Credits and Acknowledgments

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2 Credits ad Ackowledgmets Coecticut State Health Iformatio Techology Pla J U N E u u u Prepared by JSI Research & Traiig Istitute, Ic. We gratefully ackowledge the Steerig Committee who provided critical iput ad guidace to the developmet of the Coecticut State Health Iformatio Techology Pla. Thomas Agresta, MD Asylum Hill Family Practice Ceter Marybeth Boadies Office of Healthcare Access Jessica Cabaillas Coecticut Office of Policy ad Maagemet Steve Casey Coecticut Departmet of Iformatio Techology Da Clemos Commuity Health Ceter Associatio of Coecticut, Ic. Joh Gadea Coecticut Departmet of Cosumer Protectio Meg Hooper, Chair Coecticut Departmet of Public Health Mariae Hor Coecticut Departmet of Public Health Jeifer Jackso Coecticut Hospital Associatio Juliae Koopka Coecticut Departmet of Public Health Robert Mitchell Coecticut Departmet of Social Services Gregory Sulliva Coecticut Office of Policy ad Maagemet

3 Table of Cotets I. Itroductio...5 A. Healthcare System Reform ad the Role of Health IT/HIE...5 B. Coecticut Legislative Madate...9 C. Developig the Coecticut State Health IT Pla (The Pla)...11 II. Health IT/HIE Backgroud...13 A. Natioal Health IT/HIE Ladscape...13 B. Other State Health IT/HIE Iitiatives Lessos Leared...21 C. Overview - The Coecticut Healthcare Eviromet ad HIE Ladscape...24 III. A Framework for Developig Health IT/HIE i Coecticut...27 A. Key Iputs for the Developmet of the Pla...27 B. Visio, Guidig Priciples ad Goals...28 C. Key Resources...31 D. Healthcare System Trasformatio...32 E. Cosumers ad Their Role i HIE...37 IV. Critical Success Factors...39 A. Establishig the Coecticut State Regioal Health Iformatio Orgaizatio(CT State RHIO)...39 B. Patiet Privacy ad Cofidetiality...48 C. Cosumer Advocacy...53 D. Educatio ad Outreach...55 E. Quality Improvemet ad Populatio Health Maagemet...59 F. Fuctioal Requiremets, Techology Stadards ad Techical Architecture...61 G. Fudig ad Fiacial Sustaiability...76

4 T A B L E O F C O N T E N T S V. Recommedatios ad Next Steps...85 A. Overview...85 B. CT State RHIO Developmet ad Ogoig Resposibilities...87 C. Pilot Projects Itroductio Direct Patiet Care EHR ad HIEN(s) Healthcare System Moitorig ad Evaluatio Data Warehouse ad HIEN State Health Agecy Program Registry ad HIEN Coecticut State Health Iformatio Exchage Network Developmet...91 D. Closig...94 Refereces...95 VI. Appedices...99 A. Glossary of Terms...99 B. Legislative Act Authorizig the Pla C. Project Work Pla ad Key Activities D. Steerig Committee Members E. Stakeholder Iterview Participats F. Focus Group Participats G. Detailed Fuctioal Requiremets ad Techology Stadards H. Hospital Survey Excerpts I. Coecticut RHIO/HIEN Project Ivetory J. Detailed America Health Iformatio Commuity Use Cases K. Coecticut State ad Federal Laws Relatig to Health IT ad HIE L. Border State Activities M. Fudig Opportuities through The America Recovery ad Reivestmet Act N. Pilot Project Certificatio Template...162

5 Executive Summary The Federal Admiistratio ad Uited States Cogress have put health iformatio techology (health IT) frot ad ceter i the healthcare reform debate, by providig billios of dollars for states to support local health IT efforts. Health IT provides opportuities to reduce costs, icrease the quality of care ad patiet safety, improve access to care ad improve the coordiatio of care. The adoptio of health IT has bee limited i Coecticut due a rage of challeges, icludig high capital ad maiteace costs, ucertaity about retur o ivestmet ad lack of a sustaiable busiess model, privacy ad cofidetially issues, icosistet use of health IT stadards, perceived iterferece with doctor-patiet relatioships, cocer that systems will become obsolete ad lack of available staff with adequate expertise i health IT. Through the phased implemetatio of the Coecticut State Health Iformatio Techology Pla (The Pla), the state iteds to implemet solutios to may of these challeges. The Pla builds o the sigificat progress made towards establishig atioal techical ad policy stadards by the federal govermet ad the best practices demostrated by health IT ad health iformatio exchage (HIE) projects i Coecticut ad across the atio. Lessos leared from these projects provide valuable guidace o the role of state govermet, goverace structures, fudig ad fiace models, phased approaches to implemetatio, value propositios ad iteroperability. C O N N E C T I C U T S T A T E H E A L T H I T P L A N 1

6 E X E C U T I V E S U M M A R Y Over the ext five years, The Pla aims for the trasformatio of the Coecticut healthcare system through health IT ad health iformatio exchage projects, as show i Figure 1 below. FIGURE 1 The steps proposed i The Pla iclude: 1. formatio of the Coecticut State Regioal Health Iformatio Orgaizatio (CT State RHIO) as the goverig body whose role is to covee ad coordiate health iformatio exchage efforts across the state, supported by a state legislative madate; 2. implemetatio of pilot projects that build o existig Coecticut health IT ad HIE efforts to demostrate the viability of policies, procedures, best practices ad techical ifrastructure that ca subsequetly form the basis of broader activity ad itegratio throughout the state; these pilot projects will be structured to show value i the domais of Direct Patiet Care, Healthcare System Moitorig ad Evaluatio, State Health Agecies ad for a Coecticut Statewide Health Iformatio Exchage Network; ad 2 C O N N E C T I C U T S T A T E H E A L T H I T P L A N

7 E X E C U T I V E S U M M A R Y 3. developmet of a comprehesive health IT educatio ad outreach program to promote ope ad cosistet commuicatios amog cosumers ad healthcare professioals; to maximize developmet ad use of HIE capacity across the state; to esure participatio i the o-goig decisio makig process for the maagemet of persoal health iformatio; ad to esure that privacy ad security cocers are cotiually addressed, which is critical to buildig ad maitaiig stakeholder support for a Coecticut Statewide Health Iformatio Exchage Network. Implemetatio ad support of The Pla will require the provisio of sigificat fiacial ad huma capital to sustai it at a time whe Coecticut s state govermet is experiecig decliig reveue. The passage of the Health Iformatio Techology for Ecoomic Developmet Act (HITECH) withi the America Recovery ad Reivestmet Act of 2009 (ARRA) appropriates a miimum of $20 billio to be used over the ext six years to ecourage health IT ad HIE adoptio. The Pla was developed through a extesive iformatio gatherig process ivolvig may of the key stakeholders i Coecticut ad provides a roadmap to trasform the state healthcare system at a time of tremedous opportuity. The sectios of the Coecticut State Health IT Pla are as follows: CHAPTER I describes the role of health IT ad health iformatio exchage i the trasformatio of the healthcare system as well as the methodology for the developmet of this documet. CHAPTER II reviews the work to date by the federal govermet o the atioal iitiatives establishig broad-based stadards ad strategic directio for the essetial compoets of a atiowide health iformatio etwork, as well as lessos leared ad best practices from other state experieces i health IT ad health iformatio exchage iitiatives. I additio, iitiatives curretly uderway i Coecticut are described. CHAPTER III describes the framework for the executio of the Coecticut Health IT Strategic Pla, icludig the visio, goals, ad resources required. CHAPTER IV describes the critical factors that must be addressed to esure the successful trasformatio of the Coecticut healthcare system through health IT ad health iformatio exchage. CHAPTER V describes the critical ext steps for Coecticut to take over the ext five years to promote ad eable the trasformatio of the Coecticut healthcare system through health IT ad health iformatio exchage. Coecticut is well positioed to maximize federal fudig opportuities ad to take advatage of the lessos leared from the may health IT ad health iformatio exchage efforts across the coutry. The Pla will icremetally move Coecticut towards private ad secure electroic health iformatio exchage throughout the state. The Pla provides the ecessary steps to implemet this visio. C O N N E C T I C U T S T A T E H E A L T H I T P L A N 3

8 E X E C U T I V E S U M M A R Y 4 C O N N E C T I C U T S T A T E H E A L T H I T P L A N

9 I Itroductio A. Healthcare System Reform ad the Role of Health IT/HIE Amog citizes, policy makers, ecoomists ad health professioals, there is a broad cosesus that the system of deliverig ad fiacig healthcare i the Uited States is i desperate eed of reform (Iglehart, 2009; Schoe, Davis, & Collis, 2008; Kee, 2009). A estimated $2.2 trillio was spet o healthcare i the Uited States i 2007, 16.3 percet of the Gross Domestic Product (Keeha, et al. 2008); however we trail behid other developed coutries i may idicators of healthcare quality (Schoe, et al. 2007; Schoe, et al. 2009). Reducig healthcare costs is idetified as fudametal to alleviatig the ecoomic crisis facig the coutry (Cogressioal Budget Office, 2008); the curret admiistratio ad the Uited States Cogress have made healthcare reform a priority for As healthcare costs rise, Americas have foud it icreasigly difficult to remai covered by isurace. Uemploymet umbers are icreasig, reducig the umber of idividuals covered by employer sposored isurace, while those still employed have see scaled back coverage ad icreased cost sharig for coverage. As a result, a estimated 45 millio Americas lack isurace, with may more uderisured (Kaiser Family Foudatio, 2008). While there is uiversal cosesus that the healthcare system must be fixed, there is little cosesus about how to do it, with proposals ragig from a reliace o market forces to a sigle payer system ru by the federal govermet (Cogressioal Budget Office, 2008). Yet, every credible proposal for healthcare reform, regardless of its uderlyig philosophy, cites the use of health iformatio techology (health IT) as a fudametal tool for successfully improvig quality ad efficiecy of the healthcare system, as well reducig costs (HIMSS, 2008). I respose, several treds i healthcare delivery ad fiacig are gaiig mometum, with the potetial to trasform how medicie is practiced ad fiaced. Basig reimbursemet rates o the quality of care beig delivered (e.g. pay for performace), rather tha o quatify of care, is icreasig amog both private ad public payers. Growig support for stregtheig the role of prevetio ad primary care through medical homes ad telehealth techology to provide a rage of wrap aroud services, coordiated care ad disease maagemet. Icreasig roles for cosumers as active participats i their care, drive by iformatio accessible o the Iteret, provider report cards, persoal health records, ad cosumer drive health plas. C O N N E C T I C U T S T A T E H E A L T H I T P L A N 5

10 I. I N T R O D U C T I O N Natioal campaigs to idetify ad address root causes of medical errors (e.g. Istitute for Healthcare Improvemet; The Leapfrog Group for Patiet Safety). Icreasig emphasis o the practice of evidece-based medicie. Commo to each of these treds is their reliace o the ability to collect, aalyze ad use electroic data to improve direct patiet care ad to stimulate more systemic reform through improved health iformatio techology. The potetial for techology to support a larger trasformatio i healthcare is icreasigly apparet as research demostrates that health IT ca improve medicatio safety (Bates, et al. 1999; Kaushal, et al. 2003; Teich, et al. 2000; Gadhi, et al. 2005), quality of care (Dexter, et al. 2004; Chertow, et al. 2001; Peterso, et al. 2005) a compliace with treatmet guidelies (Overhage, et al. 1997; Dexter, et al. 2001), improve the efficiecy of hospital workflow (Taylor, et al. 2002) ad reduce cost of care (Tierey, et al. 1993). FIGURE 2 Healthcare Reform Healthcare for all Cosumer drive care Cost of care Medical home Prevetio & welless Quality P4P Requires Cosistet workflow Data accessibility Accuracy Accoutability Timeliess Efficiecy Commitmet HIE Natioal strategy Certified use cases Policies & procedures Techical stadards Certified systems Iteroperability True trasformatio of our healthcare system will deped o the coversio of a traditioal, disparate, paper-based system ito a atioal health iformatio etwork based o the electroic exchage of data servig the eeds of patiets, providers, ad healthcare decisio makers. For example: Istead of primary care providers usig limited time i a patiet visit searchig for laboratory results ad patiet histories i a paper chart or orderig duplicate or uecessary tests, providers will have this data easily accessible, ad preseted i formats that are useful for healthcare decisio makig ad patiet educatio. Graphs of a diabetic s hemoglobi levels over time ca become tools for patiet ad provider to review ad discuss. Electroic remiders to both provider ad patiet that recommeded tests ad procedures are due, coupled with automated test orderig at the poit of care allow for more meaigful patiet ad provider iteractio. 6 C O N N E C T I C U T S T A T E H E A L T H I T P L A N

11 I. I N T R O D U C T I O N Specialists who ow rely o little or o writte iformatio i a referral ca access the data they eed to assess patiets, ad review tests ad procedures that have already bee coducted, rather tha reorderig these same tests. This reduces cost to the system as well as time ad stress o the patiet. Subsequetly, primary care providers will be able to easily access the results of specialist visits rather tha the imperfect system of writte dictated feedback. The elderly or ill who are movig from hospital, to rehabilitatio ceter, to home or log-term care facility, ca be assured that providers at each step of this complex process of discharge ad trasfer have curret ad complete medical records, rather tha relyig o icomplete paper charts that follow them through these steps. Quality improvemet teams, rather tha relyig o aecdotal evidece, ca accurately evaluate progress i chroic disease maagemet programs or patiet safety iitiatives, ad better uderstad what elemets of their efforts are succeedig ad which are ot. Epidemiologists searchig for treds i chroic diseases ca use aggregated data to idetify risk factors. For example, the idetificatio of geographic clusters of asthma amog youg people suggests potetial evirometal factors. Providers carig for ijured or critically ill patiets ca quickly access key medical histories, allergies, ad medicatios that are critical to appropriate ad timely decisio-makig i trauma ad emergecy settigs. Virtually all other major fields have successfully maaged techological revolutios. A decade ago it would have bee hard to imagie a bak card issued i Salisbury, Coecticut could be easily used to withdraw moey i Mila or that a te-year old, usig their home computer, would be able to track the shippig status of the package that cotais their ew ipod from Amazo. Yet, with all these techological iovatios, it is estimated that 8 to 12 percet of hospitals ad 4 percet of ambulatory care providers i the U.S. have adopted comprehesive electroic medical records (Jha, et al. 2009; DesRoches, et al. 2008). The reasos for the relatively slow rate of adoptio of techology i the healthcare field are complex, but icreasigly well uderstood: high capital ad maiteace costs; ucertaity about retur o ivestmet; lack of a sustaiable busiess model; security or cofidetially issues; ot fidig a system that meets practice or departmet eeds; perceived iterferece with doctor-patiet relatioship; cocer that system will become obsolete; ad lack of available staff with adequate expertise i IT (Ash & Bates 2005; Jha, et al. 2009; DesRoches, et al. 2008). Policy makers ad academics have bee promotig the visio of trasformative health IT adoptio for early a decade, but have bee uable to leverage the fiacial resources to implemet the visio. With $20 billio pledged to ecourage health IT ad HIE adoptio through the Health Iformatio Techology for Ecoomic Developmet Act (HITECH) withi the America Recovery ad Reivestmet Act of 2009 (ARRA), the visio is ow beig fiacially supported. These elemets appear to be aligig to support more rapid ad dramatic improvemets i health iformatio techology ad health iformatio exchage. C O N N E C T I C U T S T A T E H E A L T H I T P L A N 7

12 I. I N T R O D U C T I O N Although the complexities of techology i healthcare ca easily become overwhelmig, the critical elemets are relatively straightforward: Health data throughout the healthcare system that is ow available oly o paper must be automated. The mai focus i this area is for providers ad hospitals to automate their data i electroic medical/health records. Improvemets i care, reductios of errors, stregtheed chroic disease maagemet, ad improvemets i efficiecy ca stem from this automatio. While care at the idividual provider level improves with the implemetatio of electroic health records, creatig the capacity for providers to access medical data o their patiets across providers ad settigs through electroic health iformatio exchages is the larger, log-term goal. Successful EHR implemetatios ad regioal data exchage efforts require establishig sigificat levels of collaboratio ad trust amog providers, agreemets o stadards for data to be exchaged, availability of the techical capacity to build the etwork, ad the fudig to fiace the effort. Those efforts require the oversight of a empowered ad capable regioal health iformatio orgaizatio, amely the CT State Regioal Health Iformatio Orgaizatio (CT State RHIO). Success of these apparetly straightforward iovatios i health iformatio exchage represets a microcosm of how data exchage etworks are built. They require that several systems are able to commuicate with each other, that professioals have agreed o what data are importat to trasmit, that patiets feel secure that their data are safe ad their privacy is ot beig compromised, ad that the techical systems are able to carry out these exchages of data. Local ad regioal data exchage efforts are critical iitial steps towards broader statewide ad atioal data exchage. Because patiets get most of their care withi a defied geographic regio the large majority of times, these emergig orgaizatios will provide data exchage where it is most critically eeded. These orgaizatios eed support, both fiacial ad techical i order to succeed. The challeges to buildig the ecessary collaboratio, ofte amog competitors, the eed to appropriately address cosumer ad patiet cocers about privacy ad cofidetiality, ad the techical challeges all ca slow dow or derail these efforts. Expert ad sustaied assistace at the state level ca improve the chaces these efforts will succeed. The CT State RHIO is a critical resource to esure that multiple cocurret health iformatio exchage iitiatives across the state are developig HIE capabilities that will evetually alig to provide a statewide HIE capability. The Pla icludes recommedatios for how the orgaizatio should be structured ad govered, as well as its resposibilities, buildig o the success factors emergig from federal guidace, other state efforts, ad from the curret Coecticut healthcare system ad political eviromet. The Coecticut State Legislature took the iitial steps to establish the CT State RHIO with its adoptio i 2007 of Public Act 07-2 which supported the developmet of The Pla. 8 C O N N E C T I C U T S T A T E H E A L T H I T P L A N

13 I. I N T R O D U C T I O N B. Coecticut Legislative Madate To promote the developmet of health iformatio exchage capacity i the state, the Coecticut Geeral Assembly passed Public Act No i the 2007 legislative sessio. A Act Implemetig the Provisios of the Budget Cocerig Huma Services ad Public Health, authorized the Departmet of Public Health, i cosultatio with the Office of Health Care Access to cotract through a competitive biddig process for the developmet of a Statewide Health Iformatio Techology Pla. The legislatio specified that the health iformatio techology pla at a miimum would iclude: Geeral stadards ad protocols for health iformatio exchage. Electroic stadards to facilitate the developmet of a statewide itegrated health iformatio system for use by healthcare providers ad istitutios that are fuded by the state. These stadards were to: (a) iclude provisios relatig to security, privacy, data cotet, structures ad format, vocabulary ad trasmissio protocols; (b) be compatible with ay atioal stadards i order to allow for iterstate iteroperability; (c) permit the collectio of health iformatio i a stadard electroic format ad; (d) be compatible with the requiremets for a electroic health iformatio system. Pilot programs for health iformatio exchage, projected costs ad sources of fudig for such pilot programs. Pursuat to this legislatio, i December 2007, the Coecticut Departmet of Public Health issued request for proposal (RFP) umber etitled, Developmet of a Statewide Health Iformatio Techology Pla. The RFP stated that The purpose of this Request for Proposal (RFP) is for the Coecticut Departmet of Public Health (DPH), i cosultatio with the Office of Health Care Access, to cotract with a orgaizatio to develop a Statewide Health Iformatio Techology Pla (Coecticut Health IT Pla). The RFP further stated that The Coecticut Health IT Pla must address all of the followig items: 1. Assessmet of the status of curret HIE techologies ad practices operatig i Coecticut. 2. Geeral stadards ad protocols for health iformatio exchage. 3. Electroic data stadards to facilitate the developmet of a statewide, itegrated electroic health iformatio system i Coecticut for use by healthcare providers ad istitutios that are fuded by the state icludig hospitals, commuity healthcare ceters, physicia groups, ad other providers receivig fuds from the state. Such electroic data stadards shall: 3.1. iclude provisios relatig to security, privacy, data cotet, structures ad format, vocabulary, maiteace ad trasmissio protocols, 3.2. be compatible with ay atioal data stadards i order to allow for iterstate iteroperability, C O N N E C T I C U T S T A T E H E A L T H I T P L A N 9

14 I. I N T R O D U C T I O N 3.3. permit the collectio, sharig, ad access of health iformatio i a stadard electroic format, 3.4. be compatible with the requiremets for a electroic health iformatio system, ad, 3.5. iclude rules ad stadards for the sharig, aggregatio ad storage of perso-specific ad aggregated health data. 4. Fuctioal characteristics of a Electroic Health Iformatio System as defied i Sectio 68(a)(1) of PA Implemetatio strategies, icludig, but ot limited to a pla for pilot programs for health iformatio exchage, ad projected costs ad sources of fudig for such pilot programs. Pilot programs may be used as a mechaism to assess differet busiess models, e.g. storage ad recovery of federated vs. cetralized health data. 6. Cosumer educatio ad outreach about the HIEN to healthcare providers. 7. Coordiatio with state govermet agecies, public ad private health systems, ad healthcare providers to lik HIE activities to support quality improvemet iitiatives. 8. Coordiatio with other HIE orgaizatios, states, ad the federal govermet. 9. Survey of each provider group (icludig private practitioers) to determie their curret ifrastructure (i.e., staffig, hardware, software, traiig eeds, etc.) 10. Risk-beefit aalysis of the secodary uses of healthcare data (i.e., how it will be used ad how it will be protected.) 11. Assessmet ad aalysis of federated versus cetralized data systems. 12. Projected timelie ad detailed budget estimates for developmet of a fully fuctioal statewide, itegrated electroic health iformatio system, icludig the ifrastructure eeds of each provider group. Iclude a phased-i timelie, icetives to get providers ivolved ad estimated costs for each provider group that will participate i the HIE System. 13. How Coecticut will trasitio to the Natioal Health Network oce it is available. 14. Idetified barriers to implemetatio of the Coecticut Health IT Pla ad proposed actios to address each barrier. The cotract for the developmet of the Coecticut Statewide Health Iformatio Techology Pla was awarded to JSI Research ad Traiig Istitute, Ic. (JSI), based i Bosto Massachusetts, for a cotract period startig May 1, 2008 through Jue 30, Uder the provisios of the authorizig legislatio, JSI was desigated as the lead health iformatio exchage orgaizatio for the State of Coecticut for the period of the cotract. 10 C O N N E C T I C U T S T A T E H E A L T H I T P L A N

15 I. I N T R O D U C T I O N C. Developig the Coecticut State Health IT Pla (The Pla) The developmet of The Pla was oversee by a twelve member Steerig Committee as show i Appedix D. The Steerig Committee coveed o July 9, 2008 where a iitial work pla was preseted by JSI for feedback ad commet. Subsequetly, the Steerig Committee met mothly to review project progress ad provide feedback to JSI o major elemets of the pla as they were developed. A variety of efforts were coducted to review the etire Coecticut healthcare eviromet as well as to solicit feedback from diverse stakeholders across the state. Experiece throughout the coutry has demostrated that while developig the techical aspects of health iformatio exchage are critical, esurig that the strategy meets the eeds ad addresses the cocers of a spectrum of stakeholders is perhaps the most critical determiat of success, at least i the iitial stages. Stakeholder Idetificatio At the project kick-off meetig i July 2008, JSI asked ope forum attedees ad Steerig Committee members to assist with the recruitmet of idividuals represetig diverse healthcare stakeholders throughout the state for the subsequet focus groups, surveys ad iterviews. Potetial participats were set a brief, web-based survey to solicit their participatio, their key areas of iterest or ivolvemet i Coecticut health IT ad HIE iitiatives, ad ames ad cotact iformatio of ay other appropriate stakeholders for egagemet iclusio. This provided JSI with over 200 potetial stakeholders for the iformatio gatherig activities. Healthcare Stakeholder Survey JSI coducted a 29-questio survey of stakeholders from the Coecticut healthcare system icludig commuity health ceters, physicia groups, hospital leadership, ad state agecy staff. The survey s aim was to collect baselie iformatio from a diverse set of healthcare stakeholders o their curret ad future IT ifrastructure, curret ad future HIE capabilities, ad their perspectives o opportuities ad barriers to health IT ad HIE adoptio. Hospital Survey I collaboratio with the Coecticut Hospital Associatio, hospital techical leadership, primarily Chief Iformatio Officers, were surveyed. This survey solicited iput regardig curret ad future health IT ad health iformatio exchage capabilities, level of spedig o health IT iitiatives, perceptios regardig HIE oversight, potetial state ivolvemet ad opportuities ad barriers to health IT/HIE adoptio. The summary results of the hospital survey are provided i Appedix H. Stakeholder Iterviews JSI developed a iterview guide solicitig feedback o experieces with HIE, curret HIE activity ad capacity i Coecticut, perceptios of HIE s impact o cost, quality of care ad efficiecy, ad issues associated with patiet privacy ad cofidetiality. If iterviewees were curretly ivolved with a HIEN, questios regardig project backgroud, goverace, implemetatio, sustaiability ad fiacig were icluded. Usig this guide, approximately thirty iterviews were coducted with key leadership resources of hospitals, idepedet practice associatios, commuity health ceters, state health agecies, acillary service providers, payers, professioal orgaizatios ad o-profit orgaizatios Please see Appedix E for the complete iterview list. C O N N E C T I C U T S T A T E H E A L T H I T P L A N 11

16 I. I N T R O D U C T I O N Focus Groups JSI coveed eight focus groups with various Coecticut stakeholders to obtai their perspectives o health iformatio exchage as well as to receive guidace to iform The Pla o specific domais from experts i the state. Focus groups icluded cosumer advocacy, educatio ad outreach, goverace, quality improvemet ad populatio health maagemet, legal ad legislative, commuity health, fiace, ad fuctioal requiremets ad techical stadards. A list of these participats is provided i Appedix F. Federal ad State Research JSI researched ad sythesized federal ad health idustry accepted stadards ad protocols for HIE to help determie appropriate stadards ad protocols for a Coecticut statewide HIEN. I additio, the project team researched other state HIE efforts ad compiled a set of lessos leared ad best practices to iform the recommedatios for Coecticut. Iterative Pla Developmet - The Pla was developed i close collaboratio with the project Steerig Committee. A outlie was preseted to the Committee i October 2008 for approval, ad a first draft o February 1, The fial draft was submitted for approval o April 17, 2009 ad fial report o May 18, JSI also elicited feedback through mothly meetigs with the Steerig Committee ad repeated egagemets with key stakeholders across the state. 12 C O N N E C T I C U T S T A T E H E A L T H I T P L A N

17 II Health IT/HIE Backgroud While the potetial for health IT/HIE to improve quality ad reduce the cost of care was gaiig recogitio ad system implemetatios were icreasig at the begiig of this decade, there was little cocerted activity at the federal govermet level. However, i 2004, the federal govermet laid the groudwork for such federal actio, focusig both o EHR adoptio ad the eed for a atioal system of health iformatio exchage. A. Natioal Health IT/HIE Ladscape The Office of the Natioal Coordiator for Health Iformatio Techology To lead this effort, the Executive Order established the Office of the Natioal Coordiator for Health Iformatio Techology (ONC) to provide cousel to the Secretary of Health ad Huma Services (HHS) ad departmetal leadership for the developmet ad atiowide implemetatio of a iteroperable health iformatio techology ifrastructure (the Natiowide Health Iformatio Network or NHIN). The Natioal Coordiator for Health Iformatio Techology was tasked with: Servig as the Secretary's pricipal advisor o the developmet, applicatio, ad use of health iformatio techology; Coordiatig HHS health iformatio techology policies ad programs iterally ad with other relevat executive brach agecies; Developig, maitaiig, ad directig the implemetatio of HHS strategic pla to guide the atiowide implemetatio of iteroperable health iformatio techology i both the public ad private healthcare sectors, to the extet permitted by law; ad Providig commets ad advice at the request of the Office of Maagemet ad Budget (OMB) regardig specific Federal health iformatio techology programs. C O N N E C T I C U T S T A T E H E A L T H I T P L A N 13

18 I I. H E A L T H I T / H I E B A C K G R O U N D America Health Iformatio Commuity The ONC also provided maagemet of ad logistical support for the America Health Iformatio Commuity (AHIC). The AHIC was a federally-chartered advisory committee tasked with makig recommedatios to the Secretary of HHS o how to make health records digital ad iteroperable, ecourage market-led adoptio ad esure that the privacy ad security of those records are protected at all times. I the broadest sese, AHIC provided extesive guidace for the four key fuctioal areas that eable iteroperability withi the Uited States healthcare system as represeted i Figure 3 below. FIGURE 3 What Eables HIE ad Iteroperability Practices ad Policy What are the requiremets of care provisio, privacy, etc.? What are acceptable costraits ad costs of operatig electroically? What are the requiremets for iformatio exchage ad iteroperability? Architecture (NHIN) What are the miimal costraits that ca be implemeted? Stadards How ca stadards ad requiremets support busiess opportuities? Certificatio AHIC Work Groups To carry out this missio, AHIC created seve workgroups: Populatio Health ad Cliical Care Coectios Workgroup Chroic Care Workgroup Cofidetiality, Privacy, & Security Workgroup Cosumer Empowermet Workgroup Electroic Health Records Workgroup 14 C O N N E C T I C U T S T A T E H E A L T H I T P L A N

19 I I. H E A L T H I T / H I E B A C K G R O U N D Quality Workgroup Persoalized Healthcare Workgroup The efforts of the workgroups resulted i the creatio of several use cases that represet stadards for HIE eabled cliical practice. The AHIC priorities ad use case road map which refereces existig ad plaed use cases is represeted below. FIGURE 4 AHIC Priorities ad Use Case Road Map Practices AHIC Priorities & Use Case Roadmap 4 CANDIDATE Use Cases 2008 Use Cases New Use Cases ad... Extesios & Gaps Cosumer Empowermet Use Case Registratio Medicatio History EHR Use Case Laboratory Result Reportig Biosurveillace Use Case Visit Utilizatio Cliical Data Lab & Radiology Cosumer Access to Cliical Iformatio Access to Cliical Data Provider Permissios PHR Trasfer Emergecy Respoder EHR O-site Care Emergecy Care Defiitive Care Provider Autheticatio & Authorizatio Quality Hospital Measuremet & Reportig Cliicia Measuremet & Reportig Feedback to Cliicias Medicatio Maagemet Medicatio Recociliatio Ambulatory Prescriptios Cotraidicatio Remote Moitorig Remote Moitorig of Vital Sigs & Labs (Glucose) Cosultatios & Trasfers of Care Referrals Problem Lists Trasfer of Care Public Health Case Reportig Case Reportig Bidirectioal Commuicatio Labs Adverse Evets Patiet Provider Secure Messagig Structured Remiders Persoalized Healthcare Laboratory Geetic/ Geomic Data Family Medical History Immuizatios & Respose Maagemet Resource Idetificatio Vaccie EHR Data Medical Home & Care Coordiatio PCP as Care Coordiator EHR as Med Hm Authorizatio for Release of Iformatio for Third Party Patiet/ Cosumer ROI Commuicatio Newbor Screeig Screeig & Trasitio to Pediatric Care Cliical Research Cliical Trials Data & EHRs Research Protocols Qualifyig Ptts Prior Authorizatio & Schedulig i Support of TPO Prior Auth & Schedulig Admi Data Materal & Child Health Ateatal Preatal, ad Labor & Deliv. Log-Term Care & Assessmet LTC Needs Assessmet Tools & Data Store & Forward Telemedicie Telecosults Health Data i Native Forms Geeral Laboratory Orders Medicatio Gaps Commo Device Coectivity Cli Ecouter Note Details Order Sets Cosumer Prefereces Commo Data Trasport AP Laboratory Results Ptt/Cosumer Adv Evet Rptg Ptt-reptd Probs & Outcomes Health Surveys Distributed Query Death Reptg & Surveillace Cacer & Tumor Registries Occ Health & Ijury Registries Other Adverse Evets Blood Baks Orga Door Registries C O N N E C T I C U T S T A T E H E A L T H I T P L A N 15

20 I I. H E A L T H I T / H I E B A C K G R O U N D Cocurret with the AHIC work, the Office of the Natioal Coordiator released requests for proposals ad awarded cotracts to coduct studies ad pilot projects for developig stadards for iteroperability, privacy ad security, ad idetifyig the lessos leared from early pilots. I 2006, the results were released i a report etitled The HHS Health Iformatio Techology, Major Accomplishmets. The report led to a ew roud of cotracts focused o specific areas of health IT ad HIE as represeted i Figure 5 below ad described i the followig sectios. FIGURE 5 Certificatio Stadards The Certificatio Commissio for Healthcare Iformatio Techology (CCHIT) Healthcare Iformatio Techology Stadards Pael (HITSP) America Health Iformatio Commuity The Health Iformatio Security ad Privacy Collaboratio (HISPC) Health Iformatio Network Architecture Projects (NHIN) Policy Architecture The Certificatio Commissio for Healthcare Iformatio Techology (CCHIT) CCHIT was formed to create a certificatio program to accelerate the adoptio of health iformatio techology. CCHIT serves a critical role for the atio s healthcare providers by establishig stadards for healthcare techology vedors to demostrate that their software applicatios are iteroperable. By May 2007, CCHIT had certified early 90 ambulatory electroic health record products which meet baselie criteria for fuctioality, security, ad iteroperability. I 2007, CCHIT bega testig of certificatio of hospital ipatiet electroic health record products. (See for more details). 16 C O N N E C T I C U T S T A T E H E A L T H I T P L A N

21 I I. H E A L T H I T / H I E B A C K G R O U N D The Healthcare Iformatio Techology Stadards Pael (HITSP) The America Natioal Stadards Istitute (ANSI) was selected to admiister the stadards harmoizatio iitiative. The resultig collaborative, kow as the Healthcare Iformatio Techology Stadards Pael (HITSP), brigs together experts from across the healthcare commuity, icludig cosumers, doctors, urses, hospitals, those who develop healthcare IT products as well as idividuals from govermet agecies ad stadards settig orgaizatios. The Pael's objectives are to: Establish a cooperative partership betwee the public ad private sectors to achieve a widely accepted, usable set of stadards that eable ad support widespread iteroperability amog healthcare software applicatios i a Natiowide Health Iformatio Network. Harmoize relevat stadards i the healthcare idustry to eable ad advace iteroperability of healthcare applicatios, ad the iterchage of healthcare data, to esure accurate use, access, privacy ad security, both for supportig the delivery of care ad public health. I August 2006, the former DHHS Secretary accepted three sets of iteroperability specificatios approved by the HITSP that ow form the basis for atioal iteroperability. Also accepted was the AHIC s recommedatio to develop a adoptio pla to itegrate these stadards ito software for healthcare delivery systems by December At the same time, the Presidet issued a Executive Order o Value Drive Health Care requirig federal departmets ad agecies to use health IT based o iteroperability stadards recogized by the secretary of DHHS. The Health Iformatio Security ad Privacy Collaboratio (HISPC) Differig iterpretatios of the Health Isurace Portability ad Accoutability Act (HIPAA) Privacy Rule amog states ad busiesses create disparate orgaizatio-level busiess practices across the atio. HISPC was formed to idetify ad address these differeces. RTI Iteratioal, uder cotract to AHRQ, established HISPC to parter with 33 states (icludig Coecticut) to study these issues. Each member of the collaboratio ivestigated ad reported o barriers, solutios, ad implemetatio plas related to privacy ad security. I 2007, HISPC published a atioal report providig a summary of state privacy ad security assessmets, solutios, ad implemetatio plas to help shape atioal public policies for health IT ad HIE (RTI Iteratioal, 2007). I the curret phase, which bega i April 2008, HISPC ow comprises 42 states ad territories, ad aims to address the privacy ad security challeges preseted by electroic health iformatio exchage through multistate collaboratio ( Natiowide Health Iformatio Network (NHIN) Architecture Projects I July 2004, ONC published The Decade of Health Iformatio Techology: Deliverig Cosumer-Cetric ad Iformatio Rich Health Care (DHHS, 2004). The report was subtitled Framework for Strategic Actio, ad set i motio a series of fudig opportuities from fouda- C O N N E C T I C U T S T A T E H E A L T H I T P L A N 17

22 I I. H E A L T H I T / H I E B A C K G R O U N D tios, govermet agecies, ad the private sector. ONC sposored four cosortia to desig ad evaluate stadards-based prototype architectures for the NHIN. These prototypes demostrated the advacemet of: Capabilities to fid ad retrieve healthcare iformatio iside of health iformatio exchages ad betwee health iformatio exchages; The delivery of ew data to appropriate recipiets; Key cosumer services such as cotrol over who ca access a persoal health record, data searchig, ability to choose ot to use a etwork service; User idetity proofig, autheticatio ad authorizatio; Methods for match patiets to their data without a atioal patiet idetifier; Access cotrol ad other security protectios; Specialized etwork fuctios; ad The feasibility of large-scale deploymet. Coectig for Health Coectig for Health is a public-private collaborative sposored by the Markle Foudatio with represetatives from more tha 100 orgaizatios across the spectrum of healthcare stakeholders. Its purpose is to catalyze the widespread chages ecessary to realize the full beefits of health IT, while protectig patiet privacy ad the security of persoal health iformatio. The collaborative is addressig the key challeges to creatig a etworked health iformatio eviromet that eables secure ad private iformatio sharig whe ad where it is eeded to improve health ad healthcare. A key output of the collaborative is the Commo Framework, which is represeted i summary i Figure 6 below ad ca be reviewed i detail at: 18 C O N N E C T I C U T S T A T E H E A L T H I T P L A N

23 I I. H E A L T H I T / H I E B A C K G R O U N D FIGURE 6 Coectig for Health Commo Framework Policy The Commo Framework: Overview & Priciples Stadards Policy Guides: How Iformatio is Protected Techical Guides: How Iformatio is Exchaged P1 The Architecture for Privacy i a Networked Health Iformatio Eviromet T1 The Commo Framework: Techical Issues ad Requiremets for Implemetatio P2 Model Privacy Policies ad Procedures for Health Iformatio Exchage T2 Health Iformatio Exchage: Architecture Implemetatio Guide P3 Notificatio ad Coset Whe Usig a Record Locator Service T3 Medicatio History Stadards P4 Correctly Matchig Patiets with Their Records T4 Laboratory Results Stadards P5 Autheticatio of System Users T5 Backgroud Issues o Data Quality P6 Patiets Access to their Ow Health Iformatio T6 Record Locator Service: Techical Backgroud from the Massachusetts Prototype Commuity P7 Auditig Access to ad Use of a Health Iformatio Exchage Future Techical Guides P8 Breaches of Cofidetial Health Iformatio Breaches of Cofidetial Health Iformatio Model Cotractual Laguage M1 Key Topics i a Model Cotract for Health Iformatio Key Topics i Exchage a Model Cotract for Health Iformatio Exchage M1 A Model Cotract for Health Iformatio Exchage C O N N E C T I C U T S T A T E H E A L T H I T P L A N 19

24 I I. H E A L T H I T / H I E B A C K G R O U N D The Commo Framework provides a set of policy ad techical guidace that promotes the cosistet developmet of HIENs to support iteroperability ad health iformatio exchage o a atioal level while protectig privacy ad allowig for local autoomy ad iovatio. It cosists of a set of 17 mutually-reiforcig techical documets ad specificatios, testig iterfaces, code, privacy ad security policies, ad model cotract laguage. It was developed by experts i iformatio techology, health privacy law, ad policy, ad has bee tested as oe of the prototype architectures sposored through the ONC sposored NHIN prototype project. Impact of America Recovery ad Reivestmet Act of 2009 Uder the America Recovery ad Reivestmet Act of 2009, the Office of the Natioal Coordiator for Health Iformatio Techology (ONC) is give permaet status withi the Departmet of HHS. The ONC, to be directed by a Natioal Coordiator, is give a revised madate ad a ew structure. The Natioal Coordiator for Health Iformatio Techology is tasked with: Updatig the federal HIT Strategic Pla to cotai specific objectives, milestoes, ad metrics for the adoptio of HIT, icludig the utilizatio of a electroic health record for each perso i the Uited States by Providig oversight ad coordiatio of both the HIT Policy ad HIT Stadards Committees (see descriptio below). Appoitig a Chief Privacy Officer by February 2010 to advise o privacy, security ad data stewardship ad to coordiate with states ad other agecies regardig these issues. Reviewig ad reportig to the Secretary of HHS o stadards for the electroic exchage of health iformatio ad recommedig to the Secretary by December 31, 2009 a iitial set of stadards, implemetatio specificatio ad certificatio criteria for adoptio. The ARRA establishes withi the ONC a Policy Committee to make policy recommedatios to the atioal coordiator ad a Stadards Committee to recommed stadards, implemetatio specificatios ad certificatio criteria. The HIT Policy Committee will make recommedatios to the atioal coordiator with respect to a policy framework for the developmet of atiowide HIT ifrastructure. These recommedatios will iclude techologies that protect privacy, the order of priority for the developmet of stadards as well as implemetatio specificatios ad certificatio criteria for the electroic exchage ad use of HIT ad HIE. The HIT Stadards Committee will recommed which stadards are to be adopted, alog with implemetatio specificatios ad certificatio criteria for the electroic exchage ad use of health iformatio. Although the ARRA does ot specify whether or how existig orgaizatios that have already made sigificat progress o these issues will be itegrated ito the ew structure, it is widely expected that the work of these bodies will form the foudatio for future efforts. 20 C O N N E C T I C U T S T A T E H E A L T H I T P L A N

25 I I. H E A L T H I T / H I E B A C K G R O U N D I additio, the AHIC will o loger exist uder the ew madate. However, the work of the certificatio ad stadards orgaizatios that supported the AHIC decisio makig will cotiue either through these existig orgaizatios or successor orgaizatios developed through the HIT Policy Committee or the HIT Stadards Committee. Coclusio The efforts of the atioal iitiatives outlied above have established broad-based stadards ad strategic directio for the essetial compoets of the Natiowide Health Iformatio Network. Collectively, this guidace establishes a cosistet ad comprehesive approach to plaig ad developmet of health iformatio exchage capacity at the state, regioal ad local levels. The Pla strogly recommeds a full commitmet to the federal guidace outlied above. B. Other State Health IT/HIE Iitiatives Lessos Leared Itroductio Health IT ad HIE efforts across the atio cotiue to grow. A 2006 AHRQ survey idetified 101 state-based HIE projects i 35 differet states (AHRQ, 2006). I 2008, ehealth Iitiative s aual survey of health iformatio exchages had 130 resposes, with 42 HIENs idetified as operatioal, a 31% icrease over the previous year s survey (ehealth Iitiative, 2008). May more are still i the iitiatio or plaig stages. This atioal progress is illustrated i the map below, from the State Level Health Iformatio Exchage Cosesus Project. FIGURE 7 State Level Health Iformatio Exchage Cosesus Project C O N N E C T I C U T S T A T E H E A L T H I T P L A N 21

26 I I. H E A L T H I T / H I E B A C K G R O U N D The success of these iitiatives depeds o their ability to address several complex ad iterdepedet problems cocurretly, icludig establishig iteroperability, buildig public trust, assurig stakeholder cooperatio, ad developig fiacial sustaiability. There is a growig body of experiece reflectig both successes ad failures that ca help guide iitiatives ad projects withi the state of Coecticut. Lessos from usuccessful efforts such as the Sata Barbara Couty Cliical Data Exchage i Califoria ad the Northeaster Pesylvaia Regioal Health Iformatio Orgaizatio, as well as best practices from successes such as i Utah Health Iformatio Network (UHIN) ad the Idiaa Health Iformatio Exchage (IHIE) ca be utilized i Coecticut. A detailed review of the efforts of the Coecticut border states of Massachusetts, New York ad Rhode Islad is also icluded i Appedix L. These lessos leared are described below. State Role I successful projects, state govermet is see as the catalyst for actio, geeratig mometum, credibility, ad stakeholder buy-i for HIE projects. States are geerally the iitial fuder for HIE projects ad may provide some of the iitial admiistrative ifrastructure. As projects develop, state departmets or agecies shift toward a more shared leadership role (AHRQ, 2006). States mai roles are to: Provide leadership to help set the HIE ageda ad directio for the state. Promote broad stakeholder ivolvemet to facilitate commuicatio, decisio makig, ad shared learig across these stakeholders (e.g., ifrastructure iitiatives ad addressig policy barriers). Actively participate i HIE iitiatives as a data source (e.g., Medicaid, public health, registry data) ad as a data parter (e.g., as large isurer or large employer) by exchagig patiet/employee data. Facilitate collaboratio ad coordiatio across state HIE projects to promote commuicatio, miimize project silos, ad efficietly leverage state fudig. Establish ad maitai broad-based support for HIE through support of, ad participatio i, multi-stakeholder forums ad through the developmet of a log-term visio ad strategy. Start up Fudig ad Log Term Fiacial Sustaiability Start-up fudig ad a model for log-term sustaiable reveue represet two of the most sigificat barriers to existig ad plaed health IT ad HIE projects (ehealth Iitiative, 2008; AHRQ, 2006; Adler-Milstei, Bates, & Jha, 2009). Iitial fudig for projects most ofte comes from federal ad state govermets, followed by foudatio grats ad private sector fiacig (Natioal Goverors Associatio, 2009). However, whe grats ed, project mometum is ofte lost due to the iability to fid a log-term reveue stream. This is a uiversal problem: over 80% of HIENs surveyed by the ehealth Iitiative i 2008 reported that the developmet of a sustaiable busiess model was a moderately difficult to difficult challege (ehealth Iitiative, 2008). For ew HIE iitiatives, the most commoly developed strategy is a data fee model where subscribers pay a fee to access data withi 22 C O N N E C T I C U T S T A T E H E A L T H I T P L A N

27 I I. H E A L T H I T / H I E B A C K G R O U N D the HIEN. Similarly, most existig HIENs receive recurrig subscriptio or trasactio based fees as moderate or substatial sources of support (Adler-Milstei et al., 2008). Utah s fiacig model for admiistrative trasactios may be the closest thig to a sustaiable framework (AHRQ, 2006). This uiversal challege uderscores the importace that Coecticut must place o the eed for log-term sustaiable fudig i the earliest stages of the project. Multi-Stakeholder Buy I ad Goverace State ad local health IT ad HIE efforts view the egagemet of a broad set of stakeholders who participate i goverace efforts as fudametal to success (Natioal Goverors Associatio, 2009; State Level Health Iformatio Exchage Cosesus Project, 2008; AHRQ, 2006). These stakeholders iclude hospitals, primary care physicias, health plas, commuity health cliics, employers, patiets ad/or cosumer groups, public health departmets, ad quality improvemet orgaizatios. Multistakeholder ivolvemet ad collaboratio promotes credibility, facilitates egagemet of stakeholders, ad helps overcome resistace. Leaders from HIE projects stress the importace of early egagemet of physicias to esure their buy-i (AHRQ, 2006). I their plaig, Coecticut has ivolved a broad set of stakeholders, icludig physicias, ad should cotiue to do so to esure pilot project ad log-term success. Pilot Projects/Icremetal Approach Although a iteroperable health iformatio exchage is ultimately the goal ad may states have projects that are workig towards this goal, successfully buildig a comprehesive electroic patiet data exchage is provig more difficult tha most origially imagied. Most successful HIENs have bee adopted with a icremetal approach, exchagig arrow types of data typically focusig o a targeted populatio or project (Natioal Goverors Associatio, 2009; AHRQ, 2006). For example, the Utah Health Iformatio Network (UHIN) bega exchagig claims based data before the exchage of cliical data. Iitial Value Propositio Focusig o icremetal phases ad pilot projects has helped health IT/HIE projects demostrate their value to stakeholders (AHRQ, 2006). The value propositio is geerally based o a combiatio of factors associated with efficiecy, patiet safety ad improved quality of care. As Coecticut works to idetify ad articulate their plas, develop strategies for implemetig health IT ad HIE, ad promotig its use, it will be importat to demostrate cocrete short-term successes to help build support ad promote adoptio. Iteroperability While techology stadards ad best practices provide a importat foudatio, they eed to be viewed i the cotext of several additioal compellig cosideratios. C O N N E C T I C U T S T A T E H E A L T H I T P L A N 23

28 I I. H E A L T H I T / H I E B A C K G R O U N D First, a commo techical architecture that is modular ad meets the specific health iformatio eeds of diverse healthcare costituets must be developed. Secod, a strategic decisio that techological iteroperability will be met through a series of icremetal steps buildig o sposored pilot projects must be accepted ad promoted. Third, techological iteroperability must be drive by cliical eed ad fiacial beefits. Fourth, the supportig ifrastructure that promotes iteroperability must be a shared resource for all stakeholders i the healthcare commuity. C. Overview - The Coecticut Healthcare Eviromet ad HIE Ladscape Itroductio Although federal guidace, best practices ad health IT stadards will be fudametal to the buildig of the Natiowide Health Iformatio Network, the structure ad fuctio of its local, regioal ad statewide compoets will be shaped to a sigificat extet by the culture ad priorities of local, regioal ad state health IT ad HIE projects. Several iitiatives uderway i Coecticut have laid the groudwork for a state structure, ad the priorities ad cocers of the stakeholders ivolved will shape the CT State RHIO ad state HIEN goig forward. Evaluatio There are may local ad regioal health iformatio exchage efforts uderway i Coecticut. While most are still i the early plaig stages, a umber of iitiatives are well developed, buildig stakeholder support ad developig busiess plas with the expectatio that they will move to implemetatio i the ear future. Several of these are collaboratios betwee hospitals ad their affiliated providers; the goal beig to help providers implemet a sigle EHR product that would provide data exchage betwee them, the hospital, ad other coected providers. While this is viewed as a relatively straightforward ad efficiet model, cocers still exist. The sigle product model makes it potetially more difficult for providers who choose to use other systems to coect to the hospital ad to other providers. Of greater cocer is that the sigle product model will give the participatig hospitals a competitive advatage over other hospitals i the regio through its role i the developmet ad ogoig maagemet of the data exchage capacity. However, other Coecticut stakeholders see this model as a realistic ad feasible approach to provide EHR capacity to small- ad medium-sized practices that lack the fiacial ad techical expertise to adopt o their ow. Coversely, some raise cocers about limitig the optios of these providers ad tyig them too closely to a sigle hospital system. Curretly, the perceptio i Coecticut is that while some of the regioal efforts show promise, the majority lack the fudig or visio required to successfully mout local HIE efforts that ca ultimately itegrate ito a statewide HIEN. This cocer stems from the lack of required fiacial 24 C O N N E C T I C U T S T A T E H E A L T H I T P L A N

29 I I. H E A L T H I T / H I E B A C K G R O U N D resources, a cocer heighteed as the state s ecoomic situatio has deteriorated. The recet passage of the America Recovery ad Reivestmet Act ad the substatial fudig that will be available for health IT ad HIE iitiatives, brigs reewed optimism about the future of HIE i Coecticut. I additio to fiacial cocers, competitio amog orgaizatios, the lack of a collaborative history amog providers, ad parochialism that weds orgaizatios to established ways of doig busiess all represet sigificat barriers to statewide activity ad collaboratio. Due to the competitive ature of healthcare, may of the healthcare providers i the state are reluctat to share patiet data. I Coecticut, this is more of a issue for the private practice orgaizatios tha for hospitals. Oe example of this ivolves cliical laboratory orders, where a itegrated eviromet would allow providers to order laboratory tests from the laboratories of their choosig. The icetive to participate i a exchage etwork is dimiished if a hospital laboratory fears beig put at a competitive disadvatage. Amidst these cocers, there is evidece to suggest that the situatio may be more positive. There are several existig collaboratig groups of healthcare orgaizatios that are pursuig health IT/HIE opportuities to improve the state s healthcare system. While there are oe or two examples of formally orgaized RHIOs, the majority of these may oly be loosely characterized as RHIOs. Electroic medical record adoptio by Coecticut providers mirrors the atioal treds of 10-15% (DesRoches et al., 2008; Jha et al., 2006; Jha, et al. 2009). A larger majority of the provider commuity is exposed to electroic data exchage through their relatioships with hospitals as well as laboratory, radiology ad pharmacy vedors. Because may of these relatioships rely o proprietary systems, the beefits of these systems are offset by the disparate sources of data beig maaged by their admiistrative staffs. I additio, several idepedet physicia associatios (IPAs) are supportig the developmet of EHR ad registry systems ad providig techical assistace for health IT adoptio to their members. May of the state s thirtee commuity health ceters have adopted electroic health records, ad are begiig to use these systems ot oly for patiet care, but for reportig to fuders ad state ad federal agecies, ad for quality improvemet efforts. While there is support amog the leadership of the commuity health ceters for icreased health iformatio exchage, cocers about cofidetiality ad access to records is heighteed. Protectio of immigratio status ad data about substace abuse ad metal health issues from payers ad public agecies is a key cocer of these orgaizatios. Both withi state agecies ad exterally, the challege of itegratig the state s diverse databases is viewed as early impossible. Limitatios of outdated systems, regulatory ad legal barriers, ad other bureaucratic barriers are viewed by may as isurmoutable. However, there is a desire amogst leaders i the state agecies for better itegratio ad collaboratio. The primary cocer is how to chage the existig culture to support chage. C O N N E C T I C U T S T A T E H E A L T H I T P L A N 25

30 I I. H E A L T H I T / H I E B A C K G R O U N D ehealthcoecticut, Ic. is perceived by some to be a importat orgaizatio that is represetative of the full spectrum of the Coecticut healthcare system. This optimistic view is coupled with frustratio at the udercapitalizatio of the orgaizatio ad its lack of accomplishmet ad progress to date. Curretly, the orgaizatio is developig the Coecticut Health Quality Cooperative, a payer drive program to collect, aalyze ad report healthcare data across the state to ecourage physicias to improve the quality of care they provide. While this project is gaiig recogitio, there is cocer that the project will lead to a overreliace o payers ad move the orgaizatio ito a vedor role, makig it more difficult to carry out a more eutral role of settig stadards, providig techical assistace, ad promotig advocacy ad educatio. Payers play a more importat role i Coecticut tha i other states because of the large historic presece of the isurace idustry i the state, ad their ifluece i settig the state s healthcare ageda. Ackowledgemet of the role that payers ca play i buildig icreased health iformatio exchage is tempered with privacy cocers about icreased payer access to data. Fially, there is a lack of shared uderstadig, priorities, ad laguage to promote commuicatios ad collaboratio across the state relative to HIE strategy. This is a commo problem shared by every state across the coutry. Without a shared uderstadig of where Coecticut is headed relative to HIE, healthcare costituets caot work together effectively. This challege is eve more dautig give the scope ad complexity of The Pla. To address this issue, The Pla offers a visio, priciples, goals, ad a commo busiess model. Just as importatly, it presets a commo laguage to promote a shared uderstadig of the impact of the pla o Coecticut s healthcare professioals ad leaders i the comig years. These critical elemets represet the foudatio of sustaiable commitmet to The Pla for all stakeholders i Coecticut. Collectively, they are preseted as a framework for developig health IT/HIE i Coecticut i the followig chapter. 26 C O N N E C T I C U T S T A T E H E A L T H I T P L A N

31 III A Framework for Developig Health IT/HIE i Coecticut The Pla must meet the uique ad disparate eeds of a broad rage of cliets, patiets, providers, office staff, admiistrators, researchers, public health professioals ad other healthcare costituets i Coecticut. Cliets ad patiets must uderstad ad appreciate that the icreased electroic accessibility of their healthcare data will result i better care, ad be satisfied that their privacy will ot be compromised i the process. Providers must be cofidet that the iformatio made available through HIE is complete ad accurate ad will improve the quality of care they provide. Office staff must be coviced that HIE will be worth the time ad effort. Admiistrators must be coviced that the substatial costs ad effort associated with HIE will ultimately result i real beefits to their orgaizatios. Researchers ad public health professioals must be coviced that ew opportuities for providig healthcare moitorig, evaluatio ad oversight through HIE are worthwhile ad sustaiable. To meet the eeds of this diverse group of healthcare professioals, extesive ad sustaied commuicatio ad collaboratio will be required. Also, a shared commitmet to a comprehesive ad soud busiess pla is eeded. Fially, fully qualified ad sustaied leadership is eeded to sustai the commitmet ad maage the implemetatio of the strategy over time. This sectio provides the framework to esure that these requiremets will be met. A. Key Iputs for the Developmet of the Pla I order to trasform the Coecticut healthcare system through health IT ad health iformatio exchage, The Pla must take ito accout: the atioal ad state policy cotext for health system reform ad for health IT/HIE guidace; the curret Coecticut healthcare system; ad the level of iterest ad commitmet of a broad group of costituecies whose support ad participatio is ecessary if the etwork is to succeed (Figure 8). FIGURE 8 Federal Guidace for HIE Curret CT Healthcare System Stakeholder Commitmet C O N N E C T I C U T S T A T E H E A L T H I T P L A N 27

32 I I I. A F R A M E W O R K F O R D E V E L O P I N G H E A L T H I T / H I E I N C O N N E C T I C U T Federal Guidace for the developmet of RHIOs ad HIENs, as well as the experieces of other RHIOs ad HIENs, provides a stadards-based foudatio ad a wealth of experiece to build upo i the developmet ad implemetatio of The Pla. The Curret Coecticut Healthcare Eviromet guides how The Pla is structured. The curret Coecticut healthcare eviromet is fragmeted ad does ot have a stadard framework withi which stakeholders ca effectively commuicate, collaborate ad pursue shared iteroperability goals. This represets a sigificat challege; the developmet of a shared framework ad laguage that all stakeholders ca use to commuicate is fudametal to success. Stakeholder Ivolvemet ad Commitmet is critical to the successful developmet ad implemetatio of The Pla. The curret commitmet level of Coecticut stakeholders to trasformig the healthcare system through health iformatio exchage must be stregtheed ad coordiated. Give the complexity of the healthcare eviromet ad the varyig perspectives ad priorities of the healthcare stakeholders throughout the state, The Pla must promote stroger participatio, commuicatios ad collaboratio. B. Visio, Guidig Priciples ad Goals It is widely accepted that there are tremedous opportuities for improvig the state s healthcare system through health IT/HIE. Stakeholders across Coecticut recogize this opportuity ad offered sigificat isight regardig what it will take to make The Pla successful. Through iput garered from the stakeholder iterview process, The Pla provides a shared visio, priciples ad goals as represeted below. FIGURE 9 Federal Guidace for HIE Curret CT Healthcare System Stakeholder Commitmet S h a r e d V i s i o a d P r i c i p l e s S h a r e d G o a l s 28 C O N N E C T I C U T S T A T E H E A L T H I T P L A N

33 I I I. A F R A M E W O R K F O R D E V E L O P I N G H E A L T H I T / H I E I N C O N N E C T I C U T Visio The visio statemet developed by the project team ad approved by the Steerig Committee is provided below. The Coecticut State Health IT Pla will trasform the Coecticut healthcare system by eablig substatial ad measurable improvemets i the quality of patiet care, patiet safety, ad the overall efficiecy ad effectiveess of the healthcare system through health iformatio techology ad health iformatio exchage. Priciples To implemet this visio, it must be traslated ito a shared set of priciples ad goals, ad a cosesus o the strategy for realizig the visio. Through the stakeholder iterview process, review of federal guidace ad other state experieces, as well as ogoig collaboratio with the Steerig Committee, the project team developed a set of priciples that provides the foudatio of the goals ad strategy that follow. Priciple 1 Health IT is a tool for improvig the Coecticut healthcare system. However, health IT is ot a paacea, it does ot by itself fix the system. It is a ecessary foudatio for a wide rage of efforts to trasform the healthcare system. Priciple 2 Coecticut healthcare cosumers must be cofidet that their persoal health iformatio is secure ad used appropriately. Amog cosumers ad their advocates, the privacy ad security of persoal health iformatio is paramout; the iability to esure data security ad prevet iappropriate use has bee a major obstacle ad cause of failure for may data exchage efforts. However, it is ot eough that the etwork protects the privacy of cosumers. A broad based educatio ad outreach effort directed at providers ad cosumers to covice them about privacy, security ad value of health iformatio exchage is eeded to build cofidece ad trust. Priciple 3 The future developmet of health IT ad HIE i the state will support the etire healthcare commuity. Although the implemetatio of the etwork may be icremetal, The Pla must be iclusive of the full rage of healthcare providers, settigs ad services. This icludes safety et providers, ursig homes ad rehabilitatio ceters, ad ultimately, metal health ad substace abuse providers. Priciple 4 The Coecticut Health Iformatio Exchage Network ad its associated goverace structure will maitai complete trasparecy ad opeess. C O N N E C T I C U T S T A T E H E A L T H I T P L A N 29

34 I I I. A F R A M E W O R K F O R D E V E L O P I N G H E A L T H I T / H I E I N C O N N E C T I C U T Trust ad awareess amog healthcare cosumers, healthcare professioals ad policy makers are key requiremets of The Pla. For the CT State RHIO to successfully operate withi a complex ad competitive healthcare system, there must be cofidece that it is workig for the beefit of the overall system ad its patiets, ad ot uiquely beefitig particular orgaizatios or costituecies. Priciple 5 The Coecticut State RHIO will maitai represetative, qualified ad stable leadership across the full spectrum of healthcare stakeholders i the state. Broad represetatio has bee demostrated as itegral to HIEN success ad is key to esurig ogoig participatio ad collaboratio as the health iformatio exchage etwork evolves. Priciple 6 The Coecticut Health Iformatio Exchage Network ad its associated goverace structure will provide guidace ad support to local ad regioal health iformatio exchage iitiatives. While statewide data exchage capacity is the ultimate goal, it depeds o the successful developmet of regioal efforts to coect ad exchage data. Iitially, statewide effort will focus o providig stadard settig, guidace ad techical support for the regioal HIE projects. Goals These goals describe what will be accomplished through the implemetatio of The Pla. Goal 1 Develop Orgaizatioal Structure to Support the Implemetatio of the Coecticut State Health IT Pla. The Coecticut State Regioal Health Iformatio Orgaizatio will be the etity resposible for the implemetatio ad overall success of The Pla. Goal 2 Provide a Framework to Promote Effective Commuicatios ad Maagemet. The Coecticut Health IT Pla Framework will provide a resource to promote shared uderstadig of The Pla, the shared laguage that will improve the ability of costituets to commuicate ad collaborate, ad the maagemet ad accoutability that is required to esure the effective developmet of the etwork. Goal 3 Recruit ad Sustai Qualified, Effective, ad Diverse Leadership. A leadership structure comprised of idividuals with a commitmet to statewide health iformatio exchage, represetig a diverse set of stakeholders ad a rage of expertise is istrumetal at the outset of this effort ad must be sustaied o a permaet basis. 30 C O N N E C T I C U T S T A T E H E A L T H I T P L A N

35 I I I. A F R A M E W O R K F O R D E V E L O P I N G H E A L T H I T / H I E I N C O N N E C T I C U T Goal 4 Demostrate Sustaied Commitmet to All Healthcare Costituets. Broad represetatio of stakeholders o the CT State RHIO goverig body, educatio ad outreach, cosumer advocacy, ad opeess ad trasparecy of activities will ecourage commitmet by all healthcare costituets across the state. Goal 5 Maximize Ivestmet through Strategic Plaig ad Phased Implemetatio of the Health Iformatio Exchage Network. The Pla ackowledges that there are a wide variety of healthcare costituets with varyig HIE eeds ad resources. While there are sigificat differeces amog costituets, there are may elemets of The Pla that are cosistet across these groups. Through careful plaig ad modular desig, the health iformatio exchage etwork will evolve through a icremetal process that builds capacity over time while maitaiig ivestmets. Goal 6 Promote Effective Utilizatio of Resources. The Pla leverages existig health IT projects ad resources, promotes local ad regioal health iformatio orgaizatios ad their health IT/HIE projects ad collaboratio across participatig healthcare orgaizatios. C. Key Resources FIGURE 10 Federal Guidace for HIE Curret CT Healthcare System Stakeholder Commitmet S h a r e d V i s i o a d P r i c i p l e s S h a r e d G o a l s Leadership ad Goverace Educatio ad Outreach Pilot Projects C O N N E C T I C U T S T A T E H E A L T H I T P L A N 31

36 I I I. A F R A M E W O R K F O R D E V E L O P I N G H E A L T H I T / H I E I N C O N N E C T I C U T Although there are may critical compoets to the success of The Pla, three are itegral to shortad log-term success: Leadership ad Goverace; Educatio ad Outreach; ad Pilot Projects that will support the phased developmet ad implemetatio of the HIEN. Leadership ad Goverace The Pla recommeds the formatio of the CT State RHIO which icludes a diverse goverig body represetative of its key costituecies. This orgaizatio, described i detail i subsequet sectios, will be resposible for the implemetatio of the recommedatios i The Pla. Iitially, the CT State RHIO will primarily provide support to local ad regioal health iformatio orgaizatios across the state that sposor their ow iitiatives. Educatio ad Outreach Trasformig the healthcare system through the use of health IT/HIE will impact all orgaizatios, healthcare providers, ad healthcare cosumers. Traiig programs for cliical, operatioal ad techical staffs will be required as The Pla is implemeted. A educatio ad outreach subcommittee is recommeded to promote traiig ad commuicatios programs. Ogoig commuicatios by all parties, particularly with leadership ad techical resources will be critical. Structured commuicatios protocols will be developed to esure ogoig commuicatios betwee state govermet, the CT State RHIO, ad local ad regioal health iformatio orgaizatios. Pilot Projects The State Health Iformatio Exchage Network will ot be created through a sigle comprehesive project. The complexity ad cost of a project with this scope requires sigificat huma ad fiacial resources, ad cosequetially, a sigificat amout of risk. The Pla recommeds a phased approach with a series of pilot projects to support the icremetal developmet of the Coecticut Health Iformatio Exchage Network as well as the CT State RHIO s capacity to support it. A project certificatio process will be developed through the iitial pilot projects which will subsequetly support expasio of the HIEN across the state. As proposals for subsequet health IT/HIE projects are developed ad submitted by local ad regioal health iformatio orgaizatios, the CT State RHIO will use the certificatio process to verify that those health IT/HIE projects meet the orgaizatioal, operatioal, ad techical requiremets of the broader state strategy. D. Healthcare System Trasformatio The visio of improvig the quality ad safety of patiet care ad the overall efficiecy ad effectiveess of the Coecticut healthcare system caot be achieved by health iformatio exchage aloe. While the widespread ad timely availability of data through HIE will eable ad support improvemets i the healthcare system, much broader chage is required. Healthcare professioals i all fields will be required to assess ad modify cliical practice, adapt roles ad resposibilities, ad create a eviromet that ecourages iovatio i practice through health IT/HIE. 32 C O N N E C T I C U T S T A T E H E A L T H I T P L A N

37 I I I. A F R A M E W O R K F O R D E V E L O P I N G H E A L T H I T / H I E I N C O N N E C T I C U T FIGURE 11 Federal Guidace for HIE Curret CT Healthcare System Stakeholder Commitmet HEALTH IT/HIE BUISENESS MODEL (ORG. STRUCTURE, LANGUAGE & TECHNICAL ARCHITECTURE) Leadership ad Goverace S h a r e d V i s i o a d P r i c i p l e s S h a r e d G o a l s Educatio ad Outreach H e a l t h c a r e S y s t e m Tr a s f o r m a t i o Pilot Projects Direct Patiet Care Moitorig & Evaluatio State Health Agecies Give the complexities implied by the idea of healthcare system trasformatio, the project team has structured the Coecticut healthcare system ito three distict domais as represeted i Figure 11 above. Cosider the followig examples of how the healthcare system curretly works ad how it will be improved through HIE. Direct Patiet Care I the last several decades, cosumers i the Uited States have grow accustomed to the beefits of sophisticated techology ad iformatio systems i may aspects of their daily lives ad have accepted that their privacy will be protected whe they use these systems. Their bak cards give them C O N N E C T I C U T S T A T E H E A L T H I T P L A N 33

38 I I I. A F R A M E W O R K F O R D E V E L O P I N G H E A L T H I T / H I E I N C O N N E C T I C U T easy access to fuds virtually aywhere i the world; they trasfer moey; check their balace status; pay bills; ad file their taxes electroically. They get remiders by whe their car eeds service or whe their pets are due for a veteriary visit. They order, pay for, ad check the delivery status of books, electroics, ad groceries o lie. They fid out about their childre s homework ad keep i touch with their teachers o-lie. Ad yet, whe they go to their doctor they still fill out forms, repeatedly by had, they wait while their providers pore through paper records to fid laboratory results, had carry records ad x-rays to specialists, ad whe they get there, provide basic medical iformatio that they have already give to other providers. If they go to the hospital, their ow memory or their ow paper records are ofte relied upo for basic iformatio such as medicatios they are takig, allergies ad key aspects of their medical history. Direct Patiet Care Example: A 40 year old ma is brought by ambulace to a emergecy departmet after passig out while drivig his car. His ijuries are relatively mior, but require atibiotics, his blood pressure is elevated ad his breathig is irregular. His verbal reports o his medical history are icosistet. Now: The hospital has o medical record o the patiet; the emergecy departmet physicia makes a decisio based o the patiet s self report to admiister atibiotics, which the results i a allergic reactio. Future: The staff at the emergecy departmet is able to electroically obtai basic medical iformatio o the patiet detailig care provided by a umber of Coecticut hospitals ad other healthcare settigs, alertig them ot oly to the atibiotic allergy, but also to relevat iformatio about his cardiac history. Direct patiet care orgaizatios such as hospitals, commuity cliics ad private practices represet key settigs for trasformig the way health iformatio is used to support improvemets i the quality of care ad efficiecy of the Coecticut healthcare system. It is withi these settigs that most patiets will first become aware of health IT ad how it ca beefit them. The direct patiet care eviromet is where most of the trasactios betwee primary care providers, specialists, laboratories, pharmacies, hospitals, ursig homes, ad acillary care providers that rely o the exchage of health data will occur. I compariso to the curret system illustrated above, i the trasformed system, primary care providers will have patiet iformatio stored ad retrievable i electroic health records. These records will allow providers to easily access their patiet s health iformatio, alert them whe tests or procedures are due, war of possible drug-drug or drug-allergy iteractios, ad support improved provider-patiet commuicatio. Quicker, more efficiet access to iformatio will exted beyod the provider s office. Laboratory tests ad x-ray images will be ordered electroically, ad results automatically retured to physicias ad icluded i patiet records. Medicatios will be ordered electroically ad physicias otified whether prescriptios have bee filled. Specialists will be able 34 C O N N E C T I C U T S T A T E H E A L T H I T P L A N

39 I I I. A F R A M E W O R K F O R D E V E L O P I N G H E A L T H I T / H I E I N C O N N E C T I C U T to access relevat patiet records, medicatio histories ad test results, ad primary care physicias will be able to easily access the results of specialty visits. Physicias i hospitals will have electroic access to patiet s primary care histories. Cosumers will be able to make appoitmets ad view test results olie as well as commuicate with their physicias by . Emergecy departmet physicias will ot have to rely o critically ill or trauma patiets ad their families to provide essetial health iformatio, but will be able to access records from a rage of providers the patiet may have see. Healthcare System Moitorig ad Evaluatio Orgaizatios that egage i healthcare system moitorig ad evaluatio typically do ot provide direct patiet care ad for that reaso, require access to data that may origiate at the poit of care but has udergoe some trasformatio to de-idetify the data ad protect the privacy of the patiet. Data are typically aggregated ad trasformed to meet the requiremets of specific quality or healthcare system maagemet resposibilities. Examples iclude: hospital admissio, discharge ad trasfer (ADT) iformatio for trackig hospital ipatiet activity; lab results for supportig chroic disease maagemet activities; Healthcare Effectiveess Data ad Iformatio Set (HEDIS) data for trackig physicia performace; ad claims data used for pay-for-performace programs. Healthcare System Moitorig ad Evaluatio Example: Access to behavioral health services i Coecticut has bee a ogoig cocer for state govermet ad providers of care. Over time, treatmet patters for patiets with behavioral health eeds have shifted away from providig care i traditioal ipatiet settigs towards less restrictive care settigs i the commuity. It is hoped that this shift may help alleviate hospital emergecy departmet overcrowdig, reduce uecessary admissios ad log stays i hospitals ad ultimately lead to better outcomes for patiets ad their families. The Coecticut Departmet of Metal Health ad Addictio Services (DMHAS), i particular, is iterested i the cotiuum of care for behavioral health services ad i esurig that cliets receive care i the most appropriate ad cost-effective settig. Now: The DMHAS curretly receives statewide data o ipatiet ad emergecy departmet behavioral health utilizatio treds, however, little is kow about statewide utilizatio by patiets treated o a outpatiet basis i commuity settigs. Future: A health iformatio exchage eabled eviromet would facilitate access to ocofidetial data o care provided i commuity based/outpatiet care settigs that would provide the DMHAS with more meaigful data aalyses ad produce relevat studies o behavioral health utilizatio ad access across the full spectrum of care settigs. Curretly, hospitals ad other healthcare providers are collectig ad providig healthcare data to quality orgaizatios i a variety of forms. These efforts are typically supported by participatig orgaizatios o a best effort basis, usig the most readily available techical ad orgaizatioal meas. While this approach was geerally required i the legacy healthcare eviromet, federal guidace suggests that a stadards-based approach to the developmet of health IT ad HIE i support of quality ad populatio health moitorig will provide may opportuities ad beefits. Oe of the sigificat reasos why the data are ot available is the difficulty i compilig ad aalyz- C O N N E C T I C U T S T A T E H E A L T H I T P L A N 35

40 I I I. A F R A M E W O R K F O R D E V E L O P I N G H E A L T H I T / H I E I N C O N N E C T I C U T ig this iformatio; it must be collected by reviewig charts ad records by had ad there may be o cosistecy o how the data are reported. With electroic health records ad improved data exchage, the potetial to automate ad stadardize the measuremet, feedback ad reportig of healthcare data icreases sigificatly. I this visio, a basic set of quality measures would be established for hospitals ad for cliicias ad this data could be easily gathered ad reported to exteral quality orgaizatios. With this data, cliicias ad hospitals could receive timely reports o their ow performace compared to their local peers ad to state ad atioal levels. For example, physicias could lear whether their diabetic patiets are farig as well, better or worse tha those of their peers, ad lear what specific practices are beig followed that may be differet from their ow practice, or differet from atioal stadards ad guidelies. Payers ca use this data to reward physicias that are deliverig the highest quality of care, while policy makers ca use it to idetify treds i healthcare delivery. Cosumers ca use the data through report cards ad other reportig mechaisms to help them choose health plas, primary care providers, specialists ad hospitals. State Health Agecies State health agecies require access to program related health iformatio that is specific to their ogoig resposibilities for state-level healthcare oversight ad state ad federal program maagemet resposibilities. These orgaizatios typically do ot have direct patiet care relatioships ad for that reaso, require access to data that may origiate at the poit of care but is eeded for program specific purposes for them to meet their resposibilities. A oteworthy example is the ability to maage childhood immuizatios. I this example, the data are most effective whe used bi-directioally ot oly must the state have this iformatio for moitorig ad compliace purposes, but the data are useful to providers i obtaiig a complete picture of a child s health history ad ca prevet duplicate immuizatios whe parets caot recall, or caot documet, prior immuizatios. De-idetified data ca also be more effectively used if other state departmets ca access the data to support their ow aalysis ad evaluatio efforts. State Health Agecies Example: Qualificatio for federal fuds to combat childhood obesity requires data collectio, aalysis ad reportig of data that is housed i multiple state healthcare agecies. Now: A complex set of agecy regulatios, distict datasets, ad obstacles to commuicatio amog agecies makes accurate ad complete compilatio of data difficult, resultig i datasets that fail to preset a compellig case for the fudig. Future: With stadardized rules for data exchage ad legislative ad regulatory attetio to promotig this type of exchage, data held i the differet departmets are compiled to preset a more complete picture of childhood obesity i the state, permittig applicatio for the federal fuds. Curretly, healthcare providers are required to report to various public agecies o a wide rage of both ifectious (e.g. sexually trasmitted diseases) ad o-ifectious (e.g. cacers) illesses ad health coditios. I additio, they are required to report to various agecies whe patiets respod 36 C O N N E C T I C U T S T A T E H E A L T H I T P L A N

41 I I I. A F R A M E W O R K F O R D E V E L O P I N G H E A L T H I T / H I E I N C O N N E C T I C U T adversely to medicatios or vacciatios. Today this reportig is burdesome, ad because of the myriad of reportig requiremets at local, state ad federal levels, reportig is ofte icosistet, icomplete, iaccurate ad utimely. This results i public health data that may ot truly reflect the health situatio i particular commuities or may delay the idetificatio of emergig health crises or harmful medicatios. Emergig flu epidemics, food-bore disease, or adverse evets to medicatios ca be quickly spotted whe reportig is close to real-time. This type of reportig is a ideal use for electroic health records ad electroic data exchage. Whe appropriately supported, these systems ca automatically collect ad distribute data to a rage of public agecies usig the required formats ad withi required timelies. EHRs ad HIE capacity stregthe the likelihood that public health data ca move i two directios, as providers ca quickly beefit from receivig feedback ad aalysis of the data they have reported to idetify public health treds withi their ow patiet populatio. From a public health perspective, materal ad child health ivolves a rage of programs ad agecies that are meat to improve the health ad well-beig of pregat wome ad their childre from pregacy through early childhood. May public agecies at the local, state, ad federal level have a role i materal ad child health ad there are a myriad of programs available to wome who qualify. The complexity ad quatity of these programs affects patiets, providers ad public agecies. Electroic systems at the provider ad public agecy level ca help i the assessmet of patiet eligibility for materal ad child health programs, facilitate their erollmet, ad facilitate reimbursemet to providers. These systems ca lik wome to programs that provide ot oly direct medical care, but support for basic services such as housig ad utritio, social workers ad case maagers. As with public health reportig described above, these systems will also remid providers of the rage of required screeig exams ad will facilitate reportig to various public agecies that collect iformatio o these screeig activities. Ultimately, a more cocerted ad holistic approach to the care of the pregat woma ad her child are made more feasible through the use of these electroic systems, resultig i better health outcomes for both the wome ad their ewbors. E. Cosumers ad Their Role i HIE Ultimately, the visio for improved quality of care, patiet safety, efficiecy ad effectiveess of the Coecticut health system through health IT/HIE is to create a healthcare system where patiets ad their families are better iformed ad i cotrol of their ow healthcare decisios. May of the improvemets described previously will lead to this trasformed system. Cosumer access through a patiet portal to their provider s system or use of persoal health records will allow them to schedule appoitmets, request referrals, sed medicatio refill requests, review their test results ad commuicate with their providers electroically. Iformatio o their isurers web sites or web sites of public agecies will allow patiets to select providers based o the quality of care they provide. C O N N E C T I C U T S T A T E H E A L T H I T P L A N 37

42 I I I. A F R A M E W O R K F O R D E V E L O P I N G H E A L T H I T / H I E I N C O N N E C T I C U T Cosumer access to cliical iformatio i a persoal health record supported through health iformatio exchage could sigificatly trasform cosumers participatio i their care. Today cosumers ad patiets have limited access to their ow health iformatio. Iformatio housed at their primary care provider is likely to be i paper format ad geerally ot accessible to the patiet. Whe a lab result is retured, patiets must geerally request a copy from their provider, ad they must do so each time there is a lab result. If they wat a record of their medicatio allergies, they must create ad retai it themselves. Whe they move or chage providers, their record ofte stays with their previous physicia, with oly basic medical iformatio trasmitted to the ew provider. With a persoal health record, cosumers will have the ability to maitai a readily accessible record of key medical iformatio ad history for themselves. Ideally, this record will be fed ot oly by the cosumer but also with data that are automatically trasferred from a provider s record to the cosumer s persoal health record. The cosumer will have the ability to cotrol which providers ca access their records ad what part of the record each ca access. The cosumer will be able to grat access to the record to other idividuals such as family ad healthcare proxies. I additio, as part of the cosumer s growig resposibility for their ow healthcare, cosumers may have the ability to report adverse evets through their persoal health records to providers, public agecies ad maufacturers. This direct reportig will augmet provider reportig ad has the potetial to improve the speed ad timeliess i which evets such as epidemics, food bore illess ad medicatio complicatios are idetified. Persoal health records ca be equipped with the same type of reportig fuctios as i provider health records so that reportig ca be automatically triggered by data i the persoal health record. Cosumers would also the receive otificatio of adverse evets cocerig their ow coditios, public health evets, ad problems with medicatios they are takig directly ito their persoal health records rather tha relyig o their providers to covey this iformatio. Improvemets i care delivery will supplemet this growig level of cosumer empowermet over their ow care. Techology will provide the opportuity for better moitorig of chroic coditios such as diabetes, hypertesio, depressio, ad asthma through home equipmet tied ito providers ad case maagers who are i frequet ad phoe cotact with patiets. A improved ad expaded model of primary care kow as the medical home will provide a more comprehesive approach to maagig all aspects of a patiet s healthcare through all phases of a perso s life. Together, these chages i the healthcare system supported by the improved availability ad quality of data through electroic health records ad health iformatio exchage, will lead to improved cosumer cotrol over their healthcare, ad ultimately to improved health for the over three millio citizes of Coecticut. 38 C O N N E C T I C U T S T A T E H E A L T H I T P L A N

43 IV Critical Success Factors This chapter of The Pla reviews the critical success factors that must be addressed as Coecticut develops health iformatio exchage capacity i the comig years. To fully iform those charged with implemetig The Pla, each sectio of this chapter reviews the Coecticut healthcare system as it relates to the critical success factor ad also reviews federal guidace ad lessos leared from other states related iitiatives. Recommedatios are aggregated ad sythesized i the Recommedatios ad Next Steps chapter of The Pla. Where appropriate, a aalysis of the impact or role of the America Recovery ad Reivestmet Act is icluded. A. Establishig the Coecticut State Regioal Health Iformatio Orgaizatio (CT State RHIO) Itroductio Oe of the key recommedatios is the establishmet of a ew orgaizatio: the Coecticut State Regioal Health Iformatio Orgaizatio (CT State RHIO). The CT State RHIO will be resposible for coordiatig health IT/HIE activity across the state. Idetifyig the appropriate visio, missio, scope of authority, ad goverace structure of the CT State RHIO is essetial to the short- ad log-term success of the orgaizatio. The visio ad missio must be meaigful ad relevat to the lives ad work of the RHIO s costituets. Leadership must successfully support the directio of the orgaizatio at all times, from day-to-day operatios to strategic plaig as well as durig crises. Costituets must develop a sese of trust i the ability of the orgaizatio s board to represet their best iterests ad/or the public s iterests. The primary fuctio of the RHIO is to esure that the orgaizatio serves effectively i providig a public service to its members ad stakeholders. The RHIO accomplishes this oversight ad evaluatio fuctio through its goverig body. The goverig body keeps well iformed about the activities of the orgaizatio ad commuicates appropriate iformatio to the public ad costituets withi the Coecticut healthcare system. The secod fuctio of the RHIO is to facilitate the creatio of a HIE ifrastructure. To achieve these goals, the RHIO must serve as a catalyst to promote collaboratio ad policy chage amog stakeholders; promote iteroperability ad atioal stadards; C O N N E C T I C U T S T A T E H E A L T H I T P L A N 39

44 I V. C R I T I C A L S U C C E S S F A C T O R S advace the adoptio of health iformatio exchage; promote sustaiability of the ifrastructure ad systems; ad esure effective ad ethical use of persoal health iformatio. Coecticut Eviromet ad Stakeholder Perspective To date, the Goveror s office ad the Coecticut State Legislature have take prelimiary steps to formalize a strategy for the developmet of health iformatio exchage capacity at the state level. The passage i 2007 of legislatio authorizig ad fudig the developmet of The Pla was a importat first step. While there is cosesus amog Coecticut stakeholders of the importace of the statewide RHIO to coordiate goverace fuctios, there is cocer about the RHIO havig a techical operatios role. May stakeholders perceive that if the RHIO is placed i the role of a vedor, competitio with other vedors will dimiish its capacity to provide effective goverace, thus distortig the RHIO s capacity to be eutral ad ubiased i its decisio-makig. However, this cocer must be balaced with the eed for the RHIO to set ad promote a specific techical architecture ad ifrastructure that will drive statewide HIE capabilities. To resolve this potetial coflict, the RHIO must act as commuicator, facilitator ad techical resource to the local ad regioal health iformatio exchage efforts across Coecticut. By settig the state strategy ad developig policies, techical guidace ad a resource pool, the RHIO will support local ad regioal efforts. This approach will promote cosistecy ad build trust that will ultimately icrease the chaces of the successful developmet of statewide HIE capacity. I Coecticut, there are several existig collaboratig groups of healthcare orgaizatios that are developig approaches to utilize health IT/HIE to improve the state s healthcare system. Examples iclude but are ot limited to: Coecticut Health Iformatio Network (CHIN) - I 2007, the State Legislature passed a law to create the CHIN, a research-based health iformatio exchage to lik diverse databases across state health agecies. Collaborators iclude the Uiversity of Coecticut Ceter for Public Health Policy, the Office of Health Care Access, Developmetal Services, Child Welfare, ad the Departmet of Public Health. The system is curretly i limited pilot release. Coecticut Hospital Associatio (CHA) CHA is a membership-based orgaizatio that represets over 140 healthcare orgaizatios across the state. Health iformatio exchage related services iclude: CHIMENET, a private data etwork servig hospitals statewide; CHIMEDATA, a data collectio ad aalysis service that aalyzes hospital data ad produces utilizatio, fiacial, maagemet ad other types of reports; ad the Toward Excellece i Care (TEIC) program, which provides acute care hospitals with quality improvemet services. 40 C O N N E C T I C U T S T A T E H E A L T H I T P L A N

45 I V. C R I T I C A L S U C C E S S F A C T O R S Departmet of Iformatio Techology (DOIT) DOIT admiisters the HIPAA Program for the State of Coecticut, issuig formal statewide policy for patiet privacy ad cofidetiality withi state health agecies. DOIT has also formed the ehealth workgroup cosistig of iterested parties from a variety of state health agecies. ehealthcoecticut ehealthcoecticut is the most developed RHIO i the state ad cosists of a group of seior-level healthcare professioals from multiple disciplies that meet o a mothly basis to promote collaboratio ad health iformatio exchage. The orgaizatio has a Board of Directors that represets virtually all healthcare costituecies across the state. The orgaizatio has several stadig ad ad-hoc subcommittees that meet o a ogoig basis to support the orgaizatio. Curretly, the orgaizatio is developig the Coecticut Health Quality Cooperative, a quality-based iitiative that will collect, aalyze ad report healthcare data across the state to assist physicias to improve the quality of care they provide. Greater Bridgeport Primary Care Actio Group (BPCAG) This collaborative of Bridgeport Hospital, St. Vicet s Medical Ceter, ad three federally quality health ceters (FQHCs) i the New Have area received a $250,000 grat to develop a registry for trackig patiet activity across providers. The collaborative is curretly i the vedor egagemet process. Safety.et A group of safety et providers are discussig ways to implemet electroic health records across a etwork of commuity health ceters. Other collaboratig groups There are several collaboratios amog Coecticut healthcare providers withi specific markets. Hospitals have made good progress i developig capacity withi their orgaizatios ad to a limited degree, with etworks of hospitals such as the Greater Hartford Coalitio, the Easter Coecticut Health Network ad the Middlesex Health Iformatio Exchage. I additio, ProHealth, a primary care physicia orgaizatio, has a ogoig focus of usig health IT/HIE to improve quality of care ad patiet safety while miimizig health IT related costs for their physicia members. While the collectio of embryoic RHIOs ad their associated health IT/HIE developmet efforts described throughout this documet reflect a solid commitmet by Coecticut s healthcare commuity, there are may barriers to the successful developmet of a statewide goverig RHIO ad statewide HIE capacity. These barriers, as listed below, are addressed through the recommedatios of The Pla. 1. Lack of Legislative Authority Curretly, o existig Coecticut etity has the authority or stadig to establish, promote ad maage a statewide strategy for health iformatio exchage. C O N N E C T I C U T S T A T E H E A L T H I T P L A N 41

46 I V. C R I T I C A L S U C C E S S F A C T O R S 2. Lack of Mometum ad Cosistecy I Coecticut, there are a limited umber of successful health iformatio exchage iitiatives, but there are also a umber of strugglig ad failed attempts at improvig healthcare through the use of health IT/HIE. 3. Lack of Fudig Each existig local orgaizatio lacks adequate fudig to sustai its activities. Noe of these orgaizatios are i a positio to address statewide health iformatio exchage without substatial ad ogoig fudig. The curret fiscal crisis i Coecticut makes sigificat fudig from the state ulikely i the ear future. 4. Lack of Orgaizatioal Capacity Noe of the existig health IT/HIE efforts are adequately staffed to support ecessary statewide goverace fuctios, or are they adequately supported through stadig ad ad-hoc subcommittees. These limitatios prevet the developmet of a comprehesive strategy across the wide rage of cotet areas that must be addressed such as the critical success factors preseted i this chapter. 5. Lack of Broad-Based Strategy, Techical Visio or Plaig for HIE Developmet Curret strategy ad busiess plas typically are tied to specific projects that lack a broad strategic focus ad scalability to other areas ad orgaizatios. Ivestmets, techical ifrastructure ad resource developmet for the use of techology are also tied to specific projects. 6. Lack of Leadership Although there has bee iterest i statewide health iformatio exchage expressed by the Goveror s office ad by the Coecticut State Legislature, there has ot bee the type of fully iformed ad sustaied leadership ecessary to formalize statewide strategy. At the same time, o highly visible, well respected health IT/HIE champio has emerged, suggestig a absece of the type of fully iformed leadership ecessary to formalize ad sustai statewide HIE strategy. 7. Lack of Broad Commitmet ad Support Awareess ad support for existig health iformatio exchage projects are very fragmeted. There is curretly o firm commitmet to a specific strategy for how HIE capacity will develop over time. The curret budget crisis poses additioal challeges: fudig for RHIO startup programs will be modest, ad state fudig will ot be sufficiet to support a aggressive developmet schedule of HIE ifrastructure. Guidace ad Lessos Leared Through iput from stakeholders across Coecticut, ad existig federal guidace ad lessos leared from other state experieces, several steps were idetified as critical to the developmet of the proposed CT State RHIO. These iclude: 42 C O N N E C T I C U T S T A T E H E A L T H I T P L A N

47 I V. C R I T I C A L S U C C E S S F A C T O R S Establishig the legal authority ad structure for the RHIO Defiig the missio of the RHIO Articulatig the purpose ad fuctio of the RHIO Developig a structure for goverace ad oversight Hirig strog ad experieced seior staff members Idetifyig ad obtaiig fiacial resources ecessary for the RHIO ad HIEN developmet ad operatios 1. Establishig the Legal Authority ad Structure for the RHIO How the CT State RHIO is established has cosiderable bearig o the perceptio of the orgaizatio by stakeholders ad shapes decisios by these stakeholders cocerig whether, ad i what maer, they choose to participate i RHIO iitiatives. As a result, the source of authority for the CT State RHIO is a critical factor for success. The majority of existig statewide RHIOs are established by state govermets, through statute, executive order, sole source cotractig or memorada of uderstadig betwee state health agecies ad o-profit orgaizatios. States may also madate that a state agecy be created to serve as the RHIO, or desigate a existig state agecy to be the RHIO. I other cases, RHIOS have bee started by collaboratios of stakeholders without a official role by the state. I these istaces, the source of authority of the state-level RHIO comes from the commuity s acceptace of its role. The preferred source of authority for a state RHIO is a legislative madate. This approach has the beefit of requirig the ivolvemet of all braches of govermet, ofte brigig broad bipartisa political support. It helps to avoid uilateral decisio-makig regardig RHIO fuctios or fudig, creates a shared visio ad owership of the resultig work of the RHIO, ad promotes public perceptio of eutrality i its decisio-makig. 2. Defiig the Missio of the RHIO Geerally, state RHIOs are established to represet the public s iterest through the provisio of a public service. RHIOs are charged with providig leadership, fosterig collaboratio, ad facilitatig activity throughout the state. Their resposibility is to commuicate, educate, covee ad coordiate ecessary stakeholders i order to promote iteroperability ad atioal stadards; advace the use of HIE; promote sustaiability of ifrastructure ad systems; ad esure effective ad ethical use of persoal health iformatio. 3. Articulatig the Purpose ad Fuctio of the RHIO The two mai resposibilities of a RHIO iclude a coveig role that brigs costituecies together for iformatio sharig, advocacy, ad orgaizatioal policy settig ad a coordiatig role that helps shape HIE activities throughout the state through cosistet stadards ad practices. Virtually all state RHIOs have these coveig ad coordiatig fuctios as part of their roles. The goals of these activities are to: C O N N E C T I C U T S T A T E H E A L T H I T P L A N 43

48 I V. C R I T I C A L S U C C E S S F A C T O R S Set participatory guidelies of its members; Seek fudig; Idetify ad promote stadards ad best practices; Support HIEN iitiatives; Update, revise ad promote the state health IT pla; Assess ad moitor progress towards the goals of the state health IT pla; Establish statewide HIEN capabilities; Esure sustaiability. Techical operatios resposibilities are ofte part of a RHIO s resposibility ad iclude buildig ad marketig ifrastructure, applicatios ad services. While all existig state RHIO models egage i goverace fuctios, ot all have adopted the techical role. The iclusio of the techical operatios role is iflueced by may factors, icludig the particular market eviromet ad the size of the state. The role of the state RHIO may adapt ad adjust over time, coformig to the chagig eviromet withi the state or the eeds of the stakeholders. The followig table represets the goverace ad techical operatio roles respectively. TABLE 1 G O V E R N A N C E TECHNICAL OPERATIONS (OPTIONAL) Coveig Coordiatig Operatig Establish a trusted platform for educatio, egotiatio ad decisio-makig Advocate o behalf of local stakeholders to advace statewide HIE Iform policy developmet to advace statewide HIE Facilitate cosumer iput Track, assess & distribute iformatio o HIE efforts Establish ad maitai techical roadmap Facilitate aligmet with local, iterstate, regioal, & atioal strategies Promote cosistet applicatio of effective statewide HIE policies & practices Facilitate collaborative developmet of public policy optios & ogoig healthcare reform efforts Ow or maage cotracts for hardware, software, & techical capacity to facilitate statewide HIE: ifrastructural compoets (e.g., MPI, RLS), applicatios (e.g., cliical messagig, erx, EHR), ad services (e.g., implemetatio guides, stadards, workflow optimizatio) * From AHIC State Level HIE Cosesus Project 44 C O N N E C T I C U T S T A T E H E A L T H I T P L A N

49 I V. C R I T I C A L S U C C E S S F A C T O R S 4. Developig a Structure for Goverace ad Oversight Meetig the challege of establishig a workable goverace structure that truly represets the broad costituecies affected by health iformatio exchage is critical to the success of the state RHIO. State RHIOs are geerally govered by a board of directors or other goverig body charged with overseeig ad maitaiig the coheret visio ad strategy of the RHIO, settig policy, raisig ad maagig fuds, ad evaluatig the RHIO s strategies ad activities. The goverig body accomplishes this oversight ad evaluatio fuctio by keepig well iformed about the activities of the RHIO, makig decisios that are i the best iterests of the RHIO ad the healthcare system that it supports, ad by commuicatig appropriate iformatio to stakeholders o a regular basis. The goverig body has formal resposibilities for esurig the RHIO adheres to all legal requiremets ad bylaw stipulatios icludig, but ot limited to: hirig ad firig of the top executive; delegatig maagemet fuctios (e.g., plaig, staffig, etc) to the top executive; developig ad approvig strategic plas (icludig fiacial plas); ad maitaiig the effectiveess of the goverig body. I additio, the goverig body has iformal or supportig resposibilities which may iclude commuity egagemet, fudraisig, ad others related to the ature of the RHIO. Figure 12 details the recommeded Orgaizatioal Chart. a. Goverig Body Size - State RHIO experieces reveal that the goverig body should be comprehesive i its membership yet small eough to fulfill the ecessary activities to support the RHIO. I a effort to be iclusive, may RHIOs choose to covee a large goverig body. However, this approach ca become uwieldy, creatig a eviromet where coductig the RHIO s busiess becomes difficult. Too large a goverig body ca result i delays i decisiomakig, while too small a goverig body creates a eviromet where decisios are made without all the ecessary perspectives. The average goverig body size is 12 to 15 idividuals, with additioal formal iput from stakeholders obtaied through subcommittees ad workgroups. b. Stakeholder Represetatio - The goverig body ad its subcommittees must represet a broad rage of costituecies that are represetative of the overall healthcare system i Coecticut. Below is a list of orgaizatios ad stakeholders which may be cosidered for board ad subcommittee positios: Hospitals, itegrated delivery etworks or hospital associatios; Medical research orgaizatios; Physicias, medical practices, or state medical society; Cosumers (patiets); Healthcare safety et providers; Pharmacists ad other healthcare professioals; Employers or busiess groups; Health plas; C O N N E C T I C U T S T A T E H E A L T H I T P L A N 45

50 I V. C R I T I C A L S U C C E S S F A C T O R S Medicaid agecies; Departmet of Health; Other state agecies with health-related missios; ad Health techology leaders. Because RHIO authority ad fudig geerally comes from the state, the goveror ad state legislators are usually ot give seats o the board; other mechaisms eed to be developed to make sure these key stakeholders are ivolved i decisio makig ad kept iformed o the orgaizatio ad its progress. Associatios may appoit a represetative, while i some cases the goveror or govermet agecies will select or omiate idividual board members to represet specific stakeholder groups. Havig seior leadership is critical sice people who are able to make decisios o behalf of their orgaizatios are goig to be the most effective members of the goverig body. These leaders should be well regarded i their respective commuities ad provide support for egagig additioal supporters. Orgaizatioal represetatio ad idividual skills should be take ito accout as members are selected. c. Stadig ad Ad-Hoc Subcommittees - The formal ad iformal resposibilities idetified above shape the ature of goverig body busiess ad the subcommittee structure. Stadig subcommittees should be established i the bylaws of the state RHIO. They are typically permaet ad are itegral to fulfillig the RHIO s legal resposibilities. Ad-hoc subcommittees, which fulfill iformal resposibilities, are formed to address a time-limited issue ad geerally do ot appear i the bylaws. For both stadig ad ad-hoc subcommittees, it is importat to iclude both members of the goverig body as well as other importat stakeholders. 5. Hirig Strog ad Experieced Seior Staff Members Give that the state RHIO will serve as the coordiator ad facilitator of health IT/HIE efforts across the state o both orgaizatioal ad techical levels, it is imperative that the state RHIO have seior level, fully qualified staff. The complexity ad volume of activities eeded to successfully establish ad carry out the missio of the orgaizatio caot be met by voluteer efforts aloe, o matter how committed voluteers are. The RHIO staff must iclude full-time resources to sustai the level ad quality of commitmet ecessary to be successful. Iitially, state RHIO staff should iclude a executive director ad a techical director. The executive director serves as the seior level maager for the RHIO ad will work with the goverig body to develop the logistics for implemetatio of health iformatio exchage i the state. He or she will have a i-depth uderstadig of all RHIO activities ad will serve i a leadership role regardig commuicatios with all exteral orgaizatios that have busiess with the RHIO. The executive director will have formal resposibility for some subcommittees ad will esure that all subcommittee activities are aliged with the overall strategy of the RHIO. I cocert with the techical director, the executive director will meet with costituets across the state ad help build ad sustai ogoig support for the RHIO. 46 C O N N E C T I C U T S T A T E H E A L T H I T P L A N

51 I V. C R I T I C A L S U C C E S S F A C T O R S The techical director serves as the seior level maager for the phased developmet ad implemetatio of the health iformatio exchage etwork ifrastructure at the state level. The techical director will orgaize the techical subcommittee ad will be resposible for techical policy, stadards, fuctioal requiremets, ad techical architecture as well as prioritizatio, moitorig ad evaluatio of HIEN ifrastructure projects. The techical director will collaborate with other techology leaders across the state to esure that local ad regioal HIE efforts are aliged with the overall state strategy. 6. Idetifyig ad Obtaiig Fiacial Resources Necessary for the Proper RHIO/ HIEN Developmet ad Operatios The RHIO caot fuctio without base-level fudig that allows for the hirig of key staff, establishig the goverig body ad subcommittees, ad establishig ogoig RHIO operatios. Iitial capital fudig for RHIO formatio ad HIEN developmet are typically obtaied through federal, state ad private grat fudig sources. Other sources of fudig support ogoig operatios ad are typically i the form of membership, usage, or trasactios fees. Fudig issues are described i more detail i sectio G of this chapter (Fudig ad Fiacial Sustaiability). Federal fudig through the ARRA will be available to support the plaig ad implemetatio of health iformatio exchage at the state level. This fudig requires states to desigate oe etity that has the authority to develop statewide HIE capacity. If Coecticut is grated fudig uder this program, it ca help support the costs of the iitial years of HIEN developmet ad operatio. FIGURE 12 Recommeded Orgaizatioal Chart Goverig Body members } Iclusive of critical stakeholders Stadig Subcommittees Ad-Hoc Subcommittees Executive Committee Fiace Committee Operatios ad Goverace Committee } { Icluded i Bylaws Coveed as ecessary to accomplish orgaizatioal objectives, ot i Bylaws. Icorporates broader array of stakeholders to iform board decisios. Patiet Privacy & Cofidetiality Educatio & Outreach Techology Stadards ad Architecture Legal/Legislative Cosumer Advocacy C O N N E C T I C U T S T A T E H E A L T H I T P L A N 47

52 I V. C R I T I C A L S U C C E S S F A C T O R S B. Patiet Privacy ad Cofidetiality Itroductio Addressig privacy ad cofidetiality issues are critical to the success of the Coecticut State Health IT Pla sice healthcare cosumers will oly support health iformatio exchage if they trust that their persoal health iformatio is kept private ad cofidetial. While electroic health iformatio offers substatial beefits to patiets ad healthcare orgaizatios, ad is much easier to search, share ad trasmit tha paper-based data, it also itroduces ew ad complex risks to the privacy ad cofidetiality of patiets. If patiets ad cosumer advocates do ot trust electroic health iformatio exchage, they may take steps to opt-out or otherwise limit the developmet of the HIEN ad thereby limit the beefits of health iformatio exchage. Of greater cocer is if mistrust leads patiets to avoid seekig care. Give these cocers, rigorous protectio of health iformatio is essetial to the log-term success of the Coecticut State Health IT Pla. I order for orgaizatios to exchage health iformatio effectively, ad i a maer that is trusted, laws, policies ad busiess practices must be i place to establish acceptable uses of persoal health iformatio, recogize who is authorized to access persoal health iformatio, ad defie the extet to which patiets ca give or withhold access to their persoal health iformatio. I additio, the desig of privacy ad cofidetiality safeguards must be techically feasible ad practically sustaiable from a operatioal perspective. I developig a strategy to address the laws, policies ad busiess practices to eable private ad cofidetial electroic health iformatio exchage, the project team reviewed the specific healthcare ad legal eviromet i Coecticut; results from the Coecticut Health Iformatio Security & Privacy Iitiative (CT-HISPI); atioal policy priciples from the Commo Framework developed by Coectig for Health; ad the potetial impact of the ARRA o the Health Isurace Portability ad Accoutability Act (HIPAA). Coecticut Eviromet ad Stakeholder Perspective Iterviews ad focus groups with Coecticut stakeholders idicate that while they support the purpose of HIE ad believe that it will improve quality of care, patiet safety ad the overall efficiecy of the healthcare system, issues of privacy ad cofidetiality must be fully addressed. The issues raised by Coecticut stakeholders iclude: 1. Need for Cosistet Uderstadig of the Legal Status ad Role of the RHIO Coecticut stakeholders questio the legal ramificatios of creatig a CT State RHIO ad its authority for maagig persoal health iformatio i support of HIE. As specified by HIPAA, the CT State RHIO ad HIEN will be positioed as a busiess associate of healthcare providers as well as other covered etities with which they exchage data. Healthcare providers regulated by HIPAA must have clear iformatio use agreemets i place with those to whom they disclose persoal health iformatio. While this may be attaied through busiess associate agreemets (BAAs), some stakeholders also expressed cocer that 48 C O N N E C T I C U T S T A T E H E A L T H I T P L A N

53 I V. C R I T I C A L S U C C E S S F A C T O R S the CT State RHIO should be regulated ad that its members be accoutable to some govermet body or agecy. 2. Authority for Secodary Uses of Data is Iadequate Several orgaizatios across the state have existig programs that require secodary uses of data. Whe ad where legally permitted, health iformatio exchage provides opportuities for populatio-based healthcare iitiatives ad public health etities to more readily access persoal health iformatio for secodary use purposes. Curretly, Coecticut state law does ot fully support secodary uses of data. While there is evidece that existig RHIOs have addressed this issue for their specific purposes, the issue has to be addressed i the cotext of statewide HIE to eable populatio-based health maagemet, quality iitiatives ad public health oversight. 3. Need for Proactive Egagemet with Cosumers ad Developig Trust The large majority of cosumers i Coecticut are supportive of their persoal health iformatio beig part of a health iformatio exchage etwork. However, for the remaiig cosumers who cotiue to be resistat to the idea of health iformatio exchage, there is the possibility that they will attempt to derail the developmet of health IT/HIE i the state if their cocers are ot proactively ad completely addressed. Therefore, a comprehesive positio statemet o health iformatio exchage, with a clear message to cosumers ad their advocates about how their iformatio will be used, maaged ad protected, will be a fudametal step i developig cosumer trust ad commitmet. There are geerally three optios for the iclusio of patiet data i the HIEN. Oe optio should be chose for all o-sesitive persoal health iformatio exchage to esure cosistecy. Opt-I: Data are ot exchaged by default util the patiet provides coset. w Legthy ad time cosumig process. w Less data available, more icomplete data. w Potetial duplicatio of services. w Provides high level of cosumer cotrol but may be admiistratively burdesome for cosumers ad healthcare orgaizatios. Opt-Out: Data are exchaged by default uless restricted by the patiet. w Perceived value by cosumers. w Less costly ad lower admiistrative burde tha opt-i. w More sustaiable. w All or othig opt-out is reasoable but selective opt-out may be umaageable. w Icreases likelihood data will be available whe eeded, thus potetially improvig quality of care. w Provides high level of cosumer cotrol with lower admiistrative burde. C O N N E C T I C U T S T A T E H E A L T H I T P L A N 49

54 I V. C R I T I C A L S U C C E S S F A C T O R S Notificatio of use: Uder state ad federal law, appropriate iformatio ca be shared as log as HIPAA rules are followed which requires that covered etities otify cosumers that their persoal health iformatio is shared over the HIEN. w w w w w Maitais status quo of curret practices. High level of data available. Admiistrative burde is low ad/or elimiated. Adheres to curret stadards of privacy ad cofidetiality. Sharig of patiet data through HIE is potetially more secure tha curret practices. 4. Federal ad Coecticut State Privacy Law Existig state ad federal laws must be reviewed ad thoroughly uderstood. State laws may eed to be modified to promote health iformatio exchage ad ew laws may eed to be itroduced. The health iformatio exchage etwork must be structured to esure adherece to patiet privacy laws at both state ad federal levels. A list of relevat federal ad Coecticut statutes is provided i Appedix K. 5. Lack of Cosistet Role-Based Privileges ad Accoutabilities There are several health iformatio exchage iitiatives i Coecticut that are developig rolebased privileges ad accoutabilities to promote patiet privacy ad cofidetiality. However, these efforts are ot aliged across iitiatives ad may potetially coflict with each other as health iformatio exchage efforts become more itegrated. The CT State RHIO must develop comprehesive guidace relative to user idetificatio, autheticatio, ad role-based authorizatio of HIEN users to esure that privacy ad cofidetiality of a statewide system ca be implemeted ad sustaied. 6. Coecticut Health Iformatio Security & Privacy Iitiative (CT-HISPI) Coecticut has already doe a tremedous amout of work towards addressig privacy ad cofidetiality issues through CT-HISPI, a collaborative project that assessed how Coecticut s privacy ad security busiess practices ad policies will ifluece the exchage of electroic health iformatio. The iitiative was a three-phase project, headed by the Public Health Foudatio of Coecticut, that documeted the curret health iformatio security ad privacy eviromet i Coecticut, assessed variatios across busiess etities, idetified barriers to legitimate flow of electroic health iformatio, proposed solutios, ad developed a proposed pla of actio. The CT-HISPI group idetified the followig major categories of issues to be addressed i Coecticut to esure a secure ad private HIE i Coecticut 1 ad helped iform our recommedatios. 1 Please see Coecticut HISPI origial documetatio for more detail: Privacy ad Security Solutios for Iteroperable Health Iformatio Exchage, Coecticut Health Iformatio Security ad Privacy Iitiative, Deliverable #6: Implemetatio Pla Report developed by the Public Health Foudatio of Coecticut, Ic. ad the Coecticut Ceter for Primary Care. 50 C O N N E C T I C U T S T A T E H E A L T H I T P L A N

55 I V. C R I T I C A L S U C C E S S F A C T O R S Idetity: the lack of provider ad patiet idetity maagemet. Autheticatio: the lack of trust mechaisms i digital trasactios. Authorizatio: lack of uiform authorizatio to release PHI, ad a iability to verify digital authorizatio across eterprises. Access Cotrol: the lack of uiformity of local access cotrol decisios. Physical Security: the lack of stadards for sharig data. Exchage Protocols ad Stadards: the lack of guidelies for secodary uses of data, a icosistet defiitio of HIPAA s miimum ecessary disclosure requiremet, lack of stadards for iteroperability, ad icosistet iformatio exchage policies. Data Itegrity/Autheticatio: the lack of trust mechaisms for accuracy of data. Audit, Digital Sigature: the icosistet policies for breaches of Persoal Health Iformatio (PHI). Corporate Policies ad Practices: the logitudial view is ot available ad the curret paper culture is widespread. State ad Federal Laws, Regulatios, ad Practices: the legal status of a RHIO, ad curret federal ad state laws. Guidace ad Lessos Leared 1. Coectig for Health s Commo Framework Coectig for Health s Commo Framework is a set of sevetee mutually-reiforcig techical documets ad specificatios, testig iterfaces, privacy ad security policies, ad model cotract laguage ( idex.html). The Commo Framework outlies ie core priciples that orgaizatios watig to participate i health iformatio exchage should adopt to esure private ad secure iformatio exchage. These ie priciples iclude: Opeess ad Trasparecy There should be a geeral policy of opeess about developmets, practices, ad policies with respect to persoal data. Idividuals should be able to kow what iformatio exists about them, the purpose of its use, who ca access ad use it, ad where it resides. Purpose Specificatio ad Miimizatio The purposes for which persoal data are collected should be specified at the time of collectio, ad the subsequet use should be limited to those purposes or others that are specified o each occasio of chage of purpose. Collectio Limitatio Persoal health iformatio should oly be collected for specified purposes, should be obtaied by lawful ad fair meas ad, where possible, with the kowledge or coset of the data subject. C O N N E C T I C U T S T A T E H E A L T H I T P L A N 51

56 I V. C R I T I C A L S U C C E S S F A C T O R S Use Limitatio Persoal data should ot be disclosed, made available, or otherwise used for purposes other tha those specified. Idividual Participatio ad Cotrol Idividuals should cotrol access to their persoal iformatio. Data Itegrity ad Quality All persoal data collected should be relevat to the purposes for which they are to be used ad should be accurate, complete, ad curret. Security Safeguards ad Cotrol Persoal data should be protected by reasoable security safeguards agaist such risks as loss or uauthorized access, destructio, use, modificatio, or disclosure. Accoutability ad Oversight Etities i cotrol of persoal health data must be held accoutable for implemetig these iformatio practices. Remedies Legal ad fiacial remedies must exist to address ay security breaches or privacy violatios. 2. HIPAA ad the Role of the America Recovery ad Reivestmet Act Federal law recogizes the importace of maitaiig the privacy ad security of health iformatio, as evideced by the Health Isurace Portability ad Accoutability Act (HIPAA) eacted i This Act directed the U.S. Departmet of Health ad Huma Services (DHHS) to develop federal privacy ad security regulatios related to health iformatio. DHHS issued the HIPAA Privacy Rule i 2000, regulatig how covered etities use ad disclose protected health iformatio, ad the Security Rule i 2003, requirig that covered etities safeguard electroic forms of protected health iformatio agaist ay reasoably aticipated risks. The America Recovery ad Reivestmet Act (ARRA) of 2009 maitais ad expads the curret HIPAA patiet health iformatio privacy ad security protectios, especially as patiet health iformatio is electroically trasferred through health IT systems. The ARRA ameds HIPAA to protect patiet health iformatio with the followig key provisios: applies the HIPAA rules directly to busiess associates ad other o-hipaa covered etities for the electroic exchage of patiet health iformatio; o-covered etities, such as RHIOs are ow required to have busiess associate agreemets with covered etities; allows patiets to pay out-of-pocket for a healthcare service ad request o-disclosure of the redered service; authorizes icreased civil moetary pealties for HIPAA violatios; defies which actios costitute a breach (icludig some iadvertet disclosures); requires a accoutig of disclosures to a patiet upo request; imposes restrictios o certai sales ad marketig of protected health iformatio; grats authority to state attoreys geeral to eforce HIPAA. 52 C O N N E C T I C U T S T A T E H E A L T H I T P L A N

57 I V. C R I T I C A L S U C C E S S F A C T O R S The Secretary of the DHHS, as well as other relevat agecies, will be providig details through the regulatory rule-makig process o the expaded privacy ad security requiremets. Uless otherwise specified, the privacy provisios become effective o February 17, C. Cosumer Advocacy Itroductio Give the potetial for cosumer support or cosumer fear ad mistrust, the CT State RHIO eeds to place high priority o egagig people early ad ofte i plaig the developmet of the CT State RHIO ad the CT State HIEN. Cosumers ad cosumer advocacy orgaizatios will provide iput ad advice o the developmet of the products affectig their healthcare ad persoal health iformatio. The potetial for oppositio ad failure is greatly reduced if a eviromet of trust ad collaboratio is created by the CT State RHIO leadership ad staff. Cosumers will similarly be importat facilitators i promotig the CT State RHIO ad HIEN as itegral to the Coecticut healthcare system. Policymakers ad the state legislature will expect that CT State RHIO leadership, healthcare stakeholders ad cosumers are i cocert regardig the value of health IT/HIE. Policy chages ad fiacig will oly be successful ad esure the logevity of state RHIO activities with this coordiated ad cohesive approach. Coecticut Eviromet ad Stakeholder Perspective Coecticut has a broad etwork of orgaizatios workig to improve the health ad socioecoomic status of populatios, may of which have a history as beig disefrachised or vulerable. Some of the orgaizatios have a primary focus o cosumer advocacy for example, the Coecticut Ceters for Idepedet Livig has cosumer advocacy as a core fuctio of the orgaizatio. Other orgaizatios have a secodary focus o cosumer advocacy, such as Coecticut s etwork of federally qualified health ceters (FQHCs) which icludes the provisio of quality healthcare to the uderserved ad uisured. While advocacy may ot be a primary fuctio of these orgaizatios, they ofte egage i advocacy as a meas to accomplish their primary goal. I additio, sigificat efforts i both the o-profit ad state govermet sectors have bee made to address the advocacy eeds of the broader cosumer populatio. For example, the Coecticut Health Policy Project Cosumer Health Actio Network ad the Coecticut Departmet of Cosumer Protectio both focus o empowerig cosumers through advocacy ad educatio. There is a varied history of collaboratio betwee state govermet ad ot-for-profit cosumer orgaizatios which ca be stregtheed to esure the success of the CT State RHIO ad HIEN. I Coecticut today, there are o orgaizatios which specifically focus o egagig cosumers regardig health IT/HIE. However, give the spectrum of govermetal ad ot-for-profit orgaizatios with advocacy as their primary or secodary fuctio, there are ample opportuities for the CT State RHIO to act as a coveer ad orgaizer of these cosumer experts to esure adequate cosumer ivolvemet ad buy-i. C O N N E C T I C U T S T A T E H E A L T H I T P L A N 53

58 I V. C R I T I C A L S U C C E S S F A C T O R S Guidace ad Lessos Leared 1. Cosumer Iput Cosumers ad cosumer represetatio orgaizatios are as eager to discuss their desire for health IT/HIE to make improvemets i quality of care ad overall health as they are to reveal their fears ad cocers. Cosumers should be cosistetly ad proactively egaged relative to their perspectives o health IT/HIE. Their cocers should be addressed ad the perceived beefits of health IT/HIE should be promoted. Patiet cocers iclude: Privacy ad cofidetiality of persoal health iformatio; Lack of uderstadig of how health IT/HIE works; Icomplete or iaccurate persoal health iformatio; Overall protectio ad safety of persoal health iformatio; Access to iformatio by uauthorized users (such as payers or employers). While privacy ad cofidetiality issues are still major cocers, there is substatial awareess of the potetial beefits of health IT/HIE. Perceived beefits of health IT/HIE by cosumers iclude: Readily available healthcare iformatio for cosumers ad their providers; More complete ad accurate healthcare iformatio; Availability of complex iformatio that the cosumer might ot otherwise be able to uderstad; Easier access to healthcare through e-visits, telehealth ad telemedicie; Streamlied patiet visits by automatig data collectio ad eligibility screeig. All of these issues suggest that cosumers ad/or cosumer advocacy groups should represet the eeds of the cosumers ad special iterest groups as the CT State HIEN is developed. 2. Cosumer Access to Their Persoal Health Iformatio Patiet access to their health iformatio is a key cosumer value for health IT/HIE. The ability of cosumers to view their health records ad add appropriate cotet is a importat service offerig of the HIEN. Beyod persoal health records, other olie cotet ca be made available to educate ad iform cosumers. Fially, the HIEN may support direct patiet commuicatio with their physicias or other healthcare professioals. 3. Iformatio Dissemiatio The CT State RHIO must esure that relevat iformatio is cosistetly made available to cosumers ad cosumer advocacy groups i order to promote trust ad uderstadig relative to RHIO activities. This ca be accomplished by developig tools ad approaches for sharig iformatio ad by developig appropriate messagig cotet. Examples iclude: 54 C O N N E C T I C U T S T A T E H E A L T H I T P L A N

59 I V. C R I T I C A L S U C C E S S F A C T O R S Presetig iformatio at cosumer orgaizatio aual meetigs; Holdig ope forums for cosumers or their represetative orgaizatios; Developig prit materials for distributio; Workig closely with cosumer orgaizatios to itegrate messages ito their ogoig commuicatio with cosumers; ad Develop broad based public relatios campaigs layig the foudatio of what this work is ad why it is importat. D. Educatio ad Outreach Itroductio Patiets are icreasigly see as active participats i their ow healthcare, ad health iformatio exchage acceptace will be a importat compoet of cosumer-directed care ad self-maagemet of chroic diseases. For patiets, educatio ad awareess of how HIE will help improve their healthcare ad quality of life are key cosideratios for their support of health IT/HIE ad The Pla. With healthcare professioals, there is sigificat apprehesio associated with the impact health IT/HIE will have o job resposibilities, cliical workflow, costs, ad retur o ivestmet. Give that the kowledge base of stakeholders will chage over time, a staged ad icremetal approach will eed to be developed which addresses basic iformatio eeds, immediate cocers, pilot HIE project implemetatio ad more sophisticated iformatio as the CT State HIEN matures. Coecticut Eviromet Specific educatio ad outreach programs are occurrig across Coecticut. Hospitals, commuity cliics ad health systems implemetig health IT/HIE have developed veues for icreasig the uderstadig of their iitiatives, traiig of staff ad the likelihood of acceptace ad adoptio. Below are examples of the may projects curretly uderway withi Coecticut: Safety.Net is a grat supported group of Commuity Health Ceters, FQHCs ad Academic Medical Practice Ceters as well as the Ethel Doaghue Traslatig Research ito Practice Ceter at the Uiversity of Coecticut Health Ceter who are focusig o developig a Health Iformatio Techology Implemetatio pla. A large part of this effort revolves aroud educatio of the various stakeholders regardig the beefits of health IT ad HIE ad developig a commo framework ad pathway to success. The Coecticut Istitute for Cliical ad Traslatioal Sciece (CICATS) is a cosortium of the Uiversity of Coecticut Health Ceter, UCo Storrs, Hartford Hospital, St. Fracis Hospital, Hospital for Special Care, Hospital of Cetral Coecticut, Coecticut Childre s Medical Ceter ad several commuity research orgaizatios such as the Hispaic Health Coucil ad BEACON. CICATS is focused o traslatig research ito practice ad has a goal of effective implemetatio of health IT/HIE withi the parterig orgaizatios for the C O N N E C T I C U T S T A T E H E A L T H I T P L A N 55

60 I V. C R I T I C A L S U C C E S S F A C T O R S purpose of improvig the quality ad efficiecy of healthcare. There is a dedicated biomedical iformatics group that supports these efforts. The Uiversity of Coecticut Medical ad Detal Schools teach the use of health IT i a umber of ways ragig from the use of hadheld computers for iformatio retrieval at the poit-of-care, to the use of a mock electroic medical record i the third year of the family medicie rotatio to simulate the beefits ad issues that oe faces whe usig health IT i the care of patiets. UCoect ( is a ewly formed process desiged to egage a wide rage of stakeholders (legislators, patiet advocates, isurers, busiess, academic ad cliical leaders) i ogoig coversatios ad debate regardig importat healthcare related issues. A key effort is their discussio regardig the merits of establishig a regioal public utility model for chroic care coordiatio. This model would rely heavily o the use of health IT/HIE by cliicias i private practices, isurers, patiets ad state health agecies. The iaugural evet at the ed of March 2009 drew a audiece of more tha fifty leaders to a iteractive webcast evet. The Uiversity of Coecticut Departmet of Computer Sciece ad Egieerig curretly offers a ew elective i biomedical iformatics to its udergraduate studets. I additio several graduate studets have chose to focus their thesis ad study o topics of iterest i cliical iformatics. There are umerous cotiuig medical, ursig ad professioal educatio traiig evets withi the state throughout the year, may of them focusig o the adoptio of electroic medical records. May of these evets have opeigs for ivited expert speakers ad would be iterested i havig a forum o health IT/HIE. There are olie teachig opportuities through academic health ceters or their affiliated hospitals via CME courses ad certificates. Yale Medical School has a Departmet of Biomedical Iformatics with a well developed traiig program for cliicias ad researchers supported by a Natioal Library of Medicie grat. The departmet has several faculty i biomedical iformatics with expertise i the effective developmet of cliical decisio support tools, a critical factor for effective use of health IT/HIE. There are ursig schools at regioal UCo campuses ad commuity colleges that have some traiig i the use of health IT/HIE for cliical care, but would be ope to adoptig stadardized curricular offerigs if made available to them with regards to health IT/HIE adoptio ad effective use i the home, hospital or office based settigs. The Uiversity of Coecticut School of Pharmacy, as part of the PharmD curriculum, provides e-health/health IT traiig courses. The UCo School of Pharmacy coducts umerous cotiuig educatio courses each year that iclude e-health ad health IT topics for licesed practicig pharmacists. Most recetly, the CT Pharmacists Associatio has offered cotiuig educatio meetigs i collaboratio with the CT Medical Society. 56 C O N N E C T I C U T S T A T E H E A L T H I T P L A N

61 I V. C R I T I C A L S U C C E S S F A C T O R S Guidace ad Lessos Leared 1. Messagig for Cliical ad No-Cliical Healthcare Professioals While adoptio of health IT ad HIE capacity is geerally supported, factors such as retur o ivestmet prevail ad cotiue to be barriers i Coecticut. Messagig should iclude both basic educatio as well as a focus o issues related to retur o ivestmet. Other messages may iclude: Basic health IT/HIE cocepts ad laguage; How health IT/HIE will support a more efficiet system of care; How health IT/HIE will support better patiet care; ad The types of support ecessary to aid the trasitio to a HIE eabled healthcare system. More sophisticated messagig may iclude: Techical descriptios of how the system works; Appropriate applicatio of state ad atioal privacy ad security laws, guidelies or stadards; Methods of evaluatig efficacy of the system ad cotiuous quality improvemet; Patiet access to iformatio; Aticipated impact o professioal liability; ad Evidece-based research regardig the impact o patiet care. 2. Traiig ad Educatio for Healthcare Professioals I additio to geeral messagig which icreases awareess ad acceptace, cliical ad o-cliical healthcare professioals workig throughout Coecticut will require varyig levels of techical kowledge to accomplish their work i a HIE eabled eviromet. I order to accomplish this, Coecticut will eed to develop, through parterships ad alliaces with educators ad employers, a educatio ad traiig ifrastructure. Such a ifrastructure should be developed with sesitivity to the types of professioals workig i the health system ad their role i supportig health IT/HIE. For example: Computer literacy Workig i a health IT/HIE eviromet will require that staff supportig health IT/HIE work are proficiet with basic computer skills. Oly with this baselie computer literacy will staff be successful i adaptig to the ecessary admiistrative requiremets ad chages i work resposibilities. Techical traiig Users will require basic kowledge of the system ad a uderstadig of how to maximize the utility of health IT ad HIE i their day-to-day work. This techical traiig will ot be a oe size fits all model. Some professioals will require traiig to accomplish basic tasks such as data iput ad viewig while others will require more sophisticated traiig such as for complex queries, evaluatio ad moitorig. C O N N E C T I C U T S T A T E H E A L T H I T P L A N 57

62 I V. C R I T I C A L S U C C E S S F A C T O R S HIE Certificate Courses Higher level admiistrators, both cliical ad o-cliical, may require a more i-depth uderstadig of health IT/HIE i order to accomplish their fuctios ad support their professioal level staff i their orgaizatios. HIE Research Methodologies The use of health IT/HIE to advace cliical ad other research will expad greatly as the statewide health IT/HIE capacity develops. Researchers will eed to adapt their curret research methods to more effectively use the HIEN to advace their work. Advaced Degrees As the HIEN ifrastructure cotiues to mature there may be a icreasig eed for advaced degrees i the health IT/HIE professios such as health iformatics. The developmet or expasio of baccalaureate, masters ad PhD degree programs should be cosidered. 3. Messagig for Patiets ad Geeral Public Patiets ad the geeral public have a heighteed awareess ad cocer regardig security ad privacy issues. These types of issues are exacerbated withi populatios that have traditioally bee margialized ad should explicitly be addressed. Basic messagig should iclude: Basic health IT/HIE cocepts ad laguage; Uderstadig ad support for participatio i a health IT/HIE eabled healthcare system (i.e., system is same as curret paper system, yet more secure ad efficiet); Targeted or tailored messages for specific audieces or purposes. For example: secodary use of data, metal health data, childre with special health eeds, ad HIE Pilot projects. More sophisticated messagig may iclude: Patiet access to iformatio; Security features; Potetial risks ad beefits; Quality cotrol/audit fuctios; Protectios ad limits of atioal ad state laws. I additio, patiets should be explicitly ivolved i the developmet of the educatio materials as this has bee show to support the developmet of the most compellig messagig cotet. 4. Parterships ad Facilitators May stakeholders are workig i a variety of ways to provide traiig, educatio ad capacity buildig to healthcare professioals ad cosumers. While they may ot be workig i a coordiated fashio, or focusig o health IT/HIE cotet, they do provide the foudatio for the type of educatioal ad traiig ifrastructure ecessary to icrease awareess ad acceptace of health IT/HIE. These stakeholders ad orgaizatios are very adept at creatig messages ad curriculum aimed at reachig their target audieces. It will be itegral to the success of ay educatio ad outreach iitiatives to coordiate ad egage existig educatioal ad capacity buildig activities. 58 C O N N E C T I C U T S T A T E H E A L T H I T P L A N

63 I V. C R I T I C A L S U C C E S S F A C T O R S 5. ARRA Ifluece While questios still remai regardig the itet, timig ad mechaisms for the distributio of fuds through the America Recovery ad Reivestmet Act (ARRA), there is laguage regardig educatio ad traiig. Specifically, fudig will be made available to higher educatio istitutios to itegrate health IT/HIE cotet ito curricula of healthcare professioals; to develop or expad curricula for health iformatics degree programs; ad to develop regioal extesio ceters to provide traiig ad techical assistace. While these resources will ot be eough to address all the educatio ad outreach eeds of Coecticut, they are importat compoets of a overall strategy. E. Quality Improvemet ad Populatio Health Maagemet Itroductio Healthcare costs cotiue to icrease more rapidly tha the rate of improvemet i quality of care. I respose, there has bee a shift i thikig ad practice that healthcare reimbursemet should reward high-quality, high-value care rather tha just quatity of care. With this icreased emphasis o trasparecy i quality, health IT/HIE applicatios ca be powerful tools. Quality-based activities utilizig health IT/HIE applicatios iclude: collectig ad reportig data o stadardized quality idicators; embeddig relevat expert kowledge ito decisio support systems ad other tools to improve practice aroud those idicators; ad providig healthcare cosumers with eeded iformatio to aid them i choosig healthcare providers ad services based o value. A essetial requiremet uderlyig this approach is the measuremet of quality i a accurate, efficiet ad cosistet maer all while miimizig reportig burde. Health IT/HIE ca support these efforts by providig improvemets i accessibility, collectio, measuremet, ad reportig of healthcare data. I this sectio, quality improvemet ad populatio health maagemet iitiatives uderway i Coecticut are reviewed ad federal guidace usig health IT ad health iformatio exchage for improvig quality, populatio health maagemet ad public health oversight activities is described. Coecticut Eviromet ad Stakeholder Perspective There are several quality ad populatio health maagemet iitiatives curretly uderway i Coecticut aimed at drivig higher quality of care through more comprehesive cliical iformatio at the poit of care, measurig ad reportig quality with a miimum of burde o providers, ad the aggregatio of health iformatio for the purpose of public reportig of quality. These iclude: 1. Bridges to Excellece Bridges to Excellece (BTE) is a o-profit orgaizatio whose purpose is to desig ad offer icetives to physicias ad hospitals for demostratig that they have implemeted comprehesive solutios i the maagemet of patiets ad the delivery of safe, timely, effective, efficiet, equitable ad patiet-cetered care. The icetives promote the adoptio of health IT ad delivery system reegieerig as key meas to improvig the quality of patiet care as well as its efficiecy ad effectiveess. C O N N E C T I C U T S T A T E H E A L T H I T P L A N 59

64 I V. C R I T I C A L S U C C E S S F A C T O R S 2. The Coecticut Health Quality Cooperative The Coecticut Health Quality Cooperative (CHQC) is a collaborative effort betwee ehealthcoecticut ad Qualidigm to collect, aalyze ad report healthcare quality data to assist Coecticut physicias to cotiuously improve the quality of care they provide. Uder the goverace of ehealthcoecticut, this multi-year project brigs together providers, Coecticut health plas, Qualidigm, ad Bridges to Excellece to collaborate o program desig, developmet ad implemetatio. 3. The Equity ad Quality Project (EQUAL) The Coecticut Health Foudatio recetly awarded a two year grat to Qualidigm to improve the maagemet of patiets with diabetes. The project fuds the itroductio of health IT to select physicia practices that care for a culturally diverse patiet populatio. The physicias ad their staff will be traied i the techiques of teachig patiet self maagemet to stregthe the physicia/patiet partership to promote improved diabetes maagemet. 4. Medicaid Trasformatio Grat I 2007, the Coecticut Departmet of Social Services was awarded a Medicaid Trasformatio Grat (MTG) from the federal govermet to desig ad pilot test a program to implemet a statewide health iformatio exchage ad e-prescribig system for the state s Medicaid recipiets. The Coecticut Pharmacists Associatio ad the Uiversity of Coecticut School of Pharmacy are developig a subproject to improve Medicaid recipiets medicatio profiles, called the Comprehesive Active Medicatio Profile (CAMP). 5. Middlesex Professioal Services I 2007, Middlesex Professioal Services (MPS), a idepedet practice associatio, received a $1 millio grat from the Physicias Foudatio to desig ad implemet a Cliical Itegratio Project (CIP). The goal of the CIP is to improve care for patiets with selected diseases by supportig physicia adherece to cliical guidelies ad physicia performace feedback with the implemetatio of health IT/HIE. Physicias are recogized for improved patiet care through pay-for-performace (P4P) programs. Guidace ad Lessos Leared 1. AHIC Quality Workgroup Quality Visio Roadmap The America Health Iformatio Commuity (AHIC) Quality Workgroup has put forth a roadmap for the Uited States to move toward the goal of re-aligig healthcare aroud value by usig health IT/HIE. This icludes aligig icetives with patiet cetric quality improvemet over time ad across care settigs, creatig policies for data stewardship (e.g. the maagig ad storig of aggregated patiet data), addressig privacy ad security cocers for data exchage, ad determiig data collectio ad aggregatio strategies to support public reportig of cliical 60 C O N N E C T I C U T S T A T E H E A L T H I T P L A N

65 I V. C R I T I C A L S U C C E S S F A C T O R S care. I additio, there are several ifrastructure compoets that eed to be addressed icludig stadardizatio of data elemets, cosesus aroud a set of quality metrics, improvig codig sets, the ability to match patiet records ad providers, ad the use of cliical decisio support capabilities. 2. AHIC Populatio Health ad Cliical Care Coectios Workgroup The AHIC Populatio Health ad Cliical Care Coectios (PHCCC) workgroup has put forth recommedatios to facilitate the flow of reliable health iformatio amog populatio health ad cliical care systems ecessary to protect ad improve the public s health. The documet describes a workig divisio of populatio health ito five categories: 1) Public Health Surveillace ad Respose, 2) Health Status ad Disease Moitorig, 3) Health Commuicatios ad Educatio, 4) Populatio-based Cliical Care, ad 5) Populatio-based Research. Accepted recommedatios cover the areas of bi-directioal commuicatio, a busiess case for icludig public health as a itegral parter i health iformatio techology activities, a authoritative website for stadards, public health support for HITSP, public health system certificatio, ad itegratio with HIEs. I additio, the AHIC PHCCC recommeded buildig ifrastructure for public health agecies ad laboratories ad the developmet of program metrics to assess the ability of public health iformatio systems to iteroperate ad support public health ivestigatio ad respose. 3. America Medical Iformatics Associatio (AMIA) AMIA idetified the secodary use of persoal health iformatio as a critical issue for the cotiued widespread adoptio of health iformatio techology. They are curretly developig a atioal framework for the secodary use of health data that icludes a robust ifrastructure of policies, stadards, ad best practices eeded to facilitate the broad ad repeated collectio, storage, aggregatio, likage, ad trasmissio of health data with appropriate protectios for legitimate secodary use. F. Fuctioal Requiremets, Techology Stadards ad Techical Architecture Itroductio Oe of the most compellig justificatios for the formatio of the Office of the Natioal Coordiator ad the various health IT/HIE projects that have bee iitiated at the federal level is the eed to develop a comprehesive ad cosistet techical strategy for promotig iteroperability. The Office of the Natioal Coordiator, the AHIC, ad the AHRQ Natioal Resource Ceter for Health IT are positioed as key resources to support state health IT/HIE efforts. Guidace developed by these orgaizatios ad iitiatives will cotiue the substatial mometum that is uderway ad will support the evetual realizatio of the goals of the Natiowide Health Iformatio Network. C O N N E C T I C U T S T A T E H E A L T H I T P L A N 61

66 I V. C R I T I C A L S U C C E S S F A C T O R S However, eve with a soud strategy for health IT/HIE o a atioal level ad the widespread proliferatio of certified health IT systems, the realizatio of a CT State HIEN is a log way from beig realized. The complexity of the healthcare system ad just as importatly, the legacy of the healthcare system s use of proprietary health IT systems ad strategies suggests that a phased ad deliberate approach over a umber of years will be required. Oe of the most critical requiremets recommeded is that the state adopt ad promote a sigle, comprehesive techical architecture ad phased implemetatio strategy of that techical architecture. Coupled with this requiremet is the uderstadig that it is urealistic to expect that the existig health IT/HIE ifrastructure will be replaced by ew, stadardized systems. The cost ad resource requiremets to support such a trasformatio are prohibitive. The Pla provides the level of techical guidace, techical architecture ad strategy that is ecessary to eable iteroperability withi the existig techical ifrastructure of the Coecticut healthcare system. The Pla provides for a phased approach to implemetatio over its five year duratio which utilizes existig techical ifrastructure ad huma resources while providig the icremetal techology to itegrate that ifrastructure, trai ad educate existig resources, ad provide additioal resources as required to develop a fully iteroperable statewide health iformatio exchage etwork. Coecticut Eviromet ad Stakeholder Perspective Like all states, Coecticut healthcare providers ad supportig orgaizatios are ot prepared to support health iformatio exchage without sigificat ivestmet ad upgrades to existig ifrastructure. The existig healthcare techology ifrastructure cosists of outdated or proprietary legacy systems that do ot meet the fuctioal requiremets ad techology stadards ecessary to support iteroperability. Specific challeges for Coecticut healthcare system stakeholders idetified through the course of this project iclude: Approximately 10 to 15% of Coecticut physicia practices have EMR systems, which severely limits the ability to implemet a statewide health IT/HIE strategy. Public health systems have bee developed for specific programs without cosideratio for iteroperability or reusable modules. Existig HIE systems have bee developed for specific projects ad do ot have the capacity or techical capabilities for broader applicatio or scalability. While hospitals have udertake the developmet of EHR systems, these efforts have bee coducted i relative isolatio, without cosideratio for broader, itra-hospital health iformatio exchage requiremets. Icosistet data quality, particularly with patiet demographics, will limit the ability to esure timely ad accurate patiet idetificatio ad correlatio of patiet data. Icosistet use of stadard code sets ad use of proprietary code sets will limit cosistet ad accurate use of cliical data. Icosistet use of messagig stadards will limit the ability of health IT systems to share data. 62 C O N N E C T I C U T S T A T E H E A L T H I T P L A N

67 I V. C R I T I C A L S U C C E S S F A C T O R S While the challeges to developig health iformatio exchage capacity across the state are substatial, there are iitiatives uderway that may be leveraged. Qualified projects will be itegrated ito the broader HIEN strategy described i this chapter. Examples of existig techical ifrastructure developmet projects iclude: 1. ChimeNET ChimeNet provides ed-to-ed maaged solutios for etwork ifrastructures focusig o wide area etworks ad data etwork security. ChimeNet provides etwork ifrastructure, services, etwork moitorig ad techical support, web hostig, project maagemet ad disaster recovery services. 2. Coecticut Health Iformatio Network (CHIN) CHIN is a partership betwee the Uiversity of Coecticut, Akaza Research, Ic., ad Coecticut s state agecies to develop a federated computer etwork likig diverse databases across agecies. CHIN collects ad maages cliical data for healthcare research ad oversight purposes. 3. Departmet of Iformatio Techology (DOIT) DOIT provides iformatio techology IT services ad solutios to various Coecticut state agecies, effectively aligig busiess ad techology objectives through collaboratio, i order to provide the most cost-effective etwork ad systems ifrastructure ad techical support. 4. EMR Adoptio Projects There are a umber of orgaizatios such as idepedet physicia associatios that are purchasig, implemetig ad maagig certified electroic medical records systems for their member physicias. 5. Hospital-based EHR projects May hospitals across the state have developed electroic health records systems that aggregate data from legacy cliical systems such as lab, radiology, pathology, patiet registratio, admissio/discharge/trasfer (ADT), ad other cliical systems. Most hospitals make this data available to a etwork of physicias through a portal gateway, while others have projects uderway that will itegrate their EHR systems with certified EMR systems that are implemeted withi the hospital s affiliate physicia offices. 6. Office of Health Care Access (OHCA) Through its Discharge Database, OHCA collects hospital utilizatio data o all discharges from the acute care hospitals withi Coecticut. This database icludes demographic, utilizatio, cliical, charge, payer ad provider iformatio. C O N N E C T I C U T S T A T E H E A L T H I T P L A N 63

68 I V. C R I T I C A L S U C C E S S F A C T O R S Guidace ad Lessos Leared The key compoets that support the defiitio of a comprehesive health iformatio exchage techical architecture are listed below. Brief summaries are provided i the followig sectios with a more detailed review i Appedix G. Detailed specificatios for use cases eabled by health iformatio exchage which demostrate the potetial of HIE to cliicias ad other healthcare professioals. Fuctioal requiremets of the HIEN that represet the modular buildig blocks of the etwork ad how it will support the use cases. Techology stadards to promote data security, accoutability ad iteroperability. Certificatio stadards for health IT systems to promote cosistet workflow, accoutability ad iteroperability. Statewide techical architecture which demostrates a comprehesive techical framework ad strategy for the phased developmet ad implemetatio of the Statewide Health Iformatio Exchage Network. 1. Use Cases Like ay system developmet effort, the customer s expectatios for how they will use the system ad how the system will provide value must be defied before systems, databases, etworks ad software applicatios are developed. I order to harmoize recommedatios with atioal efforts ad to reuse the work doe by others, The Pla will adopt ad promote the use cases defied by the America Health Iformatio Commuity (AHIC). These use cases describe HIE eabled cliical practices ad their associated beefits. The AHIC use cases are reviewed i more detail i Appedix J. 2. Fuctioal Requiremets The health iformatio exchage compoets required to eable the use cases of the HIE ca be viewed as a series of iteroperable, modular buildig blocks or fuctioal requiremets. These buildig blocks iclude those that are implemeted ad cotrolled by ed users, ad those that are implemeted ad cotrolled by the HIEN. They ca be icremetally developed (or procured), implemeted ad maitaied to support the ogoig ad evolvig iformatio exchage eeds of the Coecticut healthcare commuity. The buildig blocks will be used by multiple use cases. The use case priorities reflect the strategy to implemet the most eeded, ad most reused buildig blocks i iitial projects. Fuctioal requiremets are described i more detail i Appedix G. The followig diagram (Figure 13) provides a visual represetatio of the fuctioal model of the CT State health iformatio exchage etwork. 64 C O N N E C T I C U T S T A T E H E A L T H I T P L A N

69 I V. C R I T I C A L S U C C E S S F A C T O R S FIGURE 13 Statewide Health Iformatio Exchage Network 3. Techology Stadards Widely accepted health iformatio techology ad health iformatio exchage stadards ad protocols serve as key eablers of health iformatio exchage as evisioed by the Office of the Natioal Coordiator for Health Iformatio Techology. The Pla groups the idetified stadards ito the followig broad categories i order to promote uderstadig of key cocepts. A more detailed review of techology stadards is provided i Appedix G. Policy Priciples are iteded to guide orgaizatios with the high level cocepts regardig how, whe ad why patiet data is shared across the health iformatio exchage etwork. These priciples suggest a overarchig framework for data sharig that must be agreed to by all participatig orgaizatios. C O N N E C T I C U T S T A T E H E A L T H I T P L A N 65

70 I V. C R I T I C A L S U C C E S S F A C T O R S Techology Priciples are iteded to provide guidace to optimize the developmet of the HIE ad maximize the potetial uses of the HIE for the broad healthcare commuity. The techology priciples take ito cosideratio the limitatios ad capabilities of the existig health IT eviromet ad support a phased developmet of HIE related capabilities. Techical Stadards focus o the physical trasmissio ad receipt of health data ad its trasport betwee participatig systems. This icludes message formats ad reliable, secure message trasport. Sematic Stadards focus o esurig shared meaig betwee sedig ad receivig parters i.e. esurig that the meaig of what was set is cosistet with the uderstadig of what was received. Sematic stadards focus o medical termiology that ca be refereced cosistetly by all parties. Process Stadards focus o higher-order workflow cocepts that make data sharig a richer ad more valuable experiece. Work i this area tries to uderstad how shared health data supports the specific activities ad workflow of the orgaizatios that use it ad the itegratio of health data ito the work settig. 4. Certificatio Stadards The potetial for iteroperability across the atio s healthcare system will ot be possible without the stadardizatio of cliical applicatios across all healthcare settigs that will evetually share data. The Certificatio Commissio for Healthcare Iformatio Techology (CCHIT) was formed i 2004 with the sole missio of acceleratig the adoptio of robust, iteroperable health iformatio techology by creatig a credible, efficiet certificatio process. The goals of product certificatio are to reduce the risks of ivestig i health IT, to facilitate iteroperability of health IT products, to ehace the availability of adoptio icetives ad to esure the privacy ad security of persoal health iformatio. The certificatio process provided by CCHIT is outlied i Figure 14 below. FIGURE 14 Gather Data Develop Criteria Develop Ispectio Process Pilot Test Fialize Lauch Certificatio Program Stakeholder priorities Availability i vedor marketplace Practicality of certificatio Release for public commet Criteria for ext year w Fuctioality w Security/ reliability w Iteroperability Roadmap for w Next year + 1 w Next year + 2 Release for public commet Methods w Self-attestatio w Juror observatio w Laboratory testig Test scearios Step-by-step test scripts Release for public commet Call for participats Radom selectio for each market segmet Coduct pilot Release for public commet w Results w Fial criteria w Fial test process ad scripts w Certificatio hadbook ad agreemet Respod to commets Fial adjustmets Commissio review ad approve Publish fial materials 66 C O N N E C T I C U T S T A T E H E A L T H I T P L A N

71 I V. C R I T I C A L S U C C E S S F A C T O R S Curretly, the CCHIT has certificatio programs established for ambulatory EHR systems ad ipatiet EHR systems. Future plas call for certificatio programs for emergecy departmet systems, health iformatio exchage etworks, persoal health records, ad stadaloe e-prescribig (see for more details). 5. Techical Architecture The Pla recogizes the eed for Coecticut to commit to a specific techical architecture to esure that techology based strategy ad decisio makig are i aligmet with the log-term goals of the pla. The Pla follows federal guidace as outlied i Appedix G that suggests that the techical architecture must provide a pathway for the existig techical ifrastructure (etworks, databases, systems ad software applicatios) to evolve to a stadards-based ifrastructure. A key cosideratio for this approach is the otio of modularity. The followig sectios describe the modular approach to the developmet of the HIEN from the perspectives of each of the three domais. Fially, the techical architecture of the Statewide HIEN is preseted. a. Federated versus Cetralized Data Repositories Direct patiet care providers such as hospitals geerally favor a federated model of health iformatio exchage, where data remais withi the origiatig provider s eviromet ad is pulled as required whe a query o a patiet s iformatio is iitiated from the HIEN. I cotrast, the cetralized model is whe patiet data are pushed from a healthcare provider system to a cetral repository where it is stored util eeded. The cetralized model is more typical of quality-based iitiatives as well as state health agecy systems where cost cocers outweigh less striget patiet privacy ad cofidetiality requiremets that are more relevat i the direct patiet care eviromet. The pros ad cos of each model are detailed below: Federated model w Pros Owership of data is retaied by origiatig provider. Origiatig provider retais cotrol over data access ad data quality. Provides a comprehesive dataset more closely resemblig data from origiatig systems. Provides real-time or ear real-time access to patiet data. Appropriate for larger healthcare providers (hospitals). w Cos Requires a elaborate patiet locator service. Requires more complex itegratio with source systems. Requires a robust etwork ad software applicatio architecture that ca retrieve ad preset patiet records i a timely maer. Requires a highly available etwork to esure cosistet access to remote data. Icreased operatios ad maiteace costs. Not appropriate for smaller providers, due to cost ad complexity. C O N N E C T I C U T S T A T E H E A L T H I T P L A N 67

72 I V. C R I T I C A L S U C C E S S F A C T O R S Cetralized model w Pros Less costly ifrastructure compared to federated model. Less costly maagemet, operatios, ad techical support. Faster respose times for patiet queries. More appropriate for healthcare oversight activities. w Cos Commiglig of data may compromise accoutability. May raise cocers of patiet privacy advocates. Updated records at poit of care may ot be captured by the cetralized system o a timely basis. The techical architecture described below recommeds a federated model for the Direct Patiet Care domai ad a cetralized model for the State Health Agecies ad Healthcare System Moitorig ad Evaluatio domais. b. Modular Framework The followig three sectios (c, d ad e) describe the techical architectures that are appropriate for the three domais described i The Pla (Direct Patiet Care, State Health Agecies ad Healthcare System Moitorig ad Evaluatio). While the techical architectures of each domai merit specific cosideratio give the varyig health iformatio exchage requiremets of each domai, there are modules that are cosistet across domais. As various HIEN projects begi to evolve across the state, the leadership of these projects must realize that the more these projects develop techical architectures that are cosistet with that of other HIENs, the stroger the ability of existig ad subsequet HIEN projects to iterface with their HIEN ad ultimately develop a statewide health iformatio exchage capability. Commo modules of the HIENs that The Pla will promote iclude: Auditig ad Accoutability (all domais) Provides structure ad resources to esure privacy, cofidetiality, security ad overall accoutability of patiet data. Data Aalysis ad Reportig (State Health Agecies ad Healthcare System Moitorig ad Evaluatio) - The value of the State Health Agecies HIEN ad the Healthcare System Moitorig ad Evaluatio HIEN will be directly tied to the amout, quality ad timeliess of iformatio that is made available to participatig healthcare providers, oversight agecies, ad state health agecy staff. Data Traslatio Service (all domais) Provides data validatio ad ormalizatio services. Specific fuctios may iclude: w Message validatio performig prelimiary verificatio that a iboud message meets baselie requiremets. w Message format traslatio traslatig messages from the format of the sedig etity to the required format of the receivig etity. 68 C O N N E C T I C U T S T A T E H E A L T H I T P L A N

73 I V. C R I T I C A L S U C C E S S F A C T O R S w De-idetificatio removig persoal idetifiers to elimiate the possibility of uiquely idetifyig a patiet. w Pseudoymizatio cocealig a patiet s idetity while still trackig specific activity. w Code set traslatio traslatig code sets from a source format to the format required by the receivig etity. Data Trasmissio Service (all domais) Maages the trasmissio ad receipt of trasactios betwee itegrated systems. Meta-Data Maagemet Service (State Health Agecies ad Healthcare System Moitorig ad Evaluatio) The State Health Agecies HIEN ad the Healthcare System Moitorig ad Evaluatio HIEN will cotai a meta-data maagemet service that will provide summary data for idetifiable (State Health Agecies domai) ad de-idetified (Healthcare System Moitorig ad Evaluatio HIEN) patiet populatios relative to quality, program maagemet, cliet maagemet, healthcare research, ad moitorig ad evaluatio eeds. Orgaizatio ad User Profiles (all domais) Provides orgaizatioal ad user hierarchy ad accoutability structure for the system. Specific fuctios may iclude: w Access privileges. w Role-based security structure. w Provider credetialig ad autheticatio. System Maagemet (all domais) Provides fuctios for system admiistrators to maitai the cosistet operatio, availability ad itegrity of the system. These fuctios may iclude: w Orgaizatio ad user erollmet. w Access privileges maagemet. w Iterface maagemet. w Operatios moitorig ad cotrol. w Master patiet idex maagemet. w Patiet matchig maagemet. c. Direct Patiet Care Domai Techical Architecture The Direct Patiet Care domai health iformatio exchage etwork, as show i Figure 15, cotais a comprehesive electroic health record system at its core. The electroic health record cotais complete logitudial health iformatio for the patiets that are stored withi that HIEN. The HIEN cotais complex system iterfaces that itercoect legacy cliical systems, acillary service providers, provider EMR systems, ad other HIENs. Give the comprehesiveess of the data maaged by this HIEN, security ad accoutability requiremets to esure patiet privacy ad cofidetiality are paramout. C O N N E C T I C U T S T A T E H E A L T H I T P L A N 69

74 I V. C R I T I C A L S U C C E S S F A C T O R S FIGURE 15 Direct Patiet Care EHR ad HIE Other Data Exchage Iterfaces State Health Agecy HIEN Health System Moitorig & Evaluatio HIEN Other HIENs Provider 1 Orgaizatio & User Profiles System Iterfaces Eterprise Master Patiet Idex Provider 2 Data Delivery & Presetatio Data Traslatio Service System Maagemet Provider EHR Modules Data Routig Service Auditig ad Accoutability Certified EMR Platform Direct Patiet Care HIEN Private labs Direct Patiet Care HIEN Registatio & ADT Lab Radiology Pathology e-prescribig Trascriptio Legacy systems Descriptios of the various modules cotaied withi the Direct Patiet Care domai Techical Architecture as illustrated i Figure 15 are provided below. Data Delivery & Presetatio Orgaizes data received from multiple sources to a cosistet uified view ad delivers the data to the receivig etity based o delivery specificatios provided by the receivig etity. EHR Modules Provide structured access to cliical iformatio for cliical system users. Modules may iclude: w Cliical documetatio. w Medicatio history. w Cliical guidelies. w Patiet demographics. w Cotiuity of care record. w Patiet flow sheets. w Discharge summaries. w Patiet iquiry. w Lab/Radiology/pathology orders ad results. w Pharmacy orders. w Radiology images. w Medical history. 70 C O N N E C T I C U T S T A T E H E A L T H I T P L A N

75 I V. C R I T I C A L S U C C E S S F A C T O R S System Iterfaces Supports data exchage from cliical legacy systems that may ot meet stadards-based data exchage requiremets. Eterprise Master Patiet Idex Provides a sigle patiet idetifier for each participatig patiet withi the regioal HIEN. Certified EMR Platform The direct patiet care HIEN will support stadards-based itegratio with oe or more certified EMR platforms. EMR fuctioality may iclude: w Cliical documetatio. w Iterfaces to acillary services providers. w Charge capture. eprescribig iterface. w Decisio support. Private lab iterface. w Dictatio ad trascriptio. w Order etry ad delivery. w eprescribig. w Results capture ad reportig. w Paper documet scaig ad storage. Commo modules The techical architecture described i this sectio uses a modular approach to systems developmet. Modules that are commo to multiple HIEN domais are represeted collectively i sectio b above. Commo modules that are part of the Direct Patiet Care HIEN iclude: w Orgaizatio ad user profiles. w Data traslatio service. w Data trasmissio service. w System maagemet. w Auditig ad accoutability. d. State Health Agecies Domai Techical Architecture The State Health Agecies HIEN, as show i Figure 16, cotais a program profile ad metadata maagemet service at its core. The program profile module provides referece iformatio of the program registry systems that are supported by the HIEN. This module esures that the HIEN ca exchage data with each itegrated program registry. The meta-data maagemet service maages data stored i the program registries ad provides a itegrated view of the data for public health oversight ad program maagemet fuctios. Data stored i the State Health Agecies domai typically origiates at the poit-of-care by healthcare providers withi the Direct Patiet Care domai. Data are set to the State Health Agecies HIEN ad routed to the appropriate program registries as required. Persoal health iformatio maaged by the State Health Agecies HIEN is typically less comprehesive tha data maaged by the direct patiet care domai HIEN ad is geerally program specific. Persoal health iformatio stored i this domai may be made available to other domais as required. C O N N E C T I C U T S T A T E H E A L T H I T P L A N 71

76 I V. C R I T I C A L S U C C E S S F A C T O R S FIGURE 16 State Health Agecies Program Registries ad HIEN Providers Orgaizatio & User Profiles Data Traslatio Service Meta Data Maagemet Service Hospitals Program Profiles Data Routig Service Master Cliet/ Patiet Idex Quality Other Data Exchage Iterfaces System Maagemet Auditig ad Accoutability Coecticut State Health Agecies HIEN Data Aalysis ad Reportig Program Registry 1 Program Registry 2 Program Registry State Health Agecy 1 Public Health Domai State Health Agecy Federal Agecies Descriptios of the various modules cotaied withi the State Health Agecies domai Techical Architecture as illustrated i figure 16 are provided below. Program Profile All itegrated program registries will be represeted i the program registry profile. This profile will specify the level of itegratio icludig data exchage techical specificatios. Master Cliet/Patiet Idex Cliets/patiets will be defied i the state health agecies HIEN with a predetermied set of demographic data elemets that will be used for cosistet idetificatio as eeded for program maagemet purposes. De-idetified cliet/patiet idetifiers will be used for populatio-based data aalysis ad reportig. Commo modules The techical architecture described i this sectio uses a modular approach to systems developmet. Modules that are commo to multiple HIEN domais are represeted collectively i sectio b above. Commo modules iclude: w Auditig ad accoutability. w Data aalysis ad reportig (State Health Agecies HIEN ad Moitorig & Evaluatio HIEN). w Data traslatio service. 72 C O N N E C T I C U T S T A T E H E A L T H I T P L A N

77 I V. C R I T I C A L S U C C E S S F A C T O R S w Data trasmissio service. w Meta data maagemet service (State Health Agecies HIEN ad Moitorig & Evaluatio HIEN). w Orgaizatio ad user profiles. w System maagemet. e. Healthcare System Moitorig & Evaluatio Domai Techical Architecture The Healthcare System Moitorig & Evaluatio domai HIEN, as show i Figure 17, cotais a program profile, meta-data maagemet service ad data warehouse at its core. The program profile module provides referece iformatio of the moitorig ad evaluatio programs that are supported by the HIEN. This module esures that the HIEN ca effectively maage data for each itegrated moitorig ad evaluatio program. The data warehouse cotais de-idetified cliet/patiet data that have bee collected from the other domais. The meta-data maagemet service maages data stored i the data warehouse ad provides a itegrated view of the data for moitorig ad evaluatio fuctios. Data stored i the moitorig ad evaluatio domai typically origiates at the poit-of-care by healthcare providers withi the Direct Patiet Care domai or withi program registries i the State Health Agecies domai. Data are set to the moitorig ad evaluatio HIEN from the other domai HIENs ad stored i the data warehouse as required. FIGURE 17 Health System Moitorig & Evaluatio HIEN Providers Orgaizatio & User Profiles Data Traslatio Service Meta Data Maagemet Service Hospitals Program Profiles Data Routig Service Data Qarehouse State Health Agecies Other Data Exchage Iterfaces System Maagemet Auditig ad Accoutability Health System Moitorig & Evaluatio HIEN Data Aalysis ad Reportig Quality Program 1 Quality Program 2 Quality Program Populatio-Based Health Orgaizatios State Health Agecies Moitorig & Evaluatio Payers C O N N E C T I C U T S T A T E H E A L T H I T P L A N 73

78 I V. C R I T I C A L S U C C E S S F A C T O R S Descriptios of the various modules cotaied withi the Moitorig & Evaluatio domai Techical Architecture as illustrated i Figure 17 are provided below. Program Profiles All itegrated moitorig ad evaluatio programs will be represeted i the program profiles module. This profile will specify the level of itegratio icludig data exchage techical specificatios. Data Warehouse All data received ad maaged by the Moitorig ad Evaluatio HIEN will be stored withi the data warehouse. The data warehouse is a highly sophisticated database egie that provides log-term access to a large amout of de-idetified health iformatio collected from healthcare providers across the state. Commo modules The techical architecture described i this sectio uses a modular approach to systems developmet. Modules that are commo to multiple HIEN domais are represeted collectively i sectio b above. Commo modules iclude: w Auditig ad accoutability. w Data aalysis ad reportig (State Health Agecies HIEN ad Moitorig ad Evaluatio HIEN). w Data traslatio service. w Data trasmissio service w Meta data maagemet service (State Health Agecies HIEN ad Moitorig ad Evaluatio HIEN). w Orgaizatio ad user profiles. w System maagemet. f. Coecticut State Health Iformatio Exchage Techical Architecture The Pla recommeds that for statewide health iformatio exchage to be possible, a statewide HEIN is required. The complexities of data exchage ad maagemet of the required fuctioality at a state-level suggests the eed for a statewide health iformatio exchage utility that will maage these capabilities i a ogoig maer. Core features of the CT State HIEN, as show i Figure 18, iclude a statewide master patiet idex, meta-data maagemet, patiet iquiry, record locator ad retrieval, data delivery ad presetatio ad persoal health record. The statewide HIEN will iclude edge servers ad data routig services that will itegrate each participatig regioal HIEN with the CT State HIEN. 74 C O N N E C T I C U T S T A T E H E A L T H I T P L A N

79 I V. C R I T I C A L S U C C E S S F A C T O R S FIGURE 18 CT State Health Iformatio Exchage Network Orgaizatio & user profiles Persoal health record Meta data maagemet service Statewide master patiet Idex System maagemet Data delivery & presetatio Patiet Iquiry Patiet matchig Recordlocator ad retrieval service Auditig ad accoutability Statewide Health Iformatio Exchage Services Edge server Data routig service Data routig service Edge server Data routig service State health agecies HIE Health system moitorig & evaluatio HIE Other HIE Providers Orgaizatio & user profiles Data traslatio service Meta data maagemet service Providers Orgaizatio & user profiles Data traslatio service Meta data maagemet service Provider 1 Provider 2 Orgaizatio & User Profiles Data delivery ad presetatio System iterfaces Data traslatio service Eterprise master patiet idex System Maagemet Hospitals Quality Program profile System maagemet Data routig service Auditig ad accoutability Master cliet/ patiet idex Data aalysis ad reportig Hospitals State health agecies Program profile System maagemet Data routig service Auditig ad accoutability Data warehouse Data aalysis ad reportig Provider EHR Modules Data routig service Auditig ad accoutability DPH program registry 1 DPH program registry 2 DPH program registry Quality program 1 Quality program 2 Quality program Trascriptio eprescribig Private labs Practice mgmt. Lab Registratio & ADT Radiology Pathology State health agecy 1 State health agecy Federal agecies State health agecies Provider Payers Direct Patiet Care 1.. HIENs CT State Health Agecies HIEN CT Healthcare System Moitorig & Evaluatio HIEN Descriptios of the various modules cotaied withi the CT State HIEN Techical Architecture as illustrated i Figure 18 are provided below. Data Delivery ad Presetatio Orgaizes data received from multiple sources to a cosistet uified view ad delivers the data to the receivig etity based o delivery specificatios provided by the receivig etity. Meta-data Maagemet Service Orgaizes ad maages refereces to cliical data stored at direct patiet care domai ad state health agecies domai edge servers. Patiet Iquiry Provides healthcare providers the ability to search for patiet iformatio from across the itegrated healthcare system. C O N N E C T I C U T S T A T E H E A L T H I T P L A N 75

80 I V. C R I T I C A L S U C C E S S F A C T O R S Patiet Matchig Service Esures that patiets are cosistetly ad accurately idetified as healthcare trasactios are received from multiple healthcare providers. This service typically uses demographic data ad complex matchig algorithms. Persoal Health Records Provides direct access for cosumers to a summary represetatio of their persoal health iformatio gathered across multiple poits of care. Cosumers may also have the ability to eter iformatio ito their PHR ad commuicate with healthcare providers. Record Locator ad Retrieval Service I cojuctio with the patiet iquiry ad meta-data maagemet services, this module idetifies the locatio of patiet records ad retrieves them for presetatio to the user. Statewide Master Patiet Idex Provides a sigle patiet idetifier for each participatig patiet withi the statewide HIE. Commo modules The techical architecture described i this sectio uses a modular approach to systems developmet. Modules that are commo to multiple HIEN domais are represeted collectively i sectio b above. Commo modules iclude: w w w Auditig ad accoutability. Orgaizatio ad user profiles. System maagemet. G. Fudig ad Fiacial Sustaiability Itroductio Start-up fudig ad a model for log-term sustaiable reveue represet two of most sigificat barriers to HIEN developmet (AHRQ, 2006; ehealth Iitiative, 2008; Adler-Milstei et al., 2008). Capital fudig requiremets iclude obtaiig resources to develop a goverig body (a RHIO) for the oversight ad coordiatio of HIE activities, as well as the developmet of techical ifrastructure supportig data exchage. The most viable approach to assurig successful start-up ad sustaiability is to maximize the fudig resources available ad to match fudig sources to the orgaizatioal eeds. Typically, iitial fudig largely comes from federal ad state govermets, as well as foudatio grats ad private sector fiacig (Natioal Goverors Associatio, 2009). However, whe grats ed, project mometum is ofte lost as fudig streams evaporate. This uderscores the importace that log-term sustaiable fudig be addressed early i the project lifecycle. A variety of methods are used to fiace the ogoig operatios of health IT/HIE iitiatives. Fiacig models i support of ogoig operatios iclude membership, trasactio ad usage fees as examples. Most stakeholders ad experts have oted that health IT/HIE costs vary tremedously ad deped o a umber of factors, such as the types of trasactios supported by the exchage, the willigess of stakeholders to provide i-kid cotributios, ad the availability of state, federal, or foudatio grats to accomplish specific scopes of work related to establishig health IT/HIE capacity. 76 C O N N E C T I C U T S T A T E H E A L T H I T P L A N

81 I V. C R I T I C A L S U C C E S S F A C T O R S Coecticut Eviromet ad Stakeholder Perspective The curret perspective of Coecticut stakeholders is that while health IT/HIE ifrastructure must be fuded by state ad federal fudig streams, there is o expectatio that the Coecticut State Legislature will direct ay sigificat amout of fudig to health IT/HIE iitiatives give the state s fiscal crisis. Recet evets at the federal level, however, with the passage of the America Recovery ad Reivestmet Act, idicate that sigificat fudig will be available i the ear-term. While the state may ot fud substatial health IT/HIE developmet efforts, there is a strog expectatio that the state should demostrate a strog commitmet to the project by fudig the operatios of the CT State RHIO (i.e. staffig). I Coecticut there are several early stage activities uderway to fud health iformatio exchage projects. For example, several hospitals are developig EHR capacity by subsidizig the cost of EMR adoptio for local physicias i their area. Similarly, some larger IPAs have plas to fud ad develop hosted EMR applicatios i support of their member physicias. I additio, several payers i the state are curretly payig a aual fee to participate i the ehealthcoecticut Heath Quality Cooperative. These activities demostrate at least prelimiary fiacial commitmets by Coecticut stakeholders to health IT/HIE. Guidace ad lessos leared 1. Fiacial Models to Support Goverace ad Ifrastructure Developmet There are umerous fudig optios available to states ad regioal health iformatio orgaizatios i their efforts to develop goverace/oversight capacity as well as techical ifrastructure to support HIE. While fee structures are sigificatly importat strategies for the ogoig sustaiability of HIENs, very differet approaches must be take to develop the etwork ad provide adequate goverace ad guidace. These typically take the form of grats from federal, state ad private istitutios. More recetly, as health IT/HIE projects have gaied mometum ad viability o a atioal level, states have developed fiacig models to support health IT/HIE adoptio. a. Federal Fudig The Uited States Departmet of HHS is drivig the developmet of HIE o a atioal level to improve patiet care ad icrease efficiecy across the healthcare system. Through several of its agecies, HHS is also providig fudig to orgaizatios egaged i buildig ad testig health IT systems ad health iformatio exchage etworks. These federal fudig sources iclude: The Office of the Natioal Coordiator for Health Iformatio Techology (ONC). Agecy for Healthcare Research ad Quality (AHRQ). Ceters for Medicaid ad Medicare Services (CMS). Health Resources ad Services Admiistratio (HRSA). The Office of Rural Health Policy (ORHP). C O N N E C T I C U T S T A T E H E A L T H I T P L A N 77

82 I V. C R I T I C A L S U C C E S S F A C T O R S The America Recovery ad Reivestmet Act icludes sigificat fudig for promotig EHR adoptio ad acceleratig costructio of the NHIN. These fuds will be fueled through the aforemetioed federal agecies ad a sigificat amout will be distributed at the state level. These opportuities will be discussed i more detail at the ed of this sectio. b. State Fudig The followig table describes the start-up ad operatioal fiacig of several operatioal RHIOs (from the Natioal Goverors Associatio 2009 Report to the State Alliace for e-health: Public Goverace Models for a Sustaiable Health Iformatio Exchage Idustry). Orgaizatio Start-Up Fiacig Ogoig Reveue Source Delaware Health Iformatio Network (DHIN) HealthBridge (Ohio) Ilad Northwest Health Services (INHS) (Washigto) $5M: State of DE ($2M i year oe, $3M year two) $2M: Match from private sector (year oe) $4.7M: AHRQ SRD grat $1.75M: Loas from commuity stakeholders Iitial ivestmets from two hospital systems (itegrated with hospital iformatio systems) Private stakeholders/data providers charged o volume of trasactios. Costs are allocated as a percetage of total costs to the state authority. Per-member per-moth (PMPM) fee for health plas. Subscriptio fee for value-added services to be implemeted. 85 percet from hospitals/health systems as mothly subscriptio fees. 15 percet from premium services (trascriptio ad billig). Total: $3.7M per year. Implemetatio cotracts. Service fees. Idiaa Health Iformatio Exchage (IHIE) Ivestmets from federal ad state govermets, Regestrief Istitute, ehealth Iitiative, ad Athem BCBS $1.8M: Biocrossroads $2M: Fairbaks Foudatio per trasactio fee for distributio of results by labs (cliical messagig, volume-based slidig scale). 30 PMPM by isurace compaies for quality reports. No fees for cliicia access to data. MedAllies/ Hudso Valley HIE (HVHIE) (New York) $1M: Stakeholder ivestmets (2001) $100K: ehealth Iitiative, Coectig Commuities for Better Health $235K: IBM/ONC grat (2005) $5M: HealNY (state grat) $12.1M: HealNY for PH reportig (2008) Tacoic IPA cotracts with MedAllies for operatios of the HVHIE. $400/moth subscriptio fee for EMR implemetatio, support, ad access to electroic orders (lab order etry; half offset by grats util pay for performace icetives begi). $72K per hospital iterface maiteace. Vermot Iformatio Techology Leaders (VITL) $2.1M: VT Legislature $2M: VT Departmet of Health $1M: Commuity stakeholders Legislatively madated fudig from VT busiesses ad members of the public at percet of medical claims. Projected to raise $32M over seve years. 78 C O N N E C T I C U T S T A T E H E A L T H I T P L A N

83 I V. C R I T I C A L S U C C E S S F A C T O R S There are umerous examples ad a wide variety of models of state promoted ad sposored health IT adoptio across the coutry. States have commissioed studies to support the developmet of strategic plas to implemet ad sustai statewide electroic health iformatio exchage (e.g., Wyomig, Delaware ad Coecticut), issued executive orders supportig techology adoptio ad/or edorsig specific techology iitiatives (e.g., Wiscosi ad Arizoa) ad directly fuded health IT adoptio programs through the disbursemet of grats ad loas withi their states (e.g., New York). Miesota has goe so far as to madate the adoptio of electroic health records by all healthcare providers i the state by Summaries of may of the state-based efforts are beig compiled ad tracked by a variety of orgaizatios across the coutry. Oe example of the summaries is the HIMSS State Dashboard beig maitaied by the Health Iformatio ad Maagemet Systems Society (HIMSS) (see for updates). A secod example is the State-level Health Iformatio Exchage Cosesus Project, which is workig to idetify the emergig characteristics ad distict roles ad cotributios of state-level HIEs uder the auspices of the Foudatio of Research ad Educatio withi the America Health Iformatio Maagemet Associatio (AHIMA see for further details). c. Private Fudig Private fudig of statewide health IT/HIE efforts have bee successful i certai markets where ecoomies of scale are domiat. Private health plas have show a kee iterest i fudig start-up costs of HIEs ad the adoptio of EHRs across multiple commuities. Private foudatios serve as a additioal fudig stream for start-up operatios or the developmet of pilot programs. Several foudatios exist withi Coecticut that could be istrumetal i supportig the start-up operatios or developmet of pilot programs. The most likely of these foudatios would be the groupig of isurace coversio foudatios ad the Coecticut Health Foudatio. Examples of fudig efforts by private health plas ad foudatios iclude: CalRHIO: Califoria s statewide RHIO was iitially capitalized by six of the state s largest health plas; each cotributed $1 millio. CalRHIO has subsequetly received fuds from federal agecies ad Califoria-based private foudatios. Blue Cross/Blue Shield: w Arkasas Blue Cross ad Blue Shield has spearheaded the Advaced Health Iformatio Network, a olie system givig physicias ad hospitals access to e-medical records ad claims databases, while pilotig low-cost wireless EHRs for small practices. w Blue Cross ad Blue Shield of Massachusetts has provided $50 millio to fud the Massachusetts ehealth Collaborative for 3 years ( This pilot project is providig EHRs software, hardware, istallatio, traiig, support to virtually all physicias i three Massachusetts commuities. C O N N E C T I C U T S T A T E H E A L T H I T P L A N 79

84 I V. C R I T I C A L S U C C E S S F A C T O R S w Blue Cross ad Blue Shield of Nebraska is the mai payer leadig the Nebraska Health Iformatio Iitiative (NeHII), a statewide system that will serve virtually every Nebraska by buildig o the existig telemedicie etwork. ( d. Stark ad Ati-Kickback Exemptios I August 2006, the DHHS published rules that provide a exceptio uder the physicia self-referral prohibitio law (Stark), as well as safe harbor uder the ati-kickback act (AKA), for the doatio of iteroperable EHR techology to physicias ad other health care practitioers or etities. There are several examples of this practice today, particularly where hospitals are promotig specific EHR platforms to their affiliated practitioers. To qualify, EHR software is deemed to be iteroperable if CCHIT has certified the software o more tha 12 moths prior to the date it is provided to the physicia orgaizatio. Uderstadig that the 12 moth restrictio may be prohibitive, CCHIT has modified their certificatio practices to esure that vedors with certified systems ca maitai the less tha 12 moth certificatio requiremets of the HHS rules. 2. Reveue Models Supportig Sustaiability Fudig to support the CT State RHIO ad its services o a ogoig basis ca be obtaied through a variety of membership ad/or usage fees. While ot ecessarily a viable optio i the ear-term, as the etwork-based ifrastructure matures ad service offerigs expad, a membership fee structure by orgaizatio type may be a practical cosideratio. Below are several of the models that ca be evaluated to support this effort. a. Maiteace Fees for Hosted Services Certai stadardized services may ultimately be hosted ad supported by a cetralized health iformatio exchage ifrastructure. Hosted services may be of value to certai users if they do ot have to maitai support staff i-house. I this model, stakeholders may pay to support shared services for all users of the HIEN. Membership fees may be equal or tiered o the basis of some factor, such as size of populatio or use. b. Trasactio Based Fees A admiistrative trasactio processig project is the most likely cadidate for this type of model i the short-term; however, this model may be cosidered for other large volume value-based services. Ulike the membership fee model, depedece o this reveue source requires iitial capital ivestmets to build the ifrastructure ad capabilities for calculatig trasactio fees. c. Service Fees - Access fees may be cosidered for services that are ot trasactio-based, particularly if their value is evidet to users. d. Traiig Fees - Assumig that a core team with a broad techical kowledge base of health IT/HIE is developed over the iitiative s first couple of years, packagig that kowledge ito a set of program offerigs may provide a reveue opportuity. For example, the Massachusetts ehealth Collaborative has recetly spu off a for-profit subsidiary, the MAeHC Professioal Services Corp., to provide services across the coutry as a way of raisig capital to expad its pilot program across Massachusetts. 80 C O N N E C T I C U T S T A T E H E A L T H I T P L A N

85 I V. C R I T I C A L S U C C E S S F A C T O R S e. Secodary Data Use - Some propoets of HIE have promoted the de-idetificatio ad repackagig of large health datasets as a reveue source. Optios may exist to evaluate the value of such data to large pharmaceutical compaies, medical device makers ad academic or cliical research istitutios. Give the sometimes cotroversial ad sesitive ature of usig secodary data ad the eed for maitaiig cofidetiality of a idividual s health iformatio, the goverace body of the RHIO should hold ogoig reviews ad discussios before icorporatig this service as part of the HIEN fuctios. 3. Role of ARRA The fudig for health IT/HIE icluded i the America Recovery ad Reivestmet Act (ARRA) presets a opportuity to jump start a ambitious effort i Coecticut to implemet the recommedatios i The Pla. The Health Iformatio Techology for Ecoomic Developmet Act (HITECH) withi the ARRA appropriates a miimum of $20 billio to be used over the ext six years to ecourage health IT ad HIE adoptio. Withi the legislatio, Cogress ackowledges the likely eed for additioal fudig ad requires HHS through the Office of the Natioal Coordiator to report aually o the level of resources that are eeded. I order for Coecticut to take full advatage of the opportuities i HITECH ad a umber of other sources of fudig for health IT withi the ARRA, there is a eed for coordiated activity amog a broad rage of stakeholders, the formatio ad state desigatio of a etity to take the lead o health iformatio exchage, ad a active role by the State of Coecticut to provide leadership ad matchig fuds that may be required to brig the maximum level of fudig to Coecticut. While the vast majority of the fudig available will be directed towards qualified providers who are meaigful users of EHRs, the requiremets of these programs are desiged to advace a broader strategy to stregthe health iformatio exchage at the state level ad to improve the quality of care. I order to meet the defiitio of meaigful use, providers must adopt certified EHR systems that iclude electroic prescribig fuctioality ad the capacity to exchage electroic health iformatio; i additio, they must submit iformatio o cliical quality o measures selected by the Secretary of HHS. The requiremet that these EHRs ca exchage data implies the existece of a ifrastructure that facilitates this exchage. It appears that the success of Coecticut providers i successfully obtaiig ARRA/HITECH fudig will be tied to the availability of a health IT/HIE ifrastructure that, as documeted i The Pla, curretly does ot exist beyod a small umber programs of limited capacity. Coecticut is ot aloe i this situatio. To facilitate the developmet of this HIE capacity, the ARRA ecourages a strog role for the state ad the developmet of statewide etities similar to the oe proposed i The Pla. Withi the $2 billio of ifrastructure fudig available through ONC, a sigificat portio, estimated at a miimum of $300 millio, is likely to be allocated to support health IT/HIE projects desiged ad operated i accordace with emergig federal C O N N E C T I C U T S T A T E H E A L T H I T P L A N 81

86 I V. C R I T I C A L S U C C E S S F A C T O R S stadards ad policies. The ARRA outlies a clear role for states ad state desigated etities to receive ad maage these fuds. Sice these HIE dollars i the form of HIE Plaig ad Implemetatio Grats are expected to be amog the fuds most quickly made available, it is importat for the state, i coordiatio with iterested stakeholders, to be vigilat i trackig the developmet of this fudig program ad i beig prepared to meet the orgaizatioal requiremets that will be ecessary to obtai these fuds. Withi HITECH, i additio to the HIE Plaig ad Implemetatio Grats, there are additioal sources of fudig that will be made available through ONC ad other agecies primarily withi HHS. These programs are outlied i detail i Appedix M, ad fall ito the followig categories: a. Grats to States to Establish EHR Loa Fuds to Facilitate EHR Adoptio These fuds ad others the state may develop through bods ad collaboratios with private parties uder the HITECH umbrella are desiged to provide up-frot fuds for the capital fudig eeded for EHR implemetatio prior to the availability of the fudig through Medicare ad Medicaid (see below). The commitmet of the Medicare ad Medicaid fudig may make EHR projects better prospects for private capital fudig as icreased Medicaid/Medicare reimbursemets to physicias will support repaymet of capital loas. The loa fud required to be established through HITECH ca be a vehicle for this fudig to physicias to promote EHR adoptio. The state should begi plaig for or idetifyig existig mechaisms that will meet the requiremets to obtai federal loa fudig ad pursue these fudig opportuities whe they become available. b. Regioal Extesio Ceters Techical assistace to healthcare providers will be provided through regioal extesio ceters which are desigated through ARRA as o-profit orgaizatios ad will be established through a federal grat program. Uified proposals coordiated amog iterested orgaizatios to meet the eeds of the broadest rage of providers will have a stroger chace for success tha may idividual proposals that will compete for these limited fuds. The state or the CT State RHIO ca play a role i ecouragig this type of coordiatio. c. Workforce Traiig Grats There are two types of workforce traiig grats available i the ARRA through the ONC: oe to improve the teachig of health IT/HIE withi medical schools ad a secod to trai a larger health iformatics workforce. State uiversities will be eligible, i additio to private istitutios, to apply for these fuds. Agai, coordiatio amog likely applicats for this fudig may be useful i stregtheig the potetial for this fudig to come to Coecticut. d. Medicaid ad Medicaid Icetive Paymets While the Medicare portio of the EHR fudig i the ARRA does ot require sigificat state activity, the Medicaid dollars will be admiistered through state s Medicaid programs. States will be required to provide 10 percet of the costs of admiisterig the program; 100 percet of the dollars expeded to providers will be paid by the federal Medicaid program. As detailed i Appedix M, Medicare fudig will be made available to providers ad hospitals for five years begiig i 2011 to ecourage the meaigful use of electroic health records 82 C O N N E C T I C U T S T A T E H E A L T H I T P L A N

87 I V. C R I T I C A L S U C C E S S F A C T O R S (see above for discussio of meaigful use). Up to a total of $44,000 per physicia ad fudig allocated o a formula for hospitals begiig with a base of $2 millio will be available. There is a 10 percet bous for physicias who practice i health professioal shortage areas (HPSAs) ad there are additioal icetives for critical access hospitals. Disicetives for those ot complyig begi i I additio, there are paymets to state Medicaid plas that implemet programs to ecourage the adoptio ad use of certified EHRs. States receive 100 percet of paymet outlays ad 90 percet of admiistratio costs. The programs may make paymets to providers up to $63,750 towards adoptio, implemetatio, upgrades, maiteace, ad operatio of certified EHRs. Paymets to hospitals are similar to those uder Medicare. The Medicaid program expads fudig to pediatricias, FQHCs, rural health cliics ad physicia assistats practicig i rural health cliics. States are required to make the assessmets of compliace. Providers must choose betwee health IT fudig through Medicare or Medicaid. e. Other Fudig Sources for Health IT ad HIE withi ARRA: Outside HITECH fudig, the State of Coecticut may receive sigificat amouts of discretioary fudig to meet the requiremets of the broader stimulus package. However, it is likely that the availability of the desigated fudig through HITECH will make it more difficult to obtai the highly competitive discretioary dollars. As the ARRA legislatio is iterpreted through the agecy rule makig process, other opportuities for health IT ad HIE fudig will emerge. Oe exists withi the Commerce Departmet, which is charged with workig with the Federal Commuicatios Commissio (FCC) to allocate at least $250 millio i grats to states, o-profits or other orgaizatios icludig broadbad providers to implemet the Broadbad Techology Opportuities program to ehace existig programs desiged to develop ad expad atioal broadbad service. This moey must be distributed by the ed of fiscal year Withi the ARRA s broader health fudig program, there is $1.5 billio i desigated fuds, to be disbursed through HRSA, for federally qualified health ceters (FQHCs) to improve their ifrastructure. These fuds ca be used for costructio, reovatio, equipmet ad acquisitio of health IT, i additio to the fudig available i HITECH. Details o fudig levels ad how the moey will be distributed are pedig from HRSA; a report to Cogress is required by mid-may. The ext steps of The Pla have bee defied withi the cotext of the critical success factors, the curret Coecticut healthcare health IT/HIE eviromet, federal fudig opportuities that are aticipated i the comig years through the ARRA ad other fudig sources, ad the ecoomic ad political climate of the State of Coecticut. I this sectio, the ext steps are structured so that they ca be accelerated or decelerated as opportuities are realized or roadblocks are ecoutered. C O N N E C T I C U T S T A T E H E A L T H I T P L A N 83

88 I V. C R I T I C A L S U C C E S S F A C T O R S 84 C O N N E C T I C U T S T A T E H E A L T H I T P L A N

89 V Recommedatios ad Next Steps A. Overview Figure 19 below provides a high level overview of how the trasformatio of the Coecticut healthcare system will be supported by The Pla. The potetial for the availability of statewide services, improved cliical care models, ad overall improvemets to the efficiecy ad effectiveess of the healthcare system as represeted i the top ad right sectio of the diagram will oly be possible if the other activities (CT State RHIO formatio, pilot projects ad the CT State HIEN) are completed ad sustaied. However, it is also importat to uderstad that icremetal beefits will be realized as the various pilot projects ad associated iitiatives are completed. FIGURE 19 C O N N E C T I C U T S T A T E H E A L T H I T P L A N 85

90 V. R E C O M M E N D A T I O N S A N D N E X T S T E P S The timelie i Figure 20 below represets key activities over the five year duratio of the pla. Note the color codes that are used to correlate the capabilities described i Figure 19 with the associated activities represeted i the timelie i figure 20. These activities will be described i more detail i the subsequet sectios. FIGURE 20 YEAR 1 YEAR 2 YEAR 3 YEAR 4 YEAR 5 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q RHIO Formatio CT State RHIO Ratified & Fuded CT State Health IT Pla Acceptace Leadership Developmet Ogoig CT State RHIO Operatios Legal & Policy Guidace Educatio & Outreach Programs Fudig & Sustaiability Developmet Promote Techical Architecture ad Strategy Pilot Project Fudig Obtaied Certificatio Templates Accepted (DPC, SHA, M&E Domais) Regioal Direct Patiet Care HIEN Implemetatios Regioal DPC HIEN Acceptace Moitorig & Eval. HIEN Implemetatio State Health Agecies HIEN Implemetatio M&E HIEN Acceptace State Agecies HIEN Acceptace Statewide HIEN Fudig Obtaied Statewide HIEN Desig / Vedor Selectio Statewide HIEN Developmet/Implemetatio 86 C O N N E C T I C U T S T A T E H E A L T H I T P L A N

91 V. R E C O M M E N D A T I O N S A N D N E X T S T E P S B. CT State RHIO Developmet ad Ogoig Resposibilities As previously discussed, the CT State RHIO represets the key leadership, maagemet ad techical resource for The Pla. The CT State RHIO will be resposible for substatial ogoig resposibilities that promote ad support the developmet of statewide HIE capabilities ad the trasformatio of the Coecticut healthcare system. 1. RHIO Formatio a. Bridge activity leadig to CT State RHIO Legislative Madate A iterim goverace structure is eeded to act o behalf of the state durig the trasitio from the actig RHIO (JSI) to the legislatively authorized CT State RHIO. This iterim authority will complete key activities to esure that mometum gaied over the past year is ot lost. Key activities will iclude: Implemetig legislatio supportig the formatio of the CT State RHIO ad its goverig body. Formalizig the missio ad role of the RHIO. Formalizig a process for the creatio ad staffig of the various subcommittees that will support the CT State RHIO as described below. Hirig a executive director ad a techical director as full-time CT State RHIO employees or cotracted third party vedors. Coordiatig HIE activity at a state level to take full advatage of the ARRA fudig opportuities. b. CT State RHIO Legislative Madate The legislative madate formig the CT State RHIO is the key activity to move The Pla forward. The legislative authority ad fudig to support RHIO staff ad other resources must be approved for The Pla to have legitimacy ad support. Key recommedatios: Iclude a broad defiitio of the orgaizatio s role i the legislatio; require the coveig ad coordiatig roles; do ot prohibit the techical operatios role. If a public-private collaborative is created as the CT State RHIO, establish the Departmet of Public Health as the liaiso/oversight agecy for that orgaizatio. Obtai fudig to support a full-time executive director ad a full-time techical director of the CT State RHIO for 5 years. Form the goverig body (board of directors or advisory committee), limitig membership to betwee 12 ad 15 members while esurig all healthcare costituets are adequately represeted. C O N N E C T I C U T S T A T E H E A L T H I T P L A N 87

92 V. R E C O M M E N D A T I O N S A N D N E X T S T E P S 2. Leadership Developmet a. Create CT State RHIO subcommittees as required to support The Pla icludig: Stadig Subcommittees w Executive ad Operatios & Goverace Subcommittees as required to support the ogoig operatios of the CT State RHIO (see chapter III, A). w A Fiace Subcommittee to pursue ad obtai capital fudig ad to develop ad implemet fiacial sustaiability models to support ogoig RHIO operatios (see sectio 3.f below). Ad-hoc Subcommittees w A Patiet Privacy ad Cofidetiality Subcommittee to formalize patiet privacy ad cofidetiality recommedatios (see sectio 3.a below). w A Legal Subcommittee that will review The Pla ad relevat state ad federal law, ad make recommedatios to esure that the CT State RHIO ad HIEN are properly aliged with state ad federal law (see sectio 3.a below). w A Cosumer Advocacy Subcommittee that will represet cosumer best iterests ad esure that commuicatios chaels betwee the CT State RHIO ad Coecticut cosumers are established ad maitaied (see sectio 3.b below). w A Educatio ad Outreach Subcommittee that will develop ad implemet a campaig to publicize the CT State RHIO ad The Pla, ad develop a ogoig program to educate stakeholders across the state (see sectio 3.c below). w A Quality Subcommittee that will to esure a sustaied commitmet to quality from strategic, policy ad project perspectives (see sectio 3.d below). w A Techical Subcommittee that will review ad approve the fuctioal requiremets, techology stadards ad techical architecture recommedatios of The Pla (see sectio 3.e below). b. Promote the developmet regioal RHIO leadership across the state withi Direct Patiet Care, Moitorig ad Evaluatio, ad State Health Agecies domais. Cosistetly share The Pla with all stakeholders across the state. Provide Educatio ad Outreach resources for regioal RHIO leadership developmet. Promote the ivolvemet of regioal RHIO leadership with CT State RHIO activities. Provide regioal RHIOs access to CT State RHIO resources i support of the developmet of policies, busiess practices ad techical ifrastructure. Promote aligmet of The Pla ad regioal RHIO efforts through project certificatio ad sposorship (see Sectio C, Pilot Projects, below). Provide fiacial assistace where practical through the coordiated pursuit of federal, state ad private fudig sources. 88 C O N N E C T I C U T S T A T E H E A L T H I T P L A N

93 V. R E C O M M E N D A T I O N S A N D N E X T S T E P S 3. Ogoig RHIO Operatios The CT State RHIO goverig body ad the various subcommittees will meet o a cosistet basis to maage The Pla ad all associated activities. Key activities iclude: a. Formalize Legal ad Policy Guidace for Statewide HIEN I cocert with the patiet privacy ad cofidetiality ad legal subcommittees, the CT State RHIO executive director ad techical director will propose to the goverig body, comprehesive legal ad policy guidace to set the foudatio for health iformatio exchage o a state level: Support health iformatio exchage for treatmet, paymet ad operatios purposes for HIPAA covered etities (otificatio of use model described i Chapter 4, Sectio B). Support health iformatio exchage for authorized secodary data uses as authorized by HIPAA (otificatio of use model described i Chapter 4, Sectio B). Establish a uiform statewide electroic patiet coset/authorizatio process for the exchage of highly sesitive persoal health iformatio. Establish uiform RHIO-wide iformatio exchage policies ad busiess agreemets icludig but ot limited to busiess associate agreemets (BAA). Establish a healthcare workforce idetify maagemet ad autheticatio system to esure accoutability ad appropriate use of the CT State HIEN. b. Cosumer Advocacy Healthcare cosumers will play a critical role i the developmet of, ad more importatly, the acceptace of the Coecticut HIEN. The CT State RHIO will develop a program for egagig cosumers, educatig them o state plas for health IT/HIE, solicitig their iput, ad providig ogoig educatio ad traiig to cosumers as required. Key aspects of the cosumer advocacy program iclude: Promote cosumer access to persoal health iformatio ad commuicate iformatio access cotrols ad accoutabilities. Commuicate CT State RHIO ad HIEN policies ad fuctioality to promote uderstadig ad acceptace. Ivolve cosumers i educatio ad outreach activities as required. c. Educatio & Outreach The CT State RHIO must take immediate ad sustaied steps to commuicate the state s commitmet to health IT/HIE. It is imperative that the CT State RHIO covey its legitimacy, capabilities ad plas to the healthcare commuity ad cosumers i a substatial ad sustaied maer. I cocert with the Educatio ad Outreach subcommittee, the CT State RHIO Executive Director will: C O N N E C T I C U T S T A T E H E A L T H I T P L A N 89

94 V. R E C O M M E N D A T I O N S A N D N E X T S T E P S Iitiate broad-based messages to the geeral commuity through all media chaels ad cosumer advocacy orgaizatios regardig plas, progress, value ad overall strategy. Formalize the CT State RHIO s relatioship with professioal orgaizatios icludig the Coecticut Hospital Associatio, the Coecticut State Medical Society, Idepedet Physicia Associatios ad state health agecies to establish chaels for commuicatios ad for submittig articles for publicatio. Develop commuicatios tools such as distributio lists, web sites ad ewsletters for issuig periodic commuicatios from the CT State RHIO to the healthcare commuity. As The Pla is fialized ad approved, schedule ad covee ope forum discussios i various healthcare settigs to review The Pla ad progress to date, ad to provide opportuity for iput ad discussio. As HIEN services evolve, formalize a program for CMEs, CEUs, admiistrator ad maagemet traiig, ad other structured educatioal programs. Develop parterships ad alliaces betwee health IT/HIE professioals, employers, educators, cosumer orgaizatios ad others to further the developmet of educatio ad traiig programs. d. Quality Improvemet ad Populatio Health Maagemet The CT State RHIO should keep iformed of emergig federal guidace regardig the use of health IT/HIE for quality improvemet iitiatives ad populatio health maagemet. Because improvig the quality of care of Coecticut s three millio residets is of the highest priority, quality improvemet ad populatio health maagemet recommedatios are made i the cotext of the other critical success factors. Recommeded ext steps iclude: Esure that proper legal ad admiistrative guidace is developed ad implemeted to eable the use of data to improve quality of care ad public health oversight. Educatio ad outreach programs must be developed to educate healthcare professioals, the public ad other stakeholders o the beefits of usig data for improvig quality. Look for specific opportuities to fud healthcare quality, populatio health maagemet ad public health oversight projects through state, federal ad private grats. Esure that the data collectio, traslatio, maagemet ad reportig capabilities of the HIEN are defied withi the cotext of quality. Promote a quality-based project i the Healthcare System Moitorig ad Evaluatio domai to esure that quality ad the associated support mechaisms are put i place from the outset. e. Promote Techical Architecture ad Strategy A key eabler for health iformatio exchage is the cosistet use of techology ad a comprehesive strategy for improvig the techical ifrastructure of the Coecticut healthcare system. The complexity of the healthcare system ad just as importatly, the legacy of the healthcare system s use of proprietary health IT systems suggests that a phased ad deliberate approach over a umber of years will be required. Key recommedatios iclude: 90 C O N N E C T I C U T S T A T E H E A L T H I T P L A N

95 V. R E C O M M E N D A T I O N S A N D N E X T S T E P S Establish fully qualified ad sustaied techical leadership by hirig a techical director ad formig the techical subcommittee to serve as key resources for the CT State RHIO. Adopt ad promote a statewide techical architecture for health iformatio exchage. Promote adoptio of stadards for iteroperable systems i all egagemets with regioal, other state, ad federal HIE projects. Do ot madate adoptio of specific techology or 3rd party vedor solutios. The cost associated with replacig or updatig techical ifrastructure to support a sigle solutio is cost prohibitive ad impractical. Healthcare providers across the state have made sigificat ivestmets i existig ifrastructure ad will ot support such a strategy. The techical architecture described i The Pla cotais the required modules that support iterfacig with existig systems. Promote ad leverage regioal HIEN projects. The Pla recommeds the creatio of multiple cocurret HIEN projects oe for each of the Moitorig & Evaluatio ad State Health Agecies domais, ad oe or more cocurret projects withi the Direct Patiet Care domai (see chapter V, C below). Provide ogoig techical support ad traiig resources that will establish the CT State RHIO as a leader ad key resource for the developmet of health iformatio exchage capacity across the state. Moitor 3rd party vedor activities. Several vedors are very aggressively developig techology ad techical support capacity for health iformatio exchage. Their techical architectures ad services vary sigificatly ad ultimately, their success i the marketplace will impact key techology-based decisios of the CT State RHIO. f. Fudig ad Fiacial Sustaiability Developmet Fudig ad fiacial sustaiability will be a critical ogoig cocer for the CT State RHIO. Highly aggressive ad sustaied programs for obtaiig grat fudig ad developig reveue streams must be pursued ad implemeted. I close collaboratio with the Fiace Subcommittee, the Executive Director will: Obtai fudig to support the CT State RHIO for the five year duratio of The Pla. Leverage existig EHR developmet projects i direct patiet care settigs. Closely moitor federal fudig chaels, particularly those that will receive the ARRA fudig. Egage with state resources to idetify opportuities for obtaiig discretioary ARRA fuds. Develop detailed fiacial models that alig with HIEN developmet over the life of The Pla. C O N N E C T I C U T S T A T E H E A L T H I T P L A N 91

96 V. R E C O M M E N D A T I O N S A N D N E X T S T E P S C. Pilot Projects 1. Itroductio The pilot projects sposored by The CT State RHIO will be specifically structured to establish policies, procedures, best practices ad techical ifrastructure that ca subsequetly be used by other similar projects. A key cosideratio is that recommeded pilot projects will leverage existig Coecticut HIE projects i order to miimize fiacial burde ad maximize the ivolvemet of HIE leaders i the state. This approach is a key factor for the strategy ad supports phased developmet ad implemetatio of the HIEN over time. Pilot projects will be selected for CT State RHIO sposorship through a ope ad competitive process whereby local or regioal health iformatio orgaizatios will submit proposals for developmet of regioal health iformatio exchage etworks. The Pla provides a structured set of objectives through project certificatio templates that will esure that pilot projects are aliged with the broader goals of The Pla. Please refer to Appedix N for a prelimiary pilot project certificatio template ad evaluatio criteria. This approach will provide the followig beefits: Promote the efforts of regioal RHIO ad HIEN iitiatives; Promote the developmet of leadership ad techical ifrastructure withi specific healthcare domais; Promote collaboratio across the state toward the commo priciples, goals ad strategy articulated i The Pla; Maximize the use of limited huma, techical ad fiacial resources; Miimize the risk ad fiacial burde icurred by the state i the early phases of The Pla; Promote the icremetal developmet of statewide health iformatio exchage capacity. 2. Direct Patiet Care EHR ad HIEN(s) A collaboratig group of providers i the Direct Patiet Care domai will develop a EHR system ad HIEN capability with itegratio to certified EMR systems supportig their local commuity providers. The project will support the developmet of a project certificatio template that will be used by subsequet Direct Patiet Care projects across the state. There is every expectatio that multiple Direct Patiet Care domai regioal iitiatives will be operatig cocurretly over the course of The Pla. The expectatio is that the CT State RHIO will egage ad collaborate with these orgaizatios ad, through the project certificatio template, promote compliace with the techical, operatioal, policy ad cliical use case guidelies specified i The Pla. 92 C O N N E C T I C U T S T A T E H E A L T H I T P L A N

97 V. R E C O M M E N D A T I O N S A N D N E X T S T E P S 3. Healthcare System Moitorig ad Evaluatio Data Warehouse ad HIEN A collaboratig group of stakeholders i the Moitorig & Evaluatio (M & E) domai will develop a cetralized data warehouse ad HIEN ifrastructure supportig oe or more cliical quality iitiatives. The project will support the developmet of techical ifrastructure ad a M & E domai project certificatio template that will be used by subsequet M & E projects across the state. The Pla recommeds that a sigle HIEN is developed for all existig M&E projects that require migratio to a iteroperable eviromet as well as servig as the statewide HIEN for all future M & E domai projects. 4. State Health Agecies Program Registry ad HIEN A collaboratig group of stakeholders will develop a program registry platform ad HIEN ifrastructure supportig oe or more state health agecies programs. The project will support the developmet of a techical ifrastructure ad a State Health Agecies domai project certificatio template that will be used by subsequet state health agecies projects. The Pla recommeds that a sigle HIEN is developed for all existig state health agecies program registries that require migratio to a iteroperable eviromet as well as servig as the statewide HIEN for all future State Health Agecies domai projects. 5. Coecticut State Health Iformatio Exchage Network Developmet The techical subcommittee of the CT State RHIO will review the strategic pla ad the Coecticut healthcare eviromet from a techical ifrastructure perspective ad begi plaig for developmet of the Coecticut State HIEN. A key elemet of this approach will be the ogoig collaboratio with regioal HIEN projects as described above. Use of techical ifrastructure ad resources developed through the pilot project phase of The Pla as well as the ability to itegrate those projects ito the broader CT State HIEN will be a critical to the overall success of The Pla. Ultimately, the CT State HIEN will evolve to the fuctioal etwork of etworks as depicted i Figure 21. C O N N E C T I C U T S T A T E H E A L T H I T P L A N 93

98 V. R E C O M M E N D A T I O N S A N D N E X T S T E P S FIGURE 21 C O N N E C T I C U T S TAT E R E G I O N A L H E A LT H I N F O R M AT I O N O R G A N I Z AT I O N COMMUNICATIONS COLLABORATION FACILITATOR FUNDING SOURCE LEADERSHIP PROJECT MANAGEMENT RESOURCE POOL STRATEGY TRAINING DIRECT PATIENT CARE MONITORING & EVALUATION STATE HEALTH AGENCIES Regioal HIEN Regioal HIEN M & E HIEN Program 1 SHA HIEN Program Registry Regioal HIEN Regioal HIEN Program 2 Program Program Registry Program Registry C O N N E C T I C U T S TAT E H E A LT H I N F O R M AT I O N E X C H A N G E N E T W O R K AUDITING COMMUNITY MPI CUSTOMER SERVICE DATA EXCHANGE OPERATIONS PERSONAL HEALTH RECORD PRIVACY AND SECURITY SHARED TECHNOLOGY TECHNICAL SUPPORT D. Closig Through the phased implemetatio of the Coecticut State Health Iformatio Techology Pla, Coecticut will lead the way towards healthcare reform i the state, rather tha waitig for aswers. The Pla builds o the sigificat progress made towards establishig atioal techical ad policy stadards by the federal govermet ad the best practices demostrated by health IT/HIE projects i Coecticut ad across the atio. The Pla also cosiders the curret fudig eviromet as a key opportuity to demostrate ad build the ecessary techical ifrastructure to support a state-wide health iformatio etwork for Coecticut s future. Key to The Pla s success will be the ability of the CT State RHIO to esure a trasparet process i the selectio of pilot projects, i the distributio of fuds, ad i the developmet of comprehesive ad iclusive process that iforms ad educates the state s healthcare professioals ad cosumers. 94 C O N N E C T I C U T S T A T E H E A L T H I T P L A N

99 V. R E C O M M E N D A T I O N S A N D N E X T S T E P S Refereces Adler G How to successfully avigate your EHR implemetatio. Fam Pract Maag 14(2): Adler-Milstei J, McAfee AP, Bates DW, Jha AK The state of regioal health iformatio orgaizatios: curret activities ad fiacig. Health Aff 27(1):w60-9. Adler-Milstei J, Bates DW, Jha AK U.S. Regioal health iformatio orgaizatios: progress ad challeges. Health Aff 28(2): The Agecy for Health Research ad Quality Evolutio of State Health Iformatio Exchage: A Study of Visio, Strategy ad Progress. Available at: Accessed Jauary 27, America Health Iformatio Maagemet Associatio (AHIMA). The State-level Health Iformatio Exchage Cosesus Project. Available at: Accessed October 22, America Recovery ad Reivestmet Act (ARRA). Available at: February 13, Arizoa Health-e Coectio. Arizoa Health-e Coectio Roadmap Available at: Accessed October 24, Ash JS, Bates DW Factors ad forces affectig EHR system adoptio: report of a 2004 ACMI discussio. J Am Med Iform Assoc 12(1):8-12. Bates DW, Teich JM, Lee J, Seger D, Kuperma GJ, Ma'Luf N, et al The impact of computerized physicia order etry o medicatio error prevetio. J Am Med Iform Assoc 6(4): Billigs J, Parikh N, Mijaovic T Emergecy departmet use i New York City: A substitute for primary care? The Commowealth Fud. The Ceters for Disease Cotrol ad Prevetio The burde of chroic diseases ad their risk factors: Natioal ad state perspectives. Available at: Accessed: April 1, Chertow GM, Lee J, Kuperma GJ, Burdick E, Horsky J, Seger DL, et al Guided medicatio dosig for ipatiets with real isufficiecy. JAMA 12;286(22): Clayto PD, Naus SP, Bowes WA 3rd, Madse TS, Wilcox AB, Orsmod G, Rocha B, Thorto SN, Joes S, Jacobse CA, Udall MR, Rhodes ML, Wallace BE, Cao W, Garder J, Huff SM, Leckma L Physicia use of electroic medical records: Issues ad successes with direct data etry ad physicia productivity. AMIA Au Symp Proc. 2005: C O N N E C T I C U T S T A T E H E A L T H I T P L A N 95

100 V. R E C O M M E N D A T I O N S A N D N E X T S T E P S Cogressioal Budget Office Key issues i aalyzig major health isurace proposals. Available at: Accessed March 25, Coectig for Health. The Coectig for Health Commo Framework: Resources for Implemetig Private ad Secure Health Iformatio Exchage. Available at: Accessed October 27, The Departmet of Health ad Huma Services. Office of the Natioal Coordiator for Healthcare Iformatio Techology The Decade of Health Iformatio Techology: Deliverig Cosumer-cetric ad Iformatio-rich Health Care. July Available at: Accessed October 27, The Departmet of Health ad Huma Services. Office of the Natioal Coordiator for Healthcare Iformatio Techology The AHIC Quality Workgroup Visio Roadmap: A Path to Improved Quality Measuremet ad Reportig Through Icreased Automatio. Available at: Accessed Jauary 7, DesRoches CM, Campbell EG, Rao SR, Doela K, Ferris TG, Jha A, Kaushal R, Levy DE, Rosebaum S, Shields AE, Blumethal D Electroic health records i ambulatory care a atioal survey of physicias. N Egl J Med ;359(1): Dexter PR, Perkis SM, Maharry KS, Joes K, McDoald CJ Ipatiet computer-based stadig orders vs physicia remiders to icrease iflueza ad peumococcal vacciatio rates: a radomized trial. JAMA 292(19): Dexter PR, Perkis S, Overhage JM, Maharry K, Kohler RB, McDoald CJ A computerized remider system to icrease the use of prevetive care for hospitalized patiets. N Egl J Med 345(13): ehealth Iitiative Fifth Aual Survey of Health Iformatio Exchage at the State ad Local Levels: Overview of 2008 Fidigs. Available at: IitiativeResults2008SurveyoHealthIformatioExchageSeptember2008Fial pdf. Accessed Jauary 27, Gadhi TK, Weigart SN, Seger AC, Borus J, Burdick E, Poo EG, et al Outpatiet prescribig errors ad the impact of computerized prescribig. J Ge Iter Med 20(9): Healthcare Iformatio ad Maagemet Systems Society (HIMSS). HIMSS State Dashboard. Available at: Accessed: October 21, Healthcare Iformatio ad Maagemet Systems Society Eablig healthcare reform usig i formatio techology recommedatios for the Obama Admiistratio ad 111th Cogress. Available at: Accessed April 1, C O N N E C T I C U T S T A T E H E A L T H I T P L A N

101 V. R E C O M M E N D A T I O N S A N D N E X T S T E P S Houser SH, Johso LA Perceptios regardig electroic health record implemetatio amog health iformatio maagemet professioals i Alabama: a statewide survey ad aalysis. Perspect Health If Maag 16;5:6. Iglehart JK The struggle for reform challeges ad hopes for comprehesive health care legislatio. N Egl J Med [Epub ahead of prit]. Jha AK, Ferris TG, Doela K, DesRoches CM, Shields AE, Rosebaum S, Blumethal D How commo are electroic health records i the Uited States? A summary of the evidece. Health Aff 25:w496-w507. Jha AK, Doola D, Gradt D, Scott T, Bates DW The use of health iformatio techology i seve atios. It J Med Iform 77(12): Jha AK, Desroches CM, Campbell EG, Doela K, Rao SR, Ferris TG, Shields A, Rosebaum S, Blumethal D Use of Electroic Health Records i U.S. Hospitals. N Egl J Med [Epub ahead of prit]. Kaiser Family Foudatio. Kaiser Commissio o Medicaid ad the Uisured The uisured: A primer. Available at: Accessed April 1, Kaushal R, Shojaia KG, Bates DW Effects of computerized physicia order etry ad cliical decisio support systems o medicatio safety: a systematic review. Arch Iter Med 163(12): Keeha S, Sisko A, Truffer C, Smith S, Cowa C, Poisal J, Clemes MK; Natioal Health Expediture Accouts Projectios Team Health spedig projectios through 2017: the baby-boom geeratio is comig to Medicare. Health Aff 27(2):w Lorezi NM, Kouroubali A, Detmer DE, Bloomrose M How to successfully select ad implemet electroic health records (EHR) i small ambulatory practice settigs. BMC Med Iform Decis Mak [Epub ahead of prit]. Massachusetts Medical Society MMS Survey: Most Doctors Are Slow to Icorporate Techology ito Practices. Available at: Accessed March 31, Miller RH, West C, Marti Brow T, Sim I, Gachoff C The value of electroic health records i solo or small group practices, Health Aff 24: The Miesota Departmet of Health. Miesota e-health Iitiative A Prescriptio for Meetig Miesota s 2015 Iteroperable Electroic Health Record Madate: A Statewide Implemetatio Pla. Available at: Accessed October 21, C O N N E C T I C U T S T A T E H E A L T H I T P L A N 97

102 V. R E C O M M E N D A T I O N S A N D N E X T S T E P S Natioal Associatio of Commuity Health Ceters Access deied: A look at America s medically disefrachised. Available at: Accessed April 1, Natioal Goverors Associatio Ceter for Best Practices Report to the State Alliace for e-health: Public Goverace Models for a Sustaiable Health Iformatio Exchage Idustry. Available at: February 24, Overhage JM, Tierey WM, Zhou XH, McDoald CJ A radomized trial of corollary orders to prevet errors of omissio. J Am Med Iform Assoc 4(5): Peterso JF, Kuperma GJ, Shek C, Patel M, Avor J, Bates DW Guided prescriptio of psychotropic medicatios for geriatric ipatiets. Arch Iter Med 165(7): RTI Iteratioal. Health Iformatio Security ad Privacy Collaboratio (HISPC) Privacy ad Security Solutios for Iteroperable Health Iformatio Exchage: Impact Aalysis. Available at: Assessed October 22, Schoe C, Osbor R, Doty MM, Bishop M, Peugh J, Murukutla N Toward higher-performace health systems: adults' health care experieces i seve coutries, Health Aff 26(6):w Schoe K, Davis K, Collis SR Buildig blocks for reform: achievig uiversal coverage with private ad public group health isurace. Health Aff 27(3): Schoe C, Osbor R, How SK, Doty MM, Peugh J I chroic coditio: experieces of patiets with complex health care eeds, i eight coutries, Health Aff 28(1):w1-16. State Level Health Iformatio Exchage Cosesus Project Roles i Esurig Goverace ad Advacig Iteroperability. Available at: Accessed October 24, Taylor R, Mazo J, Siett M Quatifyig value for physicia order-etry systems: a balace of cost ad quality. Health Fiace Maage 56(7):44-8. Teich JM, Merchia PR, Schmiz JL, Kuperma GJ, Spurr CD, Bates DW Effects of computerized physicia order etry o prescribig practices. Arch Iter Med 9;160(18): Tierey WM, Miller ME, Overhage JM, McDoald CJ Physicia ipatiet order writig o microcomputer workstatios: effects o resource utilizatio. JAMA 269(3): Vermot Iformatio Techology Leaders, Ic. (VITL) Vermot Health Iformatio Techology Pla Strategies for Developig a Health Iformatio Exchage Network. Available at: Accessed: October 22, C O N N E C T I C U T S T A T E H E A L T H I T P L A N

103 VI A P P E N D I C E S A. Glossary of Terms ADT (Admissio/Discharge/Trasfer): A hospital-based computer applicatio used to track patiet activity withi the hospital. AHIC (America Health Iformatio Commuity): Also kow as "the Commuity") formed to help advace efforts to reach the presidet s call for most Americas to have electroic health records by See AHIMA (America Health Iformatio Maagemet System): A commuity of professioals egaged i health iformatio maagemet, providig support to members ad stregtheig the idustry ad professio. See AMIA (America Medical Iformatics Associatio): AMIA is the professioal home for biomedical ad health iformatics. AMIA is dedicated to promotig the effective orgaizatio, aalysis, maagemet, ad use of iformatio i healthcare i support of patiet care, public health, teachig, research, admiistratio, ad related policy. ANSI (America Natioal Stadards Istitute): The U.S. stadards orgaizatio that establishes procedures for the developmet ad coordiatio of volutary America Natioal Stadards. Architecture: This term refers to the structure of a iformatio system ad how its pieces commuicate ad work together. ARRA: The America Recovery ad Reivestmet Act of BAA (Busiess Associate Agreemet): A cotract betwee a covered etity ad a busiess associate that establishes the permitted ad required uses ad disclosures of persoal health iformatio (protected health iformatio) by the busiess associate. CCHIT (Certificatio Commissio for Healthcare Iformatio Techology): A volutary, private-sector orgaizatio lauched i 2004 to certify health iformatio techology (health IT) products such as electroic health records ad the etworks over which they iteroperate. See C O N N E C T I C U T S T A T E H E A L T H I T P L A N 99

104 A P P E N D I C E S / G L O S S A R Y O F T E R M S CCR (Cotiuity of Care Record): A stadard specificatio iteded to foster ad improve cotiuity of patiet care, to reduce medical errors, ad to assure at least a miimum stadard of health iformatio trasportability whe a patiet is referred or trasferred to, or is otherwise see by, aother provider. CDS (Cliical Decisio Support): Cliical decisio support systems (CDSS) assist the physicia i applyig ew iformatio to patiet care ad help to prevet medical errors ad improve patiet safety. May of these systems iclude computer-based programs that aalyze iformatio etered by the physicia. CEUs: Cotiuig Educatio Uits that are recogized iteratioally as a measure of professioal educatio ad traiig. CHIMEet: A statewide etwork ad database established by the Coecticut Hospital Associatio, has the participatio of 28 of the state s 29 o-profit hospitals. CLIA (Cliical Laboratory Improvemet Amedmets): Federal regulatory stadards that apply to all cliical laboratory testig performed o humas i the Uited States, except cliical trials ad basic research. CME: Cotiuig medical educatioal that assists physicias i carryig out their professioal resposibilities more effectively ad efficietly. CPOE (Computerized Provider Order Etry): A computer applicatio that allows a physicia's orders for diagostic ad treatmet services (such as medicatios, laboratory, ad other tests) to be etered electroically istead of beig recorded o order sheets or prescriptio pads. The computer compares the order agaist stadards for dosig, checks for allergies or iteractios with other medicatios, ad wars the physicia about potetial problems. CT-HISPI (Coecticut Health Iformatio Security & Privacy Iitiative): A collaborative project desiged to assess how Coecticut s privacy ad security busiess practices ad policies ifluece the exchage of electroic health iformatio. CQI (Cotiuous Quality Improvemet): A approach to quality maagemet that builds upo traditioal quality assurace methods by emphasizig the orgaizatio of systems, ad promotes the eed for objective data to aalyze ad improve processes. Data Warehouse: A large database that stores iformatio like a data repository but goes a step further, allowig users to access data to perform research-orieted aalysis. Database: A aggregatio of records or other data that is updateable. Databases are used to maage ad archive large amouts of iformatio. Also see relatioal database. Digital Certificate: A electroic certificate (actually a uique umber) that establishes a user s idetity whe coductig busiess or other secure trasactios o a etwork such as the Iteret. See also electroic certificate. 100 C O N N E C T I C U T S T A T E H E A L T H I T P L A N

105 A P P E N D I C E S / G L O S S A R Y O F T E R M S Disease Maagemet: A coordiated ad proactive approach to maagig care ad support for patiets with chroic illesses such as diabetes, cogestive heart failure, asthma, HIV/AIDS, ad cacer. See also e-disease maagemet. EHR (Electroic Health Record): A real time patiet health record with access to evidece-based decisio support tools that ca be used to aid cliicias i decisio makig. A EHR is a medical record or ay other iformatio relatig to the past, preset or future physical ad metal health, or coditio of a patiet which resides i computers which capture, trasmit, receive, store, retrieve, lik, ad maipulate multimedia data for the primary purpose of providig healthcare ad health-related services. The EHR ca also support the collectio of data for uses other tha cliical care, such as billig, quality maagemet, outcome reportig, ad public health disease surveillace ad reportig. EHR records iclude patiet demographics, progress otes, SOAP otes, problems, medicatios, vital sigs, past medical history, immuizatios, laboratory data ad radiology reports. EMR (Electroic Medical Record): A computer-based patiet medical record. A EMR facilitates access of patiet data by cliical staff at ay give locatio; accurate ad complete claims processig by isurace compaies; buildig automated checks for drug ad allergy iteractios; cliical otes; prescriptios; schedulig; sedig to ad viewig by labs; The term has become expaded to iclude systems which keep track of other relevat medical iformatio. The practice maagemet system is the medical office fuctios which support ad surroud the electroic medical record. Ecryptio: Traslatio of data ito a code i order to keep the iformatio secure from ayoe but the iteded recipiet. eprescribig / erx: Computer techology i which physicias use hadheld or persoal computer devices to review drug ad formulary coverage ad trasmit prescriptios to a priter, EMR or pharmacy. eprescribig software ca be itegrated with existig cliical iformatio systems to allow access to patiet-specific iformatio to scree for drug iteractios ad allergies. FQHC (Federally Qualified Health Ceter): A federal desigatio from the Bureau of Primary Health Care (BPHC) ad the Ceter for Medicare ad Medicaid Services (CMS) that is assiged to private o-profit or public healthcare orgaizatios that serve predomiatly uisured or medically uderserved populatios. Formulary: A list of medicatios (both geeric ad brad ames) that are covered by a specific health isurace pla or pharmacy beefit maager (PBM), used to ecourage utilizatio of more cost-effective drugs. Hospitals sometimes use formularies of their ow, for the same reaso. HEDIS (Healthcare Effectiveess Data ad Iformatio Set): A set of health pla performace measures (e.g., prevetative medicie, preatal care, acute ad chroic disease ad member satisfactio with health plas ad doctors) that look at a pla's quality of care ad services. HAN (Health Actio Network): Commuicatio system used by the CDC to exchage disease iformatio with state ad local health departmets. C O N N E C T I C U T S T A T E H E A L T H I T P L A N 101

106 A P P E N D I C E S / G L O S S A R Y O F T E R M S HIE (Health Iformatio Exchage): The movemet of healthcare iformatio electroically across orgaizatios withi a regio or commuity. The goal of HIE is to facilitate access to ad retrieval of cliical data to provide safe, timely, efficiet, effective, equitable, patiet-cetered care. HIEN (Health Iformatio Exchage Network): The collectio of etworks, databases, systems ad software applicatios that provides the capability to electroically move cliical iformatio betwee disparate healthcare iformatio systems while maitaiig the meaig of the iformatio beig exchaged. HIPAA (Health Isurace Portability ad Accoutability Act of 1996): A federal law iteded to improve the portability of health isurace ad simplify healthcare admiistratio. HIPAA sets stadards for electroic trasmissio of claims-related iformatio ad for esurig the security ad privacy of all idividually idetifiable health iformatio. HISPC (Health Iformatio Security ad Privacy Collaboratio): Formed to ivestigate differeces i security ad privacy laws across the coutry. HIT (Health Iformatio Techology): The applicatio of iformatio processig ivolvig both computer hardware ad software that deals with the storage, retrieval, sharig, ad use of healthcare iformatio, data, ad kowledge for commuicatio ad decisio makig. HITECH (Health Iformatio Techology for Ecoomic ad Cliical Health Act): A Act that as part of The America Recovery ad Reivestmet Act of 2009 (ARRA) appropriates a miimum of 20 billio dollars to be used over the ext six years to ecourage health IT ad HIE adoptio. HITSP (Health Iformatio Techology Stadards Pael): With the America Natioal Stadards Istitute (ANSI), this orgaizatio of 18 idepedet etities serves as a cooperative partership betwee the public ad private sectors for the purpose of achievig a widely accepted ad useful set of stadards specifically to eable ad support widespread iteroperability amog healthcare software applicatios, as they will iteract i a local, regioal ad atioal health iformatio etwork for the Uited States. See HL7 (Health Level Seve): Oe of several accredited stadards (specificatios or protocols) established by ANSI (America Natioal Stadards Istitute) for cliical ad admiistrative data. Systems which are HL7 compliat improve the ability for iteroperability ad exchage of electroic data. HTML (Hypertext Markup Laguage): The basic programmig laguage for sites o the World Wide Web. This skeleto of code surrouds blocks of text ad/or images ad cotais all the ecessary commads ad display istructios. A Web browser program is eeded to iterpret HTML ad depict it as a graphical display o a computer scree. HTTP (Hypertext Trasfer Protocol): A laguage protocol used i commuicatio amog Web sites. Whe http appears as part of a Web site URL, it idicates to Web browsers, HTML spoke here.

107 A P P E N D I C E S / G L O S S A R Y O F T E R M S ICD-10 (Iteratioal Classificatio of Disease- 10th Revisio): Iteratioal disease classificatio system developed by the World Health Orgaizatio (WHO) that provides a detailed descriptio of kow diseases ad ijuries. The classificatio system is used worldwide for morbidity ad mortality statistics, reimbursemet systems ad automated decisio support i medicie. Iteret: A publicly accessible, global etwork coectig millios of computers. The Iteret carries data for applicatios such as , istat messagig ad telecoferecig, i additio to the billios of documets ad images that make up the World Wide Web. Although the terms Iteret ad Web are ofte used iterchageably, they are ot syoymous. See also World Wide Web. Iteroperability Compatibility: The ability of software ad hardware o multiple pieces of equipmet made by differet compaies or maufacturers to commuicate ad work together. IPA (Idepedet Practice Associatio): A associatio of idepedet physicias, or other orgaizatio that cotracts with idepedet physicias, ad provides services to maaged care orgaizatios o a egotiated per capita rate, flat retaier fee, or egotiated fee-for-service basis. ISP (Iteret Service Provider): A compay that provides users with access to the Iteret ad the World Wide Web. Users coect to the ISP through ordiary telephoe lies (dial-up coectios) or through faster coectios such as DSL, cable or fiber-optic lies. Although some ISPs charge by the hour, most offer mothly or yearly rates. Laboratory Iformatio System: Electroic Medical Records are repositories of patiet data either etered directly or iterfaced from exteral applicatios. Oe such applicatio is a Laboratory Iformatio System (LIS) that is typically used by hospital pathology departmets to record activity i the departmet. Legacy System: A existig IT system or applicatio, ofte built aroud a maiframe computer, which geerally has bee i place for a log time ad represets a sigificat ivestmet. Compatibility with legacy systems is ofte a major issue whe cosiderig ew applicatios. Meta data Metadata (meta data, or sometimes metaiformatio) is "data about other data", of ay sort i ay media. I data processig, metadata is defiitioal data that provides iformatio about or documetatio of other data maaged withi a applicatio or eviromet. The term should be used with cautio as all data is about somethig, ad is therefore metadata. MPI (Master Patiet Idex): A database program that collects a patiet s various hospital idetificatio umbers, e.g. from the blood lab, radiology departmet, ad admissios, ad keeps them uder a sigle, eterprise-wide idetificatio umber. MRI: Magetic resoace imagig. NHIN (Natiowide Health Iformatio Network): Describes the techologies, stadards, laws, policies, programs ad practices that eable health iformatio to be shared amog health decisio makers, icludig cosumers ad patiets, to promote improvemets i health ad healthcare. The C O N N E C T I C U T S T A T E H E A L T H I T P L A N 103

108 A P P E N D I C E S / G L O S S A R Y O F T E R M S developmet of a visio for the NHIN bega more tha a decade ago with publicatio of a Istitute of Medicie report, The Computer-Based Patiet Record. The path to a atioal etwork of healthcare iformatio is through the successful establishmet of RHIO. NIST (Natioal Istitute of Stadards ad Techology): Fouded i 1901, NIST is a o-regulatory federal agecy withi the U.S. Commerce Departmet s Techology Admiistratio, promotig U.S. iovatio ad idustrial competitiveess by advacig measuremet sciece, stadards, ad techology. See NPI (Natioal Provider Idetifier): The Health Isurace Portability ad Accoutability Act (HIPAA) of 1996 requires the adoptio of a stadard uique idetifier for healthcare providers. The NPI Fial Rule issued Jauary 23, 2004 adopted the NPI as this stadard. The NPI is a 10-digit, itelligece free umeric idetifier (10 digit umber). Itelligece free meas that the umbers do ot carry iformatio about healthcare providers, such as the state i which they practice or their provider type or specializatio. The NPI will replace healthcare provider idetifiers i use today i HIPAA stadard trasactios. Those umbers iclude Medicare legacy IDs (UPIN, OSCAR, PIN, ad Natioal Supplier Clearighouse or NSC). The provider s NPI will ot chage ad will remai with the provider regardless of job or locatio chages. See: ONC (Office of the Natioal Coordiator): Is a govermet agecy (part of HHS) that oversees ad ecourages the developmet of a atioal, iteroperable (compatible) health iformatio techology system to improve the quality ad efficiecy of healthcare. See ONCHIT (Office of the Natioal Coordiator for Health Iformatio Techology): see ONC. Ope source: Software i which the source code is available to users, who ca read ad modify the code. PAS: A patiet admiistratio systems used for recordig ad reportig admiistrative details of a patiets ecouter i a hospital. A Electroic Medical Record may iclude a PAS or be iterfaced to a PAS via HL7. Episode details geerated from the PAS may be iitially stored i a itermediate EMR ad the set to a EHR as part of a EHR extract such as a discharge summary. Patiet Record Locator: The electroic meas by which patiet files are located to assist patiets ad cliicias to fid test results, medical history, prescriptio data, ad other health iformatio. A record locator would act as a secure health iformatio search tool. PHI (Persoal Health Iformatio): Idividually idetifiable health iformatio. PHR (Persoal Health Record): A electroic applicatio through which idividuals ca maitai ad maage their health iformatio (ad that of others for whom they are authorized) i a private, secure, ad cofidetial eviromet.

109 A P P E N D I C E S / G L O S S A R Y O F T E R M S Pharmacy Iformatio Maagemet System: Electroic Medical Records are repositories of patiet data either etered directly or iterfaced from exteral applicatios. Oe such applicatio is a Pharmacy Iformatio Maagemet System (PIMS) that is typically used by hospital pharmacy departmets to record activity i the departmet. PKI (Public Key Ifrastructure): A system that uses electroic certificates ad various authorities (servers that validate certificates, registratios, etc.) to autheticate each etity i a olie trasactio. Portal: A Web site that offers a rage of resources, such as , chat boards, search egies, cotet ad olie shoppig. Practice Maagemet System: A electroic data system typically foud i cliical settigs that is typically used for fiacial maagemet, patiet schedulig ad other associated office maagemet fuctios. Pseudoymizatio: The process of removig or disguisig idetifyig demographic iformatio from a cliical trasactio i order to prevet the specific idetificatio of a perso, while still maitaiig the ability to match trasactios from multiple sources to a sigle perso. QDS (Quality Data Set): A miimum set of data elemets or types of data elemets that ca be used as the basis for developig harmoized ad machie computable quality measures. RHIO (Regioal Health Iformatio Orgaizatio): A multi-stakeholder orgaizatio that eables the exchage ad use of health iformatio, i a secure maer, for the purpose of promotig the improvemet of health quality, safety ad efficiecy. Officials from the U.S. Departmet of Health ad Huma Services (HHS) see RHIOs as the buildig blocks for the Natioal Health Iformatio Network (NHIN). Whe complete the NHIN will provide uiversal access to electroic health records. Relatioal Database: A database i which all iformatio is arraged i tables cotaiig predefied fields. Chagig a field i oe record automatically chages the same field i all related records, allowig for easy global database maagemet. Usig SQL, reports ad comparisos ca be geerated by selectig fields of iterest from the origial database. RLS (Record Locator Service): A ifrastructure compoet to support the ability to determie the locatio of patiet data across multiple participatig orgaizatios ad their cliical data systems. Scalability: The ability to add users ad icrease the capabilities of a applicatio without havig to makig sigificat chages to the applicatio software or the system o which it rus. SQL (Structured Query Laguage): A stadard commad laguage used to iteract with a database. C O N N E C T I C U T S T A T E H E A L T H I T P L A N 105

110 A P P E N D I C E S / G L O S S A R Y O F T E R M S Telehealth: The use of telecommuicatios ad iformatio techology to deliver health services ad trasmit health iformatio over distace. Sometimes called telemedicie. Telemedicie: The use of telecommuicatios ad iformatio techology to deliver health services ad trasmit health iformatio over distace. Sometimes called telehealth. The Pla: The Coecticut State Health Iformatio Techology Pla (this documet). Trasactio-Based Model: A busiess model based o service fees charged for each trasactio coducted usig the vedor s equipmet, software, services or etwork. Used by some e-health vedors, icludig providers of e-prescribig systems. See also subscriptio-based model. UI (User Iterface): The part of a applicatio that allows the user to access the applicatio ad maipulate its fuctioality. It ca iclude meus, forms, commad buttos, etc. URL (Uiform Resource Locator): A Web address. Each Web page has a uique URL. VPN (Virtual Private Network): A etwork that uses public coectios, such as the Iteret, to lik users but relies o ecryptio ad other security measures to esure that oly authorized users ca access the etwork. WAN (Wide Area Network): A computer etwork that covers a large physical area. A WAN usually cosists of multiple local area etworks (LANs). Web Server: A etworked computer that stores ad trasmits documets ad other data to Web browsers via HTTP, a Iteret data trasfer protocol. Web Site: A group of related files, icludig text, graphics, ad hypertext liks, o the World Wide Web. Accessed by typig its URL, a site usually icludes layers of supportig pages as well as a home page. Web-Eabled: Refers to software applicatios that ca be used directly through the Web. Webeabled applicatios are ofte used to collect iformatio from, or make fuctioality available to, geographically dispersed users (e.g. disease surveillace systems). Wireless Iteret: Wireless mobile computig that uses the Iteret as part of the uderlyig etwork commuicatio ifrastructure. Sometimes called wireless Web. Wireless LAN Adapter: Compoet attached to or itegrated ito a hadheld device that trasmits data wirelessly betwee the device ad a local area etwork (LAN) access poit. WLAN (Wireless Local Area Network): A LAN that uses radio frequecy techology to trasmit data over relatively short distaces. It ca replace or exted a wired LAN. World Wide Web: A iteratioal group of databases withi the Iteret cotaiig billios of documets that are formatted i HTML ad lik to other documets ad files. Although the terms Iteret ad Web are ofte used iterchageably, they are ot syoymous. See also Iteret. 106 C O N N E C T I C U T S T A T E H E A L T H I T P L A N

111 A P P E N D I C E S / L E G I S L A T I V E A C T A U T H O R I Z I N G T H E P L A N B. Legislative Act Authorizig the Pla Sec. 19a-25d. State-wide health iformatio techology pla. Desigatio of lead health iformatio exchage orgaizatio. (a) As used i this sectio: (1) Electroic health iformatio system meas a iformatio processig system, ivolvig both computer hardware ad software that deals with the storage, retrieval, sharig ad use of health care iformatio, data ad kowledge for commuicatio ad decisio makig, ad icludes: (A) A electroic health record that provides access i real-time to a patiet's complete medical record; (B) a persoal health record through which a idividual, ad ayoe authorized by such idividual, ca maitai ad maage such idividual's health iformatio; (C) computerized order etry techology that permits a health care provider to order diagostic ad treatmet services, icludig prescriptio drugs electroically; (D) electroic alerts ad remiders to health care providers to improve compliace with best practices, promote regular screeigs ad other prevetive practices, ad facilitate diagoses ad treatmets; (E) error otificatio procedures that geerate a warig if a order is etered that is likely to lead to a sigificat adverse outcome for a patiet; ad (F) tools to allow for the collectio, aalysis ad reportig of data o adverse evets, ear misses, the quality ad efficiecy of care, patiet satisfactio ad other healthcare-related performace measures. (2) Iteroperability meas the ability of two or more systems or compoets to exchage iformatio ad to use the iformatio that has bee exchaged ad icludes: (A) The capacity to physically coect to a etwork for the purpose of exchagig data with other users; (B) the ability of a coected user to demostrate appropriate permissios to participate i the istat trasactio over the etwork; ad (C) the capacity of a coected user with such permissios to access, trasmit, receive ad exchage usable iformatio with other users. (3) Stadard electroic format meas a format usig ope electroic stadards that: (A) Eable health iformatio techology to be used for the collectio of cliically specific data; (B) promote the iteroperability of health care iformatio across health care settigs, icludig reportig to local, state ad federal agecies; ad (C) facilitate cliical decisio support. (b) O or before November 30, 2007, the Departmet of Public Health, i cosultatio with the Office of Health Care Access ad withi available appropriatios, shall cotract, through a competitive biddig process, for the developmet of a statewide health iformatio techology pla. The etity awarded such cotract shall be desigated the lead health iformatio exchage orgaizatio for the state of Coecticut for the period commecig December 1, 2007, ad edig Jue 30, The statewide health iformatio techology pla shall iclude, but ot be limited to: (1) Geeral stadards ad protocols for health iformatio exchage. (2) Electroic data stadards to facilitate the developmet of a statewide, itegrated electroic health iformatio system for use by health care providers ad istitutios that C O N N E C T I C U T S T A T E H E A L T H I T P L A N 107

112 A P P E N D I C E S / P R O J E C T W O R K P L A N A N D K E Y A C T I V I T I E S are fuded by the state. Such electroic data stadards shall (A) iclude provisios relatig to security, privacy, data cotet, structures ad format, vocabulary ad trasmissio protocols, (B) be compatible with ay atioal data stadards i order to allow for iterstate iteroperability, (C) permit the collectio of health iformatio i a stadard electroic format, ad (D) be compatible with the requiremets for a electroic health iformatio system. (3) Pilot programs for health iformatio exchage, ad projected costs ad sources of fudig for such pilot programs. (c) Not later tha December 1, 2008, ad aually thereafter, the Departmet of Public Health, i cosultatio with Office of Health Care Access, shall report, i accordace with sectio 11-4a, to the joit stadig committees of the Geeral Assembly havig cogizace of matters relatig to public health, huma services, govermet admiistratio ad appropriatios ad the budgets of state agecies o the status of the statewide health iformatio techology pla. (Jue Sp. Sess. P.A. 07-2, S. 68.) History: Jue Sp. Sess. P.A effective July 1, C. Project Work Pla ad Key Activities ID Task/Activity Duratio Start Date Ed Date 1 Task A - Admiistrative Activities 241 days 7/9/2008 6/10/ Project start - Kickoff Meetig 1 day 7/9/2008 7/9/ Defie costituet groups 1 day 7/9/2008 7/9/ JSI DELIVERABLE - Submit Prelimiary Work Pla 1 day 7/9/2008 7/9/ Steerig Committee reviews prelimiary work pla 7 days 7/10/2008 7/18/ CT MILESTONE - Prelimiary Work Pla Approval 1 day 7/21/2008 7/21/ JSI Project Team weekly meetigs 236 days 7/10/2008 6/4/ Project maagemet mothly meetig 241 days 7/9/2008 6/10/ Submit mothly work pla updates 241 days 7/9/2008 6/10/ Steerig Committee mothly meetigs 221 days 7/16/2008 5/20/ JSI DELIVERABLE - Submit the CT Health IT Pla Outlie 1 day 11/19/ /19/ Steerig Committee reviews pla outlie 8 days 11/20/ /1/ CT MILESTONE - Pla outlie approval 1 day 12/3/ /3/ JSI DELIVERABLE - Submit the CT Health IT Pla First Draft 1 day 1/30/2009 1/30/ Steerig Committee reviews pla first draft 5 days 2/2/2009 2/6/ CT MILETONE - Pla first draft approval 1 day 2/9/2009 2/9/ C O N N E C T I C U T S T A T E H E A L T H I T P L A N

113 A P P E N D I C E S / P R O J E C T W O R K P L A N A N D K E Y A C T I V I T I E S 113 JSI DELIVERABLE - Submit the CT Health IT Pla Fial Draft 1 day 4/17/2009 4/17/ Steerig Committee reviews fial draft 10 days 4/17/2009 4/24/ JSI MILETONE - Fial draft presetatio 1 day 4/27/2009 4/27/ CT MILESTONE - Pla fial draft approval 1 day 5/15/2009 5/15/ JSI DELIVERABLE - Deliver 100 boud copies of the Fial CT Health 1 day 6/15/2009 6/15/2009 IT Pla 118 JSI MILESTONE - Fial pla presetatio 1 day 6/3/2009 6/3/ JSI DELIVERABLE - Trasitio of HIE database to implemetatio 1 day 6/4/2009 6/4/2009 vedor at cotract close 121 Task B - Research existig HIEN techologies ad practices i CT 78 days 7/9/ /24/ Task C - Research geeral stadards ad protocols for HIE 58 days 7/9/2008 9/26/ Task D - Coduct a survey of healthcare costituet's health 111 days 8/4/2008 1/5/2009 IT/HIE capabilities 150 Task E - Formalize electroic data stadards for a CT HIEN 45 days 10/27/ /26/ Task F - Documet the fuctioal requiremets of a CT HIEN 50 days 10/27/2008 1/2/ Task G - Develop implemetatio strategies for pilot programs 33 days 1/5/2009 2/18/ Small projects 32 days 1/5/2009 2/17/ Large projects 33 days 1/5/2009 2/18/ Task H - Develop a pla for costituet educatio ad outreach 85 days 11/3/2008 2/27/ Task I - Lik HIE activities to support quality improvemet iitiatives 75 days 11/3/2008 2/13/ Idetify stakeholders to be iterviewed 5 days 11/3/ /7/ Develop stakeholder iterview guide 9 days 11/3/ /13/ JSI DELIVERABLE - Review prelimiary approach with MH ad JK 1 day 11/14/ /14/ Recruit iterviewees 10 days 11/17/ /28/ Coduct iterviews 15 days 1/5/2009 1/23/ Develop at a glace matrix of activities 5 days 1/26/2009 1/30/ Documet aalysis of fidigs 9 days 2/2/2009 2/12/ JSI INTERNAL DELIVERABLE - Provide prelimiary report for iclusio 1 day 2/13/2009 2/13/2009 i CT Health IT Pla C O N N E C T I C U T S T A T E H E A L T H I T P L A N 109

114 A P P E N D I C E S / P R O J E C T W O R K P L A N A N D K E Y A C T I V I T I E S ID Task/Activity Duratio Start Date Ed Date 208 Task J - Cross referece health IT activities withi CT ad 40 days 1/5/2009 2/27/2009 eighborig states 217 Task K - Coordiate with other HIE orgaizatios, states ad 20 days 1/5/2009 1/30/2009 the federal govermet 224 Task L - Coduct risk beefit aalysis of secodary 14 days 2/16/2009 3/5/2009 uses of healthcare data 229 Task M - Aalyze ad assess Federated vs. Cetralized 43 days 1/6/2009 3/5/2009 HIE systems 236 Task N - Project a timelie ad budget for statewide HIE 45 days 2/19/2009 4/22/ Task O - Propose plas for trasitio to Natiowide Health 20 days 3/2/2009 3/27/2009 Iformatio Network 251 Task P - Idetify barriers to Implemetatio of CT health IT Pla 29 days 3/6/2009 4/15/ Task Q - Develop CT Health IT Pla 153 days 10/30/2008 6/1/2009 Project Key Activities Kickoff Meetig July 9, Multi-Dimesioal Research Federal Guidace Federal guidace was researched to uderstad ad documet the efforts of the various federal agecies that are promotig the developmet of the Natiowide Health Iformatio Network. Other State Research Other state research was coducted to uderstad ad documet the experieces of other states experieces relative to the developmet of health IT ad HIE capabilities. Coecticut Stakeholder Egagemets Stakeholder Idetificatio JSI used a brief web-based survey to idetify stakeholders, their areas of iterest, ad their level of iterest for participatig i the project. Healthcare Provider Survey Used to perform a prelimiary assessmet of the Coecticut healthcare eviromet ad stakeholder perspectives o curret ad plaed health IT projects. Hospital Survey I collaboratio with the Coecticut Hospital Associatio, hospital techical leadership was egaged to assess their curret ad plaed health IT capabilities. Key Stakeholder Iterviews JSI solicited feedback from stakeholders across the state o experieces with health IT ad HIE, curret health IT ad HIE activity ad capacity i Coecticut, perceptios of health IT ad HIE s impact o cost, quality of care ad efficiecy, ad issues associated with goverace, educatio ad outreach, patiet privacy ad cofidetiality. 110 C O N N E C T I C U T S T A T E H E A L T H I T P L A N

115 A P P E N D I C E S / S T E E R I N G C O M M I T T E E M E M B E R S Focus Groups JSI coveed eight focus groups to develop pla cotet i the areas of cosumer advocacy, educatio ad outreach, goverace, quality improvemet ad populatio health maagemet, legal ad legislative, commuity health, fiace, ad fuctioal requiremets ad techical stadards. Pla Developmet JSI met regularly with the Steerig Committee to report o research ad fidigs ad to solicit feedback at critical issues i The Pla s developmet. Major milestoes icluded: First draft delivery o February 2, 2009; Fial draft delivery o April 17, 2009; ad Fial Presetatio o Jue 1, D. Steerig Committee Members Purpose: To oversee ad provide iput for the developmet of a statewide health iformatio techology pla as directed by Public Act 07-2, Sectio 68. I additio, the Steerig Committee will be resposible to direct the recommedatios i the fial Pla with commet to DPH Commissioer J. Robert Galvi for his submissio to the Public Health Committee by Jue 30, Thomas Agresta, MD Asylum Hill Family Practice Ceter Marybeth Boadies Office of Healthcare Access Jessica Cabaillas Coecticut Office of Policy ad Maagemet Steve Casey Coecticut Departmet of Iformatio Techology Da Clemos Commuity Health Ceter Associatio of Coecticut, Ic. Joh Gadea Coecticut Departmet of Cosumer Protectio Mariae Hor Coecticut Departmet of Public Health Jeifer Jackso Coecticut Hospital Associatio Juliae Koopka Coecticut Departmet of Public Health Robert Mitchell Coecticut Departmet of Social Services Gregory Sulliva Coecticut Office of Policy ad Maagemet Meg Hooper, Chair Coecticut Departmet of Public Health C O N N E C T I C U T S T A T E H E A L T H I T P L A N 111

116 A P P E N D I C E S / S T A K E H O L D E R I N T E R V I E W P A R T I C I P A N T S E. Stakeholder Iterview Participats Thomas Agresta, M.D. Associate Professor ad Director of Medical Iformatics, Departmet of Family Medicie, Uiversity of Coecticut School of Medicie Physicia, Asylum Hill Family Medicie Doug Arold Executive Director, Middlesex Professioal Services Matt Borto HIT Cosultat Richard Bailey Deputy Chief Iformatio Officer, Departmet of Iformatio Techology Leah Barry ehealth CT Marybeth Boadies Research ad Plaig Director, Office of Healthcare Access Joh Brady Chief Fiacial Officer ad VP, Busiess Plaig, Coecticut Hospital Associatio Bruce Campbell Chief Iformatio Officer, Pro Health Systems Shati Carter Health Iformatio Applicatios Director, CHC Ic. Hari Chadra Techical Resource; Systems Developmet, Departmet of Public Health Scott Cleary Chief Executive Officer, SMC Parters Director, ehealthcoecticut Da Clemos Chief Fiacial Officer, Commuity Health Ceter Associatio of Coecticut, Ic. Peter Courtway Chief Iformatio Officer Dabury Hospital Charles Covi VP/Chief Iformatio Office, Machester Memorial Hospital ad Rockville Hospital (Easter Coecticut Healthcare Network) Marquis Davis Director of IT, CHC Associatio Fracois de Brates Natioal Coordiator, Bridges to Excellece David Fitzgerald Eterprise Architect/Systems IT, Aeta - Northeast Joh Gadea Director of Drug Cotrol Divisio, Departmet of Cosumer Protectio Leoard Guercia Director of Operatios, Departmet of Public Health Yvette Highsmith-Fracis Site Director, New Britai Health Ceter Meg Hooper Plaig Brach Chief, CT Departmet of Public Health Michael Hudso Presidet, Aeta Northeast Lud Johso Chief Iformatio Officer, Middlesex Hospital Vaessa Kapral IT Sectio Chief, Departmet of Public Health Kim Kalajaie VP ad Chief Iformatio Officer, Lawrece ad Memorial Hospital 112 C O N N E C T I C U T S T A T E H E A L T H I T P L A N

117 A P P E N D I C E S / F O C U S G R O U P P A R T I C I P A N T S Richard Kubica Chief Techology Officer, Hartford Hospital Matthew Katz Executive Director, Coecticut Medical Society Cheryl Lescareau VP of Cliical Performace, Pro Health Systems Joh T. Lych Director, Coecticut Ceter for Primary Care. Richard Lych VP of Health Care Maagemet for CT, Athem BCBS James O Coell Chief Fiacial Officer, Departmet of Public Health Stepha O Neil Vice Presidet, Iformatio Services Hartford Hospital Chere Parto Head of Provider Services, Aeta-Northeast Marcia Petrillo Director of Health, Qualidigm Jack Reed CEO ad Presidet, Pro Health Systems Art Schreier Easter Regioal Director, Quest Diagostics Triita Shade Director of Health, CT Ceter for Primary Care Betsy Thorquist Chief Iformatio Officer, St. Vicet s Medical Ceter Ala Treiber, PhD. Departmet of Iformatio Techology Joh Vitter Departmet of Iformatio Techology F. Focus Group Participats GOVERNANCE: Robert Mitchell Project Maager, Coecticut Departmet of Social Services Marie O Brie Meg Hooper Plaig Brach Chief, Coecticut Departmet of Public Health Fracois de Brates Chief Executive Officer, Bridges to Excellece Kevi Carr Project Director, Waterbury Health Access Program LEGAL: Patrick Moaha Garfukel Wild & Travis, P.C. C O N N E C T I C U T S T A T E H E A L T H I T P L A N 113

118 A P P E N D I C E S / F O C U S G R O U P P A R T I C I P A N T S David Mack Parter, Shipma ad Goodwi, LLP. Doa Brewer Legal Director, HIPAA Privacy Officer, Coecticut Departmet of Public Health Joh T. Lych Director, Coecticut Ceter for Primary Care Mariae Hor Director of Legal Services, Office of Research ad Developmet, Coecticut Departmet of Public Health CONSUMER ADVOCACY: Gary E. Waterhouse Executive Director, CT Associatio of Ceters for Idepedet Livig Hilary Waldma, MPH Director of Commuity Relatios ad Outreach, The Hispaic Health Coucil Kevi Lembo Director, Office of the Healthcare Advocate Elle Adrews, PhD Executive Director, Coecticut Health Policy Project Mary Alice Lee, Ph.D. Seior Policy Fellow, Coecticut Voices for Childre Kare Kagas Executive Director, Advocacy Ulimited, Ic. EDUCATION AND OUTREACH: Marie Smith, PharmD. Departmet Head, Pharmacy Practice ad Cliical Professor (E-Health), Uiversity of Coecticut School of Pharmacy Judith Fifield Professor i Family Medicie & Director of the Ethel Doaghue Traslatig Research ito Practice ad Policy Co-Director of the Coecticut Istitute for Cliical & Traslatioal Sciece (CICATS) Rebecca Crowell Fellow, TRIPP Ceter 114 C O N N E C T I C U T S T A T E H E A L T H I T P L A N

119 A P P E N D I C E S / F O C U S G R O U P P A R T I C I P A N T S Thomas Agresta, M.D. Associate Professor ad Director of Medical Iformatics, Departmet of Family Medicie, Uiversity of Coecticut School of Medicie Physicia, Asylum Hill Family Medicie Steve Demurjia Professor i Computer Sciece ad Egieerig & Director of the Graduate programs for CICATS Associate Director for BioMedical Iformatics for CICATS Scott Wetstoe Associate professor i the Dept of Commuity Medicie ad the Director of Health Affairs Policy ad Plaig for the Health Ceter QUALITY: Adrea Gelzer, M.D. Vice Presidet ad Chief Medical Officer, Gaylord Hospital Betsy Thorquist Chief Iformatio Officer, St. Vicet s Medical Ceter Ke Lalime Executive Director, Coecticut State Medical Society, IPA, Ic. Marcia Petrillo Chief Executive Officer, Qualidigm FUNCTIONAL REQUIREMENTS AND TECHNOLOGY STANDARDS: Richard Kubica Chief Techology Officer, Hartford Hospital Scott Cleary Chief Executive Officer, SMC Parters Director, ehealthcoecticut Robert Mitchell Project Maager, CT Departmet of Social Services FUNDING AND FINANCIAL: Da Clemos Chief Fiacial Officer, Commuity Health Ceter Associatio of Coecticut, Ic. Joh Brady Chief Fiacial Officer ad VP, Busiess Plaig, Coecticut Hospital Associatio C O N N E C T I C U T S T A T E H E A L T H I T P L A N 115

120 A P P E N D I C E S / F O C U S G R O U P P A R T I C I P A N T S Greg Sulliva CT Office of Policy ad Maagemet, Budget ad Fiacial Maagemet Divisio Jack Reed Presidet ad Chief Executive Officer, ProHealth Physicias Robert Mitchell Project Maager, CT Departmet of Social Services COMMUNITY HEALTH CENTERS: Ivette Ortiz Director of Operatios, Fair Have Commuity Health Ceter Arvid Shaw Executive Director, Geeratios Family Health Ceter Kathy Yacavoe Presidet/Chief Executive Officer, Southwest Commuity Health Ceter Tom Krause Chief Operatios Officer, Southwest Commuity Health Ceter Charlie Rose Chief Fiacial Officer, Hill Health Ceter Bill Machida IT Cosultat, Hill Health Ceter Sue Peters Chief Operatig Officer, Uited Commuity ad Family Services Shati Carter Health Iformatio Applicatios Director, CHC, Ic. Joe Parks MIS Director, East Hartford Commuity HealthCare Da Clemos Chief Fiacial Officer, Commuity Health Ceter Associatio of Coecticut, Ic. Pat Moro Chief Fiacial Officer, Commuity Health Ceter Associatio of CT Evely Barum Chief Executive Officer, Commuity Health Ceter Associatio of CT Tim Colby Formerly of Commuity Health Ceter Associatio of CT 116 C O N N E C T I C U T S T A T E H E A L T H I T P L A N

121 A P P E N D I C E S / D E T A I L E D F U N C T I O N A L R E Q U I R E M E N T S A N D T E C H N O L O G Y S T A N D A R D S G. Detailed Fuctioal Requiremets ad Techology Stadards Please refer to the figure just below the table whe reviewig cross refereces i the secod colum of the table. F U N C T I O N A L R E Q U I R E M E N T S Category Compoet or Applicatio/ Diagram Cross Referece Requiremet Descriptio Ed User Buildig Blocks Electroic Medical Record (EMR) E1 A electroic record of health-related iformatio o a idividual that ca be created, maaged, gathered, ad cosulted by authorized cliicias withi oe healthcare orgaizatio. Advaced EMR systems eable cliicias to perform cliical fuctios without eedig to access or create paper charts. Collect patiet demographics, history ad problems Eter diagoses ad otes usig stadard templates, voice recogitio or other techiques to capture iput as data Order medicatios, laboratory tests, medical procedures, ad referrals to other providers Commuicate orders electroically via data iterchage stadards Medicatio, laboratory, radiology ad other orders are commuicated via Health Level 7 (HL7) stadards. eprescribig: medicatio orders are etered electroically, the script is forwarded to the selected pharmacy Full-fuctio eprescribig icludes real time access to the patiet s medicatio history, access to the patiet s health pla formulary, potetial drug-drug or drug-allergy reactios alerts, ad bi-directioal electroic commuicatios betwee physicias EMRs ad pharmacy systems supportig prescriptio orderig, medicatio fill cofirmatio ad refill requests. Receive otificatio that medicatios ad other tests or procedures were performed, ad automatically store results i electroic databases Medicatio, laboratory, radiology ad other results are commuicated via HL7 stadards. C O N N E C T I C U T S T A T E H E A L T H I T P L A N 117

122 A P P E N D I C E S / D E T A I L E D F U N C T I O N A L R E Q U I R E M E N T S A N D T E C H N O L O G Y S T A N D A R D S Category Compoet or Applicatio/ Diagram Cross Referece Requiremet Descriptio Provide alerts ad suggested cliical actios based o adopted guidelies of care Examples are remiders of appropriate testig for diabetic or hypertesive patiets, reports of asthma patiets o-compliat with medicatio prescriptios, remiders to order cacer screeig tests for patiets above a certai age or with certai risk factors. Electroic Health Record (EHR) E1 A electroic record of health-related iformatio o a idividual that coforms to atioally recogized iteroperability stadards ad that ca be created, maaged, ad cosulted by authorized cliicias ad staff across more tha oe healthcare orgaizatio. It icludes patiet data gathered from etities outside the healthcare orgaizatio. Iformatio received from other orgaizatios o paper or via fax ca be scaed, stored, ad liked to the patiet s EMR for olie viewig. A EHR system icludes the fuctios of a EMR system. Cotiuity of Care Record E2 The CCR stadard is a patiet health summary stadard. It is a way to create flexible documets that cotai the most relevat ad timely core health iformatio about a patiet, ad to sed these electroically from oe care giver to aother. It cotais various sectios such as patiet demographics, isurace iformatio, diagosis ad problem list, medicatios, allergies ad care pla. These represet a sapshot of a patiet's health data that ca be useful or possibly lifesavig, if available at the time of cliical ecouter. The ASTM CCR stadard is desiged to permit easy creatio by a physicia usig a electroic health record (EHR) system at the ed of a ecouter. Eterprise master patiet idex (EMPI) E3 The ability to cosistetly maitai patiet idetity across multiple systems ad orgaizatios withi the domai of the idividual etity. The eterprise master patiet (or perso) idex is developed, operated ad cotrolled by the ed user etity. The HIE also maitais a statewide MPI that icludes ad cross refereces the perso idetificatio iformatio supplied by each etity s EMPI. Medical Summary E2 See Cotiuity of Care Record. The Cross-Eterprise Sharig of Medical Summaries profile (IHE stadard XDS-MS) provides a mechaism to automate the sharig process betwee care providers. The medical summary cotais the most relevat portios of iformatio about the patiet iteded for a specific provider or a broad rage of potetial providers i differet settigs. Patiet trasfers ad, therefore, the summary documets that accompay these trasfers, ca be categorized ito 3 primary types: Episodic, Collaborative, or Permaet. Medical Summaries are commoly created ad cosumed by electroic medical record systems at poits i time of oe of these types of trasfers of care. For example, a referral ote is a medical summary used for a collaborative trasfer of care whereby a discharge summary is a medical summary reflectig a episodic trasfer. XDS-MS uses HL7 Cliical Documet Architecture (CDA) Release 2 ad Care Record Summary as its base stadard ad costrais this to level 3 ecodig for medicatios, allergies ad problem lists. 118 C O N N E C T I C U T S T A T E H E A L T H I T P L A N

123 A P P E N D I C E S / D E T A I L E D F U N C T I O N A L R E Q U I R E M E N T S A N D T E C H N O L O G Y S T A N D A R D S Category Compoet or Applicatio/ Diagram Cross Referece Requiremet Descriptio Persoal Health Record (PHR) E4 A electroic record of health-related iformatio o a idividual that coforms to atioally recogized iteroperability stadards ad that ca be draw from multiple sources while beig maaged, shared ad cotrolled by the idividual. Idividuals typically eter ad maitai their ow iformatio, i additio to viewig iformatio created by others. Patiet Summary Record E2 See Cotiuity of Care Record ad Medical Summary HIE Buildig Blocks Data Trasmissio Service H1 The ability to support the usolicited sedig of iformatio. Data Query Service H2 The ability to receive ad respod to queries iitiated by ed users coected to the HIE. Patiet Data Sharig Permissio Service H3 Cosumers use this service to opt i or out of the HIE ad potetially specify what data they wat shared with what providers Patiet Idetificatio ad Idexig Service, or Master Patiet (or Perso) Idex H4 This service provides a stadard patiet idetity/ iformatio correlatio process to uiquely idetify a idividual. The service uses a master patiet idex (MPI), which is a database of all the uique idetificatio umbers used by all the participatig etities i the HIE. The database also has a uique idex umber, kow oly to the HIE, for every patiet for whom data have bee created. If policymakers decide to implemet as medical idetifier for each residet, this idex umber could be used to implemet that. The patiet idetificatio service employs probabilistic matchig algorithms usig data such as ame, date of birth, geder, SSN, address, ad other perso idetifiers collected by source systems. Provider Master File ad Autheticatio Service H5 The master file of all providers kow to the HIE ad authorized to iteract with it. The file maitais a uique ID for each provider (ad also stores the Natioal Provider ID) ad iformatio about the provider s orgaizatio affiliatio, role(s), privileges, ad HIE certificatio ad authority. The file is used to autheticate authorized users, as every provider who will be allowed to plug ito the HIE will have bee certified i advace as havig a HIE certified, HIPAA compliat EHR, ad beig licesed by DPH as a kow provider with o sactios. The file also stores iformatio about which providers have what rights to what iformatio, i order to assure that the HIE has privacy ad security safeguards i place i accordace with a privacy/security policy. The file also maitais demographic ad other iformatio such as addresses so the HIE ca sed secure s, provide techical support, ad i geeral iteract with all participatig providers. The ultimate solutio will iclude a real time iterface with the DPH provider master file, which is the authoritative source of providers licesed to provide patiet care i Coecticut. C O N N E C T I C U T S T A T E H E A L T H I T P L A N 119

124 A P P E N D I C E S / D E T A I L E D F U N C T I O N A L R E Q U I R E M E N T S A N D T E C H N O L O G Y S T A N D A R D S Category Compoet or Applicatio/ Diagram Cross Referece Requiremet Descriptio Pseudoymizatio Service H6 The ability to disguise protected health iformatio. Required fuctio for secodary uses (e.g., public health populatio studies, public quality reportig), where users of the iformatio do ot eed to kow the specific idetity of people. A pseudoymizatio service employs a algorithm that ca covert a perso s idetity ito a meaigless code, ad the covert the code back agai to re-idetify the perso, whe that is required. Record Locator Service H7 The ability to determie the locatio of patiet data across multiple participatig orgaizatios ad their cliical data systems. Sematic Broker, or Data Traslatio Service H8 A sematic broker service acts as a traslator, mappig local or proprietary codes to stadard code sets. HIE People Fuctios H9 Call Ceter/Customer Service Etities participatig with the HIE ca call a perso for problem solvig, educatio, or ay issue. H10 Certificatio The ability to utilize a certificatio process that icludes the requiremets (stadards ad agreemets) with which ay etity s health iformatio users must coform for exchage of data. H11 Credetialig The ability to validate or cofirm the qualificatios of licesed professioals, e.g., cliical providers. These fuctioal requiremets are distict from autheticatio ad authorizatio. H12 Istitutioal Review Board A istitutioal review board (IRB), also kow as a idepedet ethics committee (IEC) or ethical review board (ERB) is a committee that has bee formally desigated to approve, moitor, ad review biomedical ad behavioral research ivolvig humas with the aim to protect the rights ad welfare of the research subjects. The IRB evaluates ad approves or deies all requests for secodary uses of iformatio. HIE Techical Ifrastructure Auditig ad loggig The ability to support the recordig of trasactios ad associated security related data as well as the capability to review such recordigs. Autheticatio The ability to uiquely idetify ad validate (to a reasoable degree) the idetity of a etity. These requiremets are applicable to systems, services, ad orgaizatioal actors. 120 C O N N E C T I C U T S T A T E H E A L T H I T P L A N

125 A P P E N D I C E S / D E T A I L E D F U N C T I O N A L R E Q U I R E M E N T S A N D T E C H N O L O G Y S T A N D A R D S Category Compoet or Applicatio/ Diagram Cross Referece Requiremet Descriptio Authorizatio/ permissios maagemet The ability to determie ad grat access to systems, services ad data based o prescribed parameters (istatiated authorizatio/ access policies). For example, the process of gratig authority or delegatio to specified actors Commuicatios The ability to commuicate health iformatio usig stadard cotet ad message formats. Cofidetiality The ability to esure that data are ot disclosed (e.g., viewed, obtaied or made kow) to uauthorized idividuals per orgaizatioal policies. Data Access ad Update The ability to retrieve, view, ad modify data, withi prescribed policies. Data De-idetificatio The ability to remove persoal idetifyig iformatio from trasactios to a extet compatible with HIPAA privacy stadards. Data filterig The ability to support idetifyig ad/or qualifyig data that eeds to be trasmitted. Data mappig The ability to support reformattig or expressig data i differet formats for trasmissio. Data quality/itegrity The ability to esure data is correct ad complete, icludig the ability to verify that data were trasferred. Data rederig/ user iterface The ability to preset data via a user iterface. Data retrieval (pull) The ability to support the request/retrieval of data. Data routig The ability to idetify a receivig system ad esure the delivery of data. Data security The ability to protect data from uauthorized access or harm. Data source The ability to support the idetificatio of the data/iformatio poit of origi. Data storage The ability to aggregate data from disparate sources to facilitate commuicatios. For example, temporarily hold iformatio as it is beig collected to commuicate a cocise summary of the iformatio; or permaetly store data from ucoordiated sources across time to support a data registry. C O N N E C T I C U T S T A T E H E A L T H I T P L A N 121

126 A P P E N D I C E S / D E T A I L E D F U N C T I O N A L R E Q U I R E M E N T S A N D T E C H N O L O G Y S T A N D A R D S Category Compoet or Applicatio/ Diagram Cross Referece Requiremet Descriptio Data trasactios The ability to support the trasfer of data trasactios to occur amog authorized etities ad/or users upo specific trigger evets, such as automatically sedig fial lab results for ay previously set prelimiary results, sedig ay chages i medicatios prescribed, reportig medicatio errors, otifyig public health about the occurrece of a bio-hazard evet, iformig idividuals about the availability of a cliical trial, determiig hospital cesus for disaster plaig, etc Data usage The ability to costrai the cotext ad use of data exchaged. Edge Servers See Patiet Data Repositories Network security The ability to esure the safe ad secure trasport of data over a etwork No-repudiatio The ability to esure that seders/receivers of trasactios caot reasoably dey that they set a trasactio/received a trasactio. Patiet Data Repositories See Edge Server Privacy The HIE must esure that patiet ad provider privacy is protected, i compliace with state ad federal laws ad the participat s grated iformatio access permissios. The HIE maitais a table of access rights by perso to eable the implemetatio of privacy policies. Public Key Ifrastructure Used to implemet a high level of HIE security, Public Key Ifrastructure (PKI) is a arragemet that bids public keys with respective user idetities by meas of a certificate authority (CA). The user idetity must be uique for each CA. The bidig is established through the registratio ad issuace process, which, depedig o the level of assurace the bidig has, may be carried out by software at a CA, or uder huma supervisio. The PKI role that assures this bidig is called the Registratio Authority (RA). For each user, the user idetity, the public key, their bidig, validity coditios ad other attributes are made uforgeable i public key certificates issued by the CA. 122 C O N N E C T I C U T S T A T E H E A L T H I T P L A N

127 A P P E N D I C E S / D E T A I L E D F U N C T I O N A L R E Q U I R E M E N T S A N D T E C H N O L O G Y S T A N D A R D S Category Compoet or Applicatio/ Diagram Cross Referece Requiremet Descriptio Secure trasport The ability to exchage messages across a etwork that esures that trasmissios betwee systems are delivered cofidetially, reliably ad itact. Security The HIE must esure that data are protected from uauthorized access. This is eabled by usig moder techiques such as Public Key Ifrastructure to autheticate users ad a Virtual Private Network with ecryptio to eable the use of the Iteret while providig ecessary protectio. Loggig of all trasactios is required, as is the capability to moitor activity with auditig programs to idetify uusual or improper activities. A Istitutioal Review Board govers the use of all data, ad sets policy such as requirig pseudoymizatio for all secodary uses of data. Time sesitive data access The ability to provide time-sesitive data request/respose iteractios to specific target systems (e.g., query of immuizatio registry, request for curret medicatio list). Trasiet data The ability of a system to fuctio as a data repository for a give etity for a give period of time or purpose. Trasport ad cotet stadards Trasport requests for ad resposes regardig locatio of iformatio, requests for data, data itself, ad other types of messages (such as otificatios of the availability of ew data) to destiatios usig geeral idustry recogized trasport types. HIE Busiess Requiremets Accuracy A measure of the applicatio service quality from the customer s perspective, the precisio with which resposes are provided to customer iquiries. Busiess Rules Policy drive dyamic requiremets that may chage durig the operatio of the system, requirig that the system adapt to the chage without major rework. Performace A measure of the degree to which a etity satisfies its iteded purpose. C O N N E C T I C U T S T A T E H E A L T H I T P L A N 123

128 A P P E N D I C E S / D E T A I L E D F U N C T I O N A L R E Q U I R E M E N T S A N D T E C H N O L O G Y S T A N D A R D S Category Compoet or Applicatio/ Diagram Cross Referece Requiremet Descriptio Robustess A measure of the ability of system to adjust to uaticipated coditios (i.e., the ability of a system to adjust to uaticipated coditios without losig its edurace ad level of quality). Scalability A measure of the ability of system to adjust or exted to hagig demads (user load, data load). Sustaiability A measure of the eterprise s ability to support itself over time with fiacial ad huma resources that eable services to be delivered ad additioal services to be developed. Statewide Health Iformatio Exchage Network 124 C O N N E C T I C U T S T A T E H E A L T H I T P L A N

129 A P P E N D I C E S / D E T A I L E D F U N C T I O N A L R E Q U I R E M E N T S A N D T E C H N O L O G Y S T A N D A R D S Techology Stadards This sectio describes techology stadards that will be employed by the HIEN. These are basic, reusable fuctios or compoets that must be i place to support the buildig blocks ad i tur the ed user fuctioality. Widely accepted health iformatio techology (health IT) ad health iformatio exchage (HIE) stadards ad protocols serve as key eablers of health iformatio exchage as evisioed by the Office of the Natioal Coordiator for Health Iformatio Techology (ONCHIT). The sectio first groups the idetified stadards ito the followig broad categories i order to promote uderstadig of key cocepts ad the outlies each category i more detail. For the techical, sematic, ad process stadards, JSI icludes recommedatios for specific stadards for the CT State RHIO to cosider whe developig the health iformatio exchage etwork. Policy Priciples are iteded to guide orgaizatios with the high level cocepts regardig how, whe ad why patiet data is shared across the health iformatio exchage etwork. These priciples suggest a overarchig framework for data sharig that must be agreed to by all participatig orgaizatios. Techology Priciples are iteded to both provide guidace to optimize the developmet of the HIE ad maximize the potetial uses of the HIE for the broad healthcare commuity. The techology priciples take ito cosideratio the limitatios ad capabilities of the existig health IT eviromet ad support a phased developmet of HIE related capabilities. Techical Stadards focus o the physical trasmissio ad receipt of health data ad its trasport betwee participatig systems. This icludes message formats ad reliable, secure message trasport. Sematic Stadards focus o esurig shared meaig betwee sedig ad receivig parters i.e. esurig that the meaig of what was set is cosistet with the uderstadig of what was received. Sematic stadards focus o medical termiology that ca be refereced cosistetly by all parties. Process Stadards focus o higher-order workflow cocepts that make data sharig a richer ad more valuable experiece. Work i this area tries to uderstad how shared health data supports the specific activities ad workflow of the orgaizatios that use it ad the itegratio of health data ito the work settig. Policy Priciples The followig guidig policy priciples are excerpted from The Commo Framework developed by Coectig for Health which is supported by The Markle Foudatio. The Commo Framework outlies ie core policy priciples that orgaizatios watig to participate i health iformatio exchage should adhere to i order to esure private ad secure iformatio exchage. C O N N E C T I C U T S T A T E H E A L T H I T P L A N 125

130 A P P E N D I C E S / D E T A I L E D F U N C T I O N A L R E Q U I R E M E N T S A N D T E C H N O L O G Y S T A N D A R D S Opeess ad Trasparecy - There should be a geeral policy of opeess about developmets, practices, ad policies with respect to persoal data. Idividuals should be able to kow what iformatio exists about them, the purpose of its use, who ca access ad use it, ad where it resides. Purpose Specificatio ad Miimizatio - The purposes for which persoal data are collected should be specified at the time of collectio ad the subsequet use should be limited to those purposes or others that are specified o each occasio of chage of purpose. Collectio Limitatio - Persoal health iformatio should oly be collected for specified purposes, should be obtaied by lawful ad fair meas ad, where possible, with the kowledge or coset of the data subject. Use Limitatio - Persoal data should ot be disclosed, made available, or otherwise used for purposes other tha those specified. Idividual Participatio ad Cotrol - Idividuals should cotrol access to their persoal iformatio: w w w w Idividuals should be able to obtai from each etity that cotrols persoal health data, iformatio about whether or ot the etity has data relatig to them; Have persoal data relatig to them commuicated withi a reasoable time (at a affordable charge, if ay), ad i a form that is readily uderstadable; Be give reasos if a request (as described above) is deied, ad to be able to challege such deial; ad Challege data relatig to them ad have it rectified, completed, or ameded. Data Itegrity ad Quality - All persoal data collected should be relevat to the purposes for which they are to be used ad should be accurate, complete, ad curret. Security Safeguards ad Cotrols - Persoal data should be protected by reasoable security safeguards agaist such risks as loss or uauthorized access, destructio, use, modificatio, or disclosure. Accoutability ad Oversight - Etities i cotrol of persoal health data must be held accoutable for implemetig these iformatio practices. Remedies - Legal ad fiacial remedies must exist to address ay security breaches or privacy violatios. Techology Priciples The Commo Framework outlies eight core techology priciples to allow fragmeted health iformatio etworks to coect to oe aother to ultimately form a atiowide health iformatio etwork. 126 C O N N E C T I C U T S T A T E H E A L T H I T P L A N

131 A P P E N D I C E S / D E T A I L E D F U N C T I O N A L R E Q U I R E M E N T S A N D T E C H N O L O G Y S T A N D A R D S Make it Thi - Oly the miimum umber of rules ad protocols essetial to widespread exchage of health iformatio should be specified as part of a Commo Framework. It is desirable to leave to the local systems those thigs best hadled locally, while specifyig at a atioal level those thigs required as uiversal i order to allow for exchage amog subordiate etworks. Avoid Rip ad Replace - Ay proposed model for health iformatio exchage must take ito accout the curret structure of the healthcare system. While some ifrastructure may eed to evolve, the system should take advatage of what has bee deployed today. Similarly, it should build o existig Iteret capabilities, usig appropriate stadards for esurig secure trasfer of iformatio. Separate Applicatios from the Network - The purpose of the etwork is to allow authorized persos to access data as eeded. The purpose of applicatios is to display or otherwise use that data oce received. The etwork should be desiged to support ay ad all useful types of applicatios, ad applicatios should be desiged to take data i from the etwork i stadard formats. This allows ew applicatios to be created ad existig oes upgraded without re-desigig the etwork itself. Decetralizatio - Data stay where they are. The decetralized approach leaves cliical data i the cotrol of those providers with a direct relatioship with the patiet, ad leaves judgmets about who should ad should ot see patiet data i the hads of the patiet ad the physicias ad istitutios that are directly ivolved with his or her care. Federatio - The participatig members of a health etwork must belog to ad comply with agreemets of a federatio. Federatio, i this view, is a respose to the orgaizatioal difficulties preseted by the fact of decetralizatio. Formal federatio with clear agreemets builds trust that is essetial to the exchage of health iformatio. Flexibility - Ay hardware or software ca be used for health iformatio exchage as log as it coforms to a Commo Framework of essetial requiremets. The etwork should support variatio ad iovatio i respose to local eeds. The etwork must be able to scale ad evolve over time. Privacy ad Security - All health iformatio exchage, icludig i support of the delivery of care ad the coduct of research ad public health reportig, must be coducted i a eviromet of trust, based upo coformace with appropriate requiremets for patiet privacy, security, cofidetiality, itegrity, audit, ad iformed coset. Accuracy - Accuracy i idetifyig both a patiet ad his or her records with little tolerace for error is a essetial elemet of health iformatio exchage. There must also be feedback mechaisms to help orgaizatios to fix or clea their data i the evet that errors are discovered. C O N N E C T I C U T S T A T E H E A L T H I T P L A N 127

132 A P P E N D I C E S / D E T A I L E D F U N C T I O N A L R E Q U I R E M E N T S A N D T E C H N O L O G Y S T A N D A R D S Techical Stadards The followig table outlies widely accepted techical stadards used to support health iformatio exchage ad iteroperability of Health IT systems. T E C H N I C A L S T A N D A R D S Category Stadard Descriptio Network Coectivity Iteret Egieerig Task Force (IETF) Trasmissio Cotrol Protocol/Iteret Protocol (TCP/IP) Versio 4 This is the de facto etworkig stadard of the Iteret ad most mature itra-orgaizatioal local area ad eterprise-wide etworks. Web Applicatios Web Browser compatible with IETF Hypertext Trasfer Protocol (HTTP) Versio 1.1 This represets the miimum level of compliace for web-based applicatios. Specific applicatios may be depedet o other software or compatibility (e.g., Java, Javascript). Trasport Ecryptio IETF Trasport Layer Security (TLS) Versio 1.0/Secure Socket Layer (SSL) Versio 3.0 This is the de facto trasport ecryptio protocol of the Iteret. Note that trasport ecryptio is oly ecessary whe data is trasported over public (isecure) etworks ad ot whe data is trasported over private (secure) etworks. Autheticatio Userame/Strog Password Public Key Ifrastructure (PKI) Hardware Tokes Biometric Devices May strategies exist, ad their specific use will deped o the applicatio. Specific rules may differ for userame/password for specific applicatios. Multi-factor autheticatio may also be ecessary for some applicatios. Applicatio Architecture Multi-tier, with separatio betwee presetatio layer, busiess logic, ad data Service-orieted Architecture (SOA). A multi-tier architecture better esures applicatio scalability ad security. SOA is especially useful for loosely coupled, etwork applicatios that are typical of may HIE implemetatios. Cliical Cotext Maagemet HL7 CCOW Eables visual itegratio of differet healthcare applicatios Database Access ANSI Structured Query Laguage (SQL) This is the de facto query laguage for commercial ad ope source relatioal database maagemet systems. Web Applicatios Rehabilitatio Act of 1973 Sectio 508 Compliat Applicatio user iterfaces must be accessible to idividuals with disabilities. Directory Services IETF Lightweight Directory Access Protocol (LDAP) Versio 3.0 This is the de facto directory storage ad access protocol of the Iteret. 128 C O N N E C T I C U T S T A T E H E A L T H I T P L A N

133 A P P E N D I C E S / D E T A I L E D F U N C T I O N A L R E Q U I R E M E N T S A N D T E C H N O L O G Y S T A N D A R D S Category Stadard Descriptio Autheticatio Sigle Sig-o (SSO) I cojuctio with other autheticatio strategies, SSO provides a more comprehesive solutio that makes the maagemet of credetials for multiple systems easier for users. Trasport Ceters for Disease Cotrol ad Prevetio Public Health Iformatio Network (PHIN) PHIN is a framework to promote iteroperability amog public health reportig systems. PHIN stadards will be relevat for a subset of HIE activities related to systems ad fuctios with its domai Trasport SOAP, Web Services, ebxml Various trasport mechaisms may be employed by HIE applicatios to eable iteroperability betwee systems. Cliical Documets Health Level 7 (HL7) Versio 3.0 Cliical Documet Architecture (CDA/CDA R2) Provides a model ad architecture for the developmet of documets that are both machie readable ad huma readable to eable data exchage betwee systems. Specific cliical documets may be developed ad required for specific HIE fuctios. Sematic Stadards The followig table outlies widely accepted cliical amig ad amig code set (sematic) stadards used to support health iformatio exchage ad iteroperability of Health IT systems. S E M A N T I C S T A N D A R D S Stadard Descriptio Digital Imagig ad Commuicatios i Medicie (DICOM) PS Eables iteroperability with medical images, especially with respect to imagig devices ad other medical systems. Health Level 7 (HL7) Versio 2. Messagig Stadard This is the message stadard supportig cliical data exchage widespread use withi the medical commuity. While Versio 2.5 is the versio curretly released, earlier subversios of the Versio 2 stadard may be i use ad may cotiue to be recommeded some istaces. Health Level 7 (HL7) Versio 3.0 Messagig Stadard This versio is emergig over time as the preferred stadard, replacig Versio 2. This will be a gradual trasitio over a umber of years. Itegratig the Healthcare Eterprise (IHE) Techical Frameworks These techical frameworks provide pre-developed profiles which serve as implemetatio guides for HL7 messages iteded to specific purposes. Accredited Stadards Committee (ASC) X12 Stadards Release Electroic data iterchage stadards most relevat to processig isurace claims ad other busiess activities i healthcare. C O N N E C T I C U T S T A T E H E A L T H I T P L A N 129

134 A P P E N D I C E S / D E T A I L E D F U N C T I O N A L R E Q U I R E M E N T S A N D T E C H N O L O G Y S T A N D A R D S S E M A N T I C S T A N D A R D S Stadard Descriptio Natioal Coucil for Prescriptio Drug Programs (NCPDP) SCRIPT Stadard Versio 8.1 Developed for trasmittig prescriptio iformatio electroically betwee prescribers ad providers usig stadard EDIFACT ASC X12 data tables where possible addressig the electroic trasmissio of ew prescriptios, chages of prescriptios, prescriptio refill requests, prescriptio fill status otificatios, cacellatio otificatios, ad relayig of medicatio history. CMS Healthcare Commo Procedure Code System (HCPCS)/America Medical Associatio (AMA) Curret Procedural Termiology (CPT ) Fourth Editio (CPT-4) This is the stadard codig for procedures widely used i the healthcare commuity: Level I: Hospital Outpatiet Procedures (CPT4) Level II: Products, supplies ad other services Ceters for Disease Cotrol ad Prevetio (CDC) Race ad Ethicity Code Sets These code sets are based o curret federal stadards. College of America Pathologists Systematized Nomeclature of Medicie Cliical Terms (SNOMED CT ) This is the stadard codig used for a wide variety of medical ad healthcare terms. Iteratioal Classificatio of Diseases, Nith Editio, Cliical Modificatios (ICD-9-CM) This is the stadard codig used for diagoses ad procedures by hospitals: Volume 1 & 2: Hospital diagoses Volume 3: Ipatiet hospital procedures Iteratioal Classificatio of Diseases, 10th revisio, Related Health Problems (ICD-10 CM) This revisio to ICD-9-CM cotais a umber of importat improvemets. This stadard is ot yet widely implemeted. Logical Observatio Idetifiers Names ad Codes (LOINC ) This is the stadard codig for laboratory ad cliical observatios used by healthcare systems ad messagig (like HL7). Natioal Library of Medicie (NLM) Uified Medical Laguage System (UMLS) RxNorm This is the stadard for codig the ames of drugs ad dose forms. Natioal Drug Code (NDC) This is a uiversal product idetifier for huma drugs. 130 C O N N E C T I C U T S T A T E H E A L T H I T P L A N

135 A P P E N D I C E S / H O S P I T A L S U R V E Y E X C E R P T S Process Stadards The followig table outlies widely accepted process stadards used to support cosistet use of health IT i cliical settigs. P R O C E S S S T A N D A R D S Stadard Health Level 7 (HL7) EHR System Fuctioal Model Various subject matter or project specific requiremets icludig Uified Modelig Laguage (UML) Versio 2.0 compliat use cases Certificatio Commissio for Healthcare Iformatio Techology (CCHIT) certified Ambulatory ad Ipatiet Electroic Health Record Products Health Level 7 (HL7) EHR Iteroperability Model Draft Stadard for Trial Use (DSTU) America Health Iformatio Commuity Use Cases Descriptio This serves as a referece to the features desirable for a electroic health record system from the user s poit of view. HIE systems ad applicatios should have a specific body of descriptive material cocerig their desired purpose ad fuctioality. Oly CCHIT-certified systems are recommeded for deploymet by participatig orgaizatios. I additio, the state may recommed a smaller subset of certified systems as beig preferred for deploymet. Certificatio for hospital ipatiet products is ot yet complete. This is a compaio stadard to the Health Level 7 (HL7) EHR System Fuctioal Model ad cliical messagig. It provides a meas of esurig iteroperability through the developmet ad implemetatio of iteroperability profiles which specify a set of characteristics withi a data exchage trasactio. This draft stadard is early i its developmet ad will take several years to mature. Detailed specificatios for use cases eabled by health iformatio exchage which demostrate the potetial of HIE to cliicias ad other healthcare professioals. H. Hospital Survey Excerpts Hospitals are critical to the success of health iformatio exchage capacity i the state. Hospitals geerate the largest volume of healthcare related trasactios, have well established health IT ifrastructures, have substatial techical ad fiacial resources, ad as HIPAA covered etities, have a deep uderstadig of the sesitivities ad requiremets associated with sharig persoal health iformatio. I collaboratio with the Coecticut Hospital Associatio, JSI coducted a survey of the hospitals i the state. Fourtee hospitals respoded ad key excerpts of the survey are refereced below. Color codig displayed i the tables represets the followig: Gree well positioed to support health iformatio exchage across most/all respodets. Yellow margially positioed to support health iformatio exchage across some respodets. Red limited capacity to support health iformatio exchage across most respodets. NOTE: Health iformatio exchage capacity betwee hospitals is sigificatly depedet o the developmet of a regioal or statewide health iformatio exchage etwork. C O N N E C T I C U T S T A T E H E A L T H I T P L A N 131

136 A P P E N D I C E S / H O S P I T A L S U R V E Y E X C E R P T S Health IT Systems ad Health Iformatio Exchage Capabilities Do you curretly have IT applicatios i the followig cliical areas ad if so, do they have electroic data iterfaces to other systems? IT Applicatios (Do you curretly have IT applicatios i the followig cliical areas?) Iterfaces (If yes, do they have electroic data iterfaces to other systems?) Acute Care 12 (85.7%) 9 (75%) ADT 14 (100%) 14 (100%) Emergecy Departmet 13 (92.9%) 9 (69.2%) Lab 14 (100%) 14 (100%) Pathology 14 (100%) 13 (92.9%) Pharmacy 14 (100%) 12 (85.7%) Radiology 14 (100%) 13 (92.9%) Trascriptio 14 (100%) 14 (100%) * Not all respodets aswered every questio. Percetages iclude oly those that respoded. For the respodig orgaizatios, the survey shows a sigificat ivestmet i health IT systems across all fuctioal areas ad also, a sigificat potetial for data exchage ad data itegratio through established iterfaces. Does your hospital have or are you plaig to implemet a Electroic Health Record system? Thirtee (92.9%) of the 14 respodig hospitals curretly have EHR systems, with the fial oe i the plaig process to implemet oe. If yes, please specify the fuctios that your EHR system supports or will support i the ear future 132 C O N N E C T I C U T S T A T E H E A L T H I T P L A N

137 A P P E N D I C E S / H O S P I T A L S U R V E Y E X C E R P T S Fully Partially Withi ext year Next 2-3 Years Not plaed Cliical documetatio 3 (21.4) 8 (57.1) 2 (14.3) 1 (7.1) 0 (0) Cliical guidelies 1 (7.1) 6 (42.9) 3 (21.4) 3 (21.4) 1 (7.1) Discharge Summaries 4 (28.6) 4 (28.6) 3 (21.4) 2 (14.3) 1 (7.1) Drug iteractio alerts 8 (57.1) 3 (21.4) 2 (14.3) 1 (7.1) 0 (0) Patiet home moitorig 2 (14.3) 1 (7.1) 0 (0) 2 (14.3) 9 (64.3) Lab orders 11 (78.6) 2 (14.3) 0 (0) 1 (7.1) 0 (0) Lab results 11 (78.6) 2 (14.3) 0 (0) 1 (7.1) 0 (0) Medicatio history 8 (57.1) 3 (21.4) 2 (14.3) 1 (7.1) 0 (0) Pathology orders 10 (71.4) 3 (21.4) 0 (0) 1 (7.1) 0 (0) Pathology results 11 (78.6) 2 (14.3) 0 (0) 1 (7.1) 0 (0) Patiet access to HER 1 (7.1) 0 (0) 0 (0) 3 (21.4) 10 (71.4) Patiet demographics 11 (78.6) 2 (14.3) 0 (0) 1 (7.1) 0 (0) Patiet flow sheets 4 (28.6) 4 (28.6) 5 (35.7) 1 (7.1) 0 (0) Patiet medical history 7 (50.0) 4 (28.6) 1 (7.1) 2 (14.3) 0 (0) Pharmacy orders 11 (78.6) 1 (7.1) 1 (7.1) 1 (7.1) 0 (0) Radiology images 10 (71.4) 2 (14.3) 0 (0) 1 (7.1) 1 (7.1) Radiology orders 11 (78.6) 2 (14.3) 0 (0) 1 (7.1) 0 (0) Radiology results 11 (78.6) 2 (14.3) 0 (0) 1 (7.1) 0 (0) * Not all respodets aswered every questio. Percetages iclude oly those that respoded. C O N N E C T I C U T S T A T E H E A L T H I T P L A N 133

138 A P P E N D I C E S / H O S P I T A L S U R V E Y E X C E R P T S This survey questio shows a sigificat ad cosistet commitmet to the developmet of EHR systems. Note that the large majority of respodets idicate full or partial fuctioality for each fuctioal area withi existig EHR systems. Does your hospital provide or are you plaig to provide access to hospital-based EHR data i ay of the followig cliical settigs? Fully Partially Withi ext year Next 2-3 Years Not plaed Cliics O Site 8 (57.1) 2 (14.3) 2 (14.3) 2 (14.3) 0 (0) Cliics Off Site 7 (50.0) 3 (21.4) 1 (7.1) 2 (14.3) 1 (7.1) Emergecy Departmet 8 (57.1) 3 (21.4) 2 (14.3) 1 (7.1) 0 (0) Hospital ipatiet departmets 10 (71.4) 1 (7.1) 2 (14.3) 1 (7.1) 0 (0) Log term care settigs 4 (28.6) 3 (21.4) 1 (7.1) 0 (0) 6 (42.9) MD Offices O site 8 (57.1) 1 (7.1) 1 (7.1) 3 (21.4) 1 (7.1) MD Offices Off site 7 (50.0) 2 (14.3) 2 (14.3) 3 (21.4) 0 (0) Post-Acute care settigs 4 (28.6) 3 (21.4) 0 (0) 1 (7.1) 6 (42.9) * Not all respodets aswered every questio. Percetages iclude oly those that respoded. The resposes suggest a sigificat commitmet to makig EHR data accessible to a variety of cliical settigs, particularly withi the formal hospital eviromet. The results suggest a somewhat lower commitmet to providig access to physicia offices ad by extesio, direct itegratio ad data sharig with physicia EMR systems due to icreased costs ad extesive formal commitmet o the part of all parties. Fially, EHR access i log-term ad post-acute care settigs is a sigificatly lower priority. 134 C O N N E C T I C U T S T A T E H E A L T H I T P L A N

139 A P P E N D I C E S / H O S P I T A L S U R V E Y E X C E R P T S Does your hospital share cliical data electroically with other orgaizatios? If yes, please check all that apply. T Y P E O F D A T A Number of Hospitals that electroically share cliical data with other orgaizatios ADT Iformatio Claims data Images Lab Results Lab Orders Patiet Demographics Prescriptios Radiology orders Radiology Results Trascriptio otes Commuity Health Ceters Free stadig imagig ceters Laboratories Log-term care facilities CT state agecies Other hospitals Payers Public health departmet Retail pharmacies 1 1 School cliics Based o iterview results ad geeral hospital busiess practices, we expected much higher participatio for cliical data sharig with laboratories, Coecticut state agecies, ad payers. C O N N E C T I C U T S T A T E H E A L T H I T P L A N 135

140 A P P E N D I C E S / H O S P I T A L S U R V E Y E X C E R P T S Has your hospital implemeted or are you plaig to implemet ay of the followig modules withi your HIE related systems/applicatios? Fully Partially Withi ext year Next 2-3 Years Not plaed Missig Data exchage iterface egie 5 (35.7) 2 (14.3) 4 (28.6) 2 (14.3) 1 (7.1) 0 (0) Data security framework 7 (50.0) 0 (0) 4 (28.6) 1 (7.1) 2 (14.3) 0 (0) Data warehouse 3 (21.4) 2 (14.3) 2 (14.3) 6 (42.9) 1 (7.1) 0 (0) Electroic health record 3 (21.4) 3 (21.4) 4 (28.6) 4 (28.6) 0 (0) 0 (0) Master patiet idex 4 (28.6) 1 (7.1) 4 (28.6) 3 (21.4) 2 (14.3) 0 (0) Patiet locator service 1 (7.1) 0 (0) 0 (0) 3 (21.4) 8 (57.1) 2 (14.3) Patiet portal 0 (0) 1 (7.1) 2 (14.3) 2 (14.3) 8 (57.1) 1 (7.1) Patiet privacy framework 3 (21.4) 0 (0) 0 (0) 3 (21.4) 6 (42.9) 2 (14.3) Persoal health record 0 (0) 0 (0) 0 (0) 2 (14.3) 10 (71.4) 2 (14.3) Physicia portal 4 (28.6) 5 (35.7) 2 (14.3) 1 (7.1) 0 (0) 2 (14.3) Program reµgistry 0 (0) 1 (7.1) 0 (0) 0 (0) 10 (71.4) 3 (21.4) Provider locator service 1 (7.1) 1 (7.1) 0 (0) 2 (14.3) 7 (50.0) 3 (21.4) * Not all respodets aswered every questio. Percetages iclude oly those that respoded. 136 C O N N E C T I C U T S T A T E H E A L T H I T P L A N

141 A P P E N D I C E S / H O S P I T A L S U R V E Y E X C E R P T S These results suggest a sigificat commitmet by respodets to develop the ifrastructure for a electroic health record ad data exchage capability withi their specific orgaizatios, servig their immediate commuity of healthcare professioals. The results also show limited itetios ad/or low priority for extedig their HIE capabilities to the broader healthcare commuity or patiet commuity. Opportuities ad Barriers to Adoptio Where do you thik the greatest opportuities lie with electroic health records ad health iformatio exchage? Please check oe for each. Fully Low Moderate Strog Access to curret medical record 0 (0) 0 (0) 6 (42.9) 8 (57.1) Access to patiet history 0 (0) 0 (0) 4 (28.6) 10 (71.4) Miimize adverse drug reactios 0 (0) 1 (7.1) 3 (21.4) 10 (71.4) Miimize redudat tests 0 (0) 3 (21.4) 6 (42.9) 5 (35.7) Ehace Quality of Care 0 (0) 0 (0) 4 (28.6) 10 (71.4) Timely delivery of orders/results 0 (0) 1 (7.1) 8 (57.1) 5 (35.7) These results show a strog ad cosistet perceived value for all suggested EHR ad HIE opportuities. C O N N E C T I C U T S T A T E H E A L T H I T P L A N 137

142 A P P E N D I C E S / H O S P I T A L S U R V E Y E X C E R P T S What do you cosider to be barriers to adoptio of EHRs ad HIE? Not a barrier Somewhat of a barrier Sigificat Barrier Acceptace by cliical staff 3 (21.4) 8 (57.1) 3 (21.4) Competitive climate with other hospitals 8 (57.1) 3 (21.4) 3 (21.4) Fear that techology will chage 7 (50.0) 6 (42.9) 1 (7.1) HIPAA compliace/patiet privacy 4 (28.6) 6 (42.9) 4 (28.6) Impact o cliical process 1 (7.1) 8 (57.1) 5 (35.7) Iitial cost of ivestmet 0 (0) 3 (21.4) 11 (78.6) Iteroperability with other systems 0 (0) 7 (50.0) 7 (50.0) Lack of time or resources 0 (0) 5 (35.7) 9 (64.3) Legal barriers 5 (35.7) 6 (42.9) 3 (21.4) Ogoig cost to maitai 0 (0) 6 (42.9) 8 (57.1) Techology does t meet eeds 5 (35.7) 7 (50.0) 2 (14.3) Uprove retur o ivestmet 6 (42.9) 3 (21.4) 5 (35.7) Well traied IT staff 4 (28.6) 9 (64.3) 1 (7.1) * Not all respodets aswered every questio. Percetages iclude oly those that respoded. These results idicate that the fiacial ad other resources required to support EHRs ad HIE capacity are the biggest cocers. However, it is also clear that all barriers to adoptio must be specifically addressed give that a large umber of respodets view each potetial barrier as either somewhat or sigificat barriers. 138 C O N N E C T I C U T S T A T E H E A L T H I T P L A N

143 A P P E N D I C E S / H O S P I T A L S U R V E Y E X C E R P T S HIE Oversight ad State Ivolvemet Which of the followig approaches have you foud helpful to support your EHR/HIE related projects? Not Helpful Somewhat Helpful Very Helpful Madatory Missig /a Ogoig collaboratio with hospital seior maagemet 0 (0) 2 (14.3) 2 (14.3) 9 (64.3) 1 (7.1) 0 (0) Participatio i a regioal health iformatio orgaizatio 3 (21.4) 8 (57.1) 0 (0) 1 (7.1) 2 (14.3) 0 (0) Ogoig collaboratio with cliical staff 0 (0) 0 (0) 5 (35.7) 8 (57.1) 1 (7.1) 0 (0) Ogoig collaboratio with other healthcare providers 0 (0) 3 (21.4) 6 (42.9) 4 (28.6) 1 (7.1) 0 (0) Ogoig collaboratio with 3rd party health IT vedors 1 (7.1) 1 (7.1) 6 (42.9) 4 (28.6) 2 (14.3) 0 (0) Formalized educatio ad traiig programs 1 (7.1) 4 (28.6) 2 (14.3) 5 (35.7) 2 (14.3) 0 (0) Formalized HIE policies 1 (7.1) 5 (35.7) 2 (14.3) 4 (28.6) 2 (14.3) 0 (0) Private grats 5 (35.7) 3 (21.4) 4 (28.6) 0 (0) 1 (7.1) 1 (7.1) Federal grats 5 (35.7) 3 (21.4) 4 (28.6) 0 (0) 1 (7.1) 1 (7.1) Compliace with federal HIE stadards 1 (7.1) 5 (35.7) 1 (7.1) 4(28.6) 3 (21.4) 0 (0) The results show a cosistet uderstadig ad awareess of the eed for commuicatio, collaboratio, educatio ad a commitmet to stadards ad best practices to maximize the potetial of successful EHR adoptio ad HIE related projects. The lack of ivolvemet of RHIOs as well as grat fiacig suggests that these projects may be hospital-cetric with limited ivolvemet of the broader healthcare commuity. C O N N E C T I C U T S T A T E H E A L T H I T P L A N 139

144 A P P E N D I C E S / H O S P I T A L S U R V E Y E X C E R P T S Would you support the use of cliical data origiatig at your hospital for other purposes? If yes, please check all that apply. T Y P E O F D A T A Check if Yes ADT Iformatio Claims data Images Lab Results Lab Orders Patiet Demographics Prescriptios Radiology orders Radiology Results Trascriptio otes Public health programs 11/14 (78.6) 5/7 (71.4) 3/7 (42.9) 3/7 (42.9) 6/7 (85.7) 2/7 (28.6) 6/7 (85.7) 5/7 (71.4) 1/7 (14.3) 6/7 (85.7) 3/7 (42.9) Quality programs 11/14 (78.6) 4/6 (66.7) 2/6 (33.3) 2/6 (33.3) 6/6 (100) 1/6 (16.7) 6/6 (100) 4/6 (66.7) 1/6 (16.7) 5/6 (83.3) 2/6 (33.3) * Not all respodets aswered every questio. Percetages iclude oly those that respoded. Survey results show a fairly strog commitmet to makig cliical data available to public health ad quality-based orgaizatios for secodary uses. What assistace might the State of Coecticut provide to support your EHR ad HIE related efforts? Not helpful Somewhat Helpful Very Helpful Madatory Provide educatio ad traiig resources 3 (21.4) 4 (28.6) 6 (42.9) 1 (7.1) Provide forums to promote commuicatio/collaboratio 1 (7.1) 5 (35.7) 7 (50.0) 1 (7.1) Provide fudig 0 (0) 0 (0) 11 (78.6) 3 (21.4) Provide access to capital to fud health IT programs 1 (7.1) 1 (7.1) 8 (57.1) 4 (28.6) Sposor/fud HIE goverace 1 (7.1) 5 (35.7) 6 (42.9) 2 (14.3) Develop a statewide HIE ifrastructure 0 (0) 6 (42.9) 7 (50.0) 1 (7.1) Formalize policy ad legal guidace to promote HIE 1 (7.1) 4 (28.6) 5 (35.7) 4 (28.6) Provide techical support resources 3 (21.4) 4 (28.6) 7 (50.0) 0 (0) * Not all respodets aswered every questio. Percetages iclude oly those that respoded. Survey results idicate a strog desire for the state to adopt a leadership role ad provide sigificat resources to support EHR ad HIE related projects. 140 C O N N E C T I C U T S T A T E H E A L T H I T P L A N

145 A P P E N D I C E S / P I L O T P R O J E C T C E R T I F I C A T I O N T E M P L A T E I. Pilot Project Certificatio Template The project certificatio template is a tool that will be used to verify that health iformatio exchage projects meet the criteria ecessary to esure that they are supportig the state strategy for health iformatio exchage ad that the health iformatio exchage capabilities they are developig will evetually be able to support iformatio exchage at the state level ad evetually itegrate with the Natiowide Health Iformatio Network (NHIN) as required. Project certificatio criteria iclude: Eligibility Ay public or private healthcare orgaizatio or collaboratig group of healthcare orgaizatios i the State of Coecticut may apply. A healthcare orgaizatio is defied as ay orgaizatio that is directly ivolved with the provisio of patiet care or ay orgaizatio that is ivolved with the oversight or maagemet of the Coecticut healthcare system. Orgaizatioal preparedess The sposored orgaizatio must have active support from commuity stakeholders as well as structured ad ogoig oversight from a well defied leadership group such as a regioal health iformatio orgaizatio (RHIO). For collaboratig groups, a lead orgaizatio will be desigated. The lead orgaizatio must have demostrated experiece i health IT/HIE. Collaboratio The degree to which the orgaizatio demostrates collaboratio with a existig group of healthcare orgaizatios as well as its willigess to serve as a health IT/HIE champio for the state by sharig relevat project iformatio with the CT State RHIO ad other collaboratig orgaizatios across the state. Project impact The proposal must clearly describe how the project will result i improvemets i the overall healthcare system. Relevat criteria may iclude: Patiet populatio served Healthcare professioal populatio served Relevace to the broader healthcare commuity Cost of care reductio Healthcare system efficiecy improvemet Quality of care improvemet Patiet safety improvemet Busiess pla The proposal must clearly describe the size of the patiet ad healthcare professioal commuity impacted by the project, the reveue geeratig model that will sustai the project, the level of preparedess for the medical commuity to participate i the project, the approach to marketig offered services, ad the required resources ecessary to sustai the project followig implemetatio. C O N N E C T I C U T S T A T E H E A L T H I T P L A N 141

146 A P P E N D I C E S / P I L O T P R O J E C T C E R T I F I C A T I O N T E M P L A T E Educatio ad outreach The proposal will cotai plas for educatio ad outreach for cosumers, the healthcare professioals that will use the system, ad the support staff that will operate ad maitai the system. Project pla The proposal will cotai a detailed project pla that provides a review of all key project activities ad associated resource requiremets. Key milestoes ad timelie will be icluded as part of the project pla. Staffig The proposal will demostrate that the project has the required resources to support the project from iceptio through implemetatio as well as resource requiremets to sustai ogoig operatios followig implemetatio. Fiacial viability The proposal will idetify capital fudig sources (federal, state ad/or private grat fuds) that are adequate to support the project from iceptio through implemetatio. Detailed budgets must be provided that lik fudig sources to capital expeditures. Project costs must be aliged with expected value ad beefits. Reveue models will be defied ad implemeted to provide fiaces required to support log term sustaiability. Sustaiability ad expasio The proposal will demostrate that the project has potetial for expasio to a broader healthcare commuity ad/or potetial for broadeig the type of data exchaged over the etwork beyod the iitial implemetatio. Techical architecture The proposal will demostrate the degree to which the proposed techical architecture is cosistet with the techical architecture promoted by the CT State RHIO. This may iclude the followig: Ability to accommodate existig cliical systems; Compliace with health IT/HIE stadards; Supports future health IT/HIE eeds; Well defied techical support ad maiteace requiremets; Vedor fiacial stability/logevity; Techical sustaiability; Vedor refereces Stadards compliace The proposal will demostrate the degree to which the proposed techical ifrastructure is cosistet with the techical stadards promoted by the CT State RHIO. This may iclude: AHIC use cases; Messagig; 142 C O N N E C T I C U T S T A T E H E A L T H I T P L A N

147 A P P E N D I C E S / P I L O T P R O J E C T C E R T I F I C A T I O N T E M P L A T E Code sets; Security; Privacy ad cofidetiality; Auditig ad cotrol; Vedor certificatio Evaluatio The proposal will describe successful outcomes of the project ad the process for project evaluatio by the CT State RHIO. Evaluatios will be performed at specific key milestoes durig the project ad at project completio. Evaluatio criteria may iclude as appropriate: What is the impact the Coecticut healthcare system? Idicators may iclude: w umber of orgaizatios usig the etwork; w the type of healthcare orgaizatios usig the etwork; w umber of healthcare professioals usig the etwork; w umber of cosumers potetially impacted; w the type of data exchaged over the etwork. What is the impact to patiet care? Idicators may iclude: hospital legth of stay; w adherece to cliical guidelies; w timeliess ad accuracy of diagosis; w improvemets i patiet satisfactio. What is the impact to healthcare costs? Idicators may iclude: w cliicia prescribig ad/or orderig behaviors; w avoided/redirected emergecy services; w chages i claims volume/cost processed; w ability to provide iformatio relative to pay for performace stadards; w reductio i duplicative testig; w care decisios made o existig data versus additioal testig. What is the impact to the overall efficiecy of the healthcare system? Idicators may iclude: w staffig chages/redirectio; w reduced paper processig; w icreased patiet visits per day. C O N N E C T I C U T S T A T E H E A L T H I T P L A N 143

148 A P P E N D I C E S / P I L O T P R O J E C T C E R T I F I C A T I O N T E M P L A T E What is the quality of customer service offered to system users? Idicators may iclude: w system respose times; w system availability; w quality/completeess of data; w effectiveess of traiig; w help desk resposiveess; w techical support. What is the ivestmet required of a participatig orgaizatio. Idicators may iclude: w fiacial capital; w ogoig fees such as membership fees; w huma resource requiremets; w techology requiremets. J. Overview of America Health Iformatio Commuity Use Cases America Health Iformatio Commuity Use Cases 1. Patiet Provider Secure Messagig 2. Remote-Moitorig 3. Public Health Case Reportig 4. Cosultatios & Trasfers of Care 5. Immuizatios & Respose Maagemet 6. Persoalized Healthcare 7. Cosumer Empowermet: Cosumer Access to Cliical Iformatio 8. Medicatio Maagemet 9. Quality Use Case Descriptios 1. Patiet Provider Secure Messagig Givig patiets the ability to compose ad sed a secure commuicatio to a cliicia will give them access to their cliicias i a more timely ad efficiet maer tha a office visit or a phoe call. Similarly, cliicias will beefit from havig the ability to respod to or iitiate secure commuicatios to facilitate the care process ad promote better patiet health. This commuicatio will be doe i a maer which provides appropriate iformatio to the patiet ad meets existig eeds for cliical documetatio. Givig cliicias the ability to securely commuicate remiders to patiets ad their family members will promote prevetive healthcare. These remiders could iclude items such as aual check-ups, cacer screeigs (e.g., mammograms ad colooscopies), ad immuizatios. 144 C O N N E C T I C U T S T A T E H E A L T H I T P L A N

149 A P P E N D I C E S / P I L O T P R O J E C T C E R T I F I C A T I O N T E M P L A T E 2. Remote-Moitorig The Remote Moitorig use case focuses o the commuicatio of iteroperable ambulatory remote moitorig iformatio to the EHR ad the PHR. Patiets ad family caregivers may beefit from the ability for the patiet to gather ad commuicate remote moitorig iformatio electroically from measuremet devices i a home or other o-cliical settig to a cliicia s ambulatory EHR system ad/or to the patiet s PHR. Remote moitorig could iclude, but is ot limited to, commuicatio of: physiologic measuremets (e.g., weight, blood pressure, heart rate ad rhythm, pulse oximetry, glucose), diagostic measuremets (e.g., trasthoracic impedace) medicatio trackig device iformatio (e.g., medicatio pumps, ifusio devices, electroic pillboxes), ad activities of daily livig measuremets (e.g., ADL biosesors, pedometers, sleep actigraphy). Cliicias, care maagers, ad disease maagemet programs ca beefit by beig able to better maage patiets due to the ability to receive patiet remote moitorig iformatio withi a EHR. 3. Public Health Case Reportig This use case addresses populatio health relatig to aspects of Public Health Case (PH Case) reportig ad Adverse Evet (AE) reportig. For the purposes of this use case, PH Case reportig may iclude the reportig of commuicable/ifectious ad o-ifectious diseases ad coditios. AE reportig may iclude the reportig of AEs associated with post-market vaccies ad medicatios. For both PH Case ad AE reportig, this use case focuses o usig data i EHRs ad augmetig EHR data, to assist idividuals or etities i reportig to public health orgaizatios ad maufacturers, etc. This use case also discusses the icorporatio of reportig criteria ito EHRs to assist i the possible idetificatio ad reportig of PH Cases ad AEs. Reportig criteria which are icorporated ad utilized by EHRs may iclude: geeral ad specific reportig cosideratios; the idetificatio of data ad evets that may trigger a report; additioal questios that may eed to be asked of reporters; ad the idetificatio of specific data that may eed to be reported. 4. Cosultatios & Trasfers of Care The Cosultatios & Trasfers of Care Detailed Use Case is focused o the electroic exchage of iformatio betwee cliicias, particularly betwee requestig ad cosultig cliicias, to support cosultatios such as specialty services ad secod opiios. This use case also focuses o the exchage of cliical iformatio eeded durig trasfers of care. Trasfers of care occur whe patiets are discharged ad trasferred from oe health settig to aother, such as to or from a acute care hospital, skilled ursig or rehabilitatio facility, or to home with or without home healthcare services. Patiets participate i this electroic exchage of iformatio as recipiets of iformatio exchage ad may desigate authorized recipiets of healthcare iformatio durig cosultatios ad trasfers of care. 5. Immuizatios & Respose Maagemet The Immuizatios ad Respose Maagemet Detailed Use Case addresses the exchage of iformatio supportig the distributio ad admiistratio of medicatios, vacciatios, ad other specific medical prophylaxis ad treatmet methods. This use case focuses o the iformatio eeds of cosumers, cliicias, registries, public health ad ivetory maagers carryig out routie care activities C O N N E C T I C U T S T A T E H E A L T H I T P L A N 145

150 A P P E N D I C E S / P I L O T P R O J E C T C E R T I F I C A T I O N T E M P L A T E associated with immuizatios. The use case recogizes that portios of the eeds durig o-routie or emergecy situatios, as well as those ecessary to support public health outcomes, could be accomplished usig the same ifrastructure. This use case, however, does ot address all capabilities required for public health respose plaig or respose maagemet i emergecy situatios. The Immuizatios ad Respose Maagemet Detailed Use Case focuses o: access to iformatio about idividuals who eed to receive specific vaccies, drugs, or other itervetios; the ability to report, track, ad maage admiistratio of vaccies, drugs, isolatio ad quaratie; the ability to idetify ad electroically exchage iformatio describig the treatmet or prophylaxis status of populatios; ad the ability to exchage specific resource ad supply chai data from public ad private sectors. 6. Persoalized Healthcare Persoalized healthcare describes processes by which healthcare providers ca customize treatmet ad maagemet plas for patiets based o their uique geetic make-ups. The persoalized healthcare use case focuses o the exchage of geetic/geomic test iformatio, persoal ad family health history, ad the use of aalytical tools i electroic health records (EHRs) to support cliical decisio-makig. Oe of the goals of the AHIC is to establish a pathway, based o commo data stadards, to facilitate the icorporatio of cliically useful geetic iformatio, persoal ad family health history, ad aalytical tools ito EHRs to support cliical decisio-makig. Family health history relies o gatherig data from disparate sources, icreasig the eed for iteroperability. Ideally, family health history would be gathered at the poit of care rather tha retrospectively by iterviews durig differet ecouters. Similarly, accurately recordig the data from geetic/geomic tests, as well as havig a complete record of all geetic/geomic tests performed for a cosumer regardless of the orderig cliicia, is importat. Geetic/geomic iformatio, ulike other laboratory test iformatio, may have lifelog sigificace. 7. Cosumer Empowermet: Cosumer Access to Cliical Iformatio This use case describes capabilities that would eable cosumers to access their cliical iformatio via their Persoal Health Records (PHRs). PHR cocepts, capabilities ad expectatios are evolvig rapidly as cosumers gai experiece with, ad access to, PHRs. A umber of busiess ad techology models have emerged to provide PHR capabilities to the cosumer icludig: web-based solutios provided by commercial vedors, payers, providers, HIEs; desktop solutios with or without etworkig capabilities; ad PHR solutios where the data is itegrated with EHR systems or HIEprovided systems. PHR capabilities eeded by the cosumer could iclude: data storage ad stewardship - storig, protectig, securig ad cotrollig access to the cosumers PHR iformatio; ability to participate i iformatio exchage activities with providers ad others retrievig ad providig access to the cosumer s health iformatio to those idividuals ad orgaizatios desigated by the cosumer; ability to defie ad maage the cosumer s decisios about who ca access his/her PHR iformatio; ad ability to maage iformatio over time (e.g., weight, lab results, vital sigs). 146 C O N N E C T I C U T S T A T E H E A L T H I T P L A N

151 A P P E N D I C E S / P I L O T P R O J E C T C E R T I F I C A T I O N T E M P L A T E 8. Medicatio Maagemet The Medicatio Maagemet Use Case focuses o patiet medicatio ad allergies iformatio exchage, ad the sharig of that iformatio betwee cosumers, cliicias (i multiple sites ad settigs of care), pharmacists, ad orgaizatios that provide health isurace ad provide pharmacy beefits. This use case describes medicatio maagemet i two settigs. First, the ipatiet settig icludes medicatio recociliatio ad orderig alog with other supportig iteractios i the hospital. Secod, the ambulatory settig addresses access to curret medicatio ad allergy iformatio ad support for electroic prescribig i this eviromet. May eeds withi these two settigs overlap, but the separatio is useful i emphasizig some aspects that are particular to each. The use case is focused o iformatio flows that ca be most sigificatly improved i the ear term by icreased iteroperability. This use case recogizes the uiqueess ad complexity of medicatio maagemet ad other activities i the log-term care settig. While ot all log-term care eeds ca be addressed explicitly i this use case, medicatio maagemet areas are highlighted where the existig cosideratios may also be appropriate for log-term care. This use case assumes the developig presece of electroic systems such as Electroic Health Records (EHRs), eprescribig tools, Persoal Health Records (PHRs), ad other local or Web-based solutios supportig cosumers ad cliicias, while recogizig the issues ad obstacles associated with these assumptios. This approach helps promote the developmet of loger-term efforts. A key compoet of this use case is its relatio to a existig federal iitiative o eprescribig udertake by the Ceters for Medicare & Medicaid Services (CMS). Demostratio projects for this iitiative have bee udertake i multiple eviromets, ad they are govered by existig govermet regulatios. The eprescribig iitiative requires that the followig trasactios coform to the foudatio stadards required for implemetatio by Jauary 1, 2006 for all electroic prescribig uder Part D of the Medicare Moderizatio Act (MMA): trasactios betwee prescribers (who write prescriptios) ad dispesers (who fill prescriptios) for ew prescriptios; refill requests ad resposes; prescriptio chage requests ad resposes; prescriptio cacellatio, request ad respose; ad related messagig ad admiistrative trasactios; eligibility ad beefits queries ad resposes betwee prescribers ad Part D sposors; ad eligibility queries betwee dispesers ad Part D sposors. MMA required CMS to implemet pilot projects to test additioal stadards. These additioal stadards apply to trasactios ivolvig: formulary ad beefit iformatio; medicatio history; fill status otificatio; structured ad codified SIG; cliical drug termiology (RxNorm ad other termiology systems); ad prior authorizatio. 9. Quality The AHIC Quality Use Case focuses o: 1) the impact that collectio of electroic health iformatio through a EHR has o drivig quality of care through better, more comprehesive cliical iformatio at the poit of care; 2) measurig ad reportig quality with a miimum of burde assessed o the provider; ad 3) the aggregatio of health iformatio for the purpose of public reportig of quality. This use case depicts two scearios related to quality measuremet, feedback ad reportig with respect to a patiet s ecouter with the healthcare delivery system: quality measuremet of hospital-based care ad of care provided by cliicias. This use case assumes the presece C O N N E C T I C U T S T A T E H E A L T H I T P L A N 147

152 A P P E N D I C E S / P I L O T P R O J E C T C E R T I F I C A T I O N T E M P L A T E of EHRs withi the healthcare delivery system ad promotes the developmet of loger-term efforts. The use case models the exchage of iformatio betwee the EHR ad the quality measuremet, feedback ad reportig systems. The use case allows for a hybrid model of data collectio, where claims ad or maual data collectio will be required to support certai measures that are ot supported through EHRs. This use case ackowledges the eed to iclude a combiatio of claims ad cliical (e.g., EHR) data. EHR data could be extracted for these patiets to provide a richer measure set, with more automatio. However, the use case ackowledges that maual review ad processig will cotiue to be required i may cotexts ad settigs. This use case does ot attempt to prescribe a defiitive approach to the locatio of data aggregatio. The use case does describe roles for these processes which may be fulfilled i several differet settigs. The use case also does ot describe harmoized quality measures. Separate AHIC processes will determie the iitial ad subsequet quality measures to be used. K. Coecticut State ad Federal Laws Relatig to Health IT ad HIE State Defiitio ad Purpose of a Medical Record (CGS 19a 14-40) Purpose of a Medical Records is to provide a vehicle for documetig actios i patiet maagemet ad patiet progress, providig meaigful medical iformatio to other providers ad ew providers. Shall iclude: iformatio sufficiet to justify ay diagosis ad treatmet redered, dates of treatmet, actios take by o-licesed persos whe workig uder authorizatio of providers, orders, otes ad charts. All etries must be siged by perso resposible. Patiet Access to Medical Records from Idividual Providers (CGS 20-7) CSG 20-7 is a logstadig piece of legislatio that addresses issues related to patiet access to their medical records from idividual providers ad hospitals, addresses issues of retetio of medical records, ad special circumstaces relatig to medical records. The law applies to a broad defiitio of providers icludig metal health, ad atural medicie ad other o-traditioal providers. Provider is required except i limited circumstaces to supply patiet complete ad curret iformatio about diagosis, treatmet ad progosis. Must also otify of all test results i his possessio or requested. Request from the patiet must be i writig, attorey or authorized represetative ca also make request. Must be supplied withi 30 days. (CGS 20-7c(b)) Provider ca withhold iformatio if he determies it would be detrimetal to patiet s physical or metal health or would cause patiet to harm himself or others. I these cases, iformatio ca be released to a appropriate third party or other provider who ca release it to the patiet. (CGS 20-7c(c)) Provisios for access to medical records do ot apply to ay iformatio relative to ay psychiatric, or psychological problems or coditios. (CGS 20-7c(e)) 148 C O N N E C T I C U T S T A T E H E A L T H I T P L A N

153 A P P E N D I C E S / P I L O T P R O J E C T C E R T I F I C A T I O N T E M P L A T E Patiet Access to Medical Records from Hospitals (CGS ) The same as for idividual providers described i CGS However, the record is defied broadly to iclude history, bedside otes, ad charts. Electroic Health Records (CGS 19a-25 (b ad c)) CGS 19a-25b ad 25c allow licesed istitutios to maitai records i electroic format ad permits providers to use electroic prescribig systems. Law allows healthcare istitutios to create, maitai or use medical records or medical record systems i electroic format, paper or both if the system ca store medical records ad patiet healthcare iformatio i a reproducible ad secure maer. Healthcare providers with prescriptive authority may use electroic prescribig systems. Departmet of Cosumer Protectio may advise ad assist healthcare providers i this utilizatio. Govermetal agecies are ot required to use or permit the use of electroic records or electroic sigatures Office of Health Care Access shall (i its discretio) except from certificate of eed reviews i certai circumstaces ay healthcare facility or istitutio that proposes to purchase or operate a electroic medical records system. Retetio of Medical Records Idividual Healthcare Providers Idividual providers must retai a patiet's medical records for seve years after the last treatmet date, or three years from the patiet's death. (DPH Regs 19a-14-42). Pathology slides, EEGs, ad ECG tracigs must be retaied for seve years. However, as subsequet ECGs are take, previous oes may be discarded if the results are uchaged. (DPH Regs. 19a-14-42(a)) Lab reports ad PKU reports must be kept for five years ad X-ray film for three years. (DPH Regs. 19a-14-42(b), (c)). Retetio of Medical Records Hospitals Medical records must be filed i a accessible maer i the hospital ad kept a miimum of 25 years after the patiet s discharge. Origial records ca be destied sooer if they are microfilmed by a process approved by DPH. (DPH REGS D3(D)(6)). Federal Cliical Laboratory Improvemet Amedmets (CLIA, 42 U.S.C. 263a) Laboratory with certificate of compliace uder CLIA caot release the results of its testig to ayoe other tha the healthcare istitutio or provider that requested the testig. C O N N E C T I C U T S T A T E H E A L T H I T P L A N 149

154 A P P E N D I C E S / P I L O T P R O J E C T C E R T I F I C A T I O N T E M P L A T E Family Educatioal Rights ad Privacy Act (FERPA) Family Educatioal Rights ad Privacy Act (FERPA) 20 USC 1232g, addresses parets ad studets privacy rights ad protectios with respect to educatio records. The regulatios geerally require that educatio records maitaied o behalf of a studet be kept cofidetial ad oly released to third parties with paretal or adult studet coset. FERPA also cotais exceptios that address whe paret coset is ot required. FERPA is admiistered by the Family Policy Compliace Office i the US Departmet of Educatio. Health Isurace Portability ad Accoutability Act of 1996 (HIPAA) HIPAA Privacy Rule addresses how healthcare providers, health plas, ad healthcare clearighouses use ad disclose health iformatio, whether it is i writte, spoke, or electroic form. The rule creates miimum atiowide stadards for makig sure a idividual s health iformatio is kept private The HIPAA Security Rule specifically applies to health iformatio i electroic form. The Security Rule addresses how providers, health plas ad clearighouses protect ad cotrol access to a idividual s electroic health iformatio. The rule requires a set of safeguards ragig from admiistrative (security policies ad procedures, for example) to physical (limitig physical access to buildigs or servers, for example) to techical (requirig ecryptio ad passwords, for example). The ARRA of 2009 maitais ad expads the curret HIPAA patiet health iformatio privacy ad security protectios, especially as patiet health iformatio is electroically trasferred through health IT systems. ARRA ameds HIPAA to protect patiet health iformatio with the followig key provisios: applies the HIPAA rules directly to busiess associates ad other o-hipaa covered etities (No-covered HIPAA etities, such as RHIOs are ow required to have busiess associate agreemets with covered etities) for the electroic exchage of patiet health iformatio; allows patiets to pay out of pocket for a healthcare service ad request o-disclosure of the redered service; authorizes icreased civil moetary pealties for HIPAA violatios; defies which actios costitute a breach (icludig some iadvertet disclosures); requires a accoutig of disclosures to a patiet upo request; imposes restrictios o certai sales ad marketig of protected health iformatio; ad grats authority to state attoreys geeral to eforce HIPAA. The Secretary of the Departmet of Health ad Huma Services (HHS), as well as other relevat agecies, will be providig details through the regulatory rule-makig process o the expaded privacy ad security requiremets. Uless otherwise specified, the privacy provisios become effective o February 17, C O N N E C T I C U T S T A T E H E A L T H I T P L A N

155 A P P E N D I C E S / B O R D E R S T A T E A C T I V I T I E S L. Border State Activities 1. Massachusetts HIE Activities New Eglad Healthcare EDI Network (NEHEN) NEHEN is a cosortium of the eight largest regioal payers ad providers who have desiged ad implemeted a secure electroic-commerce solutio that trasports HIPAA-compliat trasactios betwee health plas ad providers, icludig eligibility checkig, referral requests, ad claim status checkig ad submissio. NEHEN is self-sustaiig, supported 100% by member subscriptios. Electroic data iterchage is believed to have improved admiistrative processes while eablig its members to share costs, leverage experiece gaied by other participats, ad accelerate the beefits of admiistrative simplificatio. Massachusetts ehealth Collaborative The Massachusetts ehealth Collaborative (MAeHC) was formed to improve patiet safety ad quality of care by promotig the use of health iformatio techology through commuity-based implemetatio of EHRs ad health iformatio exchage. The Collaborative has recetly implemeted EHRs i a diverse set of competitively selected commuities, Greater Brockto, Greater Newburyport ad Norther Berkshire, ecompassig early 500 physicias servig over 500,000 patiets. Blue Cross ad Blue Shield of Massachusetts provided $50 millio to deploy EHRs ad HIE capacity to every provider i the three commuities with the goal of developig a commuity repository for providers to access. The Greater Brockto ecare Alliace (GBeCA) is comprised of Brockto Hospital, Caritas Good Samarita Medical Ceter, Bridgewater Goddard Park Medical Associates, Brockto Physicia Hospital Orgaizatio, Ic., Caritas Good Samarita IPA, Ic., ad Brockto Neighborhood Health Ceter. The Alliace icludes both of the commuity s acute care hospitals who together costitute 486 beds. The commuity served by the Alliace ecompasses the City of Brockto ad early 20 surroudig tows that are homes to 350,000 residets. The Alliace icludes early 400 physicias, represetig 85% of the primary care physicias ad 75% of the specialists i the commuity. These physicias provide a estimated oe millio patiet ecouters aually. The Greater Newburyport commuities of Newburyport, Newbury, Salisbury, Amesbury, West Newbury, Merrimac, ad Georgetow are situated about 35 miles orth of Bosto ad are socio-ecoomically diverse cities. Most residets receive a majority of their healthcare locally. The commuity has grow rapidly over the last several years ad the provider etwork covers close to 100,000 patiets. There are 138 cliicias i 39 practices i the greater Newburyport commuity that have EHRs ad are participatig i the Wellport etwork. Idepedetly C O N N E C T I C U T S T A T E H E A L T H I T P L A N 151

156 A P P E N D I C E S / B O R D E R S T A T E A C T I V I T I E S practicig physicias of Greater Newburyport who participate i the Wellport etwork ad physicias at the Aa Jaques Hospital are ow goig to be liked together to create a more itegrated healthcare commuity. Norther Berkshire Commuity members receive the vast majority of their healthcare services from physicias ad other healthcare professioals affiliated with Norther Berkshire Healthcare (NBH). NBH icludes: The North Adams Regioal Hospital (NARH), a 120 bed commuity hospital ad the oly acute care facility i the area; Visitig Nurses Associatio ad Hospice of Norther Berkshire; Sweet Brook Trasitioal Care ad Livig Ceters; Sweetwood Cotiuig Care Retiremet Commuity ad REACH Commuity Health Foudatio. The hospital has 80 active medical staff icludig 32 primary care physicias ad 48 specialists represetig 31 specialties. MA-SHARE MA-SHARE is a regioal collaborative created ad operated by the Massachusetts Health Data Cosortium (MHDC) to oversee the implemetatio of commuity projects for both admiistrative simplificatio ad cliical data exchage. MA-SHARE seeks to promote the iter-orgaizatioal exchage of healthcare data i a ope techology model to coect payers, providers, ad patiets i order to improve patiet safety, ecourage itegrated reportig of accurate cliical health iformatio, ad icrease admiistrative efficiecy usig a sustaiable ecoomic model. MA-SHARE achieves its goals by facilitatig ad developig regioal collaborative projects that pilot ad demostrate ew techologies ad platforms that ca be used across commuities ad eterprises. Where they exist, projects are to adhere to atioal stadards for data exchage. MA- SHARE receives fudig by Blue Cross ad Blue Shield of Massachusetts, other local health plas, provider orgaizatios, the Massachusetts Medical Society, ad a e-health Iitiative grat. The Cosortium is ow actively egaged i maagig/moitorig the followig MA-SHARE projects: Bioterrorism Sydromic Surveillace (BSS): seekig to create better meas of brigig disparate healthcare data together to permit more immediate ad accurate assessmet of public health risks ad evets. Electroic Health Records: seekig to facilitate the selectio of stadards ad adoptio of forms of electroic health records. Electroic Patiet-Cetered Commuicatio: seekig to ecourage ad facilitate the greater use of electroic commuicatios betwee patiets ad their caregivers ad healthcare payers. MedsIfo-ED: seekig to make patiets' prescriptio history data available to hospital emergecy departmets. Pathology Database Query: seekig to provide meas of hospitals, agecies ad researchers gaiig immediate, real-time access to various istitutios' pathology data. 152 C O N N E C T I C U T S T A T E H E A L T H I T P L A N

157 A P P E N D I C E S / B O R D E R S T A T E A C T I V I T I E S 2. Rhode Islad HIE Activities State ad Regioal HIE Demostratio Project ( ) I September 2004, the Rhode Islad Departmet of Health (HEALTH) was oe of six states atioally to receive a $5 millio, 5-year demostratio grat from the Agecy for Healthcare Research ad Quality (AHRQ). This grat has supported the commuity-based effort to desig ad develop curretcare (see ext). curretcare: Rhode Islad Statewide Health Iformatio Exchage The Rhode Islad Health Iformatio Exchage (HIE) Project, ow kow as curretcare, is workig towards the goal of developig, implemetig, ad evaluatig a itercoected statewide health iformatio system that uses a Master Patiet Idex as a cetral compoet to put the right iformatio ito the hads of cliicias ad their patiets whe ad where it is eeded. They are curretly workig towards three key milestoes: erollmet, data flow to curretcare, ad go live at provider pilot sites, targeted for early Jue Iitial participats i the HIE iclude a large hospital etwork, a laboratory ad the state s Departmet of Health. The Rhode Islad Quality Istitute serves as a regioal health iformatio orgaizatio ad plays a goverace role. The Rhode Islad Health Iformatio Exchage Act of 2008, which goes ito effect i March 2009, provides additioal structure for the HIE. The law madates patiet privacy safeguards ad authorizes the Departmet of Health to regulate the HIE. Cosumer protectios i the ew law iclude: a specificatio that participatio i the HIE is volutary both cosumers ad providers choose whether or ot to participate; the ability to obtai a copy of cofidetial health iformatio from the HIE; the ability to obtai a copy of a Disclosure Report relatig to access of a patiet's cofidetial health iformatio through the HIE; otificatio of breach of security of the HIE cosistet with the RI idetity theft law; the right to termiate participatio i the HIE; the right to request that iaccurate iformatio provided to the HIE be corrected through a provider; oversight by the Departmet of Health; the creatio of a HIE Advisory Commissio to make recommedatios to the Departmet of Health regardig the use of health iformatio i the HIE; ad civil ad crimial pealties for violatio of the Act. C O N N E C T I C U T S T A T E H E A L T H I T P L A N 153

158 A P P E N D I C E S / B O R D E R S T A T E A C T I V I T I E S 3. New York HIE Activities Healthcare Efficiecy ad Affordability Law for New Yorkers (HEAL NY) Capital Grat Program Passed i 2004, this program supports reorgaizatio of hospitals i New York State ad health IT/HIE iitiatives of HEAL NY, ru by the New York State Departmet of Health (NYS DOH). The Departmet has supported two competitive grat rouds for health IT. The first roud of Health IT grats were awarded i 2006 to 26 projects totalig $52.9 millio. These two year grats iteded to support adoptio of EHRs, electroic prescribig, ad developmet ad implemetatio of commuity-wide cliical data exchages. Gratees, typically commuity hospitals ad physicia practices distributed across all six regios of New York State, received a average of $1.8 millio each. I additio to requirig implemetatio of HIE ad requirig matchig fuds, HEAL NY required that all projects ivolve multiple stakeholders of various types (e.g. hospitals, physicias, payers, etc.). The secod roud of grats were awarded i 2008 to 19 projects totalig $105.7 millio. Gratees icluded RHIOs ad Commuity Health Iformatio Techology Adoptio Collaboratios. HEAL NY grats are fuded i part by bods sold to the ivestmet commuity by DASNY (the Dormitory Authority). HIXNY: A joit effort of the Iroquois Healthcare Alliace ad the New York Health Pla Associatio to create a secure, electroic service for exchagig health iformatio amog hospitals ad doctors i the Capital Regio ad Norther New York. HIXNY serves a 16-couty area icludig: Albay, Clito, Columbia, Essex, Frakli, Fulto, Greee, Hamilto, Motgomery, Otsego, Resselaer, Saratoga, Scheectady, Schoharie, Warre, ad Washigto. Health data exchaged icludes: medicatio history from RxHub, SureScripts ad HIXNY member systems; patiet demographic ad allergy data; ad New_ York state Medicaid data. Future fuctioality will iclude the exchage of progress otes, laboratory results, eligibility\beefits iformatio ad discharge summaries. Tacoic Health Iformatio Network ad Commuity (THINC) RHIO: Serves the Hudso Valley regio of New York State. The primary purpose of the THINC RHIO is to advace the use of health iformatio techology through the sposorship of a secure Health Iformatio Exchage (HIE) etwork, the adoptio ad use of iteroperable Electroic Health Records (EHRs) ad the implemetatio of populatio health improvemet activities, icludig public health surveillace ad reportig, pay-for-performace, public reportig ad other quality improvemet iitiatives. The Brox Regioal Health Iformatio Orgaizatio (Brox RHIO): Participats iclude hospitals, health systems, ambulatory care ceters, idividual physicia offices, log-term care ad home care services. Collectively, these providers deliver the vast majority of the healthcare received by the borough s 1.36 millio residets, icludig over 95% of the borough s aual hospital discharges, over 600,000 aual Emergecy Departmet visits ad 4.5 millio 154 C O N N E C T I C U T S T A T E H E A L T H I T P L A N

159 A P P E N D I C E S / B O R D E R S T A T E A C T I V I T I E S aual ambulatory care visits. The Brox RHIO wet "live" i Jue 2008 with data, excludig home care, from all Motefiore Medical Ceter, Brox Commuity Health Network, Brox Lebao Hospital, Brox Lebao Special Care Ceter, Childre's Hospital at Motefiore ad Dr. Marti Luther Kig, Jr., Medical Ceter. Brookly Health Iformatio Exchage (BHIX): BHIX is a ot-for-profit RHIO coectig healthcare providers, icludig hospitals, ursig homes, home health agecies, ad payers throughout Brookly. Shared data curretly icludes: patiet demographic iformatio, advace directive iformatio, physicia ad primary cotact iformatio, allergies, medicatios, problem lists ad diagoses, ad procedures. Greater Rochester RHIO: The Greater Rochester RHIO was created i 2006 with fudig from the Phase 1 of the HEAL NY program, as well as from local hospitals, busiesses ad health isurers. Workig with the State of New York Health Iformatio Techology Evaluatio Cosortium ad with a grat from the Greater Rochester Health Foudatio, the Rochester RHIO is actively evaluatig how health iformatio exchage ca provide value ad improve the coordiatio of care across our regio s healthcare delivery system. Wester New York Cliical Iformatio Exchage (WYNCIE). The RHIO ame for this exchage is HEALTHeLINK, ad is a collaborative cosortium that curretly icludes orgaizatios ad providers throughout the eight couties of Wester New York. HEALTHeLINK was created through a $3.5 millio grat from New York State s HealNY Iitiative. Souther Tier Health Lik (STHL): The grat award from HEAL-NY wet to a collaborative effort betwee Greater Bighamto-based STHL ad Syracuse-based Health Care Advacemet Collaborative of Cetral New York (HACCNY). STHL is a collaboratio of ie health orgaizatios i the Souther Tier ad HACCNY is a public/private collaborative of decisio-makers represetig the hospital, physicia, busiess, ad isurace sectors focused o improvig healthcare quality ad reducig costs i Cetral New York. Log Islad Patiet Iformatio Exchage (LIPIX): Recipiet of both Phase 1 ad Phase 5 HEAL-NY grat awards, the plas for Phase 5 fudig projects iclude the expasio of LIPIX fuctioality to 19 of 24 hospitals o Log Islad ad three i Quees ad to several exteded care ad outpatiet orgaizatios. I additio, LIPIX will be expadig its fuctioality to address medicatio maagemet, public health, ad cosumer (patiet) empowermet capabilities. C O N N E C T I C U T S T A T E H E A L T H I T P L A N 155

160 A P P E N D I C E S / F U N D I N G O P P O R T U N I T I E S T H R O U G H T H E A M E R I C A N R E C O V E R Y A N D R E I N V E S T M E N T A C T M. Fudig Opportuities through The America Recovery ad Reivestmet Act The followig tables outlie the six mai sources of fudig for health IT/HIE icluded i the America Recovery ad Reivestmet Act (ARRA) ad describe the potetial implicatios for Coecticut. What HIE Plaig ad Implemetatio Grats Descriptio Competitive Grat Program to support HIE Plaig or Implemetatio. Implemetatio Grats require demostratio of operatioal goverace, a techical pla, well defied cliical use cases, ad statewide privacy ad security guidace Type of Program Competitive Grat Program Details developed through rule makig process at HHS Amout Statute dedicates at least $300 millio; grat amouts to be determied Timig Upo delivery of the ew ONC strategic pla to Cogress, due 90 days after passage of the stimulus Eligibility State or state desigated etities. State desigated etity requires formal desigatio by the state, be o-profit, committed to improvig quality ad efficiecy through HIE, ad other requiremets. Fudig Source HHS through ONC (could delegate to AHRQ, HRSA, CDC, ad other agecies) CT State Ivolvemet Desigate etity or etities State matchig fuds MAY be required i 2009 ad 2010, will be required i 2011; matchig fuds may be i-kid. Appears to be the most likely source of HIE moey i the stimulus package. Implicatios for CT HIE Pla If federal schedules are met, dollars should begi to flow this year, some for plaig ad some for implemetatio. Requiremets cosistet with strategy of CT HIT Pla. Best strategy seems to be for state to oly desigate oe orgaizatio (the RHIO or the orgaizatio that will become the RHIO). A sigificat amout of progress would eed to occur quickly to meet the implemetatio grat requiremets (see descriptio uder what ). Plaig grat more likely for this year; amouts ot yet set. 156 C O N N E C T I C U T S T A T E H E A L T H I T P L A N

161 A P P E N D I C E S / F U N D I N G O P P O R T U N I T I E S T H R O U G H T H E A M E R I C A N R E C O V E R Y A N D R E I N V E S T M E N T A C T What EHR Loa Fud Descriptio A competitive grats process; states ad Idia Tribes eligible to apply for fuds (amouts to be determied) to provide loas to providers for EHR adoptio. (Note the federal dollars to the states are grats ot loas.) Type of Program Competitive grats from federal govermet to states. Loas from states to providers Amout To be determied Timig Not before Jauary 1, 2010 Eligibility To be eligible, states must submit a aual strategic pla (see below) Loas to providers for purchase of certified EHR, ehace existig EHR, traiig, or improvig the secure exchage of electroic iformatio. Fudig Source HHS through ONC (may be delegated to aother agecy). CT State Ivolvemet Match: cash match of $1 i state fuds for every $5 i federal fuds. States may raise moey from private sources to icrease size of loa pool. Submit aual strategic pla specifyig the log ad short term goals of fud, idetifyig the projects, describig selectio criteria, curret status of outstadig loas Implicatios for CT HIE Pla Potetial for HIE Pilot Projects Depedig o amout of $ available, ad availability of state match, ca provide the basis for capital loas for providers; possibility of parterig with baks to icrease size of fud. This type of loa fudig is a idetified eed of CT providers most of whom lack access to capital. Medicare/Medicaid fudig for HIT may make loa fuds more attractive to private sources. C O N N E C T I C U T S T A T E H E A L T H I T P L A N 157

162 A P P E N D I C E S / F U N D I N G O P P O R T U N I T I E S T H R O U G H T H E A M E R I C A N R E C O V E R Y A N D R E I N V E S T M E N T A C T What Workforce Traiig Grats Descriptio Two separate grat programs To colleges ad istitutios of higher educatio to expad medical health iformatics programs To medical schools to itegrate EHR ito curriculum Type of Program Competitive Grats Amout To be determied Timig To be determied Eligibility Istitutios of higher educatio Graduate health professioal schools icludig medicie, osteopathy, ursig, detistry, pharmacy, behavioral health, physicia assistat programs Priority to existig programs or those desiged to be completed i six moths Fudig Source HHS i cosultatio with Natioal Sciece Foudatio; Distributio agecy to be decided CT State Ivolvemet Grat ca oly be up to 50% of cost of program; state match would be required for state schools Match ca be reduced if cost sharig requiremets are demostrated to be detrimetal to the program Implicatios for CT HIE Pla Iterest has bee expressed i establishig/expadig medical iformatics programs at uiversities; Competitio is likely Need to determie if ay existig programs are eligible ad iterested 158 C O N N E C T I C U T S T A T E H E A L T H I T P L A N

163 A P P E N D I C E S / F U N D I N G O P P O R T U N I T I E S T H R O U G H T H E A M E R I C A N R E C O V E R Y A N D R E I N V E S T M E N T A C T What HIT Regioal Extesio Ceters Descriptio Support for the creatio of regioal ceters to provide techical assistace ad dissemiate best practices ad other iformatio leared from the atioal HIT Research Ceter (also to be established by HHS) to support ad accelerate efforts to adopt, implemet ad effectively utilize HIT that allows for HIE, is stadards based ad certificatio based. Least developed of the programs at this poit. Type of Program Competitive Grats Amout To be determied. Fudig available up to four years Timig 2009 to 2011 secretary required to release a otice withi 90 days of eactmet of ARRA describig the program ad amouts of fudig to be available. Eligibility No Profit orgaizatios that ca demostrate capacity to provide specific services, detail geographic diversity ad service area ad other fudig Fudig Source ONC CT State Ivolvemet Noe required: ONC ca oly provide up to 50% of the costs of the program BUT the match does ot have to come from the state. Implicatios for CT HIE Pla If schedules are met, this program MAY begi quickly Fudig for techical assistace for implemetatio would be a asset to implemetatio of HIE Pla Competitio for fudig likely amog orgaizatios across the state C O N N E C T I C U T S T A T E H E A L T H I T P L A N 159

164 A P P E N D I C E S / F U N D I N G O P P O R T U N I T I E S T H R O U G H T H E A M E R I C A N R E C O V E R Y A N D R E I N V E S T M E N T A C T What Medicare Icetive Paymet Provisios Descriptio Type of Program Amout Timig Eligibility Ehacemets to Medicare reimbursemet for meaigful EHR use Meaigful use requires demostratio of a certified EHR icludig electroic prescribig, that is coected to a HIE. Submissio of data o quality measures idetified by the Secretary is required. Reimbursemet through isurace carriers Up to $44,000 per physicia ad a fudig allocated o a formula for hospitals. 10% bous for physicias who practice i HPSAs (health professioal shortage areas) ad to critical access hospitals. Disicetives for those ot complyig begi i Begis i 2011, providers ad hospitals may receive paymets over 5 years; amouts declie for providers who become eligible after 2011, must quality by 2014 to receive fudig. Physicias ad hospitals receivig Medicare paymets who ca demostrate meaigful use of EHR Fudig Source CT State Ivolvemet CMS Noe seems to be required, there is o match ad Medicare dollars do ot flow through the state State could play a role i establishig bod ad loa fuds to be repaid whe Medicare EHR fuds are received. Implicatios for CT HIE Pla Sigificat boost ad icetive to EHR adoptio that is required for the HIE pla to ultimately succeed This is back-ed moey; providers ad hospitals still require upfrot capital. Federal loa fuds are oe source, will eed to be supplemeted by state or private dollars to be sufficiet. Defiitio of requiremet to be coected to a HIE requires more detail but represets icetives for HIE participatio. Depedig o laguage may affect decisios o pilot projects. Pressure to comply by 2011 is high, icreasig risk of problematic or failed adoptio. Coordiatio i obtaiig ONC fuds to support implemetatio could reduce problems i this area. 160 C O N N E C T I C U T S T A T E H E A L T H I T P L A N

165 A P P E N D I C E S / F U N D I N G O P P O R T U N I T I E S T H R O U G H T H E A M E R I C A N R E C O V E R Y A N D R E I N V E S T M E N T A C T What Medicaid Icetive Paymets Descriptio Paymets to state Medicaid plas that implemet programs to ecourage the adoptio ad use of certified EHR. States receive 100% of paymet outlays ad 90% of admiistratio costs. Paymets to providers up to $63,750 towards adoptio, implemetatio, upgrades, maiteace, ad operatio of certified EHR techo logy. Paymets to hospitals similar to those uder Medicare. Type of Program Reimbursemet through state Medicaid program (DSS). Amout See descriptio above Timig Begis i 2011 Eligibility Fudig expasio to pediatricias, FQHCs, rural health cliics ad physicia assistats practicig i rural health cliics who ca demostrate use of certified EHR techology that provides for HIE ad compliace with reportig requiremets; state is required to make these assessmets. Acute care hospitals, childre s hospitals Third party etities ecouragig EHR adoptio may qualify (purchasig ad implemetatio agets, ASPs) with 95% goig to the physicias ad 5% remaiig with the third party for admiistrative expeses. Fudig Source CMS ad State of Coecticut CT State Ivolvemet DSS ivolvemet is sigificat State must cover 10% of the admiistrative costs of ruig the program Implicatios for CT HIE Pla Required coectio to HIE is importat DSS role i HIE pla may expad or chage May be implicatios for pilot projects i the third party model Importat to determie whether this is ew moey or fudig that would have bee available previously. C O N N E C T I C U T S T A T E H E A L T H I T P L A N 161

166 A P P E N D I C E S / C O N N E C T I C U T H E A L T H I N F O R M A T I O N E X C H A N G E N E T W O R K P R O J E C T I N V E N T O R Y N. Coecticut Health Iformatio Exchage Network Project Ivetory The followig sectio cotais two parts. The first table outlies the categories of HIE projects that will icremetally develop statewide HIE capacity. The secod table lists existig HIE projects i Coecticut that may be leveraged as part of the CT State Health IT Pla. HIE PROJECT CATEGORIES Category Geeral Descriptio Recommedatio Cotiuity of care record (CCR) Provides a patiet summary icludig vital statistics, isurace ifo, provider ifo ad other summary ifo i support of a patiet trasfer or referral Defer as a follow o to direct patiet care domai pilots Iclude requiremets as part of EHR framework Electroic Health Record (EHR) ad HIE developmet Direct patiet care domai HIE ad EHR providig cliical data at the poit of care which is aggregated from multiple cliical settigs. Recommed as pilot project Requires state fudig Specify phased-i developmet that is tied to fudig availability Electroic Medical Record (EMR) promotio/adoptio Hospital-based or IPA-based promotio of a stadardsbased EMR software applicatio. Tie to direct patiet care domai pilot projects Cosider supplemetal state fudig Health Iformatio Exchage Hub A cetralized ifrastructure ad support orgaizatio that provides data exchage ad data maagemet resources Recommed as pilot project Requires state fudig Specify phased-i developmet that is tied to fudig availability Medicatio maagemet/ eprescribig Itegratio of medicatio history through prescriptio data aggregators as well as pharmacies ad providers i support of exchagig prescriptios ad medicatio iformatio Defer as a follow o to direct patiet care domai pilots Iclude requiremets as part of EHR framework Pay for performace (Chroic disease maagemet) Collectio ad reportig of cliical idicators which are tied to provider icetives for program participatio ad compliace with performace measures. Defer as a follow o to direct patiet care domai pilots Iclude requiremets as part of EHR framework Persoal health record (PHR) Similar to the CCR, the PHR provides a patiet summary icludig vital statistics, isurace ifo, provider ifo ad other summary ifo i support of patiet care ad patiet ivolvemet i the care process Defer as a follow o to state HIEN pilot Iclude requiremets as part of EHR framework 162 C O N N E C T I C U T S T A T E H E A L T H I T P L A N

167 A P P E N D I C E S / C O N N E C T I C U T H E A L T H I N F O R M A T I O N E X C H A N G E N E T W O R K P R O J E C T I N V E N T O R Y Category Geeral Descriptio Recommedatio State health agecies HIE ad program registry platform Moitorig & evaluatio HIE ad data warehouse Data collectio ad data maagemet i support of public health programs ad public health oversight fuctios. Data collectio, aalysis ad reportig based projects usig de-idetified data that support the overall quality of the CT healthcare system. Recommed as pilot project Requires state fudig Specify phased-i developmet that is tied to fudig availability Recommed as pilot project Requires state fudig Specify phased-i developmet that is tied to fudig availability EXISTING HIE PROJECTS IN CONNECTICUT Category Project Descriptio Primary Cotact Sposorig Org Cotiuity of Care Record Medicaid Trasformatio Project Cotiuity of care record for patiets referred to/from FQHCs ad Hospitals Michael Starkowski Scott Cleary DSS ehealthct EHR Developmet Easter CT Healthcare Network EHR project Hospital based EHR to physicia commuity Charlie Colvi Easter CT Healthcare Network EHR Developmet Medical Home Persoal Health Record EHR developmet i support of medical home project Shati Carter Commuity Health Ceters Ic. EHR Developmet Middlesex Hospital EHR project Hospital based EHR itegratio with CHC Ic ad affiliated physicias (ecliicalworks) Lud Johso Middlesex Hospital EHR Developmet St. Fracis EHR Project Hospital based EHR itegratio with ProHealth ad affiliated physicias (AllScripts) Kathy Demateo St. Fracis CIO EHR Developmet Bridgeport Primary Care Access Group Data exchage with 2 hospitals ad FQHCs Betsy Thorquist St. Vicet s Hospital EMR promotio/ adoptio Easter CT Healthcare Network EHR project Itegratig with two area IPAs usig AllScripts Charlie Colvi Easter CT Healthcare Networ C O N N E C T I C U T S T A T E H E A L T H I T P L A N 163

168 A P P E N D I C E S / C O N N E C T I C U T H E A L T H I N F O R M A T I O N E X C H A N G E N E T W O R K P R O J E C T I N V E N T O R Y Category Project Descriptio Primary Cotact Sposorig Org EMR promotio/ adoptio Middlesex Hospital EHR project Itegratig hospital EHR with ecliicalworks Lud Johso Middlesex Hospital EMR promotio/ adoptio St. Fracis EHR Project Hospital based EHR itegratio with AllScripts Kathy Demateo St. Fracis CIO Medicatio maagemet/ eprescribig Prescriptio Maagemet Program expaded to medicatio history ad eprescribig Schedule II through V drug distributio moitorig ad compliace Joh Gadea Dept Cosumer Protectio Pay for performace P4P - Diabetes Care Lik Chroic disease maagemet Fracois Desbrates Bridges to Excellece Pay for performace P4P - Cardiac Care Lik Chroic disease maagemet Fracois Desbrates Bridges to Excellece Pay for performace P4P - Physicia Office Lik Certificatio for program participatio Fracois Desbrates Bridges to Excellece Pay for performace Various Mostly based o stadard HEDIS measures. Disease state refereces (A1C for maagig diabetic moitorig), digital eye exams, cost icetive with payers compared to other providers. Asthmatic populatios, immuizatio bechmarks. Jack Reed Pro Health Pay for performace Chroic Disease Maagemet Diabetes performace measures tied to physicia icetives with Athem Doug Arold Richard Lych Middlesex Professioal Services Athem PHR Persoal health record PHR is developed with claims data, patiet iput, ad participatig doc iput. Made available to participatig docs. Mike Hudso Aeta 164 C O N N E C T I C U T S T A T E H E A L T H I T P L A N

169 A P P E N D I C E S / C O N N E C T I C U T H E A L T H I N F O R M A T I O N E X C H A N G E N E T W O R K P R O J E C T I N V E N T O R Y Category Project Descriptio Primary Cotact Sposorig Org State health agecies HIE/program registry platform DOIT Health iformatio exchage utility Developmet ad maagemet of HIE utility supportig data exchage for all providers i the state Rick Bailey Departmet of Iformatio Techology State health agecies HIE/program registry platform DPH/DSS Program registry cosolidatio ad data warehouse Develop stadards ad strategy for program registry ad HIE capacity to support public health programs ad data exchage with providers Meg Hooper Bob Mitchell Departmet of Public Health Departmet of Social Services State health agecies HIE/program registry platform Medicaid Trasformatio Project eprescribig ad HIE for Medicaid patiets Michael Starkowski DSS State health agecies HIE/program registry platform CHIN expasio Robert Aseltie CHIN Moitorig & evaluatio HIE/ Data warehouse Hospital Drive Quality Project Collaborative of CHA (CHIMENET, CHIMEDATA ad TEIC), OHCA ad Qualidigm Joh Brady Coecticut Hospital Associatio Moitorig & evaluatio HIE/ Data warehouse Coecticut Health Quality Cooperative Physicia Report Card with claims data from 5-6 payers Marcia Petrillo Qualidigm Moitorig & evaluatio HIE/ Data warehouse MyHealthDirect Directs patiets away from ERs ad toward CHCs for care. Da Clemos Commuity Health Ceter Associatio of Coecticut, Ic. C O N N E C T I C U T S T A T E H E A L T H I T P L A N 165

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