical solution incorporates a strategy for provision of application programming interfaces (APIs) or web services to Data Sharing Partners (DSPs) to reduce the time and effort for them to come online. It also includes a language processing application which ensures that all clinical information submitted to the HIE is mapped to standardized medical vocabularies. This technical architecture is also very well-suited to supporting the incremental and iterative approach. The first phase, funded through the AHRQ SRD project was focused on the design, development, testing, and implementation of Release 1 of currentcare. Release 1 delivers exchange involving data from laboratories and one medication DSP; this release is at the acceptance testing phase. After implementation of the initial release is complete, subsequent iterative phases of the project will deliver the exchange of additional data types, among additional DSPs and providers some of which is being funded by RI s Medicaid Transformation Grant (MTG) Business Overview It is well established that the existing healthcare system is fragmented, with patient information collected at multiple healthcare organizations on computer systems that are not linked together. As a result, complete and up to date data about a patient s health is very often not accessible available to providers, and studies show that 30 percent of first referral visits are November 18, 2010 Page 69

70 wasted because the doctor to whom the patient was referred does not have the benefit of historical patient data. Furthermore, about two-thirds of the time, when patients return to their primary care doctor; they often do not have adequate information about the outcome of the referral. Additionally, as many as 98,000 persons a year die because of medical errors, many of which could have been prevented with more organized, comprehensive access to retrospective patient information. Many aspects of this national picture are mirrored in Rhode Island; the most critical challenges include Heterogeneous EHR environment: There are 105 vendor products in use across Rhode Island, and different providers using the same product may do so in unique ways. The HIE architecture will need to aggregate information from this disparate group of EHRs in an efficient and cost-effective manner. Multiple representations of the same patient: Each system in which a patient s information resides may represent and identify that patient differently. The HIE architecture will need to reconcile those data reliably in order to present an accurate, patient-centric view to providers. Variable terminology to describe similar events: each discrete clinical event (lab order, referral, procedure) may be described in different ways across the Data Sharing Partners. The HIE architecture will need to map separate nomenclatures and coding systems to a shared standard. Disparate readiness to contribute and share data: Across Rhode Island there will be multiple Data Sharing Partners contributing information to the HIE, and they will be ready to begin contributing at different times. The HIE architecture will need to be able to add new partners easily, while scaling to support the increasing volume of data being shared. Granular patient consent: At the same time that patients are eager to realize benefits in cost-savings, safety, and coordination of care, they are also concerned to ensure that they maintain control over the sharing of their clinical data. Rhode Island has chosen to protect patient privacy and control through a consent model that mandates that only patients who have opted in will have their information transmitted to the HIE. The HIE architecture will need to ensure that no patient data is passed without this active consent Technology Overview Core Software Platform for Required Services: InterSystems HealthShare Rhode Island chose to build currentcare on the HealthShare platform because it provides a set of pre-built services that represent the main components required by an HIE: November 18, 2010 Page 70

71 Exchange: The HealthShare Exchange service extracts, transforms, exchanges, and aggregates the clinical data being shared by the health information exchange inbound from data sharing partners, and outbound to the browser-based Viewer that providers use, and to the browserbased Patient Portal. Patient Identification: To provide a reliable patient-centric view of clinical data, HealthShare relies upon probabilistic matching of patient demographic data, and maintain an enterprise master patient index (EMPI) that resolves the multiple representations of the same patient across source systems. Standardized Terminology: To maintain standardized, structured data in currentcare, HealthShare uses terminology sets such as LOINC, SNOMED, and ICD-9 and ICD-10, and relies on compendium management and terminology mapping services to appropriately translate clinical information received from data sharing partners. Patient Participation and Consent: HealthShare s consent management framework acts as a gate-keeper to determine if the patient has consented to share information and only allows information to flow if consent is confirmed. HealthShare has been enhanced specifically to enable the Participation Gateways to accommodate currentcare s opt-in consent model. Security: HealthShare supports the OpenSSO framework with which currentcare authenticates users. HealthShare encrypts all data at rest using Advanced Encryption Standard (AES) and 256- bit keys, encrypts all data in motion using SSL/TSL, and records all accesses to the EMPI and clinical systems in tamper resistant logs. Access and Data Presentation: Access and data presentation in the HealthShare platform occur through a browser-based Viewer for providers and a browser-based Patient Portal. Future HealthShare enhancements will allow providers direct access to the HIE through appropriately configured clinical applications (such as the provider s EHR application). This will allow the provider to use one system, offering a more seamless integration with the provider s usual workflow. Commercial Off The Shelf Components Two separate InterSystems products the Caché database engine and Ensemble messaging and integration engine are foundational components of the HealthShare platform. Both are proven and reliable. Caché is used in numerous high volume healthcare solutions nationwide, including enterprise level applications from Epic and GE Healthcare. In HealthShare, Caché manages data storage and retrieval for patient identity and consent information at the central Hub, and for the clinical information maintained at each data sharing partner s Edge Gateway data repository. November 18, 2010 Page 71

72 Ensemble, likewise, supports major clinical system integration architectures at health systems such as Partners Healthcare. In HealthShare, Ensemble manages the messaging between components of the service oriented architecture. Other third-party COTS components of curentcare are QuadraMed s Smart Identity Exchange, which provides robust probabilistic patient matching and EMPI to accurately reference all components of the complete medical record for each patient across every data sharing partners, and Apelon s Distributed Terminology System (DTS) which provides the necessary terminology mapping and compendium management services across the data sharing partners. Key Implemented Components The following diagram outlines the current state view of RI HIE. The logical components are explained briefly in the following diagram. November 18, 2010 Page 72

73 currentcare Initial Architecture Diagram Enrolled Patients Unenrolled Patients RI Statewide HIE: currentcare Viewer Legend Existing Included in HIE Grant To be Budgeted/ Prioritized Opt-in & Access Control PROVIDERS ACCESS GATEWAY HUB Open SSO (authentication) Other RI Specialists Healthshare (Caché database engine; Ensemble messaging platform) Apelon (terminology & compendium management QuadraMed (patient matching) currentcare ehx (ecw Aggregator) Other RI PCPs RI Providers (Thundermist Health) ecw EHRs Surescripts Gateway Existing Lab Edge Gateways Other RI Providers Other EHRs PARTICIPATION SERVICE Community Health Centers (Blackstone Valley CHC) Surescripts Eastside Labs Lifespan Labs State Labs CHS (NextGen Aggregator) NextGen EHRs Other RI Providers NextGen EHRs currentcare: Institutional Data Sharing Partners Figure 13 - Key Implemented Components November 18, 2010 Page 73

74 Hub The Hub is where shared resources reside, most importantly patient identifiers, registries, and patient consent data. It is responsible for the storage and enforcement of the consent profiles. Participation Service and Participation Gateways The Participation Service implements the RI Consent model; there are two key design elements to this service: 1. The service relies on a centrally-managed list of patients who have opted in to the RI HIE; that repository of patient consent maintained at the Hub 2. The service communicates with a Participation Gateway application that is placed within the Data Sharing Partner s environment to ensure that no clinical information leaves the DSP s environment unless the patient has been validated against the consent model. Edge Gateways Each Data Sharing Partner will either submit clinical data to its own Edge Gateway within currentcare, or have currentcare go out and retrieve the data from their own data system (Surescripts); that Edge Gateway manages the specific messaging exchange, provides inbound pipelines to put data into a standard format, and handles the storage requirements for its specific DSP. This segmentation minimizes the dependencies between DSPs allowing new DSPs to be implemented as they become ready with less effect on existing DSPs. Similarly, this approach allows the system capacity to scale incrementally. Access Gateway The Access Gateway coordinates access to data, managing the communication between the Hub, Edge Gateways, and the Viewer. Cross-terminology mappings are implemented within the Access Gateway as it prepares data for presentation in the Viewer. Authentication Customer Access Manager Server, Policy Agent and User Store are used to support login authentication, policy management and enforcement. Additionally, the currentcare system uses SSL to encrypt sensitive information in user web traffic. All system end-users will be authenticated upon log in by being presented with a series of security questions. This authentication functionality is a native part of the HealthShare product. EMR Aggregators Certain vendors provide aggregation platforms that provide the technical capability to share clinical data with instances of their specific EHR. These aggregators provide a more straightforward and cost-effective means for provider networks and individual practices to November 18, 2010 Page 74

75 participate in the statewide HIE by leveraging the EHR vendors existing connectivity and reducing the number of discrete interfaces that need to be constructed to currentcare. Viewer The viewer is the web-based application where providers login to currentcare and retrieve a patient s information Detailed view of Data Submission and Retrieval The flow of data is essential to the function of the HIE. The following sections provide an overview of how data is submitted to and retrieved from the HIE. Data Submission Figure 14 provides a step-by-step view into how data is submitted to the HIE. This process highlights the role of the participation service (or gateway) in the architecture and how it supports the Rhode Island consent model. Figure 14 - Data Submission November 18, 2010 Page 75

76 Data Retrieval Figure 15 provides a step-by-step view into how data is retrieved from the HIE. This process also highlights the role of the participation service (or gateway) in the architecture and how it supports the Rhode Island consent model. Figure 15 - Data Retrieval November 18, 2010 Page 76