Iowa e-health Strategic and Operational Plan Version 6 Developed May 2010 Revised March 2011 ONC Submission June 4, 2012

Iowa e-health Strategic and Operational Plan Version 6 Developed May 2010 Revised March 2011 ONC Submission June 4, 2012

The Iowa e-health vision is for a healthier Iowa through the use and exchange of electronic health information to improve patient-center health care and population health The Iowa e-health Strategic and Operational Plan is a required deliverable of the State Health Information Exchange (HIE) Cooperative Agreement Program sponsored by the U.S. Department of Health and Human Services Office of the National Coordinator for Health Information Technology (Health IT) and managed by the Iowa Department of Public Health. The Strategic and Operational Plan is a major milestone for Iowa summarizing the valuable discussions and planning of the e-health Executive Committee, Advisory Council and workgroups that have been taking place since January 2009. There are a variety of coordinating plans that have been developed to help execute the goals, objectives, and strategies of the Iowa e-health Strategic and Operational Plan. All plans are developed through a transparent, multi-stakeholder process to identify and satisfy the business and clinical requirements for Iowa e-health and a statewide HIE. Additional information is available at http://www.iowaehealth.org. Authorizing Legislation: 2008 Iowa Acts, Chapter 1188 (HF 2539) Iowa e-health is currently pursuing new legislation (developed in collaboration with all Iowa e-health stakeholders) that would replace the original authorizing legislation from 2008. Iowa e-health Strategic and Operational Plan Revised in June 2012 Communication Plan Risk Management Plan Business & Sustainability Plan Evaluation Plan See Goal 1; Developed in October 2010 See Goal 8; Developed in April 2011 See Goal 9; Developed in December 2011 See Goal 10; Developed in June 2011

IOWA E-HEALTH STRATEGIC AND OPERATIONAL PLAN TABLE OF CONTENTS STRATEGIC AND OPERATIONAL PLAN EXECUTIVE SUMMARY... 6 BACKGROUND: HEALTH IT IN IOWA... 11 PLANNING APPROACH... 13 SCOPE OF PLANNING AND IMPLEMENTATION... 15 ENVIRONMENTAL SCAN... 18 GAP ANALYSIS... 25 MEANINGFUL USE... 32 GOAL 1: BUILD AWARENESS AND TRUST OF HEALTH IT... 41 GOAL 2: PROMOTE STATEWIDE DEPLOYMENT AND USE OF ELECTRONIC HEALTH RECORDS... 44 GOAL 3: ENABLE THE ELECTRONIC EXCHANGE OF HEALTH INFORMATION. 47 GOAL 4: ENABLE THE EXCHANGE OF CLINICAL DATA... 64 GOAL 5: SAFEGUARD PRIVACY AND SECURITY OF ELECTRONIC HEALTH INFORMATION... 78 GOAL 6: ADVANCE COORDINATION OF ACTIVITIES ACROSS STATE AND FEDERAL GOVERNMENT... 84 GOAL 7: ESTABLISH A GOVERNANCE MODEL FOR STATEWIDE HEALTH INFORMATION EXCHANGE... 93 GOAL 8: EXECUTE BUSINESS AND TECHNICAL OPERATIONS FOR HEALTH IT... 97 GOAL 9: SECURE FINANCIAL RESOURCES TO DEVELOP AND SUSTAIN A STATEWIDE HIE... 102 GOAL 10: MONITOR AND EVALUATE HEALTH IT PROGRESS AND OUTCOMES... 109 PROJECT RISK ASSESSMENT... 112 APPENDIX A: IOWA LEGISLATION & LAW... 113 APPENDIX B: IOWA E-HEALTH STAKEHOLDERS... 126 APPENDIX C: LETTER OF SUPPORT FROM THE STATE MEDICAID DIRECTOR... 129 APPENDIX D: LETTER OF SUPPORT FROM THE PUBLIC HEALTH DEPARTMENT... 131 APPENDIX E: LETTER OF SUPPORT FROM THE REGIONAL EXTENSION CENTER... 132 APPENDIX F: LETTER OF SUPPORT FROM IOWA NEBRASKA PRIMARY CARE ASSOCIATION... 133 APPENDIX G: ONC-REQUIRED PERFORMANCE MEASURES AND REPORTING... 134 APPENDIX H: ONC TECHNICAL ASSISTANCE REQUEST... 137 APPENDIX I: ONC FOUR-YEAR BUDGET ESTIMATE... 138

IOWA E-HEALTH STRATEGIC AND OPERATIONAL PLAN CHANGE HISTORY AND PLAN APPROVALS Change History Date: Changes: 5/21/10 Original plan 5/28/10 Revision to the cover page 8/6/10 Added Change History and Plan Approvals, added Strategic and Operational Plan Summary, and update a few tasks and appendix items to reflect an August addendum to ONC 10/8/10 Added information from an October addendum to ONC 11/17/10 Updated the project plan schedule and added information from the November addendum to ONC 3/25/11 Incorporated content from the three previous addendums to ONC, removed and/or updated several appendix items, added letters of support to appendix, and made slight revisions throughout plan to reflect current activities. Full summary of changes available upon request. 6/04/12 Revised to align with recommendations from Program Information Notice (February 2012) and to include 1) Business & Financial Sustainability Plan; 2) Evaluation Plan; 3) Privacy & Security Framework; 4) Project Management Plan; 5) Tracking Program Progress Plan Approvals Description Approved By: Date: Approval of the original 2010 Iowa e-health e-health Executive 5/21/10 Strategic and Operational Plan Committee Approval of revisions and additions to the Strategic and Operational Plan. Revisions and additions were made based on additional guidance received from ONC through a State HIE Cooperative Agreement Program Information Notice in July 2010. e-health Executive Committee 8/6/10 Approval of the October addendum to the Strategic and Operational Plan. Addendum was developed in coordination with ONC Technical Assistance to provide additional information about: 1) Iowa s environmental scan; 2) Provider Directory and Secure Messaging; 3) Lab Interoperability; 4) e- Prescribing; and 5) Implementation Schedule. ONC-approval of the Strategic and Operational Plan Approval of revised Strategic and Operational Plan 1. Approval of revised Strategic and Operational Plan e-health Executive Committee 10/8/10 ONC 1/31/11 e-health Executive Committee e-health Executive Committee 3/25/11 6/01/12

STRATEGIC AND OPERATIONAL PLAN EXECUTIVE SUMMARY Health information technology (health IT) is recognized by public and private sector leaders as a key tool to support health reform across the nation. President George W. Bush s executive order in 2004, which called for every American to have an electronic health record (EHR) by 2014, was reaffirmed in the American Recovery and Reinvestment Act (ARRA) signed by President Barack Obama on February 17, 2009. The ARRA will result in a $19 billion investment in a health IT infrastructure for the United States. This funding will support technical assistance for EHR adoption, incentives to health providers implementing and using EHRs, and technical infrastructure to enable health information exchange (HIE) among health care professionals. The 2010 Iowa e-health Strategic and Operational Plan was a required deliverable of the State HIE Cooperative Agreement Program and was developed to allow Iowa to access $8,375,000 of planning and Iowa e-health Vision implementation funds from 2010 to 2014. The ARRA funds A healthier Iowa through the use have helped Iowa e-health begin to execute the tasks and and exchange of electronic health activities necessary to achieve the vision and goals of Iowa e- information to improve patientcentered health care and Health. population health This 2012 revision to the Strategic and Operational Plan is a major milestone for Iowa, which summarizes the valuable discussions and planning of the e- Health Executive Committee, Advisory Council and workgroups that have been taking place since January 2009. This Strategic and Operational Plan was developed through a transparent, multistakeholder process to identify and satisfy the business and clinical requirements for a statewide HIE. Governance The current governance model is best described as a government-led structure with accountability to a multi-stakeholder, public-private Executive Committee and Advisory Council. This structure was established by health reform legislation (2008 Iowa Acts, Chapter 1188). The legislation specified nine organizations to be represented on the Executive Committee and eight organizations on the Advisory Council. The Executive Committee serves as the governing body with assistance from advisors on the Advisory Council and the Iowa Department of Public Health (IDPH) serves as the legal business entity. With this model, IDPH provides accountability and transparency for planning and execution of Iowa e-health project activities based on direction and decisions by the Executive Committee and Advisory Council. To this end, the State Health IT Coordinator is instrumental in engaging various stakeholder organizations. IDPH serves as the business entity providing the personnel resources to convene the e-health Executive Committee, Advisory Council, and multi-stakeholder workgroups. Together, IDPH, the State Health IT Coordinator, the Executive Committee and Advisory Council, and e-health workgroups, provide transparency and accountability to Iowa e-health planning and implementation activities. Goal 7 of the Strategic and Operational Plan provides additional information about governance objectives, strategies, and tasks. Finance and Sustainability From the inception of Iowa e-health, sustainable operations have been a priority for Iowa stakeholders. Stakeholders are acutely aware of the need to operationally and financially sustain Iowa e-health goals, services, and activities throughout the statewide HIE lifecycle (see Goal 8 Execute Business and Technical Operations for Health IT). There are several funding streams available as a result of the American Recovery and Reinvestment Act of 2009 that will help advance Iowa e-health priorities. However, these funding streams alone cannot provide the financial sustainability necessary to support the desired outcomes of Iowa e-health. Following passage of SF 404 by the Iowa Legislature in 2011, Iowa e-health convened a Finance Workgroup to develop a comprehensive Business & Financial Sustainability IOWA E-HEALTH STRATEGIC AND OPERATIONAL PLAN (JUNE 2012) 6

Plan. The plan was approved by the State Board of Health and submitted to Iowa s Governor and general assembly in December 2011 for consideration during the 2012 legislative session. The Business & Financial Sustainability Plan provides a foundation for program sustainability. Specifically, the business plan provides financial projections, identifies financial strategies (e.g., grants, fees, or taxes), and informs strategies for statewide HIE services and operations to enable long-term sustainability (see Goal 9 Secure Financial Resources to Develop and Sustain a Statewide HIE). Technical Infrastructure Iowa s technical approach is to directly offer services through a statewide HIE as described in Goal 3 of the Strategic and Operational Plan. Iowa s statewide HIE, the Iowa Health Information Network, will enable the electronic exchange of health information in a secure format between authorized health care professionals and organizations. Goal 4 of the Strategic and Operational Plan describes the various HIE services to be provided through the statewide HIE (e.g., clinical care summaries, laboratory results, immunization reporting). With a connection to the statewide HIE, providers will be able to share data from disparate EHRs with other Iowa providers, and eventually with providers across the nation through the Nationwide Health Information Network (NwHIN) to provide continuity of care for their patients. This includes connection to federal care delivery organizations (e.g., Veterans Affairs, Indian Health Services, and Department of Defense). By building the statewide HIE based on HHS interoperability standards, Iowa will be prepared to connect to the NwHIN, as available. By establishing the statewide HIE infrastructure, Iowa will be more prepared to fully use health IT to improve quality of health care, assure patient safety, and increase efficiency in health care delivery. Providers Patients Web Portal EHR Systems Statewide Health Information Exchange Decentralized data storage Master Patient Index Record Locator Service Security Controls Standards Inte *e.g EHS Gre To e * Iowa IOWA E-HEALTH STRATEGIC AND OPERATIONAL PLAN (JUNE 2012) 7

Without a statewide HIE Each health care provider must build point-to-point connections. With a statewide HIE Each health care provider is connected. State procurement processes enabled the selection of an HIE to work with Iowa e-health and applicable e-health workgroups to ensure Iowa builds a system that meets the needs of Iowa stakeholders. Iowa e-health selected Xerox (formerly ACS, Inc.) to serve as Iowa s HIE vendor. Xerox brings their project management expertise, as well as several sub-contracting agencies to provide a comprehensive set of HIE-related services to the state. Informatics Corporation of America (ICA) is providing the software behind the HIE s infrastructure. Additional technical details (e.g., the incremental reach to different types of providers) will be available once Iowa is able to execute a vendor contract and begin work with an experienced HIE vendor. Privacy and Security Patients must trust that their electronic health information is kept confidential and secure, and providers must trust the availability and integrity of their patients information to make the best health care decisions. Privacy policies and security controls can provide assurances to patients; however, it is important to find the appropriate balance of policies and security controls (e.g., data confidentiality, availability, and integrity) to allow providers access to the information they need to treat their patients. Goal 5 of the Strategic and Operational Plan describes privacy and security strategies, including the Iowa e-health Privacy and Security Framework that aligns with the Privacy and Security Program Information Notice issued by the Office of the National Coordinator for Health IT in March 2012. Iowa e-health pursued legislation in 2012 to establish privacy and security policies (patient consent). The Iowa e-health Bill (SF 2318) was signed into law by Iowa s Governor, enabling Iowa e-health to move forward as an opt-out state. Business and Technical Operations A combination of dedicated staff resources and vendor contracts is a project management approach that leverages the expertise of the vendor community for critical tasks, but also provides dedicated state-level support to provide coordination, oversight, and accountability. The Office of Health IT, under the direction of the State HIT Coordinator and the Iowa Department of Public Health s Deputy Director, has been established within IDPH and is responsible for day-today operations of Iowa e-health. State procurement processes (e.g., requests for proposals) will be utilized to secure vendor contracts. A member of the Office of Health IT will be assigned to each vendor contract, serving as a primary point of contact for each vendor. The staff member will be responsible for escalating issues and monitoring change requests throughout the lifecycle of the contract. A dedicated IT project manager will closely monitor activities of the HIE vendor and two program coordinators will share responsibility for monitoring activities of the assessment, evaluation plan, business plan, and communication plan vendors. Goal 8 of the Strategic and Operational Plan describes the roles and functions of Office of Health IT staff members and the current and planned vendor contracts. IOWA E-HEALTH STRATEGIC AND OPERATIONAL PLAN (JUNE 2012) 8

A Project Management Plan is provided as a supplement to this Strategic & Operational Plan. The project plan provides a list of tasks, timelines for task initiation and completion, and a work breakdown structure among stakeholders. There are several interdependencies among the tasks that will impact the project timeline. For example: To support the multi-stakeholder nature of Iowa e-health, some decisions cannot be made without review, discussion, and approval by the e-health Executive Committee, Advisory Council, or workgroups. While stakeholders are highly engaged, time and scheduling constraints can still prolong decision-making processes. There are a number of planning and implementation decisions that will be made once Iowa is able to execute contracts with applicable vendors (e.g., technical infrastructure, business plan). The project plan will be monitored closely by the Office of Health IT and e-health Executive Committee and Advisory Council. Tasks and expectations will be refined as environmental scans are completed and vendor contracts are executed and monitored. Coordination with Medicaid In Iowa, the Iowa Medicaid Enterprise is the entity charged with administering the Iowa Medicaid Program. Iowa Medicaid exists under the Iowa Department of Human Services, which is separate from the Iowa Department of Public Health. Rather than developing a separate health information exchange, Iowa Medicaid s vision is to use the statewide HIE as the mechanism to integrate delivery of services and implement several of the goals and objectives outlined in their Medicaid HIT Plan (see Goal 6 Advance Coordination of Activities Across State and Federal Government). Iowa Medicaid is represented on the e-health Advisory Council and participates in all e-health workgroups. Regional Extension Center Iowa s Health Information Technology Regional Extension Center (HITREC) is operated by an Iowabased non-profit organization called Telligen (formerly IFMC). The Iowa HITREC will provide local technical assistance for primary care providers, and critical access hospitals in the adoption, utilization and meaningful use of electronic health records to improve the health and safety of Iowans. Specific services will include: direct onsite technical assistance to providers, vendor selection and group purchasing, and implementation and project management. The Iowa HITREC is represented on the e-health Advisory Council and participates in all e-health workgroups. Leveraging Existing Assets In Iowa there is a need for a statewide effort to facilitate exchange of information between providers with different EHRs. While health systems have had some success integrating information from EHRs from ambulatory referring providers, this is generally limited to providers using the same EHR system. To expand capacity to electronically exchange health information, while avoiding duplication of effort, the HIE Infrastructure and Services Workgroup, with representation from Iowa s large health systems, is convening topic-specific subcommittees to address areas of HIE interoperability and services. This includes lab interoperability (see Strategy 4.3.1). Iowa will also leverage existing assets by working to connect the provider organizations that have demonstrated their HIE capacity to the statewide HIE (see Environmental Scan). This includes three large health systems at HIMSS Stage 6 of EHR implementation and use [i.e., University of Iowa Hospitals and Clinics (UIHC), Broadlawns Medical Center, and Mercy Health Network North Iowa]. Iowa e-health has discussed participation in the statewide HIE with all three organizations; including detailed conversations about participating in Iowa s HIE pilots. Other Iowa-based health systems are rapidly adopting and using EHRs and many have contacted Iowa e-health to determine ways to connect with Iowa s statewide HIE. Additionally, NHIN Direct IOWA E-HEALTH STRATEGIC AND OPERATIONAL PLAN (JUNE 2012) 9

is a component of planned organizational strategies for many Iowa providers. The statewide HIE s utilization of NHIN Direct protocols and specifications will help incentivize providers to join the statewide HIE. Iowa stakeholders have been thoroughly engaged in Iowa e-health planning and acknowledge that point-to-point connectivity is inefficient and, at the current time, little interoperable electronic health information is exchanged (e.g., many manual processes are required to establish point-topoint connections between disparate EHR systems). Stakeholders embrace the value proposition for the statewide HIE and are poised to begin pilot testing and information exchange with the statewide HIE as soon as the infrastructure is in place. Persistence The Iowa Department of Public Health (the State Designated Entity for the State Health Information Exchange Cooperative Agreement), Iowa Medicaid Enterprise, and the Iowa Regional Extension Center are committed to working together to reach all providers throughout the state of Iowa, including those providers that may not be ready to embrace health IT and the tools available to them. With a coordinated communication and outreach plan that leverages professional media and peer champions, Iowa e-health will persist in conversations with Iowa providers to help Iowa achieve an important piece of health reform, which is improved patientcentered health care and population health through the use and exchange of electronic health information. IOWA E-HEALTH STRATEGIC AND OPERATIONAL PLAN (JUNE 2012) 10

BACKGROUND: HEALTH IT IN IOWA Health information technology (health IT) has increasingly been recognized by public and private sector leaders as a key tool to support health reform across the nation. Systematic flaws of the health care system must be corrected to facilitate improvements in health care quality, safety, and efficiency. President George W. Bush s executive order in 2004 which called for every American to have an electronic health record by 2014 was reaffirmed in the American Recovery and Reinvestment Act (ARRA) signed by President Barack Obama on February 17, 2009. The ARRA resulted in a $19 billion investment in a health IT infrastructure for the United States. The funding opportunity has provided planning and implementation grants needed to support the development of standard specifications and policies to facilitate interoperability, technical assistance for electronic health record (EHR) and health information exchange (HIE) adoption, expansion of education programs, and incentives to health providers through Medicare and Medicaid. Collecting health data in the right format and developing the infrastructure to exchange health data among health care institutions allows access to real-time health information. This benefits providers, patients, and the population. Real-time health information serves as a tool to help providers make the best health care decisions, provides patients with continuity of care regardless of the provider the patient visits, and enhances population health through use and analysis of the data collected and maintained throughout the system. Health Reform in Iowa In 2007, Iowa s health reform effort began in earnest with the formation of the Commission on Affordable Health Care Plans for Small Businesses and Families (the Commission) by the Iowa Legislature. Membership consisted of 10 legislators, eight members of the public representing various health care and insurance interests appointed by a legislative council, five consumers appointed by the Governor, and three state agency directors or their designees to serve as ex officio members. The Commission was charged to review, analyze, and make recommendations on a broad spectrum of issues relating to the affordability of health care for Iowans, including health IT. The Commission s final report is available at http://www.legis.state.ia.us/lsadocs/intreport/2008/ippaf000.pdf. In 2008, the Iowa Legislature enacted the Commission s recommendations with House File 2539, which established eleven advisory councils charged with making recommendations for health reform in Iowa. One of the eleven advisory councils is the e-health Executive Committee and Advisory Council administered by the Iowa Department of Public Health (IDPH). The e-health Executive Committee, with technical assistance from the e-health Advisory Council and IDPH, is charged with the following: - Developing a statewide health information technology plan by July 1, 2009; - Identifying existing and potential health IT efforts, and integrating with state and national efforts to avoid incompatibility and duplication; - Coordinating public and private efforts to provide the network and communications backbone for health IT; - Promoting the use of telemedicine defined as the use of communications and information technology for the delivery of care, usually in ways not otherwise available in the patient s immediate environment; - Addressing workforce needs generated by increased use of health IT; - Recommending rules to be adopted in accordance with Iowa Code chapter 17A to implement all aspects of the plan and the network; - Coordinating, monitoring and evaluating the adoption, use, interoperability, and efficiencies of health IT in the state; IOWA E-HEALTH STRATEGIC AND OPERATIONAL PLAN (JUNE 2012) 11

- Seeking and applying for any federal or private funding to assist in implementation and support of the health IT system; - Identifying state laws and rules that present barriers to development of the health IT system. With a broad health IT scope, the e-health Executive Committee and Advisory Council first established the 2009 Iowa Health Information Technology Plan (the 2009 Plan) to serve as a preliminary strategic plan for Iowa e-health. The 2009 Plan was approved by the e-health Executive Committee in June 2009 and the Iowa State Board of Health in July 2009. The 2009 Plan was subsequently submitted to the Iowa Legislature and included as an attachment to Iowa s application for the ARRA State HIE Cooperative Agreement Program available through the Office of the National Coordinator for Health IT (ONC) 1. The 2009 Plan served as a foundation for the development of the 2010 Iowa e-health Strategic and Operational Plan. The 2010 Strategic and Operation Plan, as well as this revision is a required deliverable of the State HIE Cooperative Agreement Program and allows Iowa to access $8,375,000 of planning and implementation funds from 2010 to 2014. These ARRA funds helped Iowa e-health execute the tasks and activities described throughout this document. 1 Office of the National Coordinator for Health IT, State Health Information Exchange Cooperative Agreement Program Funding Opportunity Announcement (September 2009). IOWA E-HEALTH STRATEGIC AND OPERATIONAL PLAN (JUNE 2012) 12

PLANNING APPROACH In January 2009, the first e-health Executive Committee and Advisory Council convened. Under the direction of the Executive Committee and Advisory Council, several volunteer workgroups were established to provide additional subject matter expertise for components of the planning process. Workgroups include: a) HIE Infrastructure and Networks: To assess and make recommendations regarding the necessary infrastructure including hardware, connectivity, and software, to support the statewide HIE. b) Continuity of Care Document and Interoperable EHRs: To define the types of clinical data to be exchanged through the statewide HIE including but not limited to: the continuity of care document, e-prescriptions and medication history, population health data (e.g., immunizations, reportable diseases), lab results, and quality reporting. c) Governance and Finance: To determine the type of business structure and financial model most suitable for supporting a sustainable statewide HIE. d) Provider Adoption of EHRs: To research and make recommendations on ways to achieve widespread adoption of certified EHRs and to promote participation in the statewide HIE. e) Safeguard Privacy and Security: To make recommendations for policies and procedures that will provide protections to consumers and providers and secure trust and support for statewide HIE. f) Health IT Workforce and Education: To prepare the health IT workforce and advance health IT curriculum and training. g) Evaluation: To provide feedback and guide development and implementation of a comprehensive evaluation plan. Additional subcommittees have been established to support specific activities of the workgroups. Subcommittees include: h) Communication & Outreach: To provide communication and marketing expertise on a comprehensive communication strategy to reach providers and consumers. i) Assessment: To provide guidance and recommendations regarding health IT assessment tools and data analysis. j) Provider Directory: To define the requirements and minimum data set for a statewide provider directory. k) Lab Interoperability: To clarify expectations for laboratory standards and technical assistance needs. l) E-Prescribing: To clarify the role of the HIE in e-prescribing and to guide the development of communication and outreach materials that can be used to increase e-prescribing prevalence. m) Participation Agreement: To provide feedback on proposed HIE participation agreement(s). The e-health Executive Committee, Advisory Council, and workgroups are comprised of diverse stakeholders from public and private entities including health care providers, professional associations, government, payers, educators, researchers, and consumers. (See Appendix B for stakeholder involvement) To support the activities of the Executive Committee, Advisory Council, and the workgroups, Iowa Department of Public Health assembled an internal e-health team, now formalized as the Office of Health IT. The Office of Health IT provides leadership to harmonize all committee, council, workgroup, and staff activities necessary to support day-to-day and long-term Iowa e-health planning and implementation. The following diagram illustrates the interaction among various public and private stakeholders for Iowa e-health: IOWA E-HEALTH STRATEGIC AND OPERATIONAL PLAN (JUNE 2012) 13

IOWA E-HEALTH STRATEGIC AND OPERATIONAL PLAN (JUNE 2012) 14

SCOPE OF PLANNING AND IMPLEMENTATION Stakeholders involved in the e-health Executive Committee, Advisory Council, and workgroups, have been highly engaged in the collaborative planning process and contributing significant amounts of volunteer time and intellectual resources. Together, the group established the vision, guiding principles, and goals to define the scope of a comprehensive statewide health IT planning effort. Vision The Iowa e-health vision is for a healthier Iowa through the use and exchange of electronic health information to improve patient-centered health care and population health. This initiative will produce a public good that will: Improve quality of health care Assure patient safety Increase efficiency in health care delivery Promote and protect the health of Iowans Guiding Principles Goals Engage in a collaborative, public-private, multi-stakeholder effort Create a sustainable health information exchange which makes information available when and where it is needed Ensure the system incorporates provider priorities and appropriate user education Instill confidence in consumers that their health information is secure, private, and accessed appropriately Build on smart practices and align with federal standards to ensure interoperability within and beyond the state Build awareness and trust of health IT Promote statewide deployment and use of electronic health records Enable the electronic exchange of health information Establish specific clinical exchanges and applications Safeguard privacy and security of electronic health information Advance coordination of activities across state and federal government programs Establish a governance model for statewide health information exchange Ensure sustainable business and technical operations for health IT Secure financial resources to develop and sustain a statewide HIE Monitor and evaluate health IT progress and outcomes The scope of planning is organized into goals, objectives, strategies, and tasks and described in the narrative found on pages 38-108. Some of the tasks have been completed since the inception of Iowa e-health planning in January 2009, while many are planned to be initiated and completed before December 31, 2013. IOWA E-HEALTH STRATEGIC AND OPERATIONAL PLAN (JUNE 2012) 15

The following outline provides an overview of the goals and objectives: Goal 1: Build awareness and trust of health IT Objective 1.1: Establish a program brand and identity. Objective 1.2: Begin raising awareness about health IT and Iowa e-health. Objective 1.3: Engage consumers to obtain their perspectives, concerns and priorities. Objective 1.4: Develop and execute a statewide communication and outreach campaign. Goal 2: Promote statewide deployment and use of electronic health records Objective 2.1: Provide technical assistance to providers adopting and implementing EHR systems and connecting to the statewide HIE. Objective 2.2: Assess barriers for provider adoption, and pursue resources and opportunities to overcome those barriers. Goal 3: Enable the electronic exchange of health information Objective 3.1: Develop a statewide health information exchange. Objective 3.2: Support the enhancement of network capacity and access to allow providers to connect and exchange information through the statewide HIE. Objective 3.3: Enable inter-state health information exchange. Goal 4: Enable the exchange of clinical data Objective 4.1: Establish a statewide provider directory. Objective 4.2: Enable secure messaging among providers. Objective 4.3: Enable interoperability between laboratories and providers. Objective 4.4: Increase adoption of e-prescribing in provider practices and clinics. Objective 4.5: Enable the exchange of continuity of care documents (CCD). Objective 4.6: Enable the use of the HIE to collect immunization data. Goal 5: Safeguard privacy and security of electronic health information Objective 5.1: Identify privacy and security barriers and formulate strategies to address those barriers. Objective 5.2: Develop a privacy and security framework. Objective 5.3: Establish trust agreements with participating providers. Objective 5.4: Establish oversight to ensure compliance with privacy and security policies. Goal 6: Advance coordination of activities across state and federal government Objective 6.1: Harmonize Iowa e-health activities and Iowa Medicaid Enterprise health IT planning. Objective 6.2: Build an appropriately trained, skilled health IT workforce. Objective 6.3: Align health IT project activities with federally funded, state-based programs. Objective 6.4: Align project activities with federal care delivery organizations. Objective 6.5: Align project activities with other American Recovery and Reinvestment Act (ARRA) programs. Objective 6.6: Ensure coordination between Iowa and neighboring states. Objective 6.7: Align Iowa e-health with broader health care reform efforts. Goal 7: Establish a governance model for statewide health information exchange Objective 7.1: Explore governance options and establish a governance entity. Objective 7.2: Establish policies and procedures to govern operations of Iowa e-health and the statewide HIE. Objective 7.3: Engage in multi-stakeholder, public-private collaboration. Goal 8: Ensure sustainable business and technical operations for health IT Objective 8.1: Provide resources and project management to carry out Iowa e-health goals, services, and activities. Objective 8.2: Provide resources and program management to sustain Iowa e-health goals, services, and activities. IOWA E-HEALTH STRATEGIC AND OPERATIONAL PLAN (JUNE 2012) 16

Goal 9: Secure financial resources to develop and sustain a statewide HIE Objective 9.1: Establish a business plan to inform strategies for statewide HIE services and operations, provide financial projections, and identify financial strategies to enable sustainability. Objective 9.2: Execute financial strategies to develop, implement, and maintain a statewide HIE. Objective 9.3: Be fiscally responsible with all funding revenues and expenditures. Objective 9.4: Hold vendors accountable to achieve deliverables. Objective 9.5: Implement financial policies, procedures and controls as required by the state HIE cooperative agreement program. Goal 10: Monitor and evaluate health IT progress and outcomes Objective 10.1: Conduct a baseline environmental scan. Objective 10.2: Develop an evaluation plan to determine whether changes in health care quality, safety, efficiency, and population health have occurred as a result of health IT. Objective 10.3: Perform comprehensive evaluations of Iowa e-health. The ONC funding opportunity announcement for the State HIE Cooperative Agreement Program in October 2009 explained that, developing capacity for health information exchange is an incremental process that requires demonstrated progress across five essential domains: governance, finance, technical infrastructure, business and technical operations, and legal/policy. 2 The following diagram illustrates how Iowa s ten goals link to the ONC s five domains. 2 Office of the National Coordinator for Health IT, State Health Information Exchange Cooperative Agreement Program Funding Opportunity Announcement (September 2009). p. 10. IOWA E-HEALTH STRATEGIC AND OPERATIONAL PLAN (JUNE 2012) 17

ENVIRONMENTAL SCAN A thorough understanding of the health IT landscape throughout the state will help Iowa plan and implement services to support health IT adoption. In April 2009, the Iowa Hospital Association (IHA) invited Iowa e-health to gather information regarding hospital health IT use, as part of the IHA annual survey. In December 2009, Iowa e-health worked with Iowa State University to conduct a provider practice and clinic health IT assessment. In 2010, Iowa e-health worked with the University of Iowa s Public Policy Center, to conduct assessments in five additional health provider settings: 1) home health, 2) long-term care, 3) pharmacies, 4) laboratories, and 5) radiology centers. A final report is available at http://iowaehealth.org that summarizes a range of health IT topics including: Provider health IT capabilities and preparedness to participate in a statewide HIE Preferences for types of high value clinical data exchange or HIE services Benefits and barriers to health IT adoption is expected in November 2010. Iowa e-health is planning to work with the Iowa Regional Extension Center (REC) monthly and will conduct environmental scans annually to address identified gaps in data collection and to support long-term evaluation planning. The next Environmental Scan is being planned for late 2012. Iowa s Provider Landscape: Hospitals 3 Iowa is home to 118 hospitals. The following data is a summary of Iowa s hospital landscape: 90 of Iowa s 99 counties contain at least one hospital and no Iowan is more than 25 miles from a hospital. 67% (78) hospitals have 1-25 acute beds [22% (1,814) of acute-care beds in state]. 14% (18) hospitals have 26-99 acute beds [11% (935) of acute-care beds in state]. 8% (9) hospitals have 100-199 acute beds [15% (1,201) of acute care beds in state]. 8% (10) hospitals have 200-399 acute beds [32% (2,595) of acute care beds in state]. 4% (3) hospitals have 400 or more acute beds [20% (1,646) of acute-care beds in state]. 77% (92) hospitals are classified as rural [i.e., not located in a Metropolitan Statistical Area (MSA)] [30% (2474) of acute-care beds in state] 18% (22) of Iowa s hospitals are considered urban (i.e., located within a MSA) [57% (4,695) of acute-care beds in state]. 5% (6) of Iowa s hospitals are categorized as rural referral centers (i.e., rural hospitals that have operating characteristics similar to a typical urban hospital) [8% (625) of acute-care beds in state]. 70% (82) hospitals are classified as critical access hospitals [29% (2,397) of acute-care beds in state] There are approximately 6,000 practicing physicians and mid-level practitioners (e.g., ARNPs) Provider working in 1,400 practice locations across Iowa. Practices and Clinics 4 76% (4,560) of Iowa's primary care physicians (PCPs) are employed by a hospital, integrated system, or a regional physician-owned network. 97% (1,358) of Iowa s provider practices exist as part of a larger health system. 3% (42) of Iowa s provider practices report having no arrangement with a larger health system. Labs There are approximately 2,800 CLIA laboratories in Iowa. 5 Medicaid s top 10 lab providers based on volume of claims paid in FY10 were responsible for 209,135 claims and received $6M in Medicaid claims reimbursement:48% of Medicaid s lab claims come from independent labs, with the remainder coming from clinics. The top 10 labs by claim volume in Iowa include: State Hygienic Laboratory at the University of Iowa (5%), Central Iowa Hospital Corp (5%), Metropolitan Medical Lab PLC (5%), Medical Labs of Eastern Iowa (3%), Weland Clinical Laboratories PC (3%), Quest Diagnostics LLC (3%), Collaborative Laboratory Serv LLC (3%), Laboratory Corp of America (3%), United Clinical Labs (3%), Center for Disease Detection (2%)[CDC]). 6 The State Hygienic Laboratory at the University of Iowa is Iowa s public health laboratory. a. 833,342 tests were processed at the State Hygienic Laboratory during FY2009. 3 Iowa Hospital Association, Profiles, 2010. www.ihaprofiles.org/index.php (accessed September 30, 2010). 4 Iowa Regional Extension Center, e-mail message to Iowa e-health, September 22, 2010. 5 Centers for Disease Control and Prevention, Clinical Laboratories Improvement Amendment (CLIA) Oscar Database, CLIA Laboratory Demographics, www.cdc.gov/clia/oscar.aspx (accessed November 4, 2009). 6 Iowa Medicaid Enterprise, e-mail message to Iowa e-health, September 23, 2010. IOWA E-HEALTH STRATEGIC AND OPERATIONAL PLAN (JUNE 2012) 18

Pharmacies 8 Payers b. 5,556 physicians/pas/nurses used the State Hygienic Laboratory for clinical service testing in FY2009. c. 6,852 physicians/pas/nurses used the State Hygienic Laboratory for newborn screening in FY2009. 7 There are 913 licensed pharmacies in Iowa. 86% (781) are classified as general pharmacies 14% (132) are classified as hospital pharmacies The population of Iowa is approximately 3,000,000 people. Public Payers in Iowa 9 1) In 2007, Medicare covered 17% (513,929) of Iowans and Medicaid covered 16% (470,000) of Iowans. Approximately 2% (70,000) of these were also covered by both Medicare and Medicaid. In 2010, Iowa Medicaid Enterprise estimates an increase in Medicaid enrollment to 18%. 2) 12% (43,830) of Iowans are covered by other public insurance plans (e.g., hawk-i). Private Payers in Iowa 10 3) 45% (1,700,000 covered lives) are covered by employee-based or private insurance plans. 25. 44% (1,300,000 covered lives) of Iowa s private insurance marketplace is covered by Wellmark, Inc. 26. 7% (93,000 covered lives) of Iowa s private insurance marketplace is covered by Wellmark Health Plan of Iowa. 27. 49% (87,500 covered lives) of Iowa s private insurance marketplace is split by other private payers (e.g., Humana, United Healthcare, Principal Financial Group no private payer in this sector covers more than 6% of the remaining private insurance marketplace). 4) 8% (238,140 Iowans) are uninsured. Iowa s Current HIE Capabilities (i.e., electronic exchange of EHR data): Hospitals 11 Electronic capabilities within hospital/health system: 32% (38) hospitals are able to exchange lab reports with other hospitals in their system, 71% (25) of those had 2-way communication. 28% (33) hospitals are able to share patient discharge summaries with other hospitals in their system. 21% (25) hospitals are able to exchange clinical care summaries with other hospitals in their system, 8% (2) of those had 2-way capabilities. Electronic capabilities with providers outside the hospital/health system: 11% (13) hospitals are able to exchange lab reports with hospitals outside their system, 15% (2) of those had 2-way communication. 5% (6) hospitals are able to share patient discharge summaries with hospitals outside their system. 9% (10) hospitals are able to share patient discharge summaries with clinics outside their system. Approximately 46% (145) provider practices have an EHR. Provider 82% (123) providers with an EHR access patient allergy and medication lists most or all of the time. Practices and Clinics 12 78% (117) of providers with an EHR access a clinical care summary (patient problem or procedure lists) most or all of the time. 77% (113) of providers with an EHR access clinical notes most or all of the time. 60% (87) of providers with an EHR access e-prescribing most or all of the time. 40% (123) of providers use e-prescribing software separate from an EHR. 59% (77) of providers with an EHR view image results most or all of the time. 57% (80) of providers with an EHR receive structured lab results most or all of the time. 23% (28) of providers with an EHR access reminders for guideline-based interventions and/or screening tests most or all of the time. 13% (11) of providers with an EHR access public health reporting most or all of the time. Iowa will collect data about patient portal functionality as part of future environmental scan efforts. However, Iowa e-health is aware that University of Iowa Hospitals and Clinics (Epic) has tested and is preparing to implement a patient portal. 100% of payers accept electronic eligibility and claims transactions, in accordance with HIPAA regulations. Payers Pharmacies 63% (569) of Iowa s 913 licensed pharmacies can accept electronic prescribing and refill requests. 13 18% (1080) of Iowa providers are certified to use Surescripts. 11 16% (2,813,116) prescriptions were routed electronically in 2009. 14 7 State Hygienic Laboratory at the University of Iowa, e-mail message to Iowa e-health, September 30, 2010. 8 Iowa Board of Pharmacy, e-mail message to Iowa e-health, June 22, 2010. 9 Kaiser State Health Facts, Iowa State Health Facts, www.statehealthfacts.org (accessed September 30, 2010). 10 Iowa Insurance Division, e-mail message to Iowa e-health, September 30, 2010 11 Iowa Hospital Association, 2009 IHA Member Health Information Technology Assessment Survey, (April 2009). 12 Iowa Department of Public Health, Iowa e-health Physician Practice Baseline HIT Assessment, (February 2010). 13 Surescripts, e-mail message to Iowa Pharmacy Association, February 2, 2010. IOWA E-HEALTH STRATEGIC AND OPERATIONAL PLAN (JUNE 2012) 19

Labs 10 Health Departments Provider Practices and Clinics 18 50% of labs are able to produce and deliver structured lab results (using a laboratory information system software product). 39% of labs are able to receive orders electronically (using an electronic order interface with the main reference lab). 40% of lab results are currently being delivered electronically (to at least some of their providers). The state health department (IDPH) currently receives electronic immunization and notifiable laboratory results, primarily through web-based data entry systems [i.e., Immunization Registry (IRIS) and Iowa Disease Surveillance System (IDSS)]. More than 1,000 organizations are using IRIS; 2,613,670 vaccinations were added to IRIS in 2009. Approximately 210 organizations are using IDSS; 53,000 reports of infectious diseases were submitted to IDSS in 2009. IDPH currently receives HL7 messages into IDSS from the State Hygienic Laboratory. IDPH does not currently collect syndromic surveillance data. At this time, there are no plans to implement collection of syndromic surveillance data; however, the implementation of a statewide HIE would provide infrastructure to begin considering this option. 15 Common EHR products: Hospitals 16 1) Products most commonly used in the general medical and surgical areas of Iowa hospitals include: CPSI: 17 Hospitals (14% of total facilities representing 1147 acute-care beds) Healthland: 13 Hospitals (11% of total facilities representing 900 acute-care beds) Cerner: 11 Hospitals (9% of total facilities representing 737 acute-care beds) Meditech: 11 Hospitals (9% of total facilities representing 737 acute-care beds). Epic: 5 hospitals (4% of total facilities representing 741 acute-care beds). 7 hospitals in Iowa Health System (6% of total facilities representing 1368 acute-care beds) are in the process of changing over to using Epic as their EHR. 17 Other: EHRs with a presence in Iowa include: Allscripts, ecw, Greenway, HMS, Medhost, Siemens, Keane, and McKesson. The Iowa REC will work with all EHR vendor products implemented in 81 of Iowa s critical access hospitals and an additional 6 rural hospitals (77% of total facilities representing 2397 acute-care beds]. Iowa e-health will refine estimates with the help of the Iowa REC, Ambulatory Estimated through the HIE participation interest form, and through continued EHR Product Market Reach evaluation and assessment. Allscripts 28% (33) McKesson 11% (13) Sage 9% (11) Healthland 8% (9) Cerner % (8) LSS 6% (7) Next Gen 5% (6) Other** 26% (32) Products have been selected by the Iowa REC for ambulatory care settings. Additional Iowa REC selected products include EHS, Greenway, eclinical Works, and e-mds. As of October 4, 2010, products have been certified by an ONC Authorized Testing and Certification Body. **Other EHRs with an Iowa presence include: InteGreat, Connexin, CPSI, Eclipsys, e-mds, GE, AmazingCharts.com, AllMeds, CareData, eclinical Works, Sage, Epic (ambulatory), Greenway, Novell, Praxis, and EHS Addressing Meaningful Use Requirements in Iowa: Medicaid 19 Iowa Medicaid Enterprise (IME) estimates that approximately 50% (600) of the estimated 1,200 eligible professionals in the state may request EHR incentive payments during calendar year (CY) 2011. 10% (60) of the remaining 600 eligible professionals are expected to request EHR incentive payments during CY2012-2016. 100% (37) of the acute-care hospitals in Iowa are expected to be eligible for incentives through Medicaid. 90% (82) of Iowa s rural and critical access hospitals (2397 acute-care beds) are expected to be eligible for incentives through Medicaid. It is estimated that $125M to $225M in incentive payments will be paid during the course of the entire meaningful use incentive program (2011-2021). Medicare 17 43% (600) of Iowa s providers intending to apply for meaningful use incentives are anticipated to apply for incentive payments through Medicare during CY2011. 15% (90) of eligible professionals are expected to apply for incentive payments through Medicare in CY2011. 22% (307) of Iowa s providers are considered Health Provider Shortage Areas according to data provided by HRSA. This enables those providers, if eligible, to apply for an additional 10% Medicare meaningful use 14 Surescripts, Iowa Progress Report of e-prescribing, www.surescripts.com (August 9, 2010) 15 Center for Acute Disease Epidemiology, e-mail message to Iowa e-health, September 30, 2010. 16 Iowa Hospital Association, 2009 IHA Member Health Information Technology Assessment Survey, (April 2009). 17 University of Iowa Hospitals and Clinics, e-mail message to Iowa e-health, October 4, 2010. 18 Iowa Department of Public Health, Iowa e-health Physician Practice Baseline HIT Assessment, (February 2010). 19 Iowa Medicaid Enterprise. State Medicaid Health Information Technology Plan, Version 1.0, (September 2010). IOWA E-HEALTH STRATEGIC AND OPERATIONAL PLAN (JUNE 2012) 20

incentive bonus. At this time, Iowa is unable to estimate total funding for Iowa providers through the Medicare incentive program. Iowa has requested this data from the regional CMS office, is waiting for a response, and will continue to follow up. In addition, an inventory of many assets and demonstrated achievements of health IT in Iowa has been compiled and will be leveraged to advance health IT and build a statewide HIE. Even though Iowa is not currently engaged in a statewide HIE, our stakeholders have accomplished many health IT milestones that will facilitate planning and successful implementation throughout Iowa. Iowa has been able to learn from its experienced stakeholders through workgroup discussions (facilitated by Iowa subject matter experts) where they have shared smart practices and lessons learned. Iowa also plans to leverage technology assets (e.g., provider directories and master patient indexes) in development of the statewide HIE and pilot implementations planned for 2012. Assets and Achievements: Adoption of Electronic Health Records Iowa Regional Extension The Iowa REC program was developed through a cooperative agreement Center (REC) program with ONC, awarded to Telligen in February 2010. The Iowa REC provides boots on the ground technical assistance to 1,200 priority primary care providers and critical access hospitals to assist in the adoption, University of Iowa Hospital and Clinics (UIHC) Mercy Health Network (MHN) Mercy Health Network North Iowa Genesis Health System Iowa Health System Broadlawns Medical implementation, and upgrade of EHR systems. UIHC uses a CCHIT certified EHR with full computerized physician order entry in place across the inpatient and outpatient environments. The EHR is used by more than 760 staff physicians, 720 physicians in training, 1850 nurses and 4600 other professional and support staff. UIHC is currently HIMSS Stage 6 certified in its deployment of its EHR system and supports extensive device integration between bed-side physiologic monitoring devices and the EHR, as well as bar-code scanning of inpatient and outpatient medication administrations. MHN is a joint venture between Catholic Health Initiatives and Trinity Health Novi. The network includes 5 major medical centers (Clinton, Des Moines, Dubuque, North Iowa, and Sioux City), 4 rural community hospitals, 24 affiliated hospitals, and 98 physician clinic sites. The network also includes other facilities such as nursing homes and inpatient hospices. Some sites use common clinical EHRs. Some sites have computerized physician order entry (CPOE), electronic nursing documentation, and physician portals. Those sites without health IT technologies are working to implement. More than seven North Iowa hospitals and the rural referral hospital have an integrated comprehensive EHR system, the first of its kind in a U.S. rural health care setting. The system provides remote access to physicians, pharmacists and allied health professionals; shared clinical decision support logical rules; shared care (order) sets for CPOE; barcode medication administration scanning; and Nova Medicity access to lab results. Genesis utilizes a completely paperless inpatient EHR. A majority of clinical information is captured electronically at the bedside. Automation has occurred in the following care areas: Emergency Department, Laboratory, Pharmacy, Radiology, Order Management, Surgery, Intensive Care, OB/Nursery, Nursing, and Home Health. Genesis is currently implementing a physician office EHR. Electronic medical records are in use across the IHS inpatient and outpatient environment including homecare. All twelve IHS hospital senior affiliates, including two facilities in Illinois, utilize an EHR. IHS supports 134 diverse clinics with over 450 providing physicians representing rural and urban settings; 107 of 134 ambulatory clinics are utilizing a CCHIT certified EHR with a roll-out plan for 16 additional clinics during 2009. Broadlawns Medical Center ranks among a select group of hospitals across IOWA E-HEALTH STRATEGIC AND OPERATIONAL PLAN (JUNE 2012) 21

Center IowaCare: Referral Request and Record Exchange the country that are HIMSS Stage 6 certified for successful adoption of EHR capabilities. To achieve Stage 6 certification, physician documentation and charting must be implemented for at least one patient care service area. Broadlawns has achieved this documentation in all inpatient care areas. A limited information exchange pilot project is underway between two of the HIMSS Stage 6 hospitals [i.e., University of Iowa Hospitals and Clinics (UIHC) and Broadlawns Medical Center]. Iowa Medicaid prompted these two large Medicaid providers, which use different EHR products, to move forward with testing data exchange concepts. UIHC has been able to use Epic software to enable secure communication with selected providers at Broadlawns Medical Center (which uses MEDITECH software). In early 2011, the exchange between these two organizations was limited to securely exchanging PDF documents. Assets and Achievements: Infrastructure and Networks HealthNet connect: Rural HealthNet connect is a 3,600-mile fiber optic network already in place to Health care Pilot Program provide sufficient bandwidth and connectivity services to healthcare (RHCPP) providers throughout Iowa. RHCPP funds from the FCC will enable connections for about 68 rural nonprofit healthcare providers. Aside from Iowa Rural Health Telecommunications Program (IRHTP) Iowa Communications Network (ICN) Iowa Nebraska Primary Care Association (IANEPCA) University of Iowa Health and Clinics (UIHC) Master Patient Index Iowa Health System (IHS) Master Patient Index RHCPP funds, HNc is open to any other healthcare providers. Organized by the Iowa Hospital Association, the IRHTP will link approximately 80 hospital facilities through the state-owned ICN. ICN has been providing inter-hospital broadband networking for 12 years and will provide the network capacity to extend important services to rural hospitals and the communities they serve. IANEPCA through a sister company, INConcert Care, Inc., maintains a network operations center in Davenport and supports a Statewide wide area network which supports data communications for nineteen health centers (13 in Iowa and 6 in Nebraska) using practice management software, patient registry, and dental practice management software applications. UIHC currently manages an enterprise patient index system with over 20 million records. The patient index system has been shown through an external audit to be a very clean system. UIHC has had and continues technical discussions with critical access hospitals about how UIHC can scale its expertise to support patient populations in critical access hospitals. IHS has leveraged an enterprise master patient index solution to create the link between its various systems and various unique patient identifiers. The EMPI solution has provided a single patient identifier to link patient data. Assets and Achievements: Data Exchange Continuity of Care The University of Iowa Hospitals and Clinics (UIHC), Iowa Health System Document Pilot (IHS) and Telligen (formally known as IFMC) initiated a pilot as part of Iowa s Health Information Security and Privacy Collaboration (HISPC) project in 2008 to support continuity of health care among practitioners, systems, and Electronic Verification of Vital Events (EVVE) settings via the production and exchange of the continuity of care document. A pilot project between Iowa Department of Public Health Vital Records Office and Iowa Department of Transportation Motor Vehicle Office, this system allows Iowa motor vehicle offices to query the vital records office to verify the birth certificate presented by the applicant applying for their driver s license. This data exchange is representative of a matching algorithm needed to match individual data across disparate systems. IOWA E-HEALTH STRATEGIC AND OPERATIONAL PLAN (JUNE 2012) 22

Iowa Department of Public Health (IDPH) and Centers for Disease Control and Prevention (CDC) Health Alert Network (HAN) Spencer Community Health Information Exchange IDPH administers CDC programs for disease surveillance, emergency preparedness, and response to natural or bioterrorism events, flu pandemic planning, and the development of a health alert network. These systems rely on information from laboratories, hospitals, and private providers and need to support bi-directional data exchange. The HAN provides Iowa s hospitals and county public health offices a statewide trunked radio system that is fully integrated into the State Emergency Operations Center and interoperable with eight other state agencies on a selective basis. HAN also provides an automated notification system and collaborative tools for use during emergency events. The ICN provides services to support the HAN. The community of Spencer, Iowa implemented a community HIE that enables the electronic exchange of health information between various types of providers with disparate EHR systems. The Spencer community HIE will have a direct connection to the Iowa statewide HIE. Assets and Achievements: Planning and Education Forums Iowa Healthcare Information Management Systems Society (HIMSS) Chapter information technology. Iowa Health Information Management Association (IaHIMA) Health Information Security and Privacy Collaboration (HISPC) Iowa Health Information Technology Initiative The Iowa HIMSS Chapter is one of 47 regional chapters affiliated with national HIMSS society. The chapter is in its fifth year of continuing education and information sharing to lead to advancements in health IaHIMA, the Iowa Health Information Management Association, is a state organization affiliated with the national organization American Health Information Management Association (AHIMA). Founded in 1928 to improve the quality of medical records, AHIMA is dedicated to the effective management of personal health information required to deliver quality health care to all in an increasingly electronic and global environment through leadership in advocacy, education, certification, and lifelong learning. HISPC is a multi-state, collaborative project funded by the Agency for Health care Research and Quality to address the privacy and security challenges presented by electronic health information exchange across the country. Iowa has participated in HISPC since its inception in 2006. The Health Information Technology Initiative, established in 2004, was one of the initial efforts to advance the use of health IT. Led by Telligen and the Iowa Medical Society, the Iowa HIT Initiative met regularly in 2005 and 2006 and distributed a Physician Office Health Information Technology Survey in 2005 and 2007. Iowa e-health Summit Coordinated by Telligen, the summit has been held annually since 2005. This annual statewide conference promotes the value of using health IT solutions to improve health care and has drawn leaders throughout the state and the country as participants and speakers. Iowa Department of Public Health (IDPH) Community College Consortium Interdisciplinary Graduate Program in Informatics (IGPI) With regular conferences, newsletters, and press releases, IDPH is a recognized source of health information throughout Iowa. IDPH has established communication lines that can be leveraged for consumer education about e-health in Iowa. Des Moines Area Community College and Kirkwood Community college are partners with Cuyahoga Community College District, which was named a regional Community College Consortium by ONC. IGPI is a graduate program available at the University of Iowa. IGPI offers a Ph.D. or M.S. degree in Informatics with specializations in either Health Informatics or Information Science. The program also offers a Certificate in Informatics that can be adapted to meet the needs of students across a range of disciplines that contain informatics content. Current Graduate Certificates in Informatics are awarded for Bioinformatics, Geoinformatics, Health Informatics, and Information Science. IOWA E-HEALTH STRATEGIC AND OPERATIONAL PLAN (JUNE 2012) 23

Other state-level and federal health IT initiatives (e.g., Health care Information Technology Standards Panel, Nationwide Health Information Network, Health care Information Management Systems Society, and American Health Information Management Association) also provide a solid foundation for planning and implementation of health IT in Iowa. Leveraging smart practices and lessons learned will undoubtedly help Iowa achieve success. The Gap Analysis section and Goal 10 describe additional baseline data that are currently available. As planning and implementation continues, a robust evaluation plan will be developed for Iowa e-health. This evaluation plan is critical deliverable that will help Iowa continue to understand its current state and progress towards reaching its desired goals. By gathering baseline data and continuously monitoring changes, evaluation will provide important lessons learned to help shape future programs and enable continuous improvements. IOWA E-HEALTH STRATEGIC AND OPERATIONAL PLAN (JUNE 2012) 24

GAP ANALYSIS Iowa is committed to providing at least one option for Iowa providers to demonstrate stage one meaningful use. Iowa Medicaid has a lead role in administering and funding the meaningful use incentive program, however IDPH and the REC also play a critical role in successful planning and implementation. Prepared by IDPH, Iowa Medicaid, and the REC, the table on the following page provides a gap analysis and demonstrates a shared understanding of the statewide strategies to help providers achieve meaningful use requirements. This includes but is not limited to laboratory data exchange, e-prescribing and sharing of clinical care summary records. The Meaningful Use section of this Strategic and Operational Plan also provides a list of the meaningful use measures and describes the role of EHRs and the statewide HIE in helping providers meet meaningful use requirements. IOWA E-HEALTH STRATEGIC AND OPERATIONAL PLAN (JUNE 2012) 25

Gap Analysis Table The following information was prepared by Iowa Department of Public Health (IDPH) Iowa s state designated entity for health information exchange (HIE), Iowa Medicaid Enterprise (IME) Iowa s state designated entity responsible for the provider incentive program, and Telligen Iowa s health information technology regional extension center (REC). The goal of the document is to provide a gap analysis and to demonstrate a shared understanding of the statewide strategies to help providers achieve meaningful use requirements including but not limited to laboratory data exchange, e-prescribing and sharing of clinical care summary records. Area of focus: Current State Activity: Activities taking place within your state in the following three areas (can include planning efforts by geographic area): Labs % of labs able to produce and deliver structured lab results % of labs able to receive orders electronically % of providers receiving structured lab results % of lab results currently being delivered electronically Laboratory: The statewide HIE will provide laboratory results to participating providers through a version of a Continuity of Care Document. Rather than point-to-point connections between each provider and each lab throughout the state, the technical strategy is to offer a single connection to labs through the statewide HIE. Laboratory interfacing for orders and results is included in the scope of work for an HIE vendor to build a statewide HIE (contract with the HIE vendor is pending). Iowa e-health conducted an assessment of laboratories in Fall 2010. The focus was on reference labs (i.e., hospital, free-standing, and mobile labs). The sampling frame came from state CLIA database, and also includes large Medicaid labs which are out of state (e.g., Quest, BioCore). 35% of labs share data with other providers (of those that share lab results electronically, 76% share data with physicians and 55% share data with hospitals) 57% of labs receive data from other providers electronically (of those that receive data electronically, 73% receive data from other labs and 40% receive data from physicians) 51% of providers receive results electronically (of those that receive results electronically, 58% use HL7) 51% of labs are able to send electronic lab results Participation rate for the laboratory assessment was16%. Therefore, the results should be used to evaluate potential trends rather than focusing on the exact percentages for any particular questions. Iowa Department of Public Health [Center for Acute Disease and Epidemiology (CADE)] applied for an ELC grant through CDC and was notified in 2010 of an award to help the State Health Laboratory [State Hygienic Lab (SHL) in Iowa City] interface with the HIE. SHL, CADE, and the Iowa e-health participated in a call with Tennessee Public Health Department in February 2011 to learn smart practices for lab interoperability. Iowa e-health plans to convene a lab interoperability subcommittee to continue lab interoperability discussions. (See Goal 4) IOWA E-HEALTH STRATEGIC AND OPERATIONAL PLAN (JUNE 2012) 26

Area of focus: e-rx % of pharmacies accepting electronic prescribing and refill requests e-rx: The statewide HIE will provide a medication history to participating providers through a version of a Continuity of Care Document. Medication orders and refill requests will be processed through existing e- Prescribing options. These e-prescribing options include: 1) An e-prescribing function available through most certified EHR products 2) Stand-alone systems (e.g., DrFirst, InterMedHx) 3) Web-based systems [e.g., Surescripts or eprescribe Iowa (a hosting option available through Iowa Health System)] Iowa e-health conducted an assessment of pharmacies in Fall 2010. The sampling frame came from the state Board of Pharmacy, which was cross referenced with information available through Iowa Pharmacy Association. 95% of pharmacies accepting electronic prescribing 91% of pharmacies accept refill requests Participation rate for the pharmacy assessment was39%. Therefore, the results should be used to evaluate potential trends rather than focusing on the exact percentages for any particular questions. Based on information from Surescripts and the number of licensed prescribers and pharmacies from the Board of Pharmacy, approximately 18% of providers are certified to use Surescripts and 63% of pharmacies can accept e- Prescriptions. An e-prescribing subcommittee has been formed to continue e-prescribing discussions. (See Goal 4) Sharing of clinical summary records Clinical Summary Records: The statewide HIE will provide a Continuity of Care Document (CCD) to participating providers. There are several options available for providers interested in exchanging CCDs. These options include: 1) Directly from an EHR through an HL7 formatted feed through the HIE 2) To the practice s or provider s electronic inbox accessed through the statewide HIE (e.g., HIE web portal) 3) Through fax between two providers (the traditional way of transferring summaries which will need to be phased out) It is believed that many certified EHRs are able to produce the HITSP C 32 format for CCD. Discussions with Iowa e-health stakeholders demonstrate tremendous interest from providers (including but not limited to hospitals, physicians, nursing homes, and home care agencies) on the exchange of summary records [i.e.,ccd, discharge and referral summaries]. According to physician practice assessment data (February 2010) 70% of practices believe exchange of clinical summaries is a very valuable type of data to be exchanged through the HIE. Facilitation of the exchange of the CCD is included in the scope of work for an HIE vendor to build a statewide HIE (contract with the HIE vendor is pending), which will allow for the CCD to be shared between multiple providers. The CCD is viewed as a starting point, and additional clinical summaries (e.g., pediatric summary record or OB summary record to be transferred to the hospital prior to delivery) may be a different format. Iowa e- IOWA E-HEALTH STRATEGIC AND OPERATIONAL PLAN (JUNE 2012) 27

Area of focus: Health will work to obtain specifications for additional clinical summaries in later phases of this project. Gap Analysis: Health Plans % of health plans supporting electronic eligibility and claims transactions Health Departments % of health departments receiving immunizations, syndromic surveillance, and notifiable laboratory results Define gaps that need to be addressed for providers to meet stage one meaningful use requirements Labs e-rx Meaningful use menu set objectives, EPs: Incorporate clinical lab test results as structured data Meaningful use menu set objectives, Hospitals: Incorporate clinical lab test results as structured data Meaningful use menu set objectives, Hospitals: Capability to provide electronic submission of reportable lab results to public health agencies Meaningful use core set objectives, EPs: e-prescribing Health Plans: The statewide HIE will not be used to facilitate the exchange of claims transactions. In accordance with HIPAA regulations, 100% of health plans accept electronic eligibility and claims transactions. Health Departments: The statewide HIE will provide immunization histories to participating providers. For participating providers, the statewide HIE will also be used to submit immunization and reportable disease information directly from EHRs to the state public health department reducing the need for entering data into more than one system. Iowa Department of Public Health (IDPH) currently receives electronic immunization and notifiable laboratory results, primarily through web-based data entry systems [i.e., Immunization Registry Information System (IRIS) and Iowa Disease Surveillance System (IDSS)]. The state health department does not currently collect syndromic surveillance data. The state health department is conducting an assessment to determine if syndromic data will be electronically collected in the future. It is also working to upgrade its technology and standards to enable the receipt of immunization (see Goal 4) and disease information from electronic health records. In February 2011, IDPH published a letter and FAQ document to Iowa providers clarifying the status of the public health systems and providing guidance about how to handle meaningful use reporting for the public health measures. Gap 1 EHR adoption. According to the physician practice assessment data (February 2010) less than 50% of physician practices are using an EHR, and according to hospital assessment data (April 2009), a majority of hospitals (85%) have an EHR or use a combination of paper and EHR. While many facilities have some form of EHR adoption, the degree to which systems are utilized varies greatly with most sites still at basic utilization versus fully functional systems (e.g., most critical access hospitals are not using CPOE or point of care nurse charting). This is a significant barrier for collecting and exchanging any kind of standardized clinical data, in particular clinical care summaries such as the continuity of care document. Gap 2 Ability to transmit structured data between laboratories, providers, and public health. There are three primary barriers to electronic exchange of laboratory data: 1) lab compendiums are difficult for providers and laboratories to maintain; 2) standards maintained by laboratories, providers, and public health need to be established and/or upgraded; and 3) point to point connections between physician practices and laboratories is time and cost prohibitive. Based on e-health workgroup discussions, hospitals may be in a better position to integrate lab data into the EHR because they have their own labs and may have interfaced the laboratory information system with their EHR product. Iowa Department of Public Health (IDPH) maintains a statewide surveillance system, the Iowa Disease Surveillance System (IDSS), which accepts HL7 messages and can support electronic lab messages. Currently, labs around the state manually enter results, with the exception of the state public health lab (University Hygienic Laboratory). Gap 3 Ability for providers to e-prescribe and pharmacies to accept e-prescriptions. There is a lack of confidence by pharmacies in the quality of data transmitted through e-prescription software, and there is frustration by pharmacies about the cost they must incur to accept and appropriately process e-prescriptions. IOWA E-HEALTH STRATEGIC AND OPERATIONAL PLAN (JUNE 2012) 28

Area of focus: Goal Clinical summary records Meaningful use core set objectives, EPs: Provide Patients with an electronic copy of their health information, upon request Meaningful use core set objectives, EPs: Provide clinical summaries for patients for each office visit Meaningful use core set objectives, Hospitals: Provide Patients with an electronic copy of their health information, upon request Meaningful use menu set objectives, EPs: Summary of care record for each transition of care/referrals Meaningful use menu set objectives, Hospitals: Summary of care record for each transition of care/referrals What gaps need to be addressed immediately to make the most significant advancement? Gap 4 Ability for providers to exchange clinical summary records. Generation of clinical summary records may not be automated by all implemented EHR systems, and there are a variety of potential outputs for a clinical summary record. There is a need to review the level of standardization among clinical summary records. Gap 5 Ability of public health to accept electronic information from provider EHRs. While many public health information systems are web-based, they are not connected directly to EHRs. This requires duplicate data entry by providers to submit reportable information to IDPH (e.g., immunizations, reportable diseases). Modifications need to be made to the public health systems to upgrade standards and prepare the interfaces necessary to connect to the statewide HIE, and ultimately to provider EHRs. Gap 6 Coordination within Iowa and among other states pursuing similar initiatives. Within the various priorities and activities initiated as a result of the American Recovery and Reinvestment Act, there are interdependencies, which if not properly aligned can result in delays in progress and extra rework. Coordination across the strategic initiatives will help stakeholders ensure integration, alignment, and joint success throughout Iowa and the nation. All gaps (1-6) are immediate priorities in order to advance the Iowa e-health vision and goals. This includes but is not limited to provider achievement of meaningful use requirements for laboratory data, e-prescribing, and exchange of clinical care summaries. An analysis of stage one meaningful use requirements reveals that the majority of gaps will be addressed through a provider s selection and meaningful use of a certified EHR product. Iowa e-health (primarily through the REC and Iowa Medicaid) is conducting education and outreach and deploying services to help providers adopt, implement, or upgrade their EHR product and/or meet stage one meaningful use requirements. This includes HITSP standards, vocabularies, value sets, and data sets that are critical for the exchange of structured data among providers. The statewide HIE will play a critical role in enabling the capability to electronically exchange clinical care summaries and laboratory data among providers of care and patient authorized entities. Iowa Department of Public Health is currently managing a procurement process to select an HIE vendor to build a statewide HIE. A contract is pending with the selected HIE vendor. In late summer 2011, the provider directory and secure messaging will be available through the statewide HIE. By Fall 2011, Iowa will begin pilot testing direct IOWA E-HEALTH STRATEGIC AND OPERATIONAL PLAN (JUNE 2012) 29

Area of focus: Strategies Describe strategies to fill gaps so each provider is able to meet the stage one meaningful use requirements Note: Numbers in brackets reflect the location of where additional information can be found within the Iowa e-health Strategic and Operational Plan. connections between the statewide HIE and hospital EHRs to enable the exchange of the CCD. Iowa e-health is currently accepting information from Iowa providers interested in participating in pilot testing and/or HIE implementation. Iowa Medicaid and the REC will assist in developing an HIE implementation schedule to reach all interested providers. Strategy 1 a) Provide technical assistance and support to providers adopting EHRs [see Goal 2] REC services are currently operational and will strive to reach 1,200 Iowa primary care providers and 87 critical access/rural hospitals over the next 18-24 months. b) Iowa Medicaid will administer the incentive program [see Goal 6] c) Use communication and outreach to help overcome barriers to provider adoption [See Goal 2] Strategy 2 a) Conclude and compile results from the laboratory assessment; results are due by the end of September 2010 [see Goal 10] b) Secure an HIE vendor to build a statewide HIE that will maintain compendium updates and provide a single connection point for providers and laboratories [see Goal 3] c) Upgrade standards maintained by the Iowa Disease Surveillance System and the State Health Laboratory; Iowa recently received a CDC ELC grant that will provide funding to support the standards upgrade Strategy 3 a) E-Prescribing can be facilitated for providers through many certified EHR products. The REC has identified six EHR vendors for eligible professionals in small practices; all the selected vendors have e-prescribing functionality included in their product b) Coordinate communication and outreach about the e-prescribing options available [see Goal 4] Strategy 4 a) Secure an HIE vendor to build a statewide HIE that facilitates the exchange of clinical care summaries (e.g., CCD) [see Goal 4] b) The REC will verify that the six selected EHR vendors for eligible professionals in small practices can produce the HITSP C 32 format for CCD Strategy 5 a) Upgrade public health information systems to connect to the HIE and subsequently accept reportable information submitted to the HIE from EHR systems. This includes immunizations, as well as reportable diseases [see Goal 4] Strategy 6 a) Iowa Department of Public Health, Iowa Medicaid, and the REC jointly participate in Iowa e-health workgroup meetings, meet monthly to coordinate planning and implementation activities, and serve on each program s relevant advisory councils; many joint and program-specific provider education and outreach events are underway and/or planned throughout the next several years [see goal 6] IOWA E-HEALTH STRATEGIC AND OPERATIONAL PLAN (JUNE 2012) 30

Area of focus: Provide responsibilities for each of the programs Medicaid Regional Extension Center State HIE Program Lead State HIT Coordinator Beacon Community Lead (If applicable) b) Iowa Department of Public Health hired a full-time State HIT Coordinator to coordinate activities across state agencies and serve as a spokesperson for Iowa e-health [see Goal 8] c) Seek technical assistance from ONC for more national coordination about expectations and approaches to HIE services; in particular e-prescribing and laboratory data exchange [see Goal 6] Medicaid (Iowa Medicaid Enterprise): Support EHR incentive program and coordinate provider outreach with the REC. Iowa Medicaid implemented their incentive program in January 2011. Regional Extension Center (Telligen): Assist 1,200 priority primary care providers to achieve meaningful use. The territory is the state of Iowa, including 87 critical access hospitals and rural hospitals. State HIE Program Lead (Iowa Department of Public Health-State Designated Entity): Provide day-to-day operational support for Iowa e-health and establish a contract with an HIE vendor to facilitate and support meaningful use and the HIE transactions needed to support statewide and national standards State HIT Coordinator (Iowa Department of Public Health): Coordinate activities across state agencies and serve as a spokesperson for Iowa e-health with Iowa stakeholders. Track progress How will progress be measured? Iowa e-health will be developing a comprehensive evaluation plan as part of the state HIE cooperative agreement program. At minimum, the evaluation plan will monitor: 1) The number of providers receiving Medicaid EHR incentive payments within Iowa 2) The number of provider entities connected through the HIE (including but not limited to physicians, hospitals, labs, and pharmacies) 3) The volume of different types of clinical data transactions traveling through the HIE. Iowa Medicaid will assess providers status on adopting health information technical at the time of Medicaid reenrollment. This will include all Medicaid providers, not only those who are eligible for incentives. The REC will monitor milestones for Iowa priority primary care providers and critical access and rural hospitals toward achieving meaningful use. As resources allow, the REC will also pursue milestones for non-priority providers and hospitals toward achieving meaningful use. Milestones include: 1) engaging the services of the REC; 2) EHR implementation Go-Live status, including e-prescribing and quality reporting; and 3) Achieving meaningful use through optimization of the EHR. IOWA E-HEALTH STRATEGIC AND OPERATIONAL PLAN (JUNE 2012) 31

MEANINGFUL USE The Health Information Technology for Economic and Clinical Health (HITECH) Act within ARRA provided the U.S. Department of Health and Human Services (HHS) with the authority to establish programs to improve health care quality, safety, and efficiency through the promotion of health IT, which includes EHRs and the secure exchange of electronic health information. Under HITECH, eligible health care professionals and hospitals can qualify for Medicare and Medicaid incentive payments when they adopt certified EHR technology and use it to achieve meaningful use objectives. A final regulation released on July 13, 2010 defines the meaningful use objectives that providers must meet to qualify for the bonus payments. The meaningful use final rule defines a set of core and menu set measures that represent the minimum requirements for providers to meet through use of certified EHR technology in order to qualify for payments. As the convening body of Iowa e-health and the state designated entity for HIE, it is Iowa Department of Public Health s (IDPH) responsibility to coordinate with other key stakeholders, in particular the Iowa Regional Extension Center (REC) and Iowa Medicaid Enterprise (Iowa Medicaid), to ensure providers have at least one option for meeting meaningful use requirements by the start of the incentive payment program in 2011. The following diagram illustrates a highlevel timeline for Iowa e-health activities and the meaningful use provider incentive program. 2009 2010 2011 2012 2013 Planning Assessment, research, develop strategic and operational plan Foundational Infrastructure, policies and procedures Provider Directory and Secure Messag Foundational HIE functionality to securely transport health among providers Pilot HIE Testing direct connections to the HIE and value-add services Operational HIE Routine HIE for providers, incremental additio functionality and provider types Evaluation/Measurement Monitoring return on investment and other HIE value propositions Meaningful Use Provider Incentives Stage 1 Stage 2 *Meaningful Use Stage 3 to beg IOWA E-HEALTH STRATEGIC AND OPERATIONAL PLAN (JUNE 2012) 32

Without an existing statewide HIE, it will be challenging for Iowa e-health and Iowa providers to meet meaningful use timeframes. The table on the following page provides a list of the meaningful use measures and describes the role of EHRs and the statewide HIE in helping providers meet meaningful use requirements. Goal 6 of the Strategic and Operational Plan describes the coordination efforts among Iowa e-health, Iowa Medicaid and the REC, and Goal 2 describes the technical assistance available to Iowa providers. IOWA E-HEALTH STRATEGIC AND OPERATIONAL PLAN (JUNE 2012) 33

MEANINGFUL USE MATRIX Type of Measure Eligible Professionals Stage 1 Objectives Eligible Hospitals and CAHs - Stage 1 Objectives Stage 1 Measures Role of EHR, HIE, or Other Resource(s) Core Core Use CPOE for medication orders directly entered by any licensed healthcare professional who can enter orders into the medical record per state, local and professional guidelines Implement drug-drug and drugallergy interaction checks Use CPOE for medication orders directly entered by any licensed healthcare professional who can enter orders into the medical record per state, local and professional guidelines Implement drug-drug and drugallergy interaction checks More than 30% of unique patients with at least one medication in their medication list seen by the EP or admitted to the eligible hospital s or CAH s inpatient or emergency department (POS 21 or 23) have at least one medication order entered using CPOE The EP/eligible hospital/cah has enabled this functionality for the entire EHR reporting period EHR: Primarily EHR function in Stage 1 HIE: involved in Stage 2 perhaps (e.g., when sending consults or orders from one site to another, it can be carried through the HIE) EHR: Purchased application with the EHR Core Core Core Generate and transmit permissible prescriptions electronically (erx) Record demographics: o preferred language o gender o race o ethnicity o date of birth Maintain an up-to-date problem list of current and active diagnoses Record demographics: o preferred language o gender o race o ethnicity o date of birth o date and preliminary cause of death in the event of mortality in the eligible hospital or CAH Maintain an up-to-date problem list of current and active diagnoses More than 40% of all permissible prescriptions written by the EP are transmitted electronically using certified EHR technology More than 50% of all unique patients seen by the EP or admitted to the eligible hospital s or CAH s inpatient or emergency department (POS 21 or 23) have demographics recorded as structured data More than 80% of all unique patients seen by the EP or admitted to the eligible hospital s or CAH s inpatient or emergency department (POS 21 or 23) have at least one entry or an indication that no problems are known for the patient recorded as structured data EHR: Primarily an EHR function Other: Can use stand-alone web-based systems outside of their EHR (e.g., Iowa Health's e-prescribe). EHR: A functionality of the EHR EHR: A functionality of the EHR [Note: have to use the SNOMED CT or ICD-9 (p. 89); SNOMED would be more specific to describe the problem than ICD-9] IOWA E-HEALTH STRATEGIC AND OPERATIONAL PLAN (JUNE 2012) 34

Type of Measure Eligible Professionals Stage 1 Objectives Eligible Hospitals and CAHs - Stage 1 Objectives Stage 1 Measures Core Maintain active medication list Maintain active medication list More than 80% of all unique patients seen by the EP or admitted to the eligible hospital s or CAH s inpatient or emergency department (POS 21 or 23) have at least one entry (or an indication that the patient is not currently prescribed any medication) recorded as structured data Core Core Core Maintain active medication allergy list Record and chart changes in vital signs: o Height o Weight o Blood pressure o Calculate and display BMI o Plot and display growth charts for children 2-20 years, including BMI Record smoking status for patients 13 years old or older Maintain active medication allergy list Record and chart changes in vital signs: o Height o Weight o Blood pressure o Calculate and display BMI o Plot and display growth charts for children 2-20 years, including BMI Record smoking status for patients 13 years old or older More than 80% of all unique patients seen by the EP or admitted to the eligible hospital s or CAH s inpatient or emergency department (POS 21 or 23) have at least one entry (or an indication that the patient has no known medication allergies) recorded as structured data For more than 50% of all unique patients age 2 and over seen by the EP or admitted to eligible hospital s or CAH s inpatient or emergency department (POS 21 or 23), height, weight and blood pressure are recorded as structured data More than 50% of all unique patients 13 years old or older seen by the EP or admitted to the eligible hospital s or CAH s inpatient or emergency department (POS 21 or 23) have smoking status recorded as structured data Role of EHR, HIE, or Other Resource(s) EHR: A functionality of the EHR (i.e., when patient comes to clinic they take a history of the meds of what they're taking) EHR: A functionality of the EHR (Note: you need both medication list and allergy list to do the drug-allergy checks) EHR: A functionality of the EHR EHR: A functionality of the EHR IOWA E-HEALTH STRATEGIC AND OPERATIONAL PLAN (JUNE 2012) 35

Type of Measure Eligible Professionals Stage 1 Objectives Eligible Hospitals and CAHs - Stage 1 Objectives Stage 1 Measures Role of EHR, HIE, or Other Resource(s) Core Core Implement one clinical decision support rule relevant to specialty or high clinical priority along with the ability to track compliance that rule Report ambulatory clinical quality measures to CMS or the States Implement one clinical decision support rule related to a high priority hospital condition along with the ability to track compliance with that rule Report hospital clinical quality measures to CMS or the States Implement one clinical decision support rule For 2011, provide aggregate numerator, denominator, and exclusions through attestation as discussed in section II(A)(3) of this final rule For 2012, electronically submit the clinical quality measures as discussed in section II(A)(3) of this final rule EHR: A functionality of the EHR EHR: used extract the data for reporting purposes HIE: used to route the report to CMS/IME Other: portal(s) from CMS/Iowa Medicaid (e.g., in first year CMS will have a secure website where providers can upload a file) Core Core Core Provide patients with an electronic copy of their health information (including diagnostic test results, problem list, medication lists, medication allergies), upon request Provide clinical summaries for patients for each office visit Provide patients with an electronic copy of their health information (including diagnostic test results, problem list, medication lists, medication allergies, discharge summary, procedures), upon request Provide patients with an electronic copy of their discharge instructions at time of discharge, upon request More than 50% of all patients of the EP or the inpatient or emergency departments of the eligible hospital or CAH (POS 21 or 23) who request an electronic copy of their health information are provided it within 3 business days More than 50% of all patients who are discharged from an eligible hospital or CAH s inpatient department or emergency department (POS 21 or 23) and who request an electronic copy of their discharge instructions are provided it Clinical summaries provided to patients for more than 50% of all office visits within 3 business days EHR: have patient portals, or there are some prepared reports (e.g., after visit summary). HIE: could provide some integration and single-point of access (Note: this is longer-term/tier 3 HIE service) EHR: A functionality of the EHR EHR: A functionality of the EHR IOWA E-HEALTH STRATEGIC AND OPERATIONAL PLAN (JUNE 2012) 36

Type of Measure Eligible Professionals Stage 1 Objectives Eligible Hospitals and CAHs - Stage 1 Objectives Stage 1 Measures Role of EHR, HIE, or Other Resource(s) Core Core Menu Menu Capability to exchange key clinical information (for example, problem list, medication list, medication allergies, diagnostic test results), among providers of care and patient authorized entities electronically Protect electronic health information created or maintained by the certified EHR technology through the implementation of appropriate technical capabilities Implement drug formulary checks Capability to exchange key clinical information (for example, discharge summary, procedures, problem list, medication list, medication allergies, diagnostic test results), among providers of care and patient authorized entities electronically Protect electronic health information created or maintained by the certified EHR technology through the implementation of appropriate technical capabilities Implement drug-formulary checks Record advance directives for patients 65 years old or older Performed at least one test of certified EHR technology's capacity to electronically exchange key clinical information Conduct or review a security risk analysis per 45 CFR 164.308 (a)(1) and implement security updates as necessary and correct identified security deficiencies as part of its risk management process The EP/eligible hospital/cah has enabled this functionality and has access to at least one internal or external drug formulary for the entire EHR reporting period More than 50% of all unique patients 65 years old or older admitted to the eligible hospital s or CAH s inpatient department (POS 21) have an indication of an advance directive status recorded HIE: help enable the exchange Direct exchange: direct exchange between the two providers (e.g., Broadlawns/UIHC test - they will FTP their files to their server and process it into a medical record; not a manual process, but rather triggered by order or discharge) Other Product: purchase of an integrator product (e.g., RelayHealth - purchased by McKesson but an independent HIE vendor) Organizational: Will have policies around the EHR implementation Audit: Outside review of how security is working Security officer: personnel of the organization (Note: if they show they have their house in order, better prepared to begin exchange) EHR: Part of erx and CPOE components EHR: A functionality of the EHR IOWA E-HEALTH STRATEGIC AND OPERATIONAL PLAN (JUNE 2012) 37

Type of Measure Eligible Professionals Stage 1 Objectives Eligible Hospitals and CAHs - Stage 1 Objectives Stage 1 Measures Role of EHR, HIE, or Other Resource(s) Menu Menu Menu Menu Menu Incorporate clinical lab test results into certified EHR technology as structured data Generate lists of patients by specific conditions to use for quality improvement, reduction of disparities, research or outreach Send reminders to patients per patient preference for preventive/ follow up care Provide patients with timely electronic access to their health information (including lab results, problem list, medication lists, medication allergies) within four business days of the information being available to the EP Use certified EHR technology to identify patient-specific education resources and provide those resources to the patient if appropriate Incorporate clinical lab-test results into certified EHR technology as structured data Generate lists of patients by specific conditions to use for quality improvement, reduction of disparities, research or outreach Use certified EHR technology to identify patient-specific education resources and provide those resources to the patient if appropriate More than 40% of all clinical lab tests results ordered by the EP or by an authorized provider of the eligible hospital or CAH for patients admitted to its inpatient or emergency department (POS 21 or 23) during the EHR reporting period whose results are either in a positive/negative or numerical format are incorporated in certified EHR technology as structured data Generate at least one report listing patients of the EP, eligible hospital or CAH with a specific condition More than 20% of all unique patients 65 years or older or 5 years old or younger were sent an appropriate reminder during the EHR reporting period More than 10% of all unique patients seen by the EP are provided timely (available to the patient within four business days of being updated in the certified EHR technology) electronic access to their health information subject to the EP s discretion to withhold certain information More than 10% of all unique patients seen by the EP or admitted to the eligible hospital s or CAH s inpatient or emergency department (POS 21 or 23) are provided patient-specific education resources EHR: must associate with a LOINC code (Note: can manually enter results back into the EHR if it doesn't come electronically) HIE: can help with standardization and be a hub for the labs (i.e., so the providers only have to make one connection rather than with each individual lab) EHR: A functionality of the EHR EHR: A functionality of the EHR EHR: have patient portals, or there are some prepared reports (e.g., after visit summary). HIE: could provide some integration and single-point of access (Note: this is longer-term/tier 3 HIE service) EHR: can check what education is given to the patient IOWA E-HEALTH STRATEGIC AND OPERATIONAL PLAN (JUNE 2012) 38

Type of Measure Eligible Professionals Stage 1 Objectives Eligible Hospitals and CAHs - Stage 1 Objectives Stage 1 Measures Role of EHR, HIE, or Other Resource(s) Menu Menu The EP, eligible hospital or CAH who receives a patient from another setting of care or provider of care or believes an encounter is relevant should perform medication reconciliation The EP, eligible hospital or CAH who transitions their patient to another setting of care or provider of care or refers their patient to another provider of care should provide summary of care record for each transition of care or referral The EP, eligible hospital or CAH who receives a patient from another setting of care or provider of care or believes an encounter is relevant should perform medication reconciliation The EP, eligible hospital or CAH who transitions their patient to another setting of care or provider of care or refers their patient to another provider of care should provide summary of care record for each transition of care or referral The EP, eligible hospital or CAH performs medication reconciliation for more than 50% of transitions of care in which the patient is transitioned into the care of the EP or admitted to the eligible hospital s or CAH s inpatient or emergency department (POS 21 or 23) The EP, eligible hospital or CAH who transitions or refers their patient to another setting of care or provider of care provides a summary of care record for more than 50% of transitions of care and referrals EHR: part of documentation HIE: could help send the summary (i.e., discharge summary, CCD both have medication histories) to the EP EHR: functionality of an EHR HIE: can help send the summary (in particular the CCD but more detail about goals, outcomes, plan of care, etc. which is important for rehab and home care) Menu Capability to submit electronic data to immunization registries or Immunization Information Systems and actual submission in accordance with applicable law and practice Capability to submit electronic data to immunization registries or Immunization Information Systems and actual submission in accordance with applicable law and practice Performed at least one test of certified EHR technology's capacity to submit electronic data to immunization registries and follow up submission if the test is successful (unless none of the immunization registries to which the EP, eligible hospital or CAH submits such information have the capacity to receive the information electronically) EHR: must be able to prepare the data Public health: must be able to accept electronic data (FTP or HIE) HIE: can transfer the data IOWA E-HEALTH STRATEGIC AND OPERATIONAL PLAN (JUNE 2012) 39

Type of Measure Eligible Professionals Stage 1 Objectives Eligible Hospitals and CAHs - Stage 1 Objectives Stage 1 Measures Role of EHR, HIE, or Other Resource(s) Menu Capability to submit electronic data on reportable (as required by state or local law) lab results to public health agencies and actual submission in accordance with applicable law and practice Performed at least one test of certified EHR technology s capacity to provide electronic submission of reportable lab results to public health agencies and follow-up submission if the test is successful (unless none of the public health agencies to which eligible hospital or CAH submits such information have the capacity to receive the information electronically) EHR: must be able to prepare the data - may need to retype into EHR if not already in structured format Public health: must be able to accept electronic data HIE: can transfer the data Labs: send results back to providers as structured data Menu Capability to submit electronic syndromic surveillance data to public health agencies and actual submission in accordance with applicable law and practice Capability to submit electronic syndromic surveillance data to public health agencies and actual submission in accordance with applicable law and practice Performed at least one test of certified EHR technology's capacity to provide electronic syndromic surveillance data to public health agencies and follow-up submission if the test is successful (unless none of the public health agencies to which an EP, eligible hospital or CAH submits such information have the capacity to receive the information electronically) EHR: collects surveillance data Provider: could send to CDC or public health department Public health: does not currently maintain syndromic surveillance information IOWA E-HEALTH STRATEGIC AND OPERATIONAL PLAN (JUNE 2012) 40

Goal 1: Build awareness and trust of health IT Building awareness and trust of health IT is vital to promoting and implementing the electronic exchange of health information in Iowa. A common barrier of successfully implementing health IT initiatives has been effectively communicating the roles, benefits, and privacy safeguards of electronic health records (EHR) and a statewide health information exchange (HIE). Furthermore, provider and consumer concerns regarding storing and transferring patient health information by electronic means has been shown to halt development of health IT systems in other states. The approach to address this barrier will be a comprehensive communication strategy with clear messages about the benefits of health IT and outreach strategies to facilitate bi-directional communication between Iowa e-health and the numerous stakeholders (i.e., providers, consumers, hospitals, health plans, and public health) throughout Iowa. Objective 1.1: Establish a program brand and identity. Establishing a clear and recognizable program brand and identity is important to help communicate Iowa e-health to audiences. There exist many acronyms and technical terms associated with health information technology initiatives (e.g., health IT, HIT, EHR, EMR, HIE), and many local and national health IT initiatives which are occurring simultaneously. By establishing a clear and recognizable brand for use with all communication materials, Iowa e-health will effectively communicate its vision and goals to stakeholders. Strategy 1.1.1: Work with college and university students to establish a new logo and potentially an alternative name for Iowa e-health. In August 2009, Iowa e-health invited interested Iowa college and university programs to develop and propose logos and potential program names for Iowa e-health as part of a hands-on learning experience. Student groups from Dordt College, Iowa State University, and Simpson College each designed program names and logos, tested the logos with stakeholders, and presented their ideas and research to the e-health Executive Committee and Advisory Council. The e-health Executive Committee selected the final name (i.e., Iowa e-health) and logo, which was incorporated into all communication and outreach materials. All participating students received recognition from Iowa Department of Public Health, and the winning student team received a monetary award provided by the Iowa/Nebraska Primary Care Association. Diagram 1.1a: Selected Logo Objective 1.2: Begin raising awareness about health IT and Iowa e-health. Garnering stakeholders trust and support is instrumental to ensuring a sustainable statewide HIE. Iowa e- Health will communicate and conduct outreach activities throughout Iowa to inform stakeholders of the benefits, goals, and role of health IT. Through the use of this proactive communication and outreach, Iowa e- Health will address stakeholder concerns and incorporate stakeholder preferences into planning and implementation of the statewide HIE. Strategy 1.2.1: Until a formal communication and outreach plan is developed, utilize a preliminary communication plan. To proactively inform and educate Iowans about health IT activities, a preliminary communication and outreach strategy was developed in 2009 to provide coordinated information about Iowa e- Health until a more formalized communication and outreach campaign is created and executed. The preliminary communication plan captured information about target audiences (e.g., providers, consumers, health care purchasers, payers), key messages (e.g., Iowa e-health, Iowa Medicaid incentives, Iowa Regional Extension Center), communication methods (e.g., press releases, conferences, websites), and timelines for outreach. The preliminary communication plan also included preparation of communication and outreach materials, including fact sheets, frequently asked questions (FAQs), case studies, and PowerPoint presentations. These communication IOWA E-HEALTH STRATEGIC AND OPERATIONAL PLAN (JUNE 2012) 41

resources have been disseminated through presentations, meetings, email lists, and other forums to reach many stakeholder groups. Additionally, Iowa e-health maintained a website (www.iowaehealth.org/) that provided an overview of health IT in Iowa; gave information about the e-health Executive Committee, Advisory Council, and workgroups; and offered web links to additional resources. These efforts began raising awareness and building knowledge of Iowa e- Health to ensure coordination of activities among other health reform initiatives. Strategy 1.2.2: Obtain provider input on communication strategies and messages through provider focus groups. Focus groups serve as a mechanism to determine effective communication messages and strategies. Provider focus groups were conducted throughout Iowa to obtain information regarding provider preferences, perceptions, and needs of health IT. Iowa e-health conducted provider focus groups to ask questions such as: What are, or have been, your primary challenges in adopting and implementing EHRs? What have been the most successful portions of your EHR implementation? What assistance would benefit your practice in selecting, implementing or updating an EHR system? What patient information, available through the statewide HIE, would be important and beneficial to you in providing care (e.g., continuity of care document, lab orders and results, medication history, immunization history)? What concerns would prevent your practice from joining the statewide HIE? What type of support would your practice need in connecting to Iowa s HIE? What would it take for your practice to participate in meaningful use incentives available through Medicare and Medicaid? What recommendations do you have for Iowa e-health that will help ensure Iowa does this right? The information garnered through the provider focus groups was incorporated into health IT planning and implementation activities. Objective 1.3: Engage consumers to obtain their perspectives, concerns and priorities. Iowa e-health consumers (i.e., potential patients) have a vested interest in the successful implementation of the statewide HIE. Consumers may express new ideas and/or concerns that Iowa e-health must consider when developing the statewide HIE. By engaging consumers during HIE planning and implementation phases, Iowa e-health will ensure that consumer preferences, priorities, and concerns are represented and incorporated into HIE planning and implementation activities. Strategy 1.3.1: Convene the Iowa e-health consumer interest group. Iowa e-health established a consumer interest group which will provide a forum for consumers to: 1) learn about e-health related topics and policies; 2) provide feedback regarding HIE planning and implementation; and 3) help communicate the vision and goals of Iowa e-health to other consumers. The group first met in April 2010, and continues to meet regularly. Strategy 1.3.2: Plan and facilitate community forums for consumers. By engaging consumers through community forums, Iowa e-health will garner information regarding consumer perceptions, concerns and benefits of the statewide HIE. Community forums will help educate consumers about the benefits and value of the HIE and capture information in a useful format to assist Iowa e-health in planning and implementing the statewide HIE. Strategy 1.3.3: Engage Iowa businesses and health care payers to widely communicate Iowa e-health information and education. Iowa businesses and payers will potentially benefit from a statewide HIE through increased health care efficiency and coordination of care. By communicating and planning with Iowa health care payers, payer associations, labor unions, and business associations, Iowa e-health will garner participation which will help ensure the on-going success of the statewide HIE. Objective 1.4: Develop and execute a statewide communication and outreach campaign. IOWA E-HEALTH STRATEGIC AND OPERATIONAL PLAN (JUNE 2012) 42

The comprehensive communication and outreach campaign will: 1) promote Iowa e-health; 2) help consumers and providers understand the uses and value of health IT (e.g., patient safety, improved quality, efficiency, and continuity of care); 3) instill consumer and provider confidence in the statewide HIE (e.g., privacy and security controls, accurate and timely retrieval of patient information); and 4) provide support to provider groups in educating their patients about the value of appropriate health IT. The type of message to communicate may vary depending on the type of audience (e.g., providers, consumers, other stakeholders). For example, a consumer may be interested in messages that highlight the continuity of care that can be provided through a statewide HIE, while a provider may be more interested in messages about the opportunities health IT provides to improve quality, safety, and efficiency of health care delivery and the incentives and technical support available for their practice. Therefore, the Iowa e-health Communication Plan (developed 2011) proposes diverse communication messages and dissemination methods appropriate for different types of audiences, cultures, and geographic locations (e.g., rural and urban). The communication plan also establishes mechanisms to receive feedback, questions, and concerns from providers and consumers. Strategy 1.4.1: Leverage communication experts from Iowa Department of Public Health (IDPH) and an external vendor organization to develop a comprehensive communication and outreach plan. IDPH is a recognized source of information for health-related news and has successfully engaged in large communication and education efforts (e.g., H1N1 influenza prevention campaign, Iowa Smokefree Air Act compliance education, and nutrition-related social marketing). While IDPH communication experts will be helpful in disseminating messages, Iowa e-health requires a dedicated communication team to help develop creative materials and communication strategies. This dedicated team has been obtained through a vendor contract, working in coordination with IDPH communication staff, and a communication plan has been developed. A key component of the plan was the development of a new, comprehensive website to serve as a method of communicating Iowa e-health information and resources to stakeholders. Additional components of the campaign will be executed based upon recommendations outlined in the communication plan. Strategy 1.4.2: Align communication materials and strategies with the Iowa Regional Extension Center (REC) and Iowa Medicaid to reach Iowa providers. To coordinate and reduce duplicative messaging, Iowa e-health, the Iowa HITREC, and Iowa Medicaid will align information and education that is important to disseminate to Iowa providers. Each entity has various methods of communication delivery (e.g., distribution lists, communication venues) that can be leveraged to inform the most providers possible about health IT activities in Iowa. IOWA E-HEALTH STRATEGIC AND OPERATIONAL PLAN (JUNE 2012) 43

Goal 2: Promote statewide deployment and use of electronic health records The implementation and use of electronic health records (EHR) within health care provider settings is an essential component in advancing health IT in Iowa. EHRs serve as building blocks for enabling the electronic exchange of health information. Even as provider assessment data indicates adoption rates of EHRs in Iowa are generally low, adoption rates continue to rise, with an expected increase resulting from meaningful use provider incentives. Iowa providers use a variety of EHR products, which may or may not meet certification requirements [e.g., Certification Commission for Health Information Technology (CCHIT) requirements] or lack the ability to connect to a statewide health information exchange (HIE). Many EHR products are unable to connect to other EHR products and a statewide HIE for reasons such as inconsistent data coding of standard vocabularies. The Office of the National Coordinator for Health IT (ONC) is in the process of establishing certification programs for purposes of testing and certifying health IT. These programs will provide assurance to purchasers and other users that an EHR system offers the necessary technological capability, functionality, and security to help them meet meaningful use. Beyond considerations of EHR certification, there are other electronic clinical systems in use by provider types (e.g., pharmacies, labs, radiology centers) which must be considered when implementing a statewide HIE. As EHR technology and requirements emerge and evolve, it is important to provide clear information and support to providers to create a sustainable health IT infrastructure in Iowa. Though providers are experiencing greater pressure to adopt, implement, and upgrade EHR systems to meet meaningful use requirements, it is important to recognize Iowa providers unique needs and preferences when using health IT to improve health care in Iowa. Objective 2.1: Provide technical assistance to providers adopting and implementing EHR systems and connecting to the statewide HIE. As providers prepare to adopt and implement an EHR system and connect to the statewide HIE, they will need resources and support. The resources and support will help providers make informed decisions about the EHR options available, disseminate lessons learned from other providers, and understand the standardization requirements necessary for interoperability. When new health IT systems are introduced or changed within provider settings, it often disrupts day-to-day activities, and can create undesired consequences (e.g., inefficiencies, workflow issues, etc.). By offering hands-on technical support and resources, the transition and integration of EHR systems can be a successful and positive experience leading to improved patient-centered workflow designs, increased efficiencies, and improved quality of care. This assistance is necessary as more and more providers adopt EHR systems to meet meaningful use requirements. In addition, as the statewide HIE enters phased implementation, Iowa e-health must ensure providers are informed of the process and requirements of connecting to the statewide HIE. Through outreach and education, Iowa e-health needs to inform providers of the functionality and services available and the minimum requirements and participation expectations (e.g., privacy and security policies, technical infrastructure requirements, etc.). Iowa e-health will need to identify and provide technical assistance (in lieu of financial assistance) to guide providers in establishing a connection to the statewide HIE. This technical assistance can be provided through partnerships with the Iowa Regional Extension Center (Iowa REC), Iowa Medicaid, the HIE vendor, and professional health care organizations and associations. Strategy 2.1.1: Provide technical assistance for EHR selection, implementation, or upgrades to ONC-priority providers through the Iowa REC. Iowa providers are at different levels of EHR adoption and use, and generally have limited resources available for health IT. Health care providers will need education, training, and technical support to adopt, implement, and upgrade EHR systems. Through an ONC program made available through ARRA, Iowa s HITREC, operated by an Iowa-based non-profit organization called Telligen, will provide support to Iowa priority providers (see Strategy 6.5.1). Priority providers include physicians, IOWA E-HEALTH STRATEGIC AND OPERATIONAL PLAN (JUNE 2012) 44

physician s assistants, and nurse practitioners with prescriptive privileges, who work in family practice, internal medicine, pediatrics, and OB/GYN settings. The Iowa REC will provide local technical assistance for Iowa priority primary care providers, and critical access hospitals in the adoption, utilization and meaningful use of electronic health records to improve the health and safety of Iowans. Specific services will include: direct onsite technical assistance to providers, vendor selection and group purchasing, and implementation and project management. Strategy 2.1.2: Provide technical assistance to providers not targeted for REC services available through ONC funding. ONC funding will enable the Iowa HITREC to provide technical assistance to primary care providers and rural and critical access hospitals. However, there are many other providers throughout the continuum of care in Iowa that need technical assistance in adopting, implementing, or upgrading EHR systems. This assistance will help enable meaningful use of EHR systems by various types of providers and prepare more providers to connect with the statewide HIE. Given that the Iowa REC will have infrastructure and staffing already in place for core business operations, a partial solution could include expansion of Iowa REC services to assist providers outside of the ONC-defined priority primary care areas. Under this scenario, additional providers could purchase and utilize the existing expertise of the Iowa REC, while helping the Iowa REC with meet cost sharing requirements established by the ONC Regional Extension Center Cooperative Agreement Program. Once resources and opportunities for technical assistance are identified, it will be important to educate providers about the option(s) available. Objective 2.2: Assess barriers for provider adoption, and pursue resources and opportunities to overcome those barriers. Common barriers to provider adoption are the cost burden of implementing and sustaining an EHR system, disruption in patient services when implementing an EHR system, and changes in provider processes and workflows. By identifying and understanding these barriers early in the planning phase, strategies can be developed to help providers overcome these barriers and achieve meaningful use of EHRs and the statewide HIE. An example of a strategy to overcome a cost barrier is through provider incentives. Strategy 2.2.1: Use baseline assessment data (see Goal 10 or Environmental Scan) to identify common barriers to health IT adoption. Iowa e-health activities include an assessment of EHR adoption and on-going tracking of statewide HIE implementation. Iowa e-health will use information gathered through the assessments to form the basis of additional strategies that may facilitate increased adoption and use of health IT, including methods to integrate electronic patient information systems used by different types of health care providers. Strategy 2.2.2: Communicate the importance of meaningful use of health IT and the resources available to assist providers. Iowa providers are at many different stages of implementing and using EHR systems, from having no system in place to reaching full EHR implementation and widespread use of the embedded functionality. Communicating the benefits and opportunities of EHR systems will help promote the adoption of these systems within many provider settings. By providing clear and straightforward information about the role of EHRs in improving the safety, quality and efficiency of care, the requirements for meaningful use incentives, and the resources available to Iowa providers, Iowa e- Health will increase EHR adoption rates, increase the number of providers engaged in the meaningful use of EHRs, and prepare providers to connect with the statewide HIE. Strategy 2.2.3: Explore the need to promote alternative health IT solutions for providers unable to implement an EHR system and maintain a direct connection with the statewide HIE. Based on current rates of provider adoption and use of EHRs, providers are incrementally implementing EHR systems into hospital and clinic settings. As traditional EHR adoption and IOWA E-HEALTH STRATEGIC AND OPERATIONAL PLAN (JUNE 2012) 45

implementation continues to expand, Iowa providers may require an alternative, interim solution to become accustomed to using health IT as a means of improving patient-centered care and population health. Interim solutions could include EHR hosting, EHR-light, or a view-only portal to the statewide HIE. EHR Hosting Providers with limited resources and technical support may choose to partner with organizations that provide EHR hosting services. Potential hosting organizations would examine the business case and technical requirements for such an agreement. Iowa e-health would help facilitate these partnerships to promote shared resources and expertise throughout Iowa, and to help providers reach their health IT goals and specific meaningful use requirements. EHR-Light An option which would enable a greater number of providers to adopt health IT is to provide an HIEhosted version of an electronic health record (e.g., EHR-light). The EHR-light would include the functionalities to collect, store, and manage patient information. These interim solutions would assist providers in overcoming barriers of implementing a standalone EHR system, and enable providers to meet meaningful use requirements. View Only Portal Iowa e-health recognizes that many Iowa health care providers: 1) have not yet implemented an EHR system, 2) use an EHR that does not meet any new federally-established technical and functional standards, or 3) use electronic systems appropriate to their care setting (e.g., laboratory information management system, pharmacy), but not an EHR. To enable providers without an interoperable EHR to benefit from the statewide HIE, a provider portal will be developed (see Goal 3 Enable the Electronic Exchange of Health Information). This provider portal will allow providers to view and print patient information relevant to their patients care (e.g., a continuity of care document, lab orders and results, medication history, and immunization history). There may be some application modules of the portal that will allow providers using the portal to edit or upload information to the HIE. This may include an immunization module that allows providers to add information about immunizations administered; a quality reporting module that allows providers to submit quality data; or a module to support EHR-Light. Strategy 2.2.4: Explore resources to assist providers in purchasing EHRs (e.g., loan and group purchasing programs) or making technical modifications to their existing EHR products to support IHIN connection (e.g., sub-grants, low-interest loans). Many Iowa providers have already allocated substantial resources to purchase and implement EHR systems, some of which may not meet any new certification standards. However, to connect with the statewide HIE, provider EHRs must meet these standards. Finding additional resources to pay for new EHR systems or to upgrade existing systems will be difficult for many Iowa providers, even with available meaningful use provider incentives. ARRA includes a provision for ONC to develop a loan program for providers to purchase EHRs and related applications (e.g., clinical decision support tools, knowledge databases, medication administration barcode scanning), however the program was not mandated and, to-date, this program has not been made available. Organizations in Iowa may choose, however, to offer similar types of loan programs, or seek ways to use purchasing power to lower costs of health IT. The benefits of loan programs and group purchasing power would allow providers with limited resources to adopt and implement EHRs. Offering such loan programs and group purchasing programs is outside the scope of business for Iowa e-health; however, exploring those options available through other organizations, including the Iowa REC, would benefit Iowa providers. Furthermore, Iowa e-health will explore options to make sub-grants available to providers intending to connect to the IHIN for existing EHR technical modifications. These sub-grants would support providers in attaining Meaningful Use, would align with ONC-endorsed standards and specifications for Direct and query-based exchange. Additionally, sub-grant recipients will be identified based on pre-established criteria and to address gaps in IHIN service by provider type (e.g., pharmacy, laboratory, rural health clinics). IOWA E-HEALTH STRATEGIC AND OPERATIONAL PLAN (JUNE 2012) 46

Goal 3: Enable the electronic exchange of health information A statewide health information exchange (HIE) is the infrastructure that facilitates and supports the exchange of electronic health information among clinical and population health settings. The statewide HIE is a hub that connects different EHR systems and allows standardized information to flow between authorized providers and health organizations. Enabling the electronic exchange of information is a criterion for meaningful use of electronic health records (EHR), as established in American Recovery and Reinvestment Act (ARRA) 20. Iowa e-health has identified ten core components of a statewide health information exchange. These include: Core Component Brief Description 1. Data Storage Type of statewide HIE infrastructure model (e.g., centralized, federated, hybrid) that specifies where and how data will be stored 2. Master Patient Index Software to uniquely identify and match patient records from different health data systems 3. Record Locator Service Software that enables the statewide HIE to retrieve patient records stored in decentralized health data systems 4. Authentication Security controls to identify who is allowed to access the statewide HIE 5. Access and Authorization Role-based security controls to manage who an individual is permitted to use the statewide HIE 6. Auditing and Logging Security controls to monitor activity taking place through the statewide HIE 7. Transport and Content Standards Nationally recognized specifications and protocols to enable communication among different health data systems 8. Data Transactions Processes and software necessary to facilitate the exchange of various types of data through the statewide HIE 9. Participation Expectations and Minimum Prerequisites before individuals or organizations Requirements are permitted to contribute or use the statewide HIE 10. User and System Interface Methods to access the statewide HIE 1. Data Storage: Enable aggregation of data from disparate provider sources to facilitate communications. For example, temporarily hold patient information as it is being compiled to communicate a concise summary of the information; or permanently store data from select sources across time to support a data registry. A federated hybrid infrastructure model can be defined where some health data is centralized and some health data are stored at locations where care is provided. A hybrid HIE enables the exchange of data stored in existing provider networks, while maintaining an option to store data centrally for smaller providers without their own database or network. A hybrid HIE offers the most flexibility by allowing large institutions with complex EHR systems, as well as individual providers with no EHR system, to receive shared services and value from the statewide HIE. 20 American Recovery and Reinvestment Act of 2009, Pub. L. No. 111-5, (February 17, 2009). Division A Title XIII: Health Information Technology for Economic and Clinical Health Act (HITECH), Subtitle C: Grants and Loan Funding, Section 3013: State Grants to Promote Health Information Technology. p. 138. IOWA E-HEALTH STRATEGIC AND OPERATIONAL PLAN (JUNE 2012) 47

Diagram 3.1a: Federated Hybrid Infrastructure Model The HIE infrastructure will provide access to the statewide HIE through a direct connection (generally through an integrated EHR), or through a view-only portal. Additional information about the system and user interface can be found under HIE Core Component 10. Centralized storage by the statewide HIE will be minimal, including only the MPI, RLS, and other software or data files necessary to support privacy and security policies, quality metrics, and the transfer of information between statewide HIE participants. Once setup activities for the statewide HIE infrastructure have been completed, data will begin transmitting to a test environment within the statewide HIE. After the test environment demonstrates all data are being displayed accurately for the correct patient, data will begin transmitting to a production environment within the statewide HIE where data transactions are discoverable by pilot participants and full statewide HIE participants. The statewide HIE servers will be located in a secure environment with complete backup and disaster recovery capability. The backup infrastructure will include a fault tolerant geographically separated secondary data center to be utilized in the event of disaster. IOWA E-HEALTH STRATEGIC AND OPERATIONAL PLAN (JUNE 2012) 48

Diagram 3.1b: Data Flow between the MPI, RLS, and Population Health Assembly Uses cases for this data flow include, but are not limited to: A primary care provider refers a patient to a specialist or hospital and provides a summary care record; A specialist provides a summary care record back to the referring primary care provider; A hospital sends a discharge summary or continuity of care document to a referring provider; A laboratory sends lab results to an ordering provider; and A provider submits immunization information to public health. 2. Master Person Index (MPI): Utilize a standard person identity/information correlation process to uniquely identify an individual and match patient data from different providers and care settings. A core element of health information exchange is the ability to correctly match patients with their clinical data. In the absence of a single, standardized patient identifier (e.g., social security number or national patient identifier) technology and algorithms used with an MPI can link patient data from different provider networks and create timely data exchange opportunities. The MPI will be a robust, integrated software tool that will conduct all patient matching functions of the statewide HIE. The MPI stores identified data elements and metadata required to support demographicbased matching algorithms. The MPI contains an index of pointers to the network location of patient information, but does not contain the entire electronic health record. Authorized users of the statewide HIE can query the MPI database and locate patient health information maintained in decentralized provider systems. The following diagram illustrates the workflow of the MPI. IOWA E-HEALTH STRATEGIC AND OPERATIONAL PLAN (JUNE 2012) 49

Diagram 3.1c: Data Flow of the MPI There will be several requirements for the MPI technology. This includes but is not limited to: Automated algorithms to match patients with as few individually identifiable variables as necessary (e.g., name, birth date, nickname, or biometrics). This helps provide a consistent level of privacy and security controls for patient information to ensure the MPI provides the minimum necessary information to accurately identify and retrieve relevant patient records. Ability to store locations of records available for a patient. The actual patient records will not be stored in the MPI or anywhere in the statewide HIE. After the initial load of the MPI, automated processes will regularly publish locations of new records to the MPI, so providers have access to the most current patient information. Constant monitoring and tuning of the system. This includes automated and manual processes for resolving unmatched or overmatched patients, processes to monitor quality of data, system performance and utilization. Very fast response time (i.e., within seconds). Ability to store variables; such as historical patient address or other names used, an indicator of life status, an indicator of a patient s primary care provider and medical home, or a national patient identifier. Note: if a decision were made to issue a single patient identifier, this decision would likely come from the federal government in the form of a national patient identifier, rather than a number uniquely issued by each state. To prepare for the possibility of a national patient identifier, Iowa can create a placeholder data field within the MPI database to support the single patient identifier if one is assigned. Once an HIE vendor has been selected (see Strategy 3.2.2), Iowa e-health will work with the HIE vendor to further define and finalize MPI requirements. Together, the HIE vendor and Iowa e-health will at minimum: 1) select the attributes and data elements to use in the matching algorithms; 2) define the matching algorithms, rules, and positive match thresholds; 3) establish mechanisms to monitor matching success and error rates; 4) identify processes for handling duplicate matches or duplicate records; 5) develop audit trails to log record requests and updates made to the record; and 6) determine when/if MPIs are retired or rolled off of the database (e.g., decedents). IOWA E-HEALTH STRATEGIC AND OPERATIONAL PLAN (JUNE 2012) 50

3. Record Locator Service: Provide functionality that will locate where health information exists for identified individuals (i.e., a map/pointer to locations of information for the patient) The MPI and the RLS are coordinated software applications. Once a patient has been successfully identified, authorized providers can use the RLS to retrieve a copy of the patient records stored in decentralized provider systems. The RLS contains pointers to locations of information for a patient. The RLS facilitates the exchange of secure messages and documents between a patient s providers, but does not store any of the information contained in the records. Diagram 3.1d: Data Flow of the RLS 4. Authentication: Enable functionality to identify who is allowed to access the statewide HIE. Valid users may be an existing health organization s users (e.g., physicians, schedulers, nurses, and information technology personnel), independent users (e.g., independent physicians, public health), and potentially patients. The authentication policies will be addressed in the Privacy and Security Policy Framework (See Goal 5, Section 2 of the Privacy and Security Framework) and will address authentication requirements of participant organizations, which will manage authentication of their users. 5. Access and Authorization: Facilitate role-based security to manage how an individual user is permitted to use the statewide HIE. Authorization rules will support privacy and security policies such as patient consent (e.g., opt-in or opt-out) and may apply restrictions on access to specified health information. Access to patient information through the statewide HIE will be tightly controlled and will provide a greater level of security than traditional paper records systems. Access to data will be provided through rolebased security controls, which will allow the various statewide HIE participants to see only the minimum amount of information necessary to perform their job. For example, a payer organization (e.g., Iowa IOWA E-HEALTH STRATEGIC AND OPERATIONAL PLAN (JUNE 2012) 51

Medicaid) authorized to use the statewide HIE portal will have a different, more restricted view of patient information than a provider organization (e.g., hospital) that has access through the direct connection or the statewide HIE portal. The access and authorization policies will be addressed in the Privacy and Security Policy Framework (See Goal 5 Safeguard Privacy and Security of Health Information). Section 1 of Privacy and Security Framework will address authorization requirements for: 1) providers with an EHR; 2) providers without an EHR; 3) patients; 4) public health; and 5) payers. Section 3 of Goal 5 addresses access requirements for the statewide HIE (e.g., ability to disable access to user accounts for inactivity or inappropriate activity) and for provider participants (e.g., access restrictions of their users based on the user s role and job function) 6. Auditing and Logging: Log and audit all (intentional or unintentional) connections and disconnections to network services and all network configuration changes, generating alerts/notifications for system activity outside the normal range of monitoring levels/thresholds. Monitoring system events (e.g., queries sent from authorized users to the MPI, or records retrieved by authorized users through the RLS), is an essential safeguard for the statewide HIE infrastructure and important for building trust and confidence in health information exchange. Reports or alerts generated from audit records of the MPI and RLS can be used to provide transparency in how records have been accessed or exchanged and can help monitor the appropriateness of activities. However, the amount of information available in the statewide HIE audit logs is minimal compared to the audit logs maintained by providers EHR systems. Hospitals, small group practices, individual physicians, and other providers already maintain auditing requirements established through HIPAA and the ARRA Health Information Technology for Economic and Clinical Health Act (HITECH Act). These regulations require providers to monitor every access, use and change to a patient record. Because the statewide HIE is primarily decentralized, and involved only in the exchange of records from one authorized user to another, the statewide HIE audit logs will only be able to contain information such as: 1) provider log-in identification; 2) provider name; 3) provider organization; 4) date and time; 5) patient account that was accessed; 6) type of records viewed by the provider; and 7) all failed log-ins. The providers auditing processes will be able to provide detailed audit logs about additional events, such as specific updates or corrections made to a patient record, or individuals within the organization that viewed or modified a patient record. Audit and logging policies are further addressed in the Privacy and Security Policy Framework (See Goal 5 Section 4 of the Privacy and Security Framework) and will address audit requirements for both the statewide HIE, as well as provider participants. 7. Transport and Content Standards (Technical, Semantic, and Process): Communicate health information using nationally recognized standard content and messaging formats for health care professionals. Transport of data to and from electronic destinations using general industry recognized transport types (e.g., Internet Protocol Version 6) and authorized recipient s technical capability (e.g., EHR, fax, or printer). Standards will support various statewide HIE services, privacy and security policies (e.g., patient consent or special procedures for sensitive information), and connection to the Nationwide Health Information Network (NHIN). NHIN is a set of standards, services and policies that enable secure health information exchange over the Internet. The statewide HIE will be built on NHIN Connect and NHIN Direct standards to enable both intra- and inter-state health information exchanges. Participants of the statewide HIE, generally through their associated health IT vendor(s), are expected to adhere to the national standards as they are finalized by ONC. Recent regulations and guidance include: Initial Set of Standards and Certification Criteria Interim Final Rule (IFR) - An initial set of standards, implementation specifications, and certification criteria for Complete EHRs and EHR Modules for adoption by the HHS Secretary. IOWA E-HEALTH STRATEGIC AND OPERATIONAL PLAN (JUNE 2012) 52

Certification Programs Notice of Proposed Rule Making (NPRM) - A defined process to ensure that EHR technologies meet the adopted standards, certification criteria, and other technical requirements to achieve meaningful use of those records in systems. The statewide HIE standards will rely heavily on existing standards for the interoperability of health information technologies, including those established and promoted by the Health care Information Technology Standards Panel (HITSP), Health Level 7, Inc. (HL7), the National Institute of Standards and Technology (NIST), and Integrating the Health care Enterprise (IHE). The intent is to provide a minimum set of technical, semantic, and process standards necessary to facilitate and enhance health information exchange. Technical: Transport and content standards that focus on the physical transmission and receipt of health data between participating systems. This includes message formats and reliable, secure message transports (e.g., TCP/IP, HTTP, SSL, SOA, SOAP, XML, HL7, IHE, ASC x12, NCPDP, and CDA). Semantic: Vocabulary standards that focus on ensuring that the meaning of information that was sent by an HIE participant is consistent with the understanding of information that was received by another HIE participant. This includes medical terminology which can be referenced consistently by all parties (e.g., CPT, SNOMED CT, ICD-9, ICD-10, LOINC, UMLS, NCPDP and NDC). Process: Focuses on understanding how the statewide HIE supports the specific activities and workflow of the participating organizations and how the statewide HIE is integrated into the work setting. This includes issues such as data usability and timeliness, examples of process interoperability concerns. 8. Data Transactions (i.e., HIE Services): Provide functionality that will enable data to be exchanged through the statewide HIE. This may include push and pull of data through the statewide HIE upon specific trigger events, such as to request a continuity of care document, automatically send final lab results for any previously sent preliminary results, send any changes in medications prescribed, report medication errors, notify public health about the occurrence of a reportable disease. Based on federal standards and the NHIN implementation platform, the statewide HIE will enable an environment of interoperable services that are both flexible and adaptable (see Goal 4 Enable the Exchange of Clinical Data). To support the HIE services prioritized and selected by Iowa e-health, as well as other core components of the statewide HIE infrastructure, there are a variety of functions that need to be managed by automated processes and personnel. Some of these functions include, but are not limited to: Transaction error management to ensure successful delivery and receipt of HIE messages (e.g., if messages are sent but not received, there must be a process to review and reconcile); Patient-reported error reconciliation process to enable a way for patients to report errors and request changes to their information stored in the centralized MPI; Patient consent management to accurately record a patient s choice to participate in the statewide HIE (i.e., recording when a patient decides to opt-out, or recording that a patient has decided to change their opt-out status); and Provider directory to monitor HIE participation levels, enable direct messaging to and from providers, and communicate important information about Iowa e-health to providers. 9. Participation Expectations and Minimum Requirements: Utilize a certification process to clearly outline the requirements (standards and agreements) with which any entity s health information users must conform in order to exchange data within the statewide HIE. This includes but is not limited to connectivity and data storage configurations and processes (e.g., edge servers, web services), frequency for making data available through the HIE, disaster recovery, and data sharing agreements. Statewide HIE participation expectations and minimum requirements for participating health care organizations will likely include, but not be limited to the following: Connectivity (i.e., bandwidth, up-time, encryption and firewalls); Integration engine or system capable of translating information to HL7; IOWA E-HEALTH STRATEGIC AND OPERATIONAL PLAN (JUNE 2012) 53

Ongoing system monitoring; Certified EHR (as appropriate for each care setting); Compliance with data exchange content standards (i.e., ONC and HITECH standards, recognized vocabulary and content standards); Demonstrated integrity of data maintained by the participating organization (e.g., patient information stored in the organization s MPI); Auditing trails and tracking requirements; HIPAA compliance; and Personnel (e.g., IT administrator, project manager) to ensure, regardless of their size, that certain functions are reliably performed (e.g., an initial set-up to interface with the HIE, on-going administration to ensure adherence to participation agreement, and implementation of additional services as more HIE functionality is enabled). 10. User and System Interface: Enable authorized users and systems an easy way to view or connect to (query and retrieve) information accessed through the HIE. Different methods (e.g., provider portal, integrated clinician EHR) may be necessary to support different types of data transactions or HIE services. There will be two options for providers to access the statewide HIE: 1) a direction connection to the statewide HIE, generally through an integrated EHR system; and 2) a view-only portal. Through a direct connection, providers with a certified EHR system will be able to access the statewide HIE seamlessly while using their certified EHR system. Integration with specific EHR products (e.g., Epic, Cerner, Allscripts, and NextGen) will be determined by the e-health Executive Committee using information from provider assessments (see Goal 10 or Environmental Scan). Through a view-only portal, authorized providers who have a clinical data system that is not integrated for a direct connection to the statewide HIE (e.g., non-certified EHRs), will be able to query the MPI and view records retrieved by the RLS. However, these providers would not generally be making their patient records available for other providers through the statewide HIE. There may be some modules of the portal that will allow providers using the portal to edit or upload information to the statewide HIE. This may include an immunization module that allows providers to add information about immunizations administered; a quality reporting module that allows providers to submit quality data; or an EHR-light module that delivers EHR functionality to providers who are unable to adopt a full EHR. As the statewide HIE matures, additional functionality and modules may be added, and additional types of portals (e.g., a patient portal) may be developed to provide more user and system interface options. Objective 3.1: Develop a statewide health information exchange. Iowa does not have large regional or localized HIEs like many other states. Iowa stakeholders are relying on Iowa e-health to be not only the convening body of stakeholders and policy making, but also an integrator of technology. Strategy 3.1.1: Engage in a collaborative process to develop the framework for the statewide HIE. Experts from numerous provider organizations throughout Iowa came together in workgroups and/or subcommittees to develop a framework for a statewide HIE in Iowa. This included researching best practices and reviewing experience in other state HIEs and health information organizations. Products of this collaborative process are the ten core components and infrastructure diagrams appearing above. Strategy 3.1.2: Utilize a competitive procurement process to select an HIE vendor. In June 2010, Iowa released a request for proposal (RFP) to identify a qualified vendor to develop a statewide HIE in Iowa. The RFP notified the potential vendors of all core requirements, including but not limited to establishing a shared infrastructure which included a provider directory, secure provider messaging, and an HIE infrastructure using NHIN standards. The RFP also notified potential vendors that the initial two year term of the contract would be no more than $4 million. Knowing this budget constraint and the scope of work required, numerous experienced IOWA E-HEALTH STRATEGIC AND OPERATIONAL PLAN (JUNE 2012) 54

vendors submitted proposals, affirming their ability to implement a technical solution for a statewide HIE within the budget and timelines specified. Iowa issued its Notice of Intent to Award to the successful HIE vendor on October 1, 2010 and a contract is currently pending. As soon as the contract is executed with the selected HIE vendor, Iowa e-health will prioritize its scope of work with the HIE vendor to develop and offer the provider directory and secure provider messaging to all interested providers (rural and urban) in calendar year (CY) 2011. The milestone-based contract will include clear performance measures and financial disincentives to ensure the vendor meets all milestones required by ONC and Iowa e-health. With dedicated project management staff, the IDPH Office of Health IT will closely monitor the contract, timelines, and deliverables to hold the HIE vendor accountable. Strategy 3.1.3: Construct and test the core HIE infrastructure. The vendor will work with Iowa e-health to finalize business requirements and technical specifications for the statewide HIE. The vendor will be responsible for building a federally-compliant HIE system and the vendor will provide a plan to maintain compliance as national standards evolve. This will help ensure interoperability within Iowa and facilitate data exchange with other states and NHIN. o Tasks with timelines will be defined upon conclusion of the procurement process. However, tasks will likely include: Review and finalize requirements and technical specifications; Acquire and configure necessary web and data servers, the master patient index, and the record locator service to enable the core infrastructure; Connect the statewide HIE (i.e., web and data servers) to the backbone broadband providers (see Objective 3.2); Incrementally load information from provider MPIs to the statewide MPI; Establish data transport and messaging standards for providers participating in the statewide HIE; Establish authentication, authorization, access, and audit procedures; Establish standard and customizable audit functionality and reports; and Test the core infrastructure and implement HIE services (see Goal 4) While development and implementation of the provider directory and secure provider messaging are in progress, Iowa will begin development and pilot implementations of integrated interfaces and more advanced HIE services that will help Iowa meet the long-term needs and goals of its stakeholders. Working within the resource constraints identified through Iowa s business and financial sustainability planning, these long-term needs and goals include helping providers meet or exceed evolving meaningful use criteria through CY 2015. Strategy 3.1.4: Execute a phased implementation of the statewide HIE There will be three methods to access the statewide HIE: Phase 1 Web-based Portal: For access to the provider directory and secure messaging, the portal will be available to all interested providers who serve Iowa patients. Quality Reporting Tools: To enable quality reporting, the IHIN provides query/search and reporting tools to facility quality reporting and identify care patterns across the aggregated population. This capability is integrated into the portal. Direct Connection: For integrated access to the provider directory, MPI, and RLS through their existing EHR (which will have been certified by an ONC Authorized Testing and Certification Body), direct connections will generally be established for hospitals, physician practices, and laboratories. Implementation Assumptions: At minimum, the provider directory and secure provider messaging will be established in CY 2012 to help providers demonstrate stage 1 meaningful use. The goal for CY 2012 2014 is to establish direct connection interfaces with: o The common hospital EHR vendors IOWA E-HEALTH STRATEGIC AND OPERATIONAL PLAN (JUNE 2012) 55

o The EHR vendors identified by the Iowa REC for critical access and rural hospitals o The six ambulatory EHR vendors selected by the Iowa REC. o Other common ambulatory EHR vendors Once an EHR interface has been tested and implemented, care settings using the same EHR product should be able to expeditiously connect. The amount of time and work to establish the direct connections with EHR interfaces that have already been established will depend on characteristics of the individual setting, the EHR product version, and customizations that have been made to the EHR product by the practice. A detailed implementation schedule will be developed with the HIE vendor. A priority will be to connect those providers who have utilized services from the Iowa REC and Iowa Medicaid providers who reach underserved populations throughout Iowa. *Preliminary Four-Year Implementation Schedule (to be finalized with the HIE vendor): CY 2012 CY 2013 CY 2014 CY 2015 Phase 1 Web-based Portal (i.e., provider directory and secure messaging) Testing, pilot, and implementation to all interested providers. (includes but is not limited to hospitals, physician practices, labs, pharmacies) Available to all interested providers Available to all interested providers Available to all interested providers Hospital Interoperability Cumulative number of hospitals with a direct connection to the statewide HIE Physician Practice Interoperability Cumulative number of physician practices with a direct connection to the statewide HIE Lab Interoperability Pharmacy Interoperability Services Available Pilot Minimum of 8 hospitals (5 hospital EHR interfaces) Pilot Minimum of 8 physician practices (5 different ambulatory EHR interfaces) Enable ability to send lab orders and results (in human readable form) through the Phase 1 Web-based portal Communication and outreach about e- Prescribing and the marketplace options available Provider Directory Clinical Messaging Meaningful Use Reporting Minimum of 15 hospitals (8 hospital EHR interfaces) Minimum of 15 physician practices (3 ambulatory EHR interfaces) Minimum of 23 hospitals (10 hospital EHR interfaces) Minimum of 23 physician practices (2 ambulatory EHR interfaces) Promote and establish lab interoperability standards. Pilot and implement direct connections to the statewide HIE for any lab that is ready to connect. Pilot and implement direct connections to the statewide HIE to any pharmacy that is ready to connect. Meaningful Use Reporting Continuity of Care Document Lab Results Immunization Reporting Medication History Immunization History Patient Portal * Iowa e-health hopes to reach more providers than illustrated in the implementation schedule above. In preparing the preliminary schedule, Iowa was trying to be cautious of presenting an implementation schedule that was too aggressive given the evolving standards, expectations, and scope of work for a state like Iowa that has little to no existing HIE infrastructure. Pilots IOWA E-HEALTH STRATEGIC AND OPERATIONAL PLAN (JUNE 2012) 56

After the statewide HIE infrastructure has been developed and tested, the statewide HIE will be deployed in a controlled pilot implementation environment. Iowa e-health will to identify a small number of health care organizations to participate in the pilot implementation to help map the pathway to successful connection and data exchange through the statewide HIE. Participating pilot organizations will further test and examine HIE functionality such as: Network access; Security processes and procedures (e.g., user roles, access, and audit logs); Master patient index and de-duplication of patient records; Ability to accurately and securely transfer clinical data to another organization through the statewide HIE; End user testing of HIE documentation and help processes (e.g., guide to organizations connecting with HIE, scripts, FAQs, and help processes); and Response times and system performance. A successful pilot will enable data exchange for the pilot health care organizations and allow Iowa e-health to garner lessons learned to refine strategies and technical assistance for the next organizations which will connect to the statewide HIE. Pilot implementations should not be limited to a single geographic area of the state and must include different certified EHR products (i.e., Iowa e-health needs to test the statewide HIE with a variety of the most widely used certified EHRs in Iowa). To manage the workload, no more than three different EHR products should be piloted at one time. Organizations selected to participate in the pilot should serve as a "gateway" to a large network of acute, post-acute, ambulatory, or laboratory care settings. Therefore, successful integration of this pilot organization should provide access to a large number of potential HIE data contributors and users and represent a large patient volume. A small site or facility with a robust health IT system, dedicated staff, and a desire to participate may be more manageable and provide a gateway to other small providers. At minimum, participating pilot organizations will need to have demonstrated experience and competencies with health IT. This may include: 1) a fully implemented, certified EHR system (i.e., to pilot the direct connection to the statewide HIE; organizations without EHRs may be able to help pilot the viewonly portal); and 2) the ability to populate the entire CCD (which will be the first clinical data exchange type). Experience with another HIE (e.g., a provider participating in another state HIE or a demonstration project) is also desirable. Connecting to the HIE To help providers maximize their potential to receive meaningful use incentives, the following providers are priority connections to the statewide HIE: Providers utilizing services of the Iowa REC Physician offices and clinics (those with 10 or fewer professionals); Physician offices and clinics (those with 11 or more professionals); Acute care hospitals; Critical access hospitals; Community and rural health centers; and Specialty hospitals and clinics. Before the provider connects to the statewide HIE, they will need to meet the minimum requirements and participation expectations which include, but are not limited to a signed HIE participation agreement and demonstrated ability to meet minimum requirements (see Objective 3.1, Core Component 9). There is currently no funding available to provide integration services for provider organizations that wish to connect to the statewide HIE. Iowa e-health hopes the need for integration services will be minimized through the work conducted during the pilot implementations (e.g., building the EHR interfaces and HIE documentation). Provider organizations need to be prepared to provide the resources necessary to connect to the statewide HIE, submit necessary information to the statewide HIE (e.g., data for the MPI), and make modifications to their existing systems (e.g., standards). IOWA E-HEALTH STRATEGIC AND OPERATIONAL PLAN (JUNE 2012) 57

Objective 3.2: Support the enhancement of network capacity and access to allow providers to connect and exchange information through the statewide HIE. Network capacity and access serves as a foundation for health care services such as a statewide health information exchange, secure data exchange and storage, disaster recovery, telehealth and broad health care coordination. Broadband: In a rural state, such as Iowa, broadband infrastructure projects are important to enabling provider organizations to participate in a statewide HIE. Broadband is a term that can be defined in many ways, but in its simplest form means providing multiple paths of communications over a single segment of infrastructure (e.g., copper wire, fiber optics, etc.). Any broadband data network has different parts that provide the total connectivity to allow data (i.e., voice, video, images, or text) to be moved from one point to another point. The most common description of a three-part broadband network includes: 1) a network core, 2) middle mile connectivity, and 3) the final mile. A way to illustrate this concept is with a traffic system. The United States Interstate system would be equivalent of the data network s core, the local roads would be similar to the middle mile, and the driveway to the residence garage would resemble the final mile. A strong foundation for network connectivity and access in Iowa is the work completed through the Federal Communications Commission (FCC) Rural Health Care Pilot Program, as well as the small telecommunications service providers delivering broadband to rural areas throughout Iowa. Iowa Hospital Association and Iowa Health System (IHS) were FCC grant recipients in 2008, and their work has increased broadband connectivity between rural and urban hospitals and the communities they serve throughout Iowa. Iowa Network Services (INS) is a private telecommunications service provider in Iowa. IHA is an association of Iowa hospitals. Their FCC project, Iowa Rural Health Telecommunications Program, uses the ICN to establish a fiber optic network among hospitals. The ICN is an operational entity that is administered by the Iowa Telephone and Technology Commission (ITTC). The ITTC serves as an independent Executive Branch agency within the State of Iowa government body. The ICN was initially founded to provide distance learning opportunities for Board of Regent and Private College Higher Education entities, Community Colleges, as well as K-12 public and private schools in Iowa. The role of the ICN changed in the late 1990s to expand the fiber optic network capabilities to libraries, federal government, health care, and judiciary users. The core of the ICN network utilizes some 4,000 miles of fiber optics and has a point of presence in all of the 99 counties throughout the State of Iowa. Another 5,000 miles of fiber optic links are leased from private telecommunications companies in Iowa to provide the final mile connectivity. ICN is managing a project with the Iowa Hospital Association to connect 89 health care affiliated entities with one gigabit of capacity to the ICN backbone. The work to connect the 89 entities is scheduled to be completed no later than June 30, 2012. Under current state law, the ICN is prohibited from carrying network traffic for private physician offices, clinics, pharmacies, insurance companies, or residential users. IHS is a large, integrated health system in Iowa. Their FCC project, HealthNet connect (HNc), is a 3200-mile fiber optic network. The HNc backbone runs throughout Iowa and spans four states, with direct fiber connections to major metropolitan cities such as Chicago and Denver. Additionally, the HNc backbone connects to Internet2 and National Lambda Rail networks which enable direct high-speed access to these national research and academic networks. In phase one, FCC funding has enabled HNc to provide 100 Mbps connectivity services to 28 hospitals in Iowa. Remaining FCC funding will enable 40 additional nonprofit healthcare providers in rural Iowa to receive 100-mbps last-mile connections to HNc. Aside from the FCC project, the HNc network is open for use by any healthcare-related entity, including private physician offices, clinics, pharmacies, and insurance companies. INS is a private telecommunications company that provides middle mile connectivity to 150 small companies throughout the state. INS operates a network with 2,000 miles of fiber and when combined with the smaller companies comprises over 5,000 miles of fiber network. Plans are already underway to expand the current gigabit or 10-gigabit network capacity to 40G systems with implementations beginning in 2010. Other telecommunications companies include but are not limited to Frontier, Iowa Telecom and Qwest. IOWA E-HEALTH STRATEGIC AND OPERATIONAL PLAN (JUNE 2012) 58

The recommended network design for the statewide HIE utilizes: 1) the Internet as the network core to transport data to other states as needed; 2) the ICN and IHS networks and commercial networks (e.g., INS) as the middle mile to connect the hospitals, teleradiology, and hospital owned clinics traffic within the borders of Iowa; and 3) marketplace telecommunications providers to deliver the final mile connection between clinics, private physician s offices, pharmacies, and other potential HIE users. The network core and middle mile connectivity (i.e., interstate system and local roads within the traffic system analogy referenced above) would not be limited to health care traffic, just as the public roads are not strictly limited to private automobiles. Examples of local, final mile, broadband options include: 1) local telephone companies that provide DSL, Ethernet over copper, fiber to the home, and Ethernet over fiber; 2) wireless Internet service providers; and 3) cable modems. The following diagram illustrates the broadband workflow for the statewide HIE: Diagram 3.2a: Broadband Data Flow Community Hospital Co H Hospital Network B Hospital Network A Individual Physician (without local server) Local Broadband Network Internet VPN Connection L Bro Ne Server to Server Communication Physician access to remote data server Physician access to local data server Small Group Practice Broadband Mapping: IOWA E-HEALTH STRATEGIC AND OPERATIONAL PLAN (JUNE 2012) 59

Connect Iowa is a subsidiary of Connected Nation and operates as a nonprofit corporation in the state of Iowa. Through a recent grant awarded to Connect Iowa, Iowa will develop maps to illustrate current broadband access and areas where broadband is not yet available. Connect Iowa was commissioned by the Iowa Utilities Board to work with all broadband providers in the state of Iowa to create detailed maps of broadband coverage in order to accurately pinpoint remaining gaps in broadband availability in Iowa. This work will support the activities of the Iowa Broadband Deployment Governance Board, which includes developing a statewide plan for the deployment and adoption of broadband in the state. Connect Iowa will continue to update the broadband data as it is collected and develop services that can be made available to public and private entities as well as citizens. Connect Iowa will work closely with multiple broadband providers from across the state to develop a variety of broadband inventory maps. Broadband Connectivity: The connectivity needs of providers vary depending on their size and type of care setting. The type of service(s) supported through the network also impacts broadband connectivity requirements. The following diagram, an excerpt from the National Broadband Plan, shows an estimate of the minimum connectivity needed to support deployment of health IT applications, including, but not limited to, a statewide health information exchange. IOWA E-HEALTH STRATEGIC AND OPERATIONAL PLAN (JUNE 2012) 60

Chart 3.2b: Minimum Broadband Connectivity 21 Iowa e-health recently conducted a baseline provider health IT assessment (see Goal 10 or Environmental Scan). The provider practice assessment included questions regarding the type of Internet connectivity in provider settings. A total of 314 practices reported this information, and some indicated more than one type of Internet connection. Chart 3.2c: Internet Connections in Iowa Practices 22 21 Federal Communications Commission, National Broadband Plan, Chapter 10 Exhibit 10-C, http://www.broadband.gov/plan/10- healthcare/#s10. 22 Iowa Department of Public Health, Iowa e-health Physician Practice Baseline HIT Assessment, April 2010. IOWA E-HEALTH STRATEGIC AND OPERATIONAL PLAN (JUNE 2012) 61

The provider assessment included questions to learn more about current network connectivity in provider practices and clinics. A total of 234 practices completed an Internet speed test as part of this assessment. Results are as follows: 8-10.9 Mbps, 8% 11+ Mbps, 18% 4-7.9 Mbps, 24% Chart 3.2d: Physician Practice Internet Speed Test 23 0-3.9 Mbps, 51% 4-7.9 Mbps, 10% 8-10.9 Mbps, 6% 11+ Mbps, 6% 0-3.9 Mbps, 78% Reported Download Speed Reported Upload Speed The following strategies will be used to support the enhancement of network capacity and access: Strategy 3.2.1: Use existing broadband grants (e.g., FCC, USDA) to connect hospitals and independent providers to a high speed, middle mile network Strategy 3.2.2: Establish cables to connect the statewide HIE data center (see Strategy 3.1) with the FCC grant hubs (e.g., Iowa Health System and Iowa Communications Network) Objective 3.3: Enable inter-state health information exchange Iowa s HIE interoperability platform (developed in accordance with NHIN specifications) will allow participants and other NHIN-compliant entities to share patient information through standards-based protocols. This web service platform is based on NHIN/IHE-based protocols and can operate as a foundational component in an overall statewide HIE deployment, or as a standalone NHIN Gateway. The platform will support NHIN Exchange protocols, incorporating NHIN Direct protocol support, and bridge capabilities between the two standards. Both of these capabilities operate within a web-services bus framework that supports SOAP and RESTful web-services. Additionally, direct connections to the statewide HIEs such as Nebraska, Illinois, South Dakota, and Wisconsin are desirable, because there are major border cities where patients commonly visit providers in both their home state and the neighboring state. Some of the activities necessary to facilitate this exchange will include: 1) ensure broadband connectivity to applicable data centers/hies; 2) verify interoperability of messaging standards and data content standards; 3) clarify authentication processes for unaffiliated HIE users; 4) establish processes to match patients beyond the statewide master patient index; and 5) identify additional audit requirements. Strategy 3.3.1: Connect to NwHIN. Connection to NwHIN will facilitate communication with the Social Security Administration, Department of Defense, Veteran s Affairs, the Centers for Disease Control, the Centers for Medicare and Medicaid Services and other statewide HIEs. Data exchange through NwHIN will be important for the statewide HIE to facilitate quality data reporting for provider meaningful use incentives. Additionally, Iowa e-health would like to develop the capability to submit surveillance data directly to CDC via the NwHIN. 23 Iowa Department of Public Health, Iowa e-health Physician Practice Baseline HIT Assessment, April 2010. IOWA E-HEALTH STRATEGIC AND OPERATIONAL PLAN (JUNE 2012) 62

Before NwHIN is operationalized, Iowa providers may be able to adopt standards being developed by the NHIN Direct project that will allow providers to push health information to participants that may be beyond state boundaries. Strategy 3.3.2: Coordinate with neighbor states to discuss the opportunity to develop direct connections between other statewide HIEs and Iowa. The primary way to accomplish inter-state health information exchange is through NwHIN. However it may also be beneficial to have direct integration with surrounding states to expeditiously allow twoway, seamless communication. For example, connection to the neighbor states will facilitate two-way communication among providers in large border cities, such as Omaha, Sioux City, Dubuque, Rock Island, and Moline. IOWA E-HEALTH STRATEGIC AND OPERATIONAL PLAN (JUNE 2012) 63

Goal 4: Enable the exchange of clinical data The statewide HIE will use the Nationwide Health Information Network Direct specifications to enable the electronic exchange of health information in Iowa. Specifically, the statewide HIE will use these specifications for secure messaging and lab information delivery. Once the statewide health information exchange (HIE) infrastructure is established, Iowa must prioritize the HIE services (or data transactions) to facilitate through the exchange. Iowa e-health workgroups have been discussing the possibilities and logistics of offering several of the HIE services. As the HIE services are planned and implemented, clinical and population health systems may need to be modified to be interoperable with EHRs and the statewide HIE. The following table describes potential HIE services, several of which the Office of the National Coordinator (ONC) has specifically asked states to consider. It is important to note that some HIE services may not be considered priority exchanges in Iowa based on current HIE capacity and funding needs. However, the statewide HIE infrastructure will be built in a manner to add a variety of additional services as priorities change, HIE capacity grows, and additional funding becomes available. Category HIE Service Description Status in Iowa Directory Provider Directory Ability to view information about the individual who is licensed to deliver care, as well as the facility in which that care is delivered, in order to facilitate other HIE services Messaging Clinical Provider-Provider Messaging Patient-Provider Messaging Public Health- Provider Messaging Continuity of Care Document Immunization History Clinical Narrative Discharge Summary Referral Ability to provide secure messaging between providers (e.g., request for consultation). Ability for patients to ask providers questions. Ability to send public health alerts and messages to providers (e.g., public health emergency; natural disaster, etc.). Ability to provide a patient-level clinical summary document is typically transferred between providers when a patient is referred to a specialist or admitted, transferred, or discharged from a hospital. Providers can view a CCD from other providers through the statewide HIE and make CCDs from their patients available to other providers. Ability for providers and other authorized users to request and receive an immunization history from public health. Ability to provide free text that describes previous patient encounters, progress notes, and procedure notes. Ability to provide access to a hospital discharge summary through the statewide HIE. Ability to refer a patient for additional care through the statewide HIE. Base functionality of the HIE; feature of the web-based portal Feature of the webbased portal Feature of the webbased portal Feature of the webbased portal Feature of the direct connection and webbased portal To be available after IRIS migrates to a new software system and once IRIS is connected to the HIE Part of the CCD Part of the CCD Part of Provider- Provider Messaging EHR Light Ability to provide an HIE-hosted version To be further IOWA E-HEALTH STRATEGIC AND OPERATIONAL PLAN (JUNE 2012) 64

Category HIE Service Description Status in Iowa of an electronic health record, which may discussed include the CCD and computerized physician order entry (CPOE), and clinical decision support. Diagnostics orders and results Part of the CCD Laboratory Orders and Results (i.e., Clinical Pathology Results) Anatomic Pathology Results Radiology Results Ability to transmit a patient's laboratory order and the eventual results, through the statewide HIE. This includes diagnostic immunology lab and tissue typing. Ability to provide textual report that describes findings from a microscopic examination (e.g., reading pap smears, looking at a mole, autopsies). This includes cytogenetics. Ability to provide a description and interpretation of radiology or other images (e.g., x-rays, EKGs). This includes dexa reports and Echo. Images Ability to transmit images (e.g., ultrasound, MRI, and EKG). e-prescribing Medication History Ability for prescribing providers to access information about medications previously dispensed to a patient, including prescriptions from other providers. Population Health Quality Medication Orders and Dispensing History Formulary Electronic Reporting to the Immunization Registry Information System (IRIS) Electronic Reporting of Reportable Diseases Death Vital Records- Provider Provider-Birth Vital Records Submission of Quality Metrics Ability for pharmacies to receive a new prescription from a prescriber, send a refill request to a prescriber, or receive a refill response back from a prescriber. Pharmacies dispense the prescription to the patient. Ability to make drug benefit coverage information available to prescribers. Ability to electronically report immunizations administered, from providers to public health. Ability to electronically report required laboratory results for reportable diseases or conditions, from laboratories to public health. Ability to send messages from vital records to provider organization(s) so providers may update their patient record(s) upon death of the patient. Ability to electronically report required birth records, from providers to public health. Ability for eligible providers to push quality data to the statewide HIE, then the statewide HIE to the payer, for meaningful use incentives. Part of the CCD Part of the CCD Can be done using secure messaging. Part of the CCD Requires relationship to Surescripts; to be discussed further Requires relationship to Surescripts; to be discussed further To be available after IRIS migrates to a new software system and once IRIS is connected to the HIE To be further discussed To be further discussed To be further discussed Feature of the direct connection and webbased portal IOWA E-HEALTH STRATEGIC AND OPERATIONAL PLAN (JUNE 2012) 65

Category HIE Service Description Status in Iowa Automated Capture of Quality Metrics Ability to automatically capture and report quality, performance, and/or accountability measures. Feature of the webbased portal Claims Personal Health Records Quality Indicators Claims History (provider information) Enrollment Eligibility Claims History (medical information) Claims Transactions Providers Sharing Information with Patients Patients Sharing Information with Providers Ability to provide quality indicator information to providers based on patients' health needs. This may include alerts or reminders for routine care (e.g., annual checkups, blood work, foot check). Ability to combine information from payers' claims data and provide a history of providers a patient has seen. This may include a provider s name, date of service, type of care setting, and provider contact information. Ability to verify a patient s insurance eligibility and authorization for care, procedures, medications, etc. Ability to combine information from payers' claims data and provide an initial patient history that includes historical medical information such as prior diagnosis, procedures performed and/or prescription history. Ability to route health claims electronically to from providers to payers or billing clearinghouses. Ability to pull data from EHRs, labs, and other HIE transactions (e.g., listing of visits, providers seen, diagnoses, procedures, lab values) to populate a personal health record. Ability for patients to keep a selfmonitoring diary (e.g., medications, glucose levels) and allow providers to access the information through the statewide HIE. To be further discussed To be further discussed To be further discussed Not a planned HIE service Not a planned HIE service Advanced feature of the HIE that will be available after the HIE has been operational for 2-3 years Advanced feature of the HIE that will be available after the HIE has been operational for 2-3 years Objective 4.1: Establish a statewide provider directory. A provider directory contains information about the individual who is licensed to deliver care, as well as the facility in which that care is delivered. This provider directory will serve as an initial, foundational step towards Iowa s long-term vision for a robust HIE infrastructure which enables exchange of electronic health information within and outside of Iowa. A statewide provider directory will be an openly available resource for all authorized Iowa providers. The provider directory will be used to enable routing for a direct messaging service to and from providers, for monitoring of HIE participation, and for communication of important information about Iowa e-health to participating providers. The system could be expanded later to enable messaging for the purpose of required reporting to public health, voluntary reporting of quality measures, and messaging between patients and providers (depending on customer demand and financial viability of these services). One of the first activities with the HIE vendor will be to finalize business and technical requirements for the provider directory and secure messaging. Part of this process will be to determine if the vendor has other customers with which Iowa could share infrastructure in order to expedite development and IOWA E-HEALTH STRATEGIC AND OPERATIONAL PLAN (JUNE 2012) 66

availability of the provider directory and secure messaging. The HIE vendor will be contractually required to support and comply with all standards emerging from ONC, including but not limited to specifications and protocols resulting from NHIN Direct. The provider directory will: Uniquely identify each health care organization (or entity) and identify all providers associated with each organization. A provider may be associated with more than one organization (e.g., a provider may practice within a clinic and also practice at one or more hospitals). This will initially be used for direct secure messaging and will be populated using information from Organizations as they sign up for the IHIN and complete the participation agreement. They will provide a list of the users that should be loaded into the Provider Directory. We are currently determining what fields this will contain. o. The first iteration of the provider directory will be for Direct Secure Messaging. In the future we will determine if there is an opportunity for a larger provider directory that can serve as a source of provider information. We will need to come up with a business use case for this as maintaining a large scale provider directory requires a team of individuals dedicated to the process. The opportunity does exist to have an expanded provider directory, by leveraging the existing data sources (e.g., state government data sources and organizational directories), Iowa believes it can establish facility-provider relationships for 95% of all physicians who may be eligible to receive meaningful use incentives. Provider outreach and communication offered collaboratively by IDPH (the state designated entity for the State HIE Program), the Iowa REC, and Iowa Medicaid will help reach the remaining 5% of physicians eligible to receive meaningful use incentives, who will be encouraged to visit a website where they can establish an organizational or individual provider profile to participate in the Iowa e-health provider directory and secure messaging service. Potential data sources include: Iowa Department of Public Health receives a monthly data feed from the Iowa licensing boards. This database (HCPro) of credentialed professionals can be used to load the provider directory with information about 85,818 (100%) licensed Iowa providers. This includes but is not limited to licensed physicians, pharmacists, nurses, dentists, EMTs, physical and occupational therapists. Additionally, the data file from the Board of Pharmacy can populate 913 pharmacies (22% of health care facilities). Iowa Department of Inspections and Appeals (DIA) Health Facilities Division maintains information about all health care facilities licensed or certified to operate in Iowa (e.g., hospitals, nursing facilities, home care agencies, and labs). IDPH currently receives this information annually from DIA and will work with DIA to establish more frequent receipt of the facility information. By loading a data file from DIA, the provider directory can be populated with 1808 (44%) health care facilities [Note: Information about approximately 1400 physician clinics (34% of health care facilities) is not available through DIA, because clinics are not individually licensed. Data about the physician clinics can be gleaned from organizational directories that maintain information about affiliated providers]. Iowa Medicaid Enterprise maintains a directory of all current and past Medicaid providers, which includes facilities and individuals. By receiving a structured data file from Iowa Medicaid, Iowa e- Health can load and validate information for approximately 32,000 providers and facilities (based on unique NPI numbers for enrolled Medicaid providers). Wellmark Blue Cross/Blue Shield, Iowa s largest private health plan, also maintains a directory of providers and is receptive to sharing their directory to populate the statewide HIE provider directory. Wellmark can help establish organizational relationships for approximately 12,000 providers (14% of all licensed providers). Hospitals, health systems, and provider practices maintain organizational directories of all employees or affiliated providers with access to the organization s facilities and/or EHR. This includes the medical and ancillary staff most likely to need access to the statewide HIE. By receiving structured data files containing the minimum data set (established by the provider IOWA E-HEALTH STRATEGIC AND OPERATIONAL PLAN (JUNE 2012) 67

directory workgroup) from these health care entities, Iowa can begin to match licensed providers with their associated organizations or facilities. o For example, loading data files from the four largest health systems, which reach both rural and urban areas of Iowa, will help establish organizational relationships for approximately 9000 providers. There will be some duplication in each system s data file, but every piece of information will help inform relationships that will help build a robust provider directory. With approximately 7000 licensed physicians in Iowa, this represents a substantial proportion of the individuals that need to be part of the provider directory. Additionally, at least one health system has a robust database that captures information about referring providers. Iowa is exploring the possibility of using this database as an ancillary data source to help inform Iowa e-health about physician clinics and other providers in the community which may not be affiliated with one of the large health systems. Organizational directories will be solicited and accepted from any integrated health system, hospital, or other health care organization willing to prepare an automated backload of provider information for the provider directory. In addition, work will be coordinated with the Iowa REC to leverage their enumeration of small provider practices, which may not be associated with a larger health system. If the provider directory is expanded in the future, we will monitor and implement IHE Standards. There will be no fees to the state associated with acquiring any of the data sources listed above. Once Iowa executes a contract with the HIE vendor, Iowa will define the specifications and process necessary to request the data files and establish an automated process to de-duplicate and reconcile the provider and organization information available from the various sources. Access to the provider directory Initially, the provider directory will facilitate the point-to-point exchange of treatment-related information between a patient s providers (e.g., physician practices, hospitals, labs, pharmacies). Iowa Medicaid will also be able to send and receive information from enrolled providers to facilitate treatment of Medicaid patients. The electronic exchange of health information for treatment-related purposes is minimally covered by HIPAA regulations; therefore can be enabled by current privacy and security policies. Iowa e- Health pursued legislation in 2012 to establish privacy and security policies (patient consent). The Iowa e-health Bill (SF 2318) was signed into law by Iowa s Governor, enabling Iowa e-health to move forward as an opt-out state. In the absence of existing EHR interfaces with a regional or statewide HIE, providers will be able to send and retrieve information through a secure web-based portal. As secure HIE interfaces are established with various EHR products, the workflow can be streamlined and access to the provider directory can be integrated within the provider s EHR system. Over time, the provider directory can be used to facilitate advanced HIE functionality (e.g., query for available patient information, consumer access to their information, public health and quality reporting). Additional privacy and security controls (e.g., authorization, authentication, access, and audit controls) will be used to restrict access only to authorized individuals with a legitimate need to view the information. Strategy 4.1.1: Convene a provider directory workgroup. To finalize requirements for the provider directory, Iowa will form and convene a provider directory workgroup. The provider directory workgroup, working closely with the State HIT Coordinator and the HIE vendor, will be made up of local subject matter experts who routinely monitor and are aware of federal workgroups, health IT organizations (e.g., HIMSS, HITSP, CCHIT, IHE), and health IT activity (e.g., provider directories) in other states. Activities of the workgroup include: Gather and share information about provider directory requirements; Review provider directory data elements recommended by federal workgroups and/or other states; Agree on a minimum data set for Iowa s provider directory; IOWA E-HEALTH STRATEGIC AND OPERATIONAL PLAN (JUNE 2012) 68

Identify ways to collect the information needed within the minimum data set, including the need for policy levers to require the information to be submitted; and Establish expectations (e.g., timeline, staffing, and other resources) for organizations to provide the minimum data set in accordance with the Iowa e-health implementation schedule (to be finalized with the HIE vendor). Organizations participating in the provider directory workgroup will include, but not be limited to: 1) chief information officers from hospitals, clinics, pharmacies, and labs; 2) representatives from Iowa Medical Society and Iowa Osteopathic Medicine Association; 3) Iowa Department of Public Health; 4) Iowa Medicaid Enterprise; 5) Iowa Regional Extension Center; 6) Department of Inspections and Appeals; and 7) the state licensing boards. Objective 4.2: Enable secure messaging among providers. The provider directory is a key to enabling a secure messaging capability. The provider directory provides an addressing function to securely transport messages (e.g., Continuity of Care Document) among providers in alignment with emerging NHIN direct specifications. The ability of providers to securely transfer protected health information will serve as an introductory step for providers who have an interest in beginning to exchange electronic health information between their practice and other provider settings. Secure messaging can reduce reliance on less efficient forms of communication among providers (e.g., postal mail, fax, copies of records transported by patients) and provide a mechanism for providers to demonstrate electronic exchange of health information, which is necessary for stage one meaningful use. Iowa Medicaid Enterprise has identified secure provider messaging, as well as other more advanced HIE functionality, as an important component of its State Medicaid Health Information Technology Plan. It is desirable for Medicaid providers to be able to use the statewide HIE to provide Iowa Medicaid Enterprise with the necessary clinical documentation to support administrative activities, which will improve the workflow and expedite patient care. Iowa e-health will offer web based secure messaging. At minimum, the secure messaging will: Facilitate provider-to-provider messaging to support a wide variety of workflow scenarios both in and across treatment settings. Support the ability to send and receive attachments (e.g., Continuity of Care Document, discharge summary, structured lab results. Information or attachments within the message can be saved to a patient chart as a provider s EHR allows. Notify the user upon receipt of the message and applicable attachments. The notification can be delivered through the portal or routed to a secure email address. To the greatest extent possible, provider messages will be routed to existing EHR in-boxes to better integrate workflows (e.g., to prevent the need for a provider to access an additional email account). Iowa e-health will require our vendor to help load the provider directory and enable secure messaging. Contract fees for this vendor are based on completions of milestones. These milestones are based successful deployment of secured messaging capabilities to the 6000+ providers and 118 hospitals. There are four milestone payouts based on percentage of those providers and hospitals complete. In order to access the HIE, each participant will be required to sign a participation agreement. The participation agreement will outline requirements, including but not limited to: Privacy and security requirements (e.g., HIPAA compliance, role-based access, auditing trails and tracking requirements) Standards and formats of clinical data shared through the Iowa HIE Process and frequency for making information available to the statewide HIE for querying Information that must be accessible by the statewide HIE upon request Process for handling help desk requests Unique IDs will be assigned for every Direct account Strategy 4.2.1: Provide a modularized EHR to help providers meet stage 1 meaningful use requirements. IOWA E-HEALTH STRATEGIC AND OPERATIONAL PLAN (JUNE 2012) 69

Iowa e-health will offer both web-based secure messaging and a modularized EHR offering (i.e., EHR-lite). For providers that do not have an EHR system in place, Iowa will provide a broad range of HIE web applications that allow participants to access and act on patient information at the point of care, regardless of current technical capabilities. The application will enable both organizations and individual providers to meet Stage 1 meaningful use requirements. The modularized EHR (i.e., EHR-lite) is offered as an option through a provider portal and includes the following tools: Computerized physician order entry (CPOE) capabilities for eligible professionals including the ability to order labs, radiology and other ancillary services as well as to submit referrals Clinical documentation capabilities including discrete vitals data capture, health status recording and narrative assessment data capture e-prescribing capabilities, including drug-drug/drug allergy alerts and formulary checking Medication, allergy and problem list management functions Medication reconciliation capabilities Practice-specific clinical messaging and workflow capabilities Strategy 4.2.2: Host a virtual test site to ensure provider EHRs adhere to standards required fordirect connections via XCA or XDS.b. The HIE vendor has a test portal for all interested vendors to conduct testing prior to implementation. ICA will be presenting the test potal at the ehealth summit in August 2012. Currently, the Iowa REC has working relationships with EHR vendors that represent a large share of the Iowa market, according to the results of the Iowa Provider Health IT Baseline Assessment. This includes both the "selected" Iowa REC ambulatory vendors (Allscripts, McKesson, ecw, emds, Greenway, and EHS); ambulatory vendors with a large presence in Iowa (NextGen, Epic); and hospital vendors serving the critical access hospital market (CPSI, Healthland, Cerner, Meditech). The Iowa REC has in place Memorandums of Understanding (MOUs) with each selected ambulatory vendor in order to formally document the vendor's intent to provide comprehensive Meaningful Use functionality, including the functionality and standards for HIE. The Iowa REC is committed to the successful implementation of the statewide HIE to help Iowa providers meet the goal of achieving Meaningful Use. To that end, the Iowa REC will advocate to EHR vendors on behalf of Iowa providers, emphasizing the need for EHR products to align with the statewide HIE. Additionally, the Iowa REC will leverage its relationships with EHR vendors (e.g., selected vendor MOUs) to help accelerate connections to the statewide HIE. Over the next few months as the statewide HIE technical specifications become more defined, there will be an increased need for vendors to interact directly with the HIE vendor to ensure alignment. As needed, the Iowa REC will facilitate introductions between key EHR vendor contacts and Iowa e-health to foster these necessary relationships. Objective 4.3: Enable interoperability between laboratories and providers. Lab interoperability is complex due to the different sub-specialized types of laboratory and pathology tests that can be performed. There is a great deal of work that needs to be done to establish the terminology standards, the data mapping within specialized sections, and the technology to electronically transport structured lab data. The inability to share and accurately interpret laboratory results will hinder reuse of test results, thus leading to repeated tests. The ultimate goal for lab interoperability is for lab orders to be electronically sent to and from an EHR and a laboratory information system. The entire transmission will be secure and seamless among the various systems and maintain all appropriate standards for both structured and human readable data. IOWA E-HEALTH STRATEGIC AND OPERATIONAL PLAN (JUNE 2012) 70

Currently in Iowa, lab interoperability is primarily realized within labs operated by a hospital or large health system. However, there are some examples of point-to-point connections that will help Iowa prepare for broader lab interoperability throughout the state, including the development of an interface library. IDPH has an HL7 interface with the State Hygienic Lab at the University of Iowa to receive information about reportable diseases. This interface will be upgraded to HL7 2.5.1 as part of a recent ELC grant from the Centers of Disease Control and Prevention (CDC) received by IDPH. Des Moines University Clinic recently completed an interface between their EHR and Iowa Health System s lab reporting system. United Clinical Laboratories in Dubuque provides an integration of lab results between two large physician offices (Medical Associates and Dubuque Internal Medicine) and the two separately owned hospitals (Mercy Medical Center Dubuque and Finley Hospital). Trinity Health s Mercy Medical Centers in Iowa use Medicity NOVO to allow affiliated rural clinics and critical access hospitals to retrieve laboratory results electronically from the rural referral laboratory. Iowa is also pursuing a second ELC grant through CDC that will provide funding for IDPH to work with providers and their HIT vendors to build the infrastructure to support the transmission of reportable lab results using existing implementation guides and common approaches (i.e., HL7 version 2.5.1 Implementation Guide: Electronic Laboratory Reporting to Public Health, Release 1). As part of this project, Iowa plans to engage an experienced lab interoperability specialist or consulting firm that can help Iowa e-health better understand lab interoperability requirements and provide technical assistance in 2011 to laboratories preparing to upgrade their standards and connect to an HIE. Strategy 4.3.1: Convene a lab interoperability subcommittee. This subcommittee will be comprised of laboratory experts from a range of settings (e.g., hospitals, clinics, independent labs, the state lab), the HIE vendor, and others with relevant experience in this area. The subcommittee will leverage information from a recently-completed Laboratory Health IT Assessment, and determine the technical requirements for laboratories with varying IT capabilities to connect to the HIE. The group will review and recommend standards for structured and unstructured portions of lab results. Strategy 4.3.2: Establish foundational processes to send and receive electronic lab orders and results. The long-term vision is for laboratories to be connected to the various provider settings through an HIE. An interim solution for 2011 is to enroll laboratories in the provider directory and encourage them to extract lab reports from their existing information system to send to the ordering provider through secure provider messaging. Any orders and results transported through secure provider messaging will be viewable in human readable form, but may not initially be sent as fully structured data ready to be pulled into a provider s EHR or made widely available to an HIE. Over the next two years, as standards are more defined by ONC and as vendors have an opportunity to adopt those standards into their products and make their revised products readily available to the marketplace, Iowa will explore the use of policy and contracting levers to require providers to take advantage of more advanced capabilities. Strategy 4.3.3: Use communication and outreach methods to establish and promote laboratory standards. To help laboratories prepare to send and receive structured lab orders and results, Iowa will form and convene a lab interoperability workgroup. The lab interoperability workgroup will further define and clarify expectations for laboratory standards and standardized HL7 messages. This workgroup will participate in communities of practice for lab interoperability and include in-state or out-of-state lab interoperability champions that have specific experiences and lessons learned to share with others. The workgroup will also include HL7, lab interoperability, and vocabulary specialists from hospitals, clinics, independent labs, the State Hygienic Lab (public health laboratory), IDPH, and other stakeholder organizations. Once deliverables from this workgroup are available, IDPH (the state designated entity for the State HIE Program), the Iowa Regional Extension Center, and Iowa Medicaid, will use communication and outreach tools and forums to IOWA E-HEALTH STRATEGIC AND OPERATIONAL PLAN (JUNE 2012) 71

help educate laboratories about the standards they need to adopt in order to support lab interoperability. These standards include but are not limited to: HL7 2.5 or higher for messaging LOINC for coding the test and/or results SNOMED-CT for coding the results UCUM for units of measure Even with these resources, it will undoubtedly take time for laboratories to upgrade their systems and meet the defined requirements. Iowa e-health and identified lab interoperability champions will be available to Iowa laboratories throughout the next two years as they transition and adopt established standards. Strategy 4.3.4: Populate and maintain a laboratory interface library. With the laboratory standards in place to allow standardized data to travel in a structured way to EHRs, the next step will be to establish a standardized interface between laboratories and ordering providers. IDPH (the state designated entity for the State HIE Program) will serve as a facilitator and/or central hub for laboratories and ordering providers. Laboratories and ordering providers wish to establish just one interface to a robust, fully functional HIE to become connected to all other exchange partners, rather than dedicating the time and resources necessary for point-to-point connections. It will take time for robust, fully functional HIE(s) to become available for all exchange partners, but Iowa and other states can make considerable progress over the next three years (2011 2013), which will correspond to the timing of the various HITECH programs being managed by ONC. The current laboratory assessment (final report expected in November 2010) will help Iowa understand which laboratories are prepared to establish an interface with an HIE. Iowa also plans to leverage its relationship with the Iowa REC to learn more about the large and small labs that provider organizations work with regularly (additional information likely to be available by March 2011). Iowa envisions that providers using Iowa REC services will be some of the early participants in statewide HIE; therefore knowing the critical labs used by the provider organization will help Iowa prioritize support for interfaces with the more than 2,000 in-state and out-of-state laboratories that serve Iowans. As interfaces are established with an HIE, Iowa would like to make the interface standards and specifications available through an interface library that will be available to other Iowa stakeholders. This interface library can help reduce the fees that must be paid to establish a connection, and may be particularly helpful for large laboratories. Texas recently initiated a solicitation through the state HIE leadership forum for other states that want to come together to explore ways to establish the interface library, and Iowa plans to participate. Strategy 4.3.5: Use policy levers to set lab interoperability standards and implementation requirements. Iowa laboratories recognize the benefit and value of lab interoperability and will begin to take steps to enable receipt of electronic lab orders and delivery of electronic lab results back to the ordering provider. Before using contracts (e.g., Medicaid and private payer contracts), policy levers (e.g., licensing boards), or state authority (e.g., legislation) to establish laboratory mandates, Iowa would like to give laboratories an opportunity to engage in lab interoperability voluntarily. Iowa believes this is important for several reasons: Lab providers appear to be amenable to participation in an HIE Using policy levers too soon can increase the barriers to adoption Policy levers can create a sense of urgency; however urgency can also increase the chance for more errors and duplicated efforts Policy levers at this point in time may hinder cost-saving efforts to establish a standardized order interface and reduce the value and benefit of an interface library IOWA E-HEALTH STRATEGIC AND OPERATIONAL PLAN (JUNE 2012) 72

Iowa will reevaluate lab interoperability by the end of 2012 to determine if it may be necessary to reconsider policy levers and state authority to increase compliance of standards and lab interoperability. This will allow Iowa time to successfully establish an HIE infrastructure and a related consortium of experienced provider and consumer champions that can support the legislation necessary to implement policy levers. Objective 4.4: Increase adoption of e-prescribing in provider practices and clinics. E-Prescribing has been identified as a required function of certified EHRs and meaningful use of health IT. Provider practices in Iowa have several options available to them for e-prescribing. Options include: An e-prescribing function available through certified EHR products Stand-alone systems (e.g., DrFirst, InterMedHx) Free web-based systems (e.g., eprescribe Iowa available through Iowa Health System). eprescribe Iowa is a partnership between Iowa Health System and Allscripts which offers a free Web-based e-prescribing solution to physicians throughout Iowa. eprescribe Iowa is also a component of HealthNet connect, Iowa Health System's 3,200-mile fiber-optic network that stretches from Denver to Chicago. The long-term vision for e-prescribing is an entirely electronic lifecycle that facilitates medication orders and dispensing history, medication history and reconciliation, formulary, and claims processing. To support and enhance the electronic flow of information, pharmacies need to establish the technology and business agreements to receive e-prescriptions that remain electronic, rather than converting to a fax. Pharmacies and prescribing providers will need to be connected to an existing e-prescribing network (for medication orders) and to an HIE (for bi-directional exchange of information including the ability to query and retrieve patient data). At minimum beginning in mid to late 2012(final implementation schedule to be determined with the HIE vendor), all providers (including, but not limited to pharmacists) will be allowed to exchange secure messages with prescribing providers through the HIE provider portal using the Iowa e- Health provider directory and secure provider messaging service (to enable bi-directional communication). According to information from Surescripts, 2,813,116 prescriptions were routed electronically in Iowa during 2009, which represents approximately 16% of prescriptions 24.Based on information from Surescripts and a physician practice assessment in early 2010, between 18-40% of Iowa providers have e-prescribing capability and 63% of pharmacies can accept e-prescriptions. Some of the greatest barriers to pharmacies accepting e-prescriptions include: Data quality of the e-prescriptions that come to the pharmacy (e.g., errors in the medication or quantity prescribed to the patient) Transaction costs to receive and process e-prescriptions Low e-prescribing rates among prescribing providers (e.g., many prescribing providers do not e- Prescribe so there is not a need for the pharmacy to accept e-prescriptions) Iowa anticipates a substantial increase in e-prescribing as providers prepare to demonstrate meaningful use. Additionally, e-prescribing will continue to increase as prescribing providers and pharmacies establish the security controls necessary to enable e-prescribing of controlled substances. The Iowa REC is a great resource available to providers that want to implement e-prescribing in their practices. By the end of 2014, Iowa s goal is to increase e-prescribing capability for both providers and pharmacies to 90%. Strategy 4.4.1: Use education and outreach to promote e-prescribing. One of the best ways to increase e-prescribing is to use education and outreach to both pharmacies and prescribing providers. The Iowa Pharmacy Association is a great outreach resource for a large number of Iowa pharmacies. The Iowa Board of Pharmacy is also very supportive of encouraging standardization of e-prescriptions. Activities can include: Share educational materials with pharmacies through webinars, mailings, and conferences about the value and potential efficiencies of e-prescribing. 24 Surescripts, Iowa Progress Report of e-prescribing, www.surescripts.com (August 9, 2010) IOWA E-HEALTH STRATEGIC AND OPERATIONAL PLAN (JUNE 2012) 73

Encourage pharmacies to become certified and connect with an existing e-prescribing network (e.g., Surescripts). Educate prescribing providers about ways providers can help improve the quality of e- Prescriptions sent to pharmacies and subsequently reduce workflow inefficiencies for both entities. Educate prescribing providers about transactional charges the pharmacy has to pay for redundant or erroneous e-prescriptions. Convene regional meetings for prescribing providers and pharmacies to come together to talk about e-prescribing progress, concerns, and questions. This strategy is similar to an approach used in Oregon which can help remove the mentality of I m not going to do it, if you re not going to do it. Regularly follow-up with pharmacies to learn about their progress or planned activities to move towards e-prescribing. This strategy is similar to the approach used in Rhode Island which helps establish a mentality that they must be serious about e-prescribing, so maybe it s time to do it. Identify e-prescribing champions to demonstrate and promote successful e-prescribing among peers. Publicly recognize pharmacies or facilities with high e-prescribing utilization rates. Strategy 4.4.2: Explore opportunities to minimize e-prescribing costs. Pharmacies typically pay transaction fees to accept e-prescriptions from providers. These fees can be as high as 45 cents per transaction, and many pharmacies feel frustrated that they are solely responsible for paying the transaction fee. Activities can include: Explore ways to partner with other states and HIEs to better enable and contain costs of e- Prescribing for Iowa pharmacies and prescribers. Iowa is currently monitoring e-prescribing research activities being led by Tennessee. Explore the opportunity to use a procurement process to negotiate lower transaction fees or a subscription fee for using the e-prescribing network(s) currently available in the marketplace. This purchasing power could help leverage lower fees for Iowa pharmacies. Convene regional meetings for providers and pharmacies to explore opportunities to share e- Prescribing costs among the pharmacies and provider practices. Educate prescribing providers about how to use their e-prescribing tool correctly and how errors impact the pharmacies (e.g., avoidable costs). The Iowa REC and payers can be great resources to help educate providers about appropriate use of e-prescribing. Many pharmacies may be more comfortable with the e-prescribing fees once they begin to see an increase in the data quality and pharmacy workflow efficiencies. Strategy 4.4.3: Use policy levers to require e-prescribing. The need to demonstrate meaningful use through the use of e-prescribing will motivate both providers and pharmacies to adopt e-prescribing. In addition, as pharmacies recognize the benefit and value of e-prescribing, they will begin to take steps towards increasing e-prescription volume. Before using contracts (e.g., Medicaid and private payer contracts), policy levers (e.g., licensing boards), or state authority (e.g., legislation) to establish e-prescribing mandates, Iowa prefers to give pharmacies an opportunity to engage in e-prescribing voluntarily. Iowa believes this is important for several reasons: Pharmacies have generally shown a willingness to engage in e-prescribing Using policy levers too soon can increase the barriers to adoption Policy levers can create a sense of urgency; however urgency can also increase the chance for more errors, which can negatively impact quality and management of avoidable costs Policy levers at this point in time may hinder efforts by public and private organizations attempting to negotiate costs with the e-prescribing network(s) currently available in the marketplace Iowa will reevaluate e-prescribing adoption by the end of 2011 to determine if it may be necessary to reconsider policy levers and state authority to increase compliance of standards and pharmacy availability for e-prescribing. This will allow Iowa time to successfully establish an HIE infrastructure IOWA E-HEALTH STRATEGIC AND OPERATIONAL PLAN (JUNE 2012) 74

and a related consortium of experienced provider and consumer champions that can support the legislation necessary to implement policy levers. Strategy 4.4.4: Work with the HIE vendor to implement medication history. e-prescribing can provide the functionality to allow prescribing providers access to information about medications previously dispensed to a patient, including prescriptions from other providers, to help avoid duplication and reduce adverse drug events. Often, this information is useful to providers to aid in medication reconciliation (i.e., the process of reviewing with the patient the medications they have been taking and comparing the medications with the available medication history) and decision support processes (e.g., drug-drug interaction, drug-allergy checks). The medication history will likely be included as part of the summary care record (e.g., continuity of care document). Objective 4.5: Enable the exchange of continuity of care documents (CCD). The CCD is a patient clinical summary document containing a core data set of the most relevant administrative, demographic, and clinical information about a patient's health care. The CCD is typically transferred between providers when a patient is referred to a specialist or admitted or discharged from a hospital. The CCD is generally created (or compiled) by the EHR software into a standardized output format. Discrete variables are embedded within the document. As a part of the statewide HIE secured messaging strategy, Iowa e-health will provide multiple paths for allowing participants throughout the state to securely share and gain access to summary of care records. The first exchange path allows participants to exchange summary care records through secure messaging using the NHIN Direct protocol. With the NHIN Direct interoperability service, statewide HIE participants will be able to send NHIN Direct-compliant referral requests from their EHR using secure Simple Mail Transfer Protocol (SMTP) transport or external data representation (XDR) protocols. These messages can include summary of care documents via the CCD format. The statewide HIE will facilitate the routing of the transaction to the addressed provider via XDR, SMTP or representational state transfer (REST) protocols for participants depending on the capabilities of the participant s EHR. For web-based portal users, the statewide HIE will route the message to the appropriate participant based on the addressing standard, via the secure SMTP backbone protocol. The second exchange path allows participants to securely share CCD-based summary of care records utilizing the XDS.b protocol. In this model, XDS.b-compliant EHR systems may register, publish, and retrieve CCD documents from the statewide HIE through XDS.b-compliant web services. Finally, for participants that are already sharing summary of care records through an external health information exchange (e.g. large health systems), the statewide HIE will be able to exchange summary of care documents utilizing XCA protocols. Regardless of sharing method, the statewide HIE will provide a secure web portal that allows participants to access summary of care documents and exchange them through secure messaging capabilities. The following diagram provides a high-level overview of the data sharing options for summary of care documents among participants of the statewide HIE. IOWA E-HEALTH STRATEGIC AND OPERATIONAL PLAN (JUNE 2012) 75

Strategy 4.5.1: Work with the HIE vendor to implement the CCD/Summary of Care Document. The statewide HIE vendor will be responsible for piloting the CCD with a small group of provider entities while further testing the statewide HIE infrastructure. The development, testing, and pilots will be iterative to allow the gradual integration and release of subsequent HIE services. Objective 4.6: Enable the use of the HIE to collect immunization data. Iowa s Immunization Registry Information System (IRIS) is the Iowa Department of Public Health s (IDPH) current statewide immunization information system (IIS) that has been operational since 2001. As Iowa began to plan for a statewide HIE, it became apparent that a critical success factor for health IT adoption and a high-priority in Iowa, is bi-directional communication among immunization providers and public health. Strategy 4.6.1: Transition to a new immunization registry software application based on the Wisconsin Immunization Registry. In 2009, IDPH began to evaluate the capacity of the existing IRIS system to determine if it was feasible to connect with the statewide HIE given the timelines for meaningful use. Without current HL7 standards and limited by manual processes to de-duplicate patient records, IDPH began to research potential alternatives to the current system. After conducting research of other state registries, IDPH determined the best business decision was to transition to a version of Wisconsin s Immunization Registry (WIR). Currently, 16 states use the WIR application and participate in a WIR Consortium to problem solve registry issues and develop mutually beneficial enhancements with other states. IDPH is in the process of contracting with a vendor to modify and implement the WIR system in Iowa. IOWA E-HEALTH STRATEGIC AND OPERATIONAL PLAN (JUNE 2012) 76

Strategy 4.6.2: Work with the HIE vendor to establish the connection to the Immunization Registry Information System (IRIS) to enable interoperability with the statewide HIE. A timely and cost efficient strategy to enable interoperability between IRIS and EHRs is to leverage the statewide HIE as the primary method for submitting information from clinical providers EHRs to IRIS. Additionally, the statewide HIE can facilitate bi-directional exchange of information, rather than traditional one-way communication (i.e., data from clinical providers to public health). The statewide HIE can be used to provide a streamlined mechanism for pushing data about administered vaccinations to Iowa Department of Public Health s Immunization Registry Information System (IRIS); and 2) a method for providers and other authorized users to request and receive an immunization history from IRIS. IOWA E-HEALTH STRATEGIC AND OPERATIONAL PLAN (JUNE 2012) 77

Goal 5: Safeguard privacy and security of electronic health information For a statewide health information exchange (HIE) to be successful, patients must trust their electronic health information is kept confidential and secure, and providers must trust the availability and integrity of their patients information to make the best health care decisions. Privacy policies and security controls can provide assurances to patients; however it is important to find the appropriate balance of policies and security controls (e.g., data confidentiality, availability, and integrity) to allow providers access to the information they need to treat their patients. Policies and controls that are too restrictive can slow the adoption of the statewide HIE and decrease the value of the exchange for providers. Policies and controls that are too lenient can negatively decrease the trust of the statewide HIE and reduce the perceived value of the exchange of health information. Objective 5.1: Identify privacy and security barriers and formulate strategies to address those barriers. Potential risks and liabilities inherent with electronic exchange of health information contribute to resistance and a lack of trust in e-health initiatives. Barriers generally fall into three categories: 1) policy; 2) technical; and 3) education. By identifying these barriers and developing strategies to mitigate risk, Iowa is able to provide protections for both patients and providers participating in the statewide HIE. Policy One of the major policy barriers important to address are the state restrictions on sharing information among providers is that currently exist in Iowa laws 25 and policies restricting the exchange of health information between providers. These restrictions may hinder timely provision of coordinated care to patients. Ambiguity and different interpretations of the laws and policies by legal experts and providers result in provider practices that are more restrictive than federal standards, primarily defined through HIPAA 26. A specific example relates to Iowa restrictions on sharing information from specialty records (e.g., HIV/AIDS, substance abuse, mental health, genetics, etc.) among providers. Regulation requires providers to seek additional consent from the patient to share specialty records with other providers, even though sharing the information for treatment related purposes is allowed under HIPAA and may be critical to patient safety and care decisions. Traditional patient privacy laws assumed paper medical records were to be used in provider practices and that information would be shared among providers using photocopies or faxes of patient information. As providers transition to electronic health records (EHR), and as information becomes available electronically through a statewide HIE, intra- and inter-state laws and policies will need to be modified to reflect the modernized workflow. State and federal policy changes are necessary to enable some HIE services (e.g., e-prescribing and laboratory orders and results) and also to reduce redundant print and electronic data storage (e.g., inspections and appeals audit requirements). Technical Fundamentally, the statewide HIE will address inconsistent patient identifiers across provider networks. By establishing a master patient index and record locator service, providers will be able to locate and match patient information across provider networks. The statewide HIE will also be developed to support robust role-based access controls. Initially, the statewide HIE will facilitate treatment-related exchange of information between a patient s providers. As the statewide HIE matures, advanced HIE functionality may facilitate the exchange of records for purposes other than treatment; however, subsequent privacy and security policies and procedures will provide granularity to restrict access only to authorized individuals with a legitimate need to view the information. 25 Iowa Code Section 141A (HIV/AIDS) and Iowa Code Chapters 228 and 229 (Mental Health) 26 Health Insurance Portability and Accountability Act of 1996. Pub. L. No. 104-191, 110 Stat. 1936 (1996). IOWA E-HEALTH STRATEGIC AND OPERATIONAL PLAN (JUNE 2012) 78

Education With aggressive timelines for health IT adoption nationally, neglecting comprehensive patient (i.e., consumer) and provider education can result in fear and setbacks. Consumers and providers need to understand the benefits and potential impact of a statewide HIE and must have an opportunity to obtain accurate information and voice their concerns. Through communication and outreach, Iowa e-health can establish clear expectations and build awareness among providers and consumers about the statewide HIE and the privacy and security policies and controls that will be put in place to protect providers and consumers. Strategy 5.1.1: Prepare a report to the Iowa Legislature about barriers and recommendations for statewide HIE. A 2009 privacy and security report served as an introduction to the privacy and security framework being developed by Iowa e-health. The report provided an analysis of the following barriers: 1. State restrictions on sharing information from specialty records (e.g., HIV/AIDS, substance abuse, mental health, genetics, etc.) among providers; 2. Unclear patient consent policies for HIE; 3. Concern about provider liability when participating in an HIE; 4. Different interpretations among providers about HIPAA legal requirements and HITECH Act implications on HIPAA; 5. Inconsistent patient identifiers across provider networks; and 6. Consumer and provider awareness of the value and need for health IT. The 2009 report also included preliminary recommendations to overcome the identified barriers, several of which have already been implemented (e.g., the consumer interest group) or will be addressed within this 2010 Iowa e-health Strategic and Operational Plan. The foundation for the report comes from Health Information Security and Privacy Collaboration (HISPC), a national project sponsored by the Office of the National Coordinator (ONC) and Agency for Health care Research and Quality (AHRQ). Iowa was a participating state in all HISPC phases. When preparing for inter-state exchange, Iowa will revisit HISPC reports to examine additional barriers and recommendations specific to inter-state and nationwide health information exchange. At the time the 2009 report was submitted in Iowa, the proposed meaningful use criteria had not been released by the Centers for Medicare and Medicaid Services (CMS). The meaningful use requirements for participation in electronic health information exchange provide additional rationale for Iowa to move quickly in addressing these privacy and security barriers. Iowa e-health supports the removal of privacy and security barriers that hinder electronic exchange and subsequently meaningful use of EHRs, provided that transmission is secured through processes such as the banking and finance industries have been able to achieve. Strategy 5.1.2: Analyze necessary legislative changes to enable statewide HIE and overcome identified barriers. In Iowa, state law 27 provides heightened security above HIPAA regulations to protect sensitive patient information. These regulations limit the exchange of important patient information for treatment related purposes. The inability to share such information, even among a patient s regular care providers, can impact treatment decisions and compromise patient safety (e.g., providers may not have records of medications prescribed to the patient). These restrictions could also hinder providers ability to meet meaningful use requirements for health information exchange. Based on research provided by Iowa s HISPC team, the Iowa Code does not organize all relevant privacy and security laws into a single bill or code chapter. Therefore, there is a high administrative burden to make the necessary changes to enable statewide HIE. An alternative to request changes to each applicable code chapter, is to draft new policies within a comprehensive Iowa e-health legislative package. The policies within this comprehensive legislative package would include but not 27 Iowa Code Section 141A (HIV/AIDS) and Iowa Code Chapters 228 and 229 (Mental Health). IOWA E-HEALTH STRATEGIC AND OPERATIONAL PLAN (JUNE 2012) 79

be limited to HIE privacy and security policies. This allows Iowa e-health to illustrate the entire scope of Iowa e-health, and in turn, clearly outline HIE policies to supersede requirements of certain legislation as required to enable statewide health information exchange. The single, superseding policy will only apply to information exchanged through statewide HIE for treatment related purposes. Strategy 5.1.3: Monitor information from federal organizations (e.g., ONC, CMS, Food and Drug Administration, Drug Enforcement Agency) and collaborate with other state agencies about changes in regulations to reflect the modernized, electronic workflow. There are some federal laws and state administrative code that may need to be changed to allow providers to take advantage of all potential HIE services and demonstrate meaningful use of health IT. For example, there are federal laws that regulate prescriptions for controlled substances (i.e., a provider must provide a paper prescription for a controlled substance rather than issue an e-prescription). This regulation impacts e-prescribing and may hinder provider adoption. On March 1, 2010, after similar federal regulation concerns related to health IT and lab data, the Centers for Medicare and Medicaid Services, in collaboration with ONC, released Clinical Laboratory Improvement Amendments (CLIA) guidance permitting the electronic exchange of lab data. Strategy 5.1.4: Use the communication plan to education providers and consumers about the privacy and security protections that have been established for the HIE. As described in Goal 1, education is very important to the adoption of health IT and support for a statewide HIE. Some of the messages that will be important to disseminate include: who will have access to patient information; what patient information those individuals have access to view; how patient information will be secured; how participating in the statewide HIE will provide better quality of care; and why patient information can actually be more secure in electronic format rather than traditional paper records systems. Consumers need to learn about the various privacy and security controls of health information exchange, so they can make educated decisions about participating in or opting out of the statewide HIE. One of the best sources of information for consumers is from their providers. By educating providers (e.g., receptionists, nurses, physicians and others in a provider practice) about privacy and security, Iowa e-health will establish an additional channel to reach consumers. Objective 5.2: Develop a privacy and security framework. The statewide HIE is primarily decentralized, which means the statewide HIE functions as a pass through for information from provider to provider and only stores a minimal amount of data centrally. The HIE will leverage the established privacy and security systems that have already been established by provider organizations to protect patient information. Additional privacy and security assurances are included in the meaningful use requirements, which are likely to require regular security risk assessments and updates for providers using EHR systems. Before HIE implementation can occur, policies, procedures, and controls must be established to provide additional protections for patient information exchanged through the statewide HIE. The policies, procedures, and controls will address privacy and security implications of existing laws and regulations; infrastructure requirements for access, authentication, authorization, and auditing; and special considerations for the type of clinical data traveling through the statewide HIE. The framework will establish safeguards to ensure that state HIE participants adhere to legal and policy requirements. This includes, but is not limited to a risk mitigation process. The framework will also be established in a manner to allow incremental expansion or enhancement of HIE policies as additional types of HIE services are enabled. Strategy 5.2.1: Use the Safeguard Privacy and Security Workgroup to develop and describe an ideal privacy and security framework. The Safeguard Privacy and Security workgroup has been discussing key privacy and security concepts since early in 2009. In January 2010, the workgroup began crafting the privacy and security framework, which is illustrated below. IOWA E-HEALTH STRATEGIC AND OPERATIONAL PLAN (JUNE 2012) 80

Draft Framework for Statewide HIE Privacy and Security Policies Background: The Iowa Health Information Exchange (Iowa HIE) is a public/private collaboration created to facilitate the electronic exchange of health information between health care entities. Purpose: The intent of these policies is to: 1) provide information about participants rights regarding the use and disclosure of their personal health information; and 2) establish an appropriate level of security to protect participants data from unauthorized access and disclosure. These policies define the access controls and parameters necessary to achieve this protection and to provide for the secure and reliable operation of the Iowa HIE. Scope: These policies are applicable to all participants of the Iowa HIE. Participant organizations may enact procedures that are more stringent than these policies, but must not allow those procedures to conflict with, or be less restrictive than these policies. Definitions of Terms Overarching Privacy and Security Assumptions Obligations to Comply with Policies Contact for Questions regarding Policies Iowa HIE Privacy and Security Policies Section I. Authorization All individuals having access to the Iowa HIE will have a unique participant ID. It is the participant organization s responsibility to authorize, maintain, and terminate their employees permission to use the Iowa HIE. The Iowa HIE will be responsible for authorizing independent participants. Section II. Authentication An HIE participant s identity will be verified as they log into the Iowa HIE. Section III. Access With role-based access controls, participants will be restricted to functionality and information available through the statewide HIE based on their individual role and job function. Section IV. Auditing Participants will comply with audit and compliance requirements that monitor what information was accessed through the statewide HIE, by whom, when and for what purposes. Section V. Standard Participation Agreements All participant organizations and independent participants shall sign an Iowa HIE participation agreement which defines the privacy and security obligations of the parties participating in the Iowa HIE. Section VI. Patient Consent Patients can opt-out of the Iowa HIE. When a patient opts-out, the Iowa HIE will maintain a record of the patient and their opt-out decision in its master patient index, but the Iowa HIE will not facilitate the exchange of records to any requesting providers through its record locator service. Patients may choose to opt-back-in to the Iowa HIE at any time. Section VII. Compliance with HIPAA and HITECH All information maintained and exchanged through the Iowa HIE is minimally covered by the policies, procedures, and regulations established by HIPAA and HITECH. Section VIII. Breach mitigation There will be policies to resolve breaches pertaining to the Iowa HIE. Section IX. Disclosure and use of individually identifiable health information IOWA E-HEALTH STRATEGIC AND OPERATIONAL PLAN (JUNE 2012) 81

Health information will be shared with providers who have a treatment related reason to view the patient information. The provider may use the statewide HIE to report the information that is required by law. De-identified data may be available to population health and research entities, but the Iowa HIE will not sell or disclose patient information. In 2012, Iowa e-health and the Privacy & Security Workgroup worked to revise the Iowa e-health Privacy and Security Framework to align with recommendations from the Office of the National Coordinator for Health Information Technology (ONC) as outlined in a Program Information Notice (PIN) published in March 2012. Iowa e-health s Privacy and Security Framework, which was reviewed and approved by Iowa e-health s Executive Committee & Advisory Council, is included as a supplemental plan to this Strategic and Operational Plan. Strategy 5.2.2: Prepare and submit a legislative package to the Iowa Legislature to implement the privacy and security framework. Using the privacy and security framework above, specific policies are being drafted based on: 1) the U.S. Department of Health and Human Services privacy and security framework; 2) privacy and security policies established in other states; 3) national reports with recommendations for privacy and security policies; and 4) Iowa-specific preferences related to HIE privacy and security. With the assistance from the Iowa Attorney General s Office, Iowa e-health prepared a legislative package for the 2011 Iowa legislative session which would enact the statewide HIE privacy and security policies necessary to facilitate statewide HIE. Strategy 5.2.3: Promulgate administrative rules in accordance with Iowa Code (relevant to privacy and security policies) (pending adoption of the Iowa e-health legislative package). Administrative rules are adopted to implement laws that protect the public health, safety, welfare and environment, and to ensure the efficient administration of state government. Once the Iowa e-health legislative package has been signed into law, Iowa e-health will begin drafting administrative rules to provide additional details to the various policies included in the legislative package. These administrative rules will establish specific procedures (e.g., procedures necessary to support the patient consent policy). Objective 5.3: Establish trust agreements HIE participants. Trust agreements (i.e., HIE participation agreements) establish common agreement on essential policies to address compliance with applicable law, cooperation with other HIE participants, expectations to use the statewide HIE only for permitted purposes, limitation on the future use of data received through the statewide HIE, and privacy and security measures required to be in place before using the statewide HIE. At the national level, a Data Use and Reciprocal Support Agreement (DURSA) is a comprehensive, multiparty trust agreement that must be signed by Iowa e-health in order to exchange data with other exchanges through the Nationwide Health Information Network (NHIN). A similar trust agreement must be signed by all Iowa providers and other stakeholders that want to use the statewide HIE. This trust agreement may require the participating organizations to modify their own existing policies and procedures in areas such as authorization, authentication, access, and auditing. Participating organizations must ensure that each user of the statewide HIE has agreed to the new or revised policies and procedures in order to access the statewide HIE. IOWA E-HEALTH STRATEGIC AND OPERATIONAL PLAN (JUNE 2012) 82

Diagram 5.3a: Trust Agreements Strategy 5.3.1: Prepare the Statewide HIE Participation Agreement. The statewide HIE participation agreement can be adopted or modified from work that began through HISPC, as well as the DURSA and similar agreements used in other states. Strategy 5.3.2: Gather completed statewide HIE participation agreements from Iowa providers. Once the statewide HIE participation agreement has been finalized, all provider organizations and independent providers interested in using the statewide HIE will need to sign and return the agreement to the Office of Health IT for review and approval. Objective 5.4: Establish oversight to ensure compliance with privacy and security policies. The legislative package will describe the roles and responsibilities of the statewide HIE and its participants, as well as the privacy and security protections afforded to consumers, including the right to opt out of participating in the statewide HIE. Additionally, the HIE vendor (see Objective 3.1) will develop a mechanism to track and report non-compliance with privacy and security policies. This will include the use of system audits through standard and ad hoc reporting and querying functions. Strategy 5.4.1: Partner with the Iowa Attorney General s Office to enforce HIE privacy and security policies. The Attorney General s Office has the right under HITECH to bring a civil action in federal court against an individual who violates HIPAA privacy and security laws involving Iowa s residents. The Iowa Department of Public Health will be responsible for monitoring data privacy and security and usage of the IHIN. The Attorney General s Office will not be involved in the monitoring and oversight processes but will advise the department and become involved in enforcement if breaches are discovered. IOWA E-HEALTH STRATEGIC AND OPERATIONAL PLAN (JUNE 2012) 83

Goal 6: Advance coordination of activities across state and federal government In recent years, there has been a lot of state and federal government activity related to health reform (e.g., 2008 Iowa Health Reform bill, 2009 American Recovery and Reinvestment Act Health Information Technology for Economic and Clinical Health Act, 2010 Health Care and Education Affordability Reconciliation Act). This includes, but is not limited to insurance reform, health care access, workforce planning, care coordination among providers, quality monitoring, and health information technology tools. With the various priorities and activities, there tends to be interdependencies, which if not properly aligned, can result in delays in progress and extra rework. Coordination across the strategic initiatives will help stakeholders ensure integration, alignment, and joint success throughout Iowa and the nation. Objective 6.1: Harmonize Iowa e-health activities and Iowa Medicaid Enterprise health IT planning. The Iowa Medicaid program serves Iowa s most vulnerable population, including children, the disabled and the elderly. Medicaid members typically receive care from an array of different providers who are frequently not fully informed of the problem lists, prescriptions, and plans of care the member is receiving from other providers. Almost 20 percent of Medicaid members are Medicare beneficiaries who have multiple chronic diseases and have frequent hospitalizations, emergency visits and later require placement within long-term care facilities. These members require holistic care under multiple providers and case management services to manage complex multiple disease conditions. Many providers lack time and skilled case management resources to ensure clients follow-through with appointments, treatments and taking prescriptions appropriately and safely. Enrollment in Medicaid is anticipated to increase by 20 percent within the next four years with the aging (85+) Iowa population. The statewide HIE is a building block to a solution that will integrate delivery and management of disjointed services, improve health outcomes for the members, provide administrative efficiencies for the providers, and improve communication between the provider, payer and member. Since inception of Iowa e-health in 2009, Iowa Medicaid has been an active collaborator on all levels of HIE planning. Representatives of Iowa Medicaid participate in all Iowa e-health workgroups. Iowa Department of Public Health (IDPH) and Iowa Medicaid senior leadership (i.e., public health director, Medicaid director, and deputy directors) have been holding regular meetings and working together to coordinate resources to enable completion of both the 2010 Iowa e-health Strategic and Operational Plan, as well as the Iowa Medicaid Health Information Technology Plan (Iowa Medicaid HIT Plan) required by the Centers for Medicare and Medicaid Services (CMS). Joint coordination meetings among Iowa Medicaid, IDPH, and the Regional Extension Center (REC) ensure broad collaboration across three major health IT initiatives. The meetings are also an opportunity to discuss and identify opportunities to provide technical assistance to providers outside the scope of the REC (see Goal 2 Promote Deployment and Use of EHRs). Iowa Medicaid has partnered with Iowa e-health and the REC on communications and outreach to providers and consumers (see Goal 1 Build Awareness and Trust of Health IT). Iowa Medicaid has also been a key partner on preparing and releasing assessments necessary to perform an environmental scan within Iowa (see Goal 10 and Environmental Scan). Iowa Medicaid has been involved in technical infrastructure discussions to ensure the statewide HIE is able to meet Medicaid requirements for meaningful use. Iowa was able to leverage Medicaid 90/10 funding for Iowa e-health planning activities, and Iowa e-health and Iowa Medicaid are currently discussing how the 90/10 funding stream could also be leveraged for implementation (see Goal 9 Secure Financial Resources to Develop a Statewide HIE). Iowa will be positioned to request 90/10 funding for Iowa e-health once the business plan is developed and finalized. The business plan will demonstrate how implementation costs will be shared among stakeholder groups beyond government. Strategy 6.1.1: Determine shared goals, define interdependencies, and identify opportunities for integration. A close working relationship between Iowa Medicaid and Iowa e-health s Office of Health IT within IDPH is critical to ensure alignment of health IT activities and funding within state government. With an aligned vision that EHR adoption and statewide HIE can be useful tools to provide the highest IOWA E-HEALTH STRATEGIC AND OPERATIONAL PLAN (JUNE 2012) 84

quality health care in the most cost effective manner for Iowans, Iowa Medicaid and Iowa e-health have identified a variety of shared goals and priorities for health IT planning. Iowa e-health goal in the 2010 Strategic and Operational Plan Build awareness and trust of health information technology (see Goal 1) Promote statewide deployment and use of electronic health records (see Goal 2) Enable the electronic exchange of health information (see Goal 3) Coordination activities across state and federal government (see Goal 6) Monitor and evaluate health IT progress and outcomes (see Goal 10) Iowa Medicaid priorities as illustrated in the Iowa Medicaid HIT Plan Coordinate with the Iowa Regional Extension Center and Iowa e-health to provide consistent education and outreach to providers for the adoption of EHRs and connection to the statewide HIE. Support provider education efforts on benefits of EHR and HIE adoption. Medicaid provider adoption of electronic health records and health information exchange. Provide funding support for the planning and implementation of the statewide HIE. Provide access to the statewide HIE for targeted Medicaid providers where quality improvements and cost management can be realized. Utilize the statewide HIE where possible to eliminate the need for mailing or faxing medical information from providers to Iowa Medicaid. Participate in the planning and creation of a statewide HIE. Ensure the unique needs of the Medicaid population and programs are considered. Support initiatives to advance patientcentered medical homes and care coordination. Evaluate the use of incentives and disincentives and their impact on provider adoption of EHR and HIE use. There are two primary interdependencies between Iowa e-health and Iowa Medicaid: 1) meaningful use of health IT and the HIE functionality to enable meaningful use; and 2) clear communication and proactive outreach to providers and consumers to build trust and awareness of health IT adoption and the statewide HIE. Without aligned goals and expectations, success for both Iowa e-health and Iowa Medicaid will be difficult to achieve. Together, Iowa e-health and Iowa Medicaid have identified several opportunities for integration. As Iowa e-health continues to revise and expand its annual strategic and operational plans and as Iowa Medicaid prepares their Medicaid HIT Plan, many of these opportunities for integration may turn into subsequent strategies and tasks. 1) Integrate the planned statewide HIE phased rollout implementation plan into Iowa Medicaid s HIT Plan. Once the statewide HIE is operationalized, Iowa Medicaid will work with providers to send clinical data through the statewide HIE for various provider authorization and audit processes. Iowa Medicaid is working to update various policies and procedures required to enable these processes early in the statewide HIE implementation to further entice providers to adopt EHRs and use the statewide HIE. IOWA E-HEALTH STRATEGIC AND OPERATIONAL PLAN (JUNE 2012) 85

2) Use existing Iowa Medicaid technology to develop shared services for the statewide HIE. Iowa Medicaid has an established technology infrastructure that includes the Medicaid Management Information System (MMIS) and the Iowa Medicaid Electronic Records System (IMERS).There is a potential to use these existing systems to begin developing the statewide HIE provider directory and master patient index. 3) Identify and monitor providers interested in Medicaid incentive payments. Iowa was one of only four states to launch its EHR incentive payment program on January 3, 2011 and begin making payments in January. To support the program, CMS developed a national registration and attestation system (https://ehrincentives.cms.gov/hitech/login.action). This centralized location is the site for providers to register for the Medicaid and/or Medicare incentive payment program. Those registering for the Iowa Medicaid program are directed to the Iowa Medicaid site to complete attestation. Information from the registration and attestation system is being shared with Iowa e-health to assist with the statewide HIE implementation schedule. 4) Align expectations for meaningful use. In alignment with stage 1 meaningful use, there is broad agreement that Iowa s HIE must be able to: 1) monitor provider participation in the statewide HIE; 2) support the transfer of clinical information between providers using ONC standards; and 3) support data exchange with the statewide HIE for immunizations, reportable diseases and other required reporting. Iowa e-health s aim is to provide at least one way for providers to satisfy the information exchange criteria of meaningful use. 5) Collaborate with Medical Home initiatives in Iowa. In 2010, the IowaCare program was expanded. As part of the expansion, Iowa Medicaid may want to use the statewide HIE to support a Medical Home pilot which is currently planned for 2011. This pilot may be able to be used as a proof of concept to test the core components of the statewide HIE before the statewide HIE infrastructure has been established. 6) Advocate for the needs of the Medicaid population, particularly children and people with disabilities. Targeting specific Medicaid populations for health IT adoption and statewide HIE participation may help drive early cost savings for taxpayers and ensure the needs of vulnerable populations are being met. Strategy 6.1.2: Collaborate with Iowa e-health staff in the creation and review of the Iowa Medicaid HIT Plan. Iowa e-health and Iowa Medicaid worked together to prepare the Iowa Medicaid HIT Plan. The Iowa Medicaid HIT Plan was created as a deliverable to the Centers for Medicare and Medicaid Services (CMS). The Iowa Medicaid HIT Plan describes how IME will administer the EHR incentive payment program and outlines the health IT initiatives Iowa Medicaid believes will encourage the adoption and meaningful use of certified EHR technology. There are a number of Iowa Medicaid goals that rely on the successful alignment and development of a statewide HIE and other resources available through Iowa e-health. Iowa Medicaid s goal is to use the Medicaid HIT Plan as a tool to improve the quality of healthcare our members receive through the exchanges of health care information. The Iowa Medicaid Plan may be found at http://www.ime.state.ia.us/providers/ehrincentives.html. Iowa Medicaid will revise the SMHP on an annual basis to show a rolling five year vision of HIT needs within Iowa. Strategy 6.1.3: Collaborate with Iowa Medicaid staff in the creation and review of Iowa e- Health s Strategic and Operational Plan. Representatives from Iowa Medicaid have been active participants in all e-health workgroups and the monthly e-health Executive Committee and Advisory Council meetings. Iowa Medicaid has been a critical contributing stakeholder in development of the plan, similar to the many other stakeholders involved throughout the planning process. A letter of support from the Iowa Medicaid Director can be found in Appendix C. Strategy 6.1.4: Partner to complete baseline provider environmental scans to better understand the landscape and barriers of EHR adoption in Iowa. Environmental scans are important elements of the Iowa e-health Strategic and Operational Plan, as well as the Iowa Medicaid HIT Plan. Iowa Medicaid has been supportive to Iowa e-health by participating in the assessment subcommittee to develop appropriate assessment questions, securing funding from CMS to help pay for provider assessments, and using their network of provider contacts IOWA E-HEALTH STRATEGIC AND OPERATIONAL PLAN (JUNE 2012) 86

to increase assessment response rates. Iowa Medicaid will be able to use final assessment data to support the goals and objectives of their plan, to gain an understanding of potential volume for the Medicaid incentive payment program, and to understand current use of health IT among Iowa Medicaid providers. Strategy 6.1.5: Utilize the Medicaid provider and member outreach processes for communication and input into the planning processes. The network of providers and consumers available through Iowa Medicaid adds another valuable resource for Iowa e-health. Iowa Medicaid has been instrumental in using their network to develop assessment sampling frames, encourage providers to complete Iowa e-health assessments, and generate interest in the consumer interest group (see Goal 1). Through the communication and outreach subcommittee and joint Iowa e-health and Iowa Medicaid planning meetings, Iowa e-health will seek support from Iowa Medicaid regarding topics and information for Iowa Medicaid to share with their providers and consumers. Objective 6.2: Build an appropriately trained, skilled health IT workforce. As new EHR systems are implemented and connected to the statewide HIE across the state, new jobs will need to be created and existing positions may need to be adapted to support new technology, information needs, and workflow processes. There are generally four primary categories of professionals that comprise the health IT workforce. These include: 1) health information management professionals who manage health care data and information resources; 2) information technology professionals who maintain, build, and support EHRs and the statewide HIE; 3) health care professionals who will implement, adopt, and use health IT and the statewide HIE in practice; and 4) health informatics professionals who will design and update evidence-based practices and study the efficiencies and outcomes to benefit population health. Strategy 6.2.1: Monitor grant funding awards related to the health IT workforce. One of the most direct sources of funding to support the health IT workforce is the Community College Consortium. Des Moines Area Community College and Kirkwood Community college are partners with Cuyahoga Community College District, which was named a regional Community College Consortium by ONC. The purpose of the Community College Consortia is to establish or expand health IT education programs for six health IT roles. These include: 1) Practice workflow and information management redesign specialist; 2) Clinician/practitioner consultant; 3) Implementation support specialist; 4) Implementation manager; 5) Technical/software support staff; and 6) Trainer. Training is designed to be completed within six months or less and programs began in September 2010. The anticipated training capacity of the Consortia as a whole is expected to be least 10,500 students annually. Strategy 6.2.2: Identify core competencies for training the health IT workforce. Through a workforce competency study, Iowa will be able to define the skills and knowledge required to educate the health IT workforce, identify gaps in competencies needed to implement and maintain the continuous lifecycle of health IT, update existing interdisciplinary health and clinical informatics curriculum, and prepare appropriate curriculum for statewide workplace training and post-secondary education. Strategy 6.2.3: Create or enhance training and education programs. To support the emerging health IT workforce, there needs to be a new level of integration between previously distinct health care and information technology (IT) programs. IT personnel working in a health care environment need to understand standard health care terminologies so they can effectively communicate with providers. Alternatively, health care professionals need to know enough about IT to use the electronic tools, such as EHRs and the statewide HIE, to provide the best care to their patients. To develop this integration, existing education programs need to be expanded and new programs need to be developed. These programs include: 1) undergraduate and graduate degree programs and certifications; 2) continuing education credits; and 3) training and professional development workshops. IOWA E-HEALTH STRATEGIC AND OPERATIONAL PLAN (JUNE 2012) 87

The development of these educational programs must begin immediately to meet the growing demand for a trained health IT workforce. Because these educational programs will be new to many institutions, curriculum can be prepared in collaboration with faculty from community colleges and universities and designed for implementation at multiple, diverse learning institutions and settings. Organizations such as Iowa Health Information Management Systems Society Chapter, American Medical Informatics Association, Iowa Medical Group Management Association, the Center for Classifications and Clinical Effectiveness, Interdisciplinary Graduate Program in Informatics (IGPI includes faculty in bio informatics, health informatics and information science), and various Iowa e- Health project workgroups can provide forums for disseminating new or revised curricula. One challenge that must be addressed when considering new or expanded degree and certificate programs will be the number of credit hours allowable for each program. The breadth of topics students are expected to cover before they enter the workplace continues to increase, but the maximum credit hours do not. Strategy 6.2.4: Develop a workforce plan for health IT growth and recruitment. Critical to achieving the goal of Iowa e-health, is the availability of a skilled workforce that can facilitate the implementation and support of an electronic health care system. Estimates based on the data from the U.S. Bureau of Labor Statistics (BLS), U.S. Department of Education and independent studies indicate a national shortfall of approximately 51,000 qualified health IT workers who would be required over the next five years to meet the needs of hospitals and physicians as they move to adopt EHRs 28. The workforce competency study will lay the foundation for developing a health IT workforce plan. Workforce plans are commonly used to ensure organizations have the right people with the right skills in the right jobs at the right time. The workforce plan will also be an invaluable economic recovery tool that will help Iowans find jobs and reenter the workforce. At a high-level, the workforce plan will: 1) describe the new positions that need to be created to support implementation or maintenance of health IT; 2) plan ways to transition staff or adapt existing positions into health IT; 3) identify health IT positions or job classifications organizations may have difficulty filling and provide strategies for recruitment; and 4) monitor growth and demand for the health IT workforce. More specifically, this plan will include: the number of health IT specialists and clinical Informaticists in the current Iowa market; the number of health IT specialists necessary to support a provider (e.g., clinic, nursing home, or critical access hospital) preparing to adopt, build, or implement health IT; the number of health IT staff necessary to sustain a provider s health IT system (e.g., weekly content changes, security audits, and technology or knowledge content upgrades); the need and number for specific health IT roles for the statewide HIE infrastructure team; training needs for statewide HIE staff; and the number of current staff who need to be retrained (e.g., public health departments, medical records staff). Iowa Workforce Development and the Department of Public Health s Health and Long-term Care Access Advisory Council will be excellent resources to support this strategy. Objective 6.3: Align health IT project activities with federally funded, state-based programs. IDPH manages a number of federally funded, state based programs such as Maternal and Child Health, Immunizations, HIV/AIDS, Emergency Medical Services for Children, and the Epidemiology and Laboratory Capacity Cooperative Agreement. IDPH also houses the State Office for Rural Health Policy and State Office of Primary Care. Many IDPH programs maintain data systems to capture clinical and population health information (e.g., the Immunization Registry Information System (IRIS) for immunizations, the Iowa Disease Surveillance System (IDSS) for reportable diseases, and the Iowa Service Management and Reporting Tool (I-SMART) for substance abuse treatment). IDPH staff members besides those involved with the Iowa e-health program are engaged in Iowa e- Health planning. Staff are considering how these data systems and other federally funded, state based 28 Office of the National Coordinator for Health IT, Information Technology Professionals in Health Care: Program of Assistance for University-Based Training (December 2009). p. 7. IOWA E-HEALTH STRATEGIC AND OPERATIONAL PLAN (JUNE 2012) 88

programs may use the statewide HIE to streamline workflow and potentially realize efficiencies through consolidation of reporting mechanisms. For example, the state-based programs could connect directly to the Iowa s statewide HIE, or potentially through the managing federal agency which is connected to the Nationwide Health Information Network (NHIN) and able to access the Iowa s statewide HIE. Recently, the IDPH Bureau of Family Health received technical assistance from the Public Health Informatics Institute to prepare a business case model for integrating child health information systems. The business case model examined the benefits and cost of integrating systems including: vital records, the immunization registry, newborn dried bloodspot screening (NDBS), early hearing detection and intervention (EHDI) program, lead screening, the early periodic screening diagnosis and treatment (EPSDT) program, women infants and children (WIC) program, and the birth defects program. The business case model illustrated positive financial benefits in each of the programs with the exception of EPSDT. Information from the business case model can serve as a great foundation for determining the best approach for connecting public health programs to the statewide HIE. For example, IDPH could build an interface for each program, or integrate the various programs and then build a single public health interface to the statewide HIE. Strategy 6.3.1: Engage in internal IDPH strategic planning to identify subsequent strategies and tasks to align Iowa e-health activities with broader public health functions. It is important to educate IDPH supervisors, program managers, and staff about Iowa e-health, and the potential impact and opportunities of EHRs and the statewide HIE on public health programs. It is important to convene strategic planning sessions within IDPH to determine goals and tasks for coordination of informatics needs and to ensure alignment of the statewide HIE with broader population health goals. Strategy 6.3.2: Facilitate planning meetings to determine how national programs managed by other state agencies and local public health will connect to the statewide HIE. Beyond traditional health care providers, there are a number of important programs that would benefit from connecting to the statewide HIE. Meetings with organizations and programs such as State Mental Health Data Infrastructure Grants (SAMHSA), the State Children s Health Insurance Program (SCHIP, known as hawk-i in Iowa), the Department of Human Services foster care and child abuse programs, the Department of Education s Early ACCESS program, and Health Resources and Services Administration (HRSA) primary care programs will help Iowa e-health explore opportunities to further expand the use and value of the statewide HIE throughout Iowa. Objective 6.4: Align project activities with federal care delivery organizations. Iowa plans to connect to organizations such as Veterans Affairs (VA), Department of Defense, and Indian Health Systems through connection to the Nationwide Health Information Network (see Objective 3.3). The VA Medical Center in Des Moines has been involved in Iowa s planning efforts and has a role on the e-health Advisory Council. Iowa/Nebraska Primary Care Association (IA/NEPCA), which supports Federally Qualified Health Centers and Rural Health Centers in Iowa, is a member of the e-health Advisory Council. The Iowa Medicare Quality Improvement Organization (QIO), Telligen is also a member of the e-health Advisory Council and serves as Iowa s Regional Extension Center. Strategy 6.4.1: Monitor information from federal organizations (e.g., HRSA, CDC, Medicare, Veteran s Affairs, Indian Health Services) to determine how the organizations plan to connect with statewide HIEs. It is Iowa s hope that greater coordination between Medicare and other federal projects can be facilitated through ONC. IOWA E-HEALTH STRATEGIC AND OPERATIONAL PLAN (JUNE 2012) 89

Objective 6.5: Align project activities with other American Recovery and Reinvestment Act (ARRA) programs. The State HIE Cooperative Agreement Program is just one of many programs made available through the passage of ARRA in February 2009. ARRA will also provide critical funding for incentives and technical assistance for providers, broadband expansion, and workforce planning and education program development. Together, all of these programs will support the broad vision and goals of health IT throughout the nation. With the shared goals and interdependencies of the various programs, coordination and integration among programs will be critical for success. As organizations or programs are selected through the various competitive funding opportunities, more information can be added to strategic and operational plans to describe how activities will be coordinated. If the organizations selected to coordinate the other ARRA programs are not already represented on the e-health Executive Committee or Advisory Council, they may be invited to serve on the Advisory Council or workgroups to ensure alignment and communication throughout the project period. Strategy 6.5.1: Collaborate with Iowa s Regional Extension Center (REC) to promote health IT adoption and provide support for Iowa providers. Telligen (formerly IFMC) was selected by ONC as Iowa s REC in February 2010. IFMC, the Quality Improvement Organization (QIO) in Iowa, has partnered with INConcertCare, a health center controlled network representing Iowa s 12 federally qualified health centers and one migrant health center. The REC will provide technical assistance, guidance and best practice information to accelerate meaningful use of EHRs. The Iowa REC will provide both core and direct support to practices. The Iowa REC will target a minimum of 1,200 priority providers (33 percent of our primary care practitioner population) for direct assistance during the first two years of the cooperative agreement. This includes technical assistance in vendor selection and group purchasing, implementation and project management, practice workflow redesign, interoperability and health information exchange, and privacy and security best practices (see Goal 2). Initially technical assistance will be focused on priority primary care providers. Qualified providers will pay nominal service fees to the Regional Center to supplement costs not covered by federal funding. For all other providers, the Iowa REC business model will establish a fee scale based on the services needed and the size of the practice. Through ONC s application process to select the RECs throughout the nation, the Iowa e-health Executive Committee submitted a letter of support for Telligen to serve as Iowa s REC. As part of the letter of support, the e-health Executive Committee requested that at least one member of the e-health Executive Committee serve on the REC Advisory Council to ensure alignment of the Iowa REC with the broader Iowa e-health initiative. The Iowa REC is regularly involved in all e- Health workgroup meetings and collaborates closely with Iowa Medicaid and the IDPH Office of Health IT on communication and outreach (see Goal 1). The IDPH Office of Health IT, Iowa Medicaid, and the Iowa REC convene monthly planning meetings. Additionally, all three organizations are represented on both the Iowa e-health and Iowa REC advisory councils and regularly share information and updates at respective council meetings. Strategy 6.5.2: Collaborate with recipients of broadband funding to promote broadband expansion to facilitate statewide HIE. (See Strategy 3.2.1) Strategy 6.5.3: Collaborate with recipients of workforce grants to build an appropriately trained, skilled health IT workforce. (See Objective 6.2) IOWA E-HEALTH STRATEGIC AND OPERATIONAL PLAN (JUNE 2012) 90

Objective 6.6: Ensure coordination between Iowa and neighboring states in development of statewide HIEs. One of the guiding principles of Iowa e-health is to build on smart practices and align with federal standards to ensure interoperability of health IT within and beyond the state. Several states have successfully implemented HIE networks, and other states are in various planning stages with successes and challenges to share. Learning from their experiences will facilitate the development of a successful, sustainable HIE in Iowa. Additionally, to enable inter-state exchange, Iowa e-health must work closely with neighboring states to harmonize privacy and security policies and align infrastructure needs (See Strategy 3.3.2). Strategy 6.6.1: Employ technical assistance tools and forums available through ONC. Iowa e-health looks forward to the availability of technical assistance through ONC. Representatives from the Office of Health IT have already been participating in the technical assistance listserv and webinar series. They have also been reviewing information available through the state HIE toolkit and have identified several resources to share with Iowa e-health workgroups for discussion and planning. Additionally, Iowa hopes to be able to contribute to the state HIE toolkit as planning documents and deliverables are finalized in Iowa. Iowa is pleased to participate in leadership training coordinated through ONC and will attend all meetings and events as allowable based on current state travel restrictions. Strategy 6.6.2: Collaborate directly with other states to glean smart practices. Before technical assistance was made available through ONC, Iowa reviewed planning documents publicly available by other states and contacted several states directly to identify lessons learned and seek planning and implementation advice. These states include Rhode Island, Delaware, New Mexico, and Minnesota to be understand the advantages and disadvantages of different legal structures for governing the statewide HIE, as well as Nebraska to better understand the resources and processes necessary for successful participation in an HIE. Objective 6.7: Align Iowa e-health with broader health care reform efforts. Several of the other health reform advisory councils established by the 2008 Iowa health reform bill (2008 Iowa Acts, Chapter 1188, HF 2539), such as the Medical Home System Advisory Council and the Prevention and Chronic Care Management Advisory Council, will be directly impacted by successful planning and implementation of EHRs and a statewide HIE. In the Medical Home scenario, for example, health IT enables providers from many disciplines to share information about a single patient. This helps break down silos and allows for more informed patient care. In the Prevention and Chronic Care scenario, health IT creates the capacity to provide advanced care processes using real-time information to monitor and treat chronic conditions. This helps improve patient outcomes, increase quality of care, and reduce the need for costly and redundant procedures or hospitalization. The IDPH Office of Health IT has regularly attended the other health reform advisory councils and provided progress reports to the councils about Iowa e-health planning efforts. Communication among the various councils has been helpful in gathering feedback about desired functionality of the statewide HIE and identifying overlapping issues important to multiple councils. Strategy 6.7.1: Collaborate with other staff within Iowa Department of Public Health to coordinate health reform activities. IDPH is responsible for convening seven of the eleven advisory councils established by the 2008 Iowa health reform legislation. Several coordinators of these councils are also following more recent reform efforts, such as the health insurance reform of 2010. To ensure alignment among these councils, IDPH coordinates regular health care reform connections and integration team meetings with IDPH staff. A deliverable of this integration team is a health care reform newsletter, called the Check-Up. The Check-Up, which can be found at http://www.idph.state.ia.us/idpharchive/archive.aspx?channel=checkup is designed to keep interested Iowans up to date on the progress of health reform initiatives assigned to IDPH and features updates on activities of active health reform councils and other activities as authorized by the 2008 legislation. IOWA E-HEALTH STRATEGIC AND OPERATIONAL PLAN (JUNE 2012) 91

Strategy 6.7.2: Jointly participate in health reform council meetings. There are several Iowa e-health Executive Committee, Advisory Council, and workgroup members who serve on advisory councils and/or workgroups of other health reform initiatives. There are also many individuals from the other health reform councils that regularly attend the e-health Executive Committee and Advisory Council meetings. This cross-pollination among the councils provides an opportunity to create synergy, ensure alignment of activities and identify potential opportunities for collaboration. Strategy 6.7.3: Jointly promote the benefits of e-health, medical home, and prevention and chronic care. While providers can choose to integrate specific aspects of initiatives such as e-health, medical home, and prevention and chronic care, the best results will be realized when the three initiatives are fully integrated and embraced by Iowa health care providers. By understanding the shared technology needs to support medical home and prevention and chronic care management, the statewide HIE can be developed to support advanced HIE services to enable care coordination. Until that HIE functionality exists, providers can use interim tools such as a registry or an EHR with a registry function to support care coordination within their own practice setting. To maximize provider education and avoid confusing messages about multiple health reform initiatives, it is important to develop communication and outreach materials that explain the interdependencies and opportunities for integration among these health reform initiatives. IOWA E-HEALTH STRATEGIC AND OPERATIONAL PLAN (JUNE 2012) 92

Goal 7: Establish a governance model for statewide health information exchange A formal organizational structure inclusive of multiple public and private stakeholders is critical to the success of Iowa e-health. A governance entity must provide oversight of the Iowa e-health initiative and ensure accountability to protect public interest. Governance is intended to maintain a multi-stakeholder, collaborative, transparent process to create trust and consensus on an approach for statewide HIE and to enable Iowa e- Health to provide and maintain value over time. Selecting the type of governance model (e.g., government-led, public authority, non-profit) will help define the roles and responsibilities for oversight of the long-term activities, policies, and procedures related to Iowa e-health. As states move from statewide HIE planning, implementation, and sustainability, there may be different governance models that are more suitable. The governance model and related policies and procedures need to be flexible enough to adjust to policy and stakeholder changes to promote intraand inter-state interoperability. Objective 7.1: Explore governance options and establish a governance entity. The current governance model is best described as a government-led model with accountability to a multi-stakeholder, public-private e-health Executive Committee and Advisory Council. The governance structure was established by a comprehensive health reform bill (2008 Iowa Acts, Chapter 1188). The legislation specified the nine organizations to be represented on the Executive Committee and eight of the organizations represented on the Advisory Council. Additional members of the Advisory Council were appointed by the director of the Iowa Department of Public Health. The nine voting members of the Executive Committee include: three chief information officers from the three largest private health care systems in the state; the chief information officer of the University of Iowa Hospitals and Clinics; a representative from a rural hospital selected by Iowa Hospital Association; a consumer member of the State Board of Health; a licensed practicing physician selected by the Iowa Medical Society; a licensed and practicing nurse selected by the Iowa Nurses Association; and an insurance carrier selected by the Federation of Iowa Insurers. The 19 non-voting members of the Advisory Council include: a pharmacist; a licensed practicing physician; a consumer member of the State Board of Health; a member from the Iowa Medicare Quality Improvement Organization; the executive director of the Iowa Communications Network; a representative of the private telecommunications industry; a representative of the Iowa collaborative safety net provider network; a nurse Informaticist; and eleven additional members representing key stakeholder groups. With the current government-led model, IDPH provides accountability and transparency for planning and execution of project activities. IDPH provides the primary personnel resources to coordinate planning activities and convene the e-health Executive Committee, Advisory Council, and multi-stakeholder workgroups. The IDPH director currently serves as the state health IT coordinator. In addition to the e-health Executive Committee and Advisory Council, several workgroups were formed to provide subject matter expertise for components of the planning process. Active workgroups include: 1) Health Information Exchange (HIE) Infrastructure and Networks; 2) Continuity of Care Document and Interoperable Electronic Health Records (EHR); 3) Safeguard Privacy and Security; 4) Governance and Finance; 5) Health IT Workforce and Education; and 6) Provider Adoption of EHRs. The e-health Executive Committee and Advisory Council began meeting in January 2009. They meet approximately monthly to engage in critical planning discussions, establish priorities, and execute project activities. Workgroups meet more frequently to further define, research, and carry out project activities. Strategy 7.1.1: Continue the governance structure established by the Iowa Legislature in 2008 for a defined period of time. When the opportunity for federal funding for the statewide HIE arose, it became imperative to seek multi-stakeholder input and guidance regarding the preferred governance structure for Iowa e-health. IOWA E-HEALTH STRATEGIC AND OPERATIONAL PLAN (JUNE 2012) 93

The Governance workgroup weighed a variety of governance structure options, and brought forth a recommendation to the Executive Committee that IDPH should be the governance entity for the rest of the planning and beginning of HIE implementation phases, so that HIE activities such as securing staff resources and procurement could be quickly accomplished. Strategy 7.1.2: Prepare and submit a comprehensive legislative package to the Iowa Legislature to provide for the authority of the long term governance entity (i.e., Board of Directors) and the IDPH to implement the statewide HIE and services. In establishing long-term governance for Iowa e-health, it is important to assess the advantages and disadvantages of different legal business structures (e.g., government run, nonprofit, for-profit, public utility, public authority). The Governance and Finance workgroup gathered smart practices from other states and HIEs regarding experience with different governance structures and is preparing to make recommendations to the e-health Executive Committee regarding the governance structure most suitable for a successful HIE in Iowa. As the workgroup researched potential legal business structures, a document was developed to capture preferences for a long-term governing structure. Components of this document included: the purpose, scope of activities, and authority for Iowa s HIE of the entity; composition, roles and responsibilities, and terms of a Board of Directors or other oversight entity; provisions for stakeholder advisory group(s) and/or committees to obtain ongoing advice and input; key personnel (e.g., CEO or executive director) and other operational personnel outlining responsibility for supervision and evaluation of these positions; and responsibility and accountability for the business and operational functions of Iowa e-health and the statewide HIE. In order to make changes to the existing, state-led governance structure, including changes to the voting membership of the Executive Committee; current Iowa Code needs to be modified. Iowa e-health pursued legislation in 2012 to establish privacy and security policies (patient consent). The Iowa e-health Bill (SF 2318) was signed into law by Iowa s Governor, enabling Iowa e-health to move forward as an opt-out state, provides authority for Iowa e-health to collect fees for IHIN services and enables Iowa e-health to establish a separate fund for IHIN service fees to promote sustainability. Furthermore, the legislation directs Iowa e-health to research the feasibility of using the IHIN for research-related purposes in the future. Objective 7.2: Establish policies and procedures to govern operations of Iowa e-health and the statewide HIE. When the statewide HIE is given authority to operate, Iowa will need to develop policies and procedures for oversight, accountability, and business operations (See Goal 8 Execute Business and Technical Operations for Health IT). Examples of such policies include: Guidelines regarding types of e-health decisions which require approval by the governing body; Oversight and accountability of Iowa e-health and the statewide HIE ensuring success in meeting performance expectations; Rules for the governing body s oversight of finances, fiscal responsibility and fundraising; Policies regarding the hiring, oversight, and routine evaluation of Iowa e-health personnel; HIE privacy, security, and data use agreements for participants (e.g., DURSA, patient preference capabilities); HIE participating organization rules of engagement; Guidelines for inter-state data exchange; Mechanisms for release of data in case of disaster (e.g., flooding, tornadoes); Processes for adding new service lines (e.g., additional types of clinical data change; new types of users for the statewide HIE or related health data); Policies regarding secondary use of data or re-disclosure; Collection of information for e-health monitoring; Board of Directors ethics and accountability; and Guidelines regarding strategic planning activities. IOWA E-HEALTH STRATEGIC AND OPERATIONAL PLAN (JUNE 2012) 94

Strategy 7.2.1: Promulgate administrative rules in accordance with Iowa Code. Based on authorizing legislation, Iowa e-health will use an administrative rules process to define critical policies and procedures (e.g., procedures to manage patient consent). Other policies will be established within the participation agreements signed by all HIE participants. Activities will include reviewing existing resources from other states, modifying or developing applicable policies or procedures for Iowa, seeking and incorporating stakeholder input, and presenting the final policies and procedures to the Iowa e-health governance entity. Objective 7.3: Engage in multi-stakeholder, public-private collaboration. The collaborative planning approach used to-date has included a multitude of health care stakeholders as members of the e-health Executive Committee, Advisory Council, and workgroups. IDPH also maintains a list of interested parties, who receive regular communication and notice of meetings from IDPH about the Iowa e-health Project. All e-health Executive Committee and Advisory Council meetings are open to the public, and follow Iowa open meetings legal requirements. Strategy 7.3.1: Convene regular multi-stakeholder meetings with the e-health Executive Committee, Advisory Council, and workgroups. The Executive Committee is the decision-making body for Iowa e-health. The regular meetings consist of both informational and decision-making activities. The governing body is updated regarding current operations and activities for e-health, including financial information. All decisions which guide the direction of e-health are brought to this group for discussion and approval. For a current list of scheduled meetings, please visit http://www.iowaehealth.org/. Strategy 7.3.2: Convene additional e-health meetings as needed to provide information and advice to e-health Executive Committee and Advisory Council. Iowa e-health relies on a several multi-stakeholder workgroups to provide subject matter expertise for components of planning and implementation (see Planning Approach). To engage consumers and consumer organizations, Iowa e-health recently formed a consumer interest group based on a recommendation within the 2009 Privacy and Security Report (see Goal 5). The consumer interest group is a forum for health care consumers to: 1) learn about e-health related topics and policies; 2) provide feedback regarding e-health planning and implementation; and 3) help communicate the vision and goals of Iowa e-health to other Iowa consumers. The group is comprised of six (6) consumer members with diverse backgrounds, who have interest or experience in a range of health-related situations (e.g., mental health, chronic conditions, substance abuse, HIV/AIDS, physical disability, children with special needs, and recipients of Medicaid). Representatives from consumer advocacy organizations are also invited to attend consumer interest group meetings to learn and provide feedback about Iowa e-health topics and proposed policies. The workgroups, subcommittees, and consumer interest group will continue to meet until planning and implementation topics have been sufficiently explored and brought to the e-health Executive Committee. In addition, Iowa e-health can also leverage various stakeholder meetings (e.g., conferences, regional meetings) as a venue to collaborate and align activities throughout Iowa. Strategy 7.3.3: Provide accountability and transparency throughout HIE planning and implementation. Accountability and transparency throughout governance and business operations helps build trust and broad stakeholder support for initiatives such as Iowa e-health that are viewed as a public good. Iowa e-health strives to provide as much transparency as possible, working within constraints of competitive procurement processes which limit communication with potential vendors to avoid perceived or actual conflict of interest. Strategy 7.3.4: Align stakeholders to ensure collaboration and support for Iowa e-health as a public good. IOWA E-HEALTH STRATEGIC AND OPERATIONAL PLAN (JUNE 2012) 95

Iowa e-health and its governing body have a responsibility to bring entities together to help ensure organizations pursue the common interest and greater good that is central to Iowa e-health s vision and guiding principles. Iowa e-health recognizes that health care and information technology are competitive businesses, simply by nature of the environment. Iowa e-health intends to leverage, rather than duplicate, health IT assets from both public and private entities. By engaging businesses, Iowa e-health can address gaps and maximize existing investments toward broad health IT progress. By leveraging opportunities for multi-stakeholder collaboration, Iowa e-health can also help facilitate coordination and cooperation between stakeholders to advance shared health IT goals. IOWA E-HEALTH STRATEGIC AND OPERATIONAL PLAN (JUNE 2012) 96

Goal 8: Execute business and technical operations for health IT In accordance with Iowa Code [2008 Iowa Acts, Chapter 1188 (HF 2539)], the Iowa Department of Public Health (IDPH) serves as the lead agency for Iowa e-health. With support and approval from the e-health Executive Committee, the current governing body (see Goal 7), IDPH is responsible for business and technical operations to develop and maintain a statewide health information exchange (HIE). In this role, IDPH was awarded for the State HIE Cooperative Agreement Program available through the Office of the National Coordinator (ONC). IDPH will provide the leadership and accountability for successful planning and progress towards a statewide HIE. IDPH has a track record of successfully convening multistakeholder advisory bodies, developing and implementing health policy, initiating and facilitating complex system changes, managing federal grant funding, and leveraging other sources of funding. Objective 8.1: Provide resources and project management to carry out Iowa e-health goals, services, and activities. Throughout this Iowa e-health Strategic and Operational Plan, there is a broad range of tasks that must be executed to support Iowa e-health goals and objectives. This includes but is not limited to communication and outreach activities, facilitation of meetings and planning sessions, assessments and evaluation, preparation of plans and reports, and management and oversight of procurement processes and vendors. A combination of dedicated staff resources and contracts will be used to ensure completion of all strategies within this plan. The following diagram illustrates how the specific goals of this 2010 Iowa e-health Strategic and Operational Plan will be supported by the combination of dedicated staff and contracts. Diagram 8.1a: Dedicated Staff and Contracts IOWA E-HEALTH STRATEGIC AND OPERATIONAL PLAN (JUNE 2012) 97

Goal 1 Communication & Outreach Communication Coordinator Communication Plan Contract Goal 6 Coordination HIT Coor Consultin Goal 2 Provider Adoption Provider Relations Specialist Focus Group Contract Goal 7 Governance HIT Coor Legal Co Goal 3 Technical Infrastructure IT Project Manager Provider Relations Specialist Statewide HIE Contract Goal 8 Operations Program Program Goal 4 HIE Services IT Project Manager Statewide HIE Contract Goal 9 Finance Program Business Goal 5 Privacy & Security IT Project Manager Legal Counsel Contract Goal 10 Evaluation Evaluatio Assessm Note: Many staff members support a multitude of goals. There are also shared resources and planning partners who are not represented in the illustration. The combination of staff and contracts is an approach that leverages the expertise of the vendor community for critical tasks, such as the financial plan and HIE infrastructure, but also provides dedicated state-level support to provide coordination and oversight, hold vendors accountable, manage various components of the project, promote alignment between broader health reform goals and population health, and ensure compliance with all ONC requirements. Additionally, relationships with Iowa e-health stakeholders, including clinical providers, technology experts, business professionals, and others who are willing to share their knowledge, Iowa e-health has the right mix of staff and subject matter expertise to successfully plan and execute strategies. As Iowa e-health tasks are identified, the e-health Executive Committee and Advisory Council will help determine how the activities can best be performed (i.e., through dedicated staffing, staff augmentation, shared staff, volunteer workgroups, or a vendor contract), or if a scope change is warranted. IOWA E-HEALTH STRATEGIC AND OPERATIONAL PLAN (JUNE 2012) 98

The comprehensive Project Plan provides a detailed schedule and a work breakdown structure among stakeholders including IDPH, Iowa Medicaid, other state agencies, the vendor community, and the e-health Executive Committee, Advisory Council, and workgroups. Strategy 8.1.1: Establish and provide leadership and supervision to an Office of Health IT in Iowa Department of Public Health to execute and manage Iowa e-health activities. The Office of Health IT has been established within IDPH and will be responsible for the day-today operations and long-term planning for the statewide HIE. The following diagram illustrates the position of the Office of Health IT within a condensed IDPH table of organization. Diagram 8.1.1a: Table of Organization The Office of Health IT will oversee Iowa s state HIE cooperative agreement with ONC and direct the use of the funds for HIE planning and implementation. The Office of Health IT will include seven full-time employees dedicated to Iowa e-health and the statewide HIE. This includes: 6 7 State HIT (health IT) Coordinator: Provides high-level coordination across state government and with the Iowa e-health Executive Committee, Advisory Council, and other stakeholders; coordinates with ONC, National Governor s Association, and other federal partners; and collaborates with Iowa Medicaid and the Iowa Regional Extension Center. 8 Program Manager: Manages all day-to-day operations of Iowa e-health; provides functional oversight to the Office of Health IT staff; and coordinates activities of the e-health Executive Committee, Advisory Council, and workgroups. 1 Communication Coordinator: Provides staffing and research activities for Iowa e-health workgroups (e.g., Communication and Outreach); coordinates communication and outreach activities; develops requests for proposals; and monitors vendor activities. 10 Evaluation Coordinator: Provides staffing and research activities for Iowa e-health workgroups (e.g., Evaluation); coordinates assessment and evaluation activities; develops requests for proposals; and monitors vendor activities. 8 9 Program Assistant: Provides administrative support for the Office of Health IT and the e- Health Executive Committee and Advisory Council; monitors contracts and invoices; manages the Iowa e-health budget and prepares and submits financial reports. 3 4 5 IT Project Manager: The liaison between the Iowa e-health stakeholders and the IT vendor(s), assuring that business and technical requirements are met; monitors adherence to federal and state health IT standards. 2 3 Provider Relations Specialist: c Provides first-tier support for HIE user questions and issues with the master patient index and record locator service; collaborates with the Iowa REC and HIE IOWA E-HEALTH STRATEGIC AND OPERATIONAL PLAN (JUNE 2012) 99

vendor to develop and coordinate HIE training and educational materials and add new providers to the statewide HIE. The Office of Health IT will also leverage the expertise of other employees within IDPH as needed on a part-time basis. This may include, but is not limited to, technology staff within the Bureau of Information Management, the IDPH legislative liaison, and the IDPH public information officers. IDPH will also ask staff from the various public health programs to participate in Iowa e-health activities as necessary to ensure integration of all HIE related projects within state and local public health. Strategy 8.1.2: Establish vendor contracts to execute Iowa e-health activities. Requests for proposals (RFPs) will be developed to select qualified vendors to execute project activities. RFPs will allow IDPH to distribute project activities to private and nonprofit organizations that already offer services similar to those needed to fulfill health IT goals in Iowa. IDPH staff will oversee the RFP process and manage contracts to ensure compliance with all requirements. Contracts include but may not be limited to: 6 Consulting services to Iowa e-health: Provides consulting, facilitation, research, and implementation support services based on expertise in clinical practice, infrastructure, finance, privacy and security, and governance. Assessment: 10 Coordinates and performs baseline environmental scans for Iowa e-health. Legal Counsel: 5 7 Advises the Office of Health IT and the e-health Executive Committee and Advisory Council on legal issues related to the planning and implementation of a statewide HIE. 3 4 Statewide HIE: Constructs, tests, and builds the statewide HIE; integrates the statewide HIE with existing information systems as applicable; enables HIE services; and provides technical support. Business Plan: 9 Develops a business and financial sustainability plan for Iowa e-health. 10 Evaluation Plan: Develops an evaluation plan for Iowa e-health and performs evaluation activities. 1 Communication Plan: Develops a statewide communication and outreach campaign plan to effectively educate and inform the primary audiences about Iowa e-health; develops and hosts an Iowa e-health website and produces creative materials. Focus Groups: 1 Facilitates provider focus groups and analyzes information to garner information about provider preferences and perceived barriers of health information technology. Objective 8.2: Provide resources and program management to sustain Iowa e-health goals, services, and activities. Once the statewide HIE has been established and ongoing operations of HIE services are supported through the statewide HIE, Iowa e-health will be prepared to move from an implementation phase to ongoing, sustainable operations. Annual strategic planning (see Goal 10) and annual reviews and revisions to the Iowa e-health business plan (see Goal 9) and evaluation plan (see Goal 10) will provide an opportunity to evaluate Iowa e-health activities and set the course for future expectations and service delivery. To ensure Iowa operates in an efficient and sustainable manner, there are certain operating procedures (e.g., vendor management, financial management, project management) and expenses that may need to be reevaluated as the program enters ongoing operations. The expectations of the Office of Health IT and vendor contracts described in Objective 8.1 will also evolve to support operational needs. By planning for these changes early in the planning process, Iowa e-health can create a seamless transition between implementation and ongoing operations. Strategy 8.2.1: Prepare for business and technical operations throughout the statewide HIE lifecycle. The stages of the statewide HIE operations include planning, implementation, and sustainability. It is important to establish accountability and transition strategies within all vendor contracts to allow Iowa e- Health to adapt to the changing lifecycle. It is also important to have a clear method to monitor progress IOWA E-HEALTH STRATEGIC AND OPERATIONAL PLAN (JUNE 2012) 100

towards Iowa e-health goals and to monitor a risk management plan (see Project Risk Assessment) to understand and mitigate lifecycle risks. IOWA E-HEALTH STRATEGIC AND OPERATIONAL PLAN (JUNE 2012) 101

Goal 9: Secure financial resources to develop and sustain a statewide HIE Health information exchanges (HIEs) have significant start up and ongoing funding needs. According to the e-health Initiative's 2008 Annual Survey of Health Information Exchange at the State and Local Levels, 79 percent of respondents cited securing upfront funding as a significant challenge for HIE initiatives. 29 It will take many resources to accomplish all the goals and objectives of Iowa e-health, including, but not limited to, providing the technical support necessary to maintain a statewide HIE. Some of the largest expenses will include: Hardware and software; Communications; Technical support for providers; Legal expertise to safeguard privacy and security; Technical and project management support for pilot projects; and Resources for overall management and coordination of activities (start-up and ongoing operations). Through the process of preparing Iowa s application for the Office of the National Coordinator s (ONC) State HIE Cooperative Agreement Program, Iowa e-health prepared a preliminary four-year budget of approximately $25 million. Estimates for these expenses were gathered through request for information processes, experiences shared by Iowa s stakeholder organizations, and cost and budget information available from other state HIEs. As Iowa e-health moves forward from planning to implementation, additional work needs to be done to identify a more granular breakdown of funding needs for the core HIE infrastructure (see Goal 3), foundational and advanced HIE services (see Goal 4), and business and technical operations (see Goal 8). The budget will also need to reflect a required match for some funding sources. For example, the Centers for Medicare and Medicaid Services (CMS) requires a 10 percent match through their 90/10 funding stream to Medicaid agencies and the ONC State HIE Cooperative Agreement has a graduated match of 10 percent in fiscal year 2011 (October 2010-September 2011), 30 percent match in fiscal year 2012 (October 2011-September 2012), and 67 percent in fiscal year 2013 and 2014 (October 2012-March 2014). The process to secure financial resources for Iowa e-health will be strategic to support access to the statewide HIE for the maximum number of stakeholders. Objective 9.1: Establish a business and financial sustainability plan A business plan is necessary to assist Iowa e-health in planning and implementing a statewide HIE. The business plan will provide the blueprint for the statewide HIE implementation. Specifically, the business plan will serve to: 1) assess the potential market value of different HIE services; 2) provide financial projections necessary to develop and maintain a comprehensive Iowa e-health budget; and 3) identify financing strategies appropriate for Iowa. Assess the potential market value of different HIE services The e-health Executive Committee has made the determination to develop a hybrid infrastructure model (see Goal 3) and offer four core HIE services (i.e., continuity of care document, laboratory results, immunization history, and medication history; see Goal 4). As Iowa e-health considers additional HIE services, the e-health Executive Committee will need to analyze the cost-benefit analysis of each potential exchange service to determine if the service can be sustainable. Iowa e-health can use the developed business plan and associated financial modeling tools to develop a plan for statewide HIE service offerings that clearly outlines associated costs, funding needs, and corresponding funding strategies and proposals. The same tools can be used to inform plans for statewide HIE enhancements and upgrades. 29 ehealth Initiative, Fifth Annual Survey of Health Information Exchange At the State and Local Levels, Overview of 2008 Findings, September 2008. IOWA E-HEALTH STRATEGIC AND OPERATIONAL PLAN (JUNE 2012) 102

Provide financial projections necessary to develop and maintain a comprehensive budget The business plan will provide financial projections and pro forma documents to support development of a comprehensive Iowa e-health budget. This will include costs for initial HIE development, business and technical operations, additional HIE services, and system upgrades and enhancements. The financial projections will address depreciation and also include a minimum cash threshold needed in a revolving budget fund to ensure sustainable operations in varying economic conditions. Identify financing strategies appropriate for Iowa The business plan will describe the various financing strategies that are appropriate at different stages of the statewide HIE lifecycle (i.e., financing strategies in the first two years of implementation may be different than the financing strategies in subsequent years once the statewide HIE has been established and is operational and widely accessible). Existing state HIEs have struggled to find sustainable business models. Funding strategies used by other HIEs include grant funding, private contribution, subscription and/or transaction fees for HIE users, cost-sharing with existing HIEs, a health insurance claim tax, a bed tax, and/or state budget line items. The business plan will be helpful in identifying the fee structure and mix of funding streams that is appropriate for Iowa. Strategy 9.1.1: Through a Request for Proposal, procure a business plan vendor to develop business and financial models. The business plan vendor will work closely with the IDPH Office of Health IT staff and all Iowa e- Health stakeholders to develop a business plan that is appropriate for Iowa. Once finalized and approved by the e-health Executive Committee, the business plan will be submitted to ONC for approval. The business plan will be reviewed regularly and updated annually. Public and private stakeholders agree there is value in Iowa e-health, the statewide collaborative effort to increase adoption and use of health information technology (health IT). The tools and services provided through Iowa e-health and more specifically the statewide health information exchange (HIE) initiative known as the Iowa Health Information Network (IHIN) have the potential to help improve quality of health care, assure patient safety, and increase efficiency in health care delivery. The Iowa e-health Business and Financial Sustainability Plan is a major milestone for Iowa, which provides a foundation and clear path to a sustainable business model for the IHIN. The key components of a business plan are outlined throughout this document, including: market, customer, value, product, price, promotion, budget, financing and risk. The plan illustrates value cases for various stakeholder types, projects expenditures, and models various revenue strategies most appropriate for Iowa. A successful business and financial sustainability plan will instill trust among Iowa s stakeholders that the proposed plan is realistic, equitable, fair, and sustainable. Key value cases illustrated in the plan include: Providers Continuity of care Efficiencies and cost savings Reduction in medical errors Payers Improved health outcomes Reduced claims payments Lower administrative costs Consumers Continuity of care Improved health care outcomes Access to health information The Iowa e-health Business and Financial Sustainability Plan was developed by the Business and Financial Sustainability Plan Workgroup in 2011 (established in House File 649), approved by the Executive Committee and Advisory Council, and approved by the State Board of Health. The Iowa e- Health Business and Financial Sustainability Plan is provided as a supplemental plan to this Strategic and Operational Plan. Objective 9.2: Execute financial strategies to develop, implement, and maintain a statewide HIE. As described in Objective 9.1, there are a variety of funding strategies that can be used by HIEs to sustain business and technical operations. These strategies could include grant funding, private contributions, subscription and/or transaction fees, a tax, and/or state budget line items. Currently, IOWA E-HEALTH STRATEGIC AND OPERATIONAL PLAN (JUNE 2012) 103

funding for Iowa e-health primarily comes through grant funding; however, Iowa e-health recognizes this grant funding is not sustainable. Strategy 9.2.1: Apply for American Recovering and Reinvestment Act (ARRA) funding available through ONC s State HIE Cooperative Agreement Program. Through the State HIE Cooperative Agreement Program available through ONC, Iowa is eligible for $8,375,000. This amount was based on a predetermined formula and represents approximately onethird of the necessary funding to develop a statewide HIE. The funding is available to Iowa through three funding streams: 1) planning; 2) intra-state; and 3) inter-state. Until Iowa has an approved strategic and operational plan, Iowa e-health only has access to the planning funding stream ($837,500). Upon approval of a strategic and operational plan, Iowa e-health will be able to access the intra-state funding stream ($2,950,181) and inter-state funding stream ($4,587,319). Any money not used in the planning funding stream will be carried over to the inter-state funding stream. The State HIE Cooperative Agreement Program will be the first major source of capital needed to advance Iowa e-health. The majority of the funding received through the cooperative agreement will directly support the development and implementation of the statewide HIE infrastructure. Positions will be funded to coordinate project activities with the vendor community, private stakeholders, other state agencies, and ONC. This approach leverages the expertise of the vendor community for critical tasks, such as the statewide HIE infrastructure, but also provides dedicated state-level support to hold vendors accountable, manage various components of the project, promote alignment between broader health reform goals and population health, and ensure compliance with all ONC requirements. Strategy 9.2.2: Leverage Iowa Department of Public Health (IDPH) and other state funding resources. When Iowa e-health was established pursuant to 2008 health reform legislation in Iowa, very little funding was appropriated for the mandated planning and implementation activities. Due to a state government hiring freeze, IDPH had to identify shared staff and programmatic resources to help launch e-health planning activities. After being impacted by two across-the-board budget cuts, the fiscal year 2011 (July 1, 2010 June 30, 2011) appropriation for Iowa e-health is only able to fund one of the full-time employees within the Office of Health IT. Remaining state appropriation funds can be used to support small aspects of Iowa e-health, but the current appropriation is not substantial enough to support critical activities such as the statewide HIE infrastructure. Strategy 9.2.3: Working through Iowa Medicaid, seek planning and implementation funding available through CMS. IDPH and Iowa Medicaid are harmonizing health IT planning activities and trying to align financial resources to support HIE planning and implementation (see Objective 6.1). In Fall 2009, Iowa Medicaid submitted an Advance Planning Document (APD) to CMS to request 90/10 funding for Iowa Medicaid HIT planning (i.e., CMS would provide 90 percent funding for a submitted budget and the state would provide the remaining 10 percent). A portion of their funding request supported planning funds for Iowa e-health. Strategy 9.2.4: Leverage financial resources from HIE participants, in addition to state and federal funding, to ensure sustainability for Iowa e-health, the statewide HIE and HIE services. Additional financing strategies will be formulated and executed based on the approved business and financial sustainability plan. Participant resources could include license and/or participation fees; transaction fees; revenue generating HIE services; financial support and contributions from third party payers; and other grant programs. Objective 9.3: Be fiscally responsible with all funding revenues and expenditures. Transparency is important to demonstrate accountability and to maintain trust among public and private stakeholders. With the IDPH Office of Health IT currently providing project management for day-to-day Iowa e-health operations, all budget and finance policies, procedures, and controls are subject to state government IOWA E-HEALTH STRATEGIC AND OPERATIONAL PLAN (JUNE 2012) 104

processes for maintaining compliance with Generally Accepted Accounting Principles (GAAP), the United States Office of Management and Budget (OMB), and open records and public meetings procedures. A key provision of the ARRA is regular public reporting on the status of projects, spending, and job creation and retention. The Iowa Governor s Office is required to report the following to each federal agency that grants funds to Iowa: 1) how the funds will be used; 2) whether the funds were used as intended; 3) the number of jobs created/sustained by the funds; and 4) non-federal funding sources used to complete projects. This reporting will also include announcements for grant competitions, allocations of formula grants, and awards of competitive grants. Iowa has formed an ARRA implementation working group comprised of representatives of two dozen state agencies to establish a coordinated process to (a) report on stimulus funds available to Iowa through various federal grants and (b) track the federal requirements and deadlines associated with the grants. IDPH will use these established tools to make regular reports to the Governor s Office to submit to applicable federal agencies. As vendor contracts are established to perform various functions or activities related to HIE planning and implementation, reporting requirements will be outlined within the contract. Beyond standard monthly progress reports, contracts will require vendors to report the number of jobs created or retained as a result of the contract award. This will demonstrate the economic impact of ARRA in the vendor community. Strategy 9.3.1: The Office of Health IT manages the comprehensive e-health budget. As the applicant for the State HIE Cooperative Agreement Program, IDPH s Office of Health IT took the lead in preparing an initial budget for Iowa e-health. The budget was developed in collaboration with all Iowa e-health workgroups and the e-health Executive Committee and Advisory Council. Estimates for these expenses were gathered through request for information processes, experiences shared by Iowa s stakeholder organizations, and cost and budget information available from other state HIEs. As vendor contracts are executed and the business plan is developed, Iowa e-health will be able to refine budget estimates to provide a more precise budget that describes start-up and ongoing funding needs for day-to-day business and technical operations and planned upgrades and enhancements. Strategy 9.3.2: Seek opportunities for fiscal efficiencies and cost savings. To successfully manage a program that has large budget demands and limited financial resources, Iowa e-health must be very strategic and creative with regard to identifying opportunities for fiscal efficiencies. Since inception, Iowa e-health has been successful in leveraging volunteer resources and stretching the limited state budget allocation to engage in e- Health planning activities. Iowa e-health was established through volunteer participation by Iowa stakeholders. The momentum and willingness of stakeholder organizations to come together since 2009, providing in-kind contributions of staff time, has been exceptional. Stakeholder contributions are critical for meeting the match requirements of ONC for the State HIE Cooperative Agreement Program. Their contributions allow monetary resources to be reallocated for key implementation activities (e.g., the statewide HIE infrastructure) which will require vendor contracts. Iowa e-health volunteer workgroups have been creative with regard to devising options for addressing e-health needs with little or no financial outlay. For example, rather than establish a contract to develop a program brand and identity (see Goal 1), Iowa e-health invited interested college and university programs to propose logos and program names for Iowa e-health as part of a hands-on classroom project. Iowa e-health also uses the Iowa Attorney General s Office for legal and policy support rather than paying for outside legal counsel. Additionally, with the current state-led governance model, e-health Executive Committee members are covered by state liability insurance, which prevents the need to allocate monetary resources for liability insurance. As much as possible, Iowa e-health will use existing shared services (e.g., IT systems and data repositories) to reduce duplication of effort and develop new or enhanced shared services that can be leveraged again in the future (e.g., provider directory). IOWA E-HEALTH STRATEGIC AND OPERATIONAL PLAN (JUNE 2012) 105

To establish vendor contracts that provide the best value for Iowa e-health, the Office of Health IT will follow guidelines for competitive procurement processes as established by the Iowa Code. The benefits of competitive procurement include: increased participation by qualified firms, lower prices, higher quality and innovation of proposals, and decreased conflict of interest concerns. (To view Iowa s service contracting guide, visit http://das.gse.iowa.gov/procurement/scg.html.) Objective 9.4: Hold vendors accountable to achieve deliverables. Vendor compliance is integral to the progress of the implementation and continued integration with FOA requirements and ONC/meaningful use timelines. Iowa e-health will rely on external vendor contracts to execute many project activities. Throughout planning and implementation Iowa e-health must hold vendors accountable for the deliverables outlined in the vendor contract(s). Several ways to hold vendors accountable include: 1) prepare milestone-based contracts with an incentive or disincentive for performance; 2) establish a mechanism to end or transfer a contract as necessary, as part of a risk management plan; 3) maintain regular communication with the vendors to ensure progress with agreed upon deliverables; and 4) reconcile deliverables with each contract prior to processing payment for an invoice. The Office of Health IT will closely monitor all contracts, timelines, and deliverables to hold vendors accountable. They will provide dedicated project management to actively manage vendor contracts and prevent timelines and deliverables from falling off track. Strategy 9.4.1: Utilize full-time IT Project Managers to monitor all HIE deliverables. Iowa e-health has a full-time IT Project Manager dedicated to ensuring vendor compliance. Likewise, the HIE vendor (ACS) also has in place a full-time Project Manager dedicated to the statewide HIE. Weekly in-person meetings will be held to ensure that timelines are on track and that the statewide HIE vendor is meeting contractual requirements. The Iowa e-health IT Project Manager utilizes a project tracking document, which is distributed to team members on a weekly basis to communicate the status of the statewide HIE development and implementation. Strategy 9.4.2: In all vendor contracts, use contract terms and conditions approved by the Attorney General s Office. Iowa e-health uses contract general terms and conditions to hold vendors accountable to the timely and successful completion of all deliverables. Specific deliverables are outlined in each vendor s Statement of Work, along with vendor expectations to meet the deliverables. Weekly status reports, which include any potential delays in deliverables, are submitted by the HIE vendor to Iowa e-health. Strategy 9.4.3: Establish milestone based contracts. To help ensure vendor accountability, contract payments are made to vendors only upon completion of each deliverable. Additionally, IDPH withholds 10% of the total cost until the end of the contract term. These funds are released only if deliverables have been deemed timely and accurate, which helps ensure the successful completion of work. Iowa e-health is aware of the potential risks created by vendor delays and unfulfilled commitments. However, IDPH has a great deal of experience holding vendors accountable and working to complete a wide-variety of IT projects. Using this experience and lessons learned from other states, Iowa e-health will work to minimize these potential risks and develop contingencies to ensure the sustainability of the statewide HIE. The actual language from the IDPH general terms and conditions, which will be included in the HIE vendor (ACS) contract, is as follows: Compensation In consideration of Contractor (ACS) providing the Department (IDPH) with the Deliverables in accordance with the terms and conditions of this Agreement, Contractor shall be entitled to receive the fees or other compensation associated with such Deliverables as specified in Schedule A, subject to all terms and conditions of this IOWA E-HEALTH STRATEGIC AND OPERATIONAL PLAN (JUNE 2012) 106

Agreement, including, without limitation Section 5.2 (Invoices) and Section 5.3 (Retention). The Department shall not be obligated to pay any other compensation, fees, expenses, costs, charges or other amounts to Contractor in connection with this Agreement. All fees and compensation payable hereunder to Contractor are fixed, not-to-exceed amounts, and Contractor shall not be compensated on a time and materials basis. It is expressly understood and agreed that in no event will the total fees or compensation to be paid hereunder for the initial and all renewal terms (if exercised) exceed the sum of XXX. Contractor is not entitled to payment for any Deliverables provided under this Agreement if the Department reasonably determines that any Deliverables or services have not been satisfactorily or completely delivered or performed, or that any Deliverable fails to meet or conform to any applicable Specifications. No payment, including final payment, shall be construed as acceptance of any Deliverables with Deficiencies or incomplete work, and Contractor shall remain responsible for full performance in strict compliance with the terms and conditions of this Agreement. Contractor s acceptance of the last payment from the Department shall operate as a release of any and all claims related to this Agreement that Contractor may have or be capable of asserting against the Department or the State. No advance payments shall be made for any Deliverables provided by Contractor pursuant to this Agreement. Invoices Upon written receipt of notice of Acceptance from the Department with respect to one or more Deliverables, Contractor shall submit an invoice to the Department requesting payment of the fees or other compensation specified in Schedule A associated with [such Deliverable(s)], less the Retained Amount(s) to be withheld in accordance with Section 5.3. All invoices submitted by Contractor shall comply with all applicable rules concerning payment of such fees, charges or other claims and shall contain appropriate documentation as necessary to support the fees or charges included on the invoice and all information reasonably requested by the Department. The Department shall pay all approved invoices in arrears and in conformance with Iowa Code section 8A.514 and 11 Iowa Admin. Code 41.1(2). The Department may pay in less than sixty (60) days, as provided in Iowa Code section 8A.514. However, an election to pay in less than sixty (60) days shall not act as an implied waiver of Iowa Code section 8A.514. Notwithstanding anything herein to the contrary, the Department shall have the right to dispute any invoice submitted for payment and withhold payment of any disputed amount if the Department believes the invoice is inaccurate or incorrect in any way. Retention To secure Contractor s performance under this Agreement, the Department shall retain 10% of the fees or other compensation associated with each Deliverable and payable hereunder shall be the Retained Amounts. The Retained Amounts shall be payable upon the Department s delivery of written notice of Final Acceptance to Contractor, subject to the terms and conditions hereof. Objective 9.5: Implement financial policies, procedures and controls as required by the state HIE cooperative agreement program. Strategy 9.5.1: Comply with financial policies established by the State of Iowa. As a state agency, IDPH adheres to the financial policies and procedures established by the Iowa Department of Administrative Services, which provide the financial controls for state government. These policies and procedures meet or exceed the requirements of the State HIE Cooperative Agreement Program. IOWA E-HEALTH STRATEGIC AND OPERATIONAL PLAN (JUNE 2012) 107

Strategy 9.5.2: Submit all required financial reports. As required by ONC, IDPH prepares and submits semi-annual progress reports, as well as annual financial status reports within 90 days of the end of each budget period. The IDPH Office of Health IT and Bureau of Finance have scheduled in advance all reporting due dates. Additionally, IDPH complies with quarterly financial and programmatic reporting as required by the American Recovery and Reinvestment Act (ARRA). All ARRA reporting by IDPH is coordinated through a single office to ensure requirements are met. To fully adhere with all requirements, IDPH retains all programmatic records, supporting documents, statistical records, and all other required records. Such records are permanently maintained according to the federal rules for each respective program after annual Financial Status Reports are submitted. Strategy 9.5.3: Establish financial policies, procedures, and controls in all vendor contracts. To ensure the success of the statewide HIE, Iowa e-health has established deliverable-based vendor contracts. Financial policies, procedures, and controls are incorporated into all vendor contracts. These controls include regular vendor meetings, monthly progress reports, and vendor reimbursement approvals occurring only after a contract deliverable is received and approved by the IDPH Office of Health IT. The IDPH Bureau of Finance assures the reimbursement meets the requirements established by state law and policies, federal OMB and State HIE Cooperative Agreement Program contractual requirements prior to issuing payment. Additionally, state and independent auditors review the fiscal activities of all IDPH contracts. IOWA E-HEALTH STRATEGIC AND OPERATIONAL PLAN (JUNE 2012) 108

Goal 10: Monitor and evaluate health IT progress and outcomes Evaluation is a critical activity that helps a program understand their current state. By gathering baseline data and continuously monitoring changes, evaluation can provide important lessons learned to help shape future programs and enable continuous improvements. Objective 10.1: Conduct a baseline environmental scan of health IT in Iowa. In 2009-2010, Iowa conducted an environmental scan of providers from a variety of care settings. These assessments included: hospitals, provider practices and clinics, home health care providers, long-term care providers, laboratories, radiology centers, and providers in various other care settings in the state of Iowa. The assessments were intended to gather information about a range of health IT topics including: 1) provider health IT capabilities and preparedness to participate in a statewide HIE; 2) preferences for types of high value clinical data exchange or HIE services; and 3) benefits and barriers to health IT adoption. Information from each assessment was analyzed and reported. A summary of the results can be found in the Environmental Scan section of this Strategic and Operational Plan. Contact information collected within the assessments may be used to develop the state-level provider contact database and to provide follow up assistance to providers. Strategy 10.1.1: Partner with Iowa Hospital Association (IHA) to conduct an assessment of Iowa hospitals. IHA conducts regular assessments with its membership. By adding a few key e-health relevant questions, Iowa e-health used the findings to provide baseline assessment data and to further define the statewide HIE implementation schedule (See Goal 3). Strategy 10.1.2: Partner with a university research center to develop assessment questions, conduct the assessment with Iowa providers, and analyze assessment results. In 2010, Iowa e-health partnered with two state universities to conduct baseline assessments. These assessments included: Provider practices and clinics; Home health agencies; Laboratories; Pharmacies; Radiology centers; and Long-term care facilities; For each assessment, Iowa e-health used stakeholder resources to develop appropriate sampling frames, developed and sought feedback on applicable assessment questions, worked with stakeholders to publicize the assessments, finalized and cleaned the datasets, and prepared appropriate assessment reports. Findings from the assessments are being used to update and further define the HIE implementation schedule (see Goal 3). If time and funding allows, it would also be nice to conduct assessments with: long-term acute facilities, ambulatory surgery centers, end stage renal disease centers, hospice, local public health agencies, psychiatric medical institutions for children, intermediate care facilities, residential (mental retardation, mental illness) facilities, ambulances, community mental health centers, behavioral and substance abuse centers, and occupational health centers. IOWA E-HEALTH STRATEGIC AND OPERATIONAL PLAN (JUNE 2012) 109

Strategy 10.1.3: Partner with broadband projects to conduct an assessment of broadband network capacity. Iowa needs to analyze broadband connectivity and capacity to determine if there are geographic areas with limited network connectivity. A broadband mapping effort would assist Iowa in understanding whether some locations have insufficient network capacity for data exchange. Limited network connectivity could hinder provider use of the statewide HIE, or result in unacceptable response times when attempting to use the statewide HIE. There are currently two Federal Communications Commission broadband projects in Iowa (see Objective 3.2), and other broadband expansion projects may be initiated in the future. Strategy 10.1.4: Use assessment results to create a library of metrics to be used as a foundation for a broader e-health evaluation plan. A library of health IT metrics can be used for future studies and the broader e-health evaluation program. The library will consist of important items to monitor over time to measure progress in health IT in various care settings. This library may be a subset of the variables used in the baseline assessments and should contain some updated or improved assessment questions for future use. Objective 10.2: Develop an evaluation plan to determine whether changes in health care quality, safety, efficiency, and population health have occurred as a result of health IT. Iowa must systematically identify and gather applicable metrics to evaluate the impact of health IT adoption and use of a statewide health information exchange. There are several types of metrics that will be important to consider. These include: Metrics established by ONC: These measures will be provided by ONC and will relate to the following domains: governance, finance, technical infrastructure, business and technical operations, and legal/policy. Metrics may indicate HIE participation levels and types of clinical data exchanged; quality metrics aligned with meaningful use objectives; and efficiency metrics, such as redundant testing and avoidable admissions. Metrics to monitor health outcomes: These measures will illustrate the potential impact of health IT on population health and likely improvements in specific health outcomes. Metrics may indicate changes in immunization rates, well-child visits, managed outcome and treatment rates for chronic diseases, and adverse drug events resulting in hospitalization. Metrics to demonstrate return on investment: These measures will calculate the value of health IT and the statewide HIE to different stakeholders (e.g., hospitals, ambulatory providers, public health, payers, consumers). Metrics may indicate hospital or provider ability to receive meaningful use incentives because of the statewide HIE and improved workflow and efficiency of operations due to statewide HIE. Iowa e-health s 2012 Evaluation Plan is provided as part of this Strategic and Operational Plan s supplemental materials. Strategy 10.2.1: Partner with an evaluation vendor to perform evaluation activities. The evaluation coordinator within the Office of Health IT (see Strategy 8.1.1) will maintain routine metrics and reporting requirements (e.g., Appendix G ONC-Required Performance Measures and Reporting) and also work closely with an outside service provider to perform and monitor evaluation activities. Objective 10.3: Perform comprehensive evaluations of Iowa e-health. Iowa will establish a mechanism to periodically review the services offered through the statewide HIE, obtain feedback from a broad group of stakeholders regarding Iowa e-health, and engage in strategic planning to ensure the potential of the statewide HIE is maximized. This mechanism will help determine: 1) whether Iowa s HIE is successfully meeting its goals and providing value (evaluative); and 2) ensure Iowa s future direction will meet the needs and preferences of stakeholders (strategic planning). IOWA E-HEALTH STRATEGIC AND OPERATIONAL PLAN (JUNE 2012) 110

Strategy 10.3.1: Establish evaluation metrics and tools to gauge customer and stakeholder satisfaction with Iowa e-health services. The IDPH Office of Health IT will routinely collect information and feedback from customers and stakeholders. This may include survey instruments or focus groups to gather feedback. It may be appropriate for an independent evaluation vendor to participate in the collection and analysis of relevant data. The e-health Executive Committee will review customer and stakeholder satisfaction findings annually in a yearly evaluation report, or more frequently as requested by the e-health Executive Committee. Strategy 10.3.2: Engage in annual strategic planning activities. To ensure Iowa s HIE remains focused on meaningful use and realizing the full potential of the statewide HIE to improve the health of Iowans, Iowa must engage in strategic planning to periodically set the course for future service delivery. During the strategic planning session, it will be important to critically examine evaluation data to ascertain progress towards Iowa e-health goals, identify areas in need of improvement, develop strategies to address concerns, examine operational costs to recommend areas for additional or reduced funding, and review services offered through the statewide HIE. IOWA E-HEALTH STRATEGIC AND OPERATIONAL PLAN (JUNE 2012) 111

PROJECT RISK ASSESSMENT As Iowa prepares to implement a plan as important and multifaceted as the Strategic and Operational Plan, it is important to assess any aspects of the environment that could cause Iowa s implementation to suffer or fail. As described in Goal 8 of the Strategic and Operational Plan, Iowa e-health is preparing for business and technical operations throughout the statewide HIE lifecycle. This includes the development of a risk management plan available at http://www.iowaehealth.org/consumer/ehealth/plans.html. The plan is categorized by the five domains established by ONC: Governance, Finance, Legal and Policy, Business and Technical Operations, and Technical Infrastructure. Outlined within the risk management plan are processes, tools and procedures that will be used to manage and control events that could have a negative impact on the statewide HIE. Continuous risk monitoring and management will be provided by the state health IT coordinator and the IDPH Office of Health IT in conjunction with the diverse, public and private stakeholders represented on the e-health Executive Committee, Advisory Council, and workgroups. While there are many challenges ahead, the progressive planning of Iowa e-health stakeholders has resulted in the 2010 Iowa e-health Strategic and Operational Plan. With this Strategic and Operational Plan, Iowa has a resource and foundation to continue pursuing comprehensive implementation of health IT throughout Iowa. Working together, Iowa e-health will improve quality of health care, assure patient safety, and increase efficiency in health care delivery. IOWA E-HEALTH STRATEGIC AND OPERATIONAL PLAN (JUNE 2012) 112

APPENDIX A: Iowa Legislation & Law *Note: The following legislation is the authorizing legislation from 2008. 17 9 DIVISION V 17 10 IOWA HEALTH INFORMATION TECHNOLOGY SYSTEM 17 11 DIVISION XXI 17 12 IOWA HEALTH INFORMATION TECHNOLOGY SYSTEM 17 13 Sec. 23. NEW SECTION. 135.154 DEFINITIONS. 17 14 As used in this division, unless the context otherwise 17 15 requires: 17 16 1. "Board" means the state board of health created 17 17 pursuant to section 136.1. 17 18 2. "Department" means the department of public health. 17 19 3. "Health care professional" means a person who is 17 20 licensed, certified, or otherwise authorized or permitted by 17 21 the law of this state to administer health care in the 17 22 ordinary course of business or in the practice of a 17 23 profession. 17 24 4. "Health information technology" means the application 17 25 of information processing, involving both computer hardware 17 26 and software, that deals with the storage, retrieval, sharing, 17 27 and use of health care information, data, and knowledge for 17 28 communication, decision making, quality, safety, and 17 29 efficiency of clinical practice, and may include but is not 17 30 limited to: 17 31 a. An electronic health record that electronically 17 32 compiles and maintains health information that may be derived 17 33 from multiple sources about the health status of an individual 17 34 and may include a core subset of each care delivery 17 35 organization's electronic medical record such as a continuity 18 1 of care record or a continuity of care document, computerized 18 2 physician order entry, electronic prescribing, or clinical 18 3 decision support. 18 4 b. A personal health record through which an individual 18 5 and any other person authorized by the individual can maintain 18 6 and manage the individual's health information. 18 7 c. An electronic medical record that is used by health 18 8 care professionals to electronically document, monitor, and 18 9 manage health care delivery within a care delivery 18 10 organization, is the legal record of the patient's encounter 18 11 with the care delivery organization, and is owned by the care 18 12 delivery organization. 18 13 d. A computerized provider order entry function that 18 14 permits the electronic ordering of diagnostic and treatment 18 15 services, including prescription drugs. 18 16 e. A decision support function to assist physicians and 18 17 other health care providers in making clinical decisions by 18 18 providing electronic alerts and reminders to improve 18 19 compliance with best practices, promote regular screenings and 18 20 other preventive practices, and facilitate diagnoses and 18 21 treatments. 18 22 f. Tools to allow for the collection, analysis, and 18 23 reporting of information or data on adverse events, the 18 24 quality and efficiency of care, patient satisfaction, and IOWA E-HEALTH STRATEGIC AND OPERATIONAL PLAN (JUNE 2012) 113

18 25 other health care=related performance measures. 18 26 5. "Interoperability" means the ability of two or more 18 27 systems or components to exchange information or data in an 18 28 accurate, effective, secure, and consistent manner and to use 18 29 the information or data that has been exchanged and includes 18 30 but is not limited to: 18 31 a. The capacity to connect to a network for the purpose of 18 32 exchanging information or data with other users. 18 33 b. The ability of a connected, authenticated user to 18 34 demonstrate appropriate permissions to participate in the 18 35 instant transaction over the network. 19 1 c. The capacity of a connected, authenticated user to 19 2 access, transmit, receive, and exchange usable information 19 3 with other users. 19 4 6. "Recognized interoperability standard" means 19 5 interoperability standards recognized by the office of the 19 6 national coordinator for health information technology of the 19 7 United States department of health and human services. 19 8 Sec. 24. NEW SECTION. 135.155 IOWA ELECTRONIC HEALTH == 19 9 PRINCIPLES == GOALS. 19 10 1. Health information technology is rapidly evolving so 19 11 that it can contribute to the goals of improving access to and 19 12 quality of health care, enhancing efficiency, and reducing 19 13 costs. 19 14 2. To be effective, the health information technology 19 15 system shall comply with all of the following principles: 19 16 a. Be patient=centered and market=driven. 19 17 b. Be based on approved standards developed with input 19 18 from all stakeholders. 19 19 c. Protect the privacy of consumers and the security and 19 20 confidentiality of all health information. 19 21 d. Promote interoperability. 19 22 e. Ensure the accuracy, completeness, and uniformity of 19 23 data. 19 24 3. Widespread adoption of health information technology is 19 25 critical to a successful health information technology system 19 26 and is best achieved when all of the following occur: 19 27 a. The market provides a variety of certified products 19 28 from which to choose in order to best fit the needs of the 19 29 user. 19 30 b. The system provides incentives for health care 19 31 professionals to utilize the health information technology and 19 32 provides rewards for any improvement in quality and efficiency 19 33 resulting from such utilization. 19 34 c. The system provides protocols to address critical 19 35 problems. 20 1 d. The system is financed by all who benefit from the 20 2 improved quality, efficiency, savings, and other benefits that 20 3 result from use of health information technology. 20 4 Sec. 25. NEW SECTION. 135.156 ELECTRONIC HEALTH 20 5 INFORMATION == DEPARTMENT DUTIES == ADVISORY COUNCIL == 20 6 EXECUTIVE COMMITTEE. 20 7 1. a. The department shall direct a public and private 20 8 collaborative effort to promote the adoption and use of health 20 9 information technology in this state in order to improve 20 10 health care quality, increase patient safety, reduce health IOWA E-HEALTH STRATEGIC AND OPERATIONAL PLAN (JUNE 2012) 114

20 11 care costs, enhance public health, and empower individuals and 20 12 health care professionals with comprehensive, real=time 20 13 medical information to provide continuity of care and make the 20 14 best health care decisions. The department shall provide 20 15 coordination for the development and implementation of an 20 16 interoperable electronic health records system, telehealth 20 17 expansion efforts, the health information technology 20 18 infrastructure, and other health information technology 20 19 initiatives in this state. The department shall be guided by 20 20 the principles and goals specified in section 135.155. 20 21 b. All health information technology efforts shall 20 22 endeavor to represent the interests and meet the needs of 20 23 consumers and the health care sector, protect the privacy of 20 24 individuals and the confidentiality of individuals' 20 25 information, promote physician best practices, and make 20 26 information easily accessible to the appropriate parties. The 20 27 system developed shall be consumer=driven, flexible, and 20 28 expandable. 20 29 2. a. An electronic health information advisory council 20 30 is established which shall consist of the representatives of 20 31 entities involved in the electronic health records system task 20 32 force established pursuant to section 217.41A, Code 2007, a 20 33 pharmacist, a licensed practicing physician, a consumer who is 20 34 a member of the state board of health, a representative of the 20 35 state's Medicare quality improvement organization, the 21 1 executive director of the Iowa communications network, a 21 2 representative of the private telecommunications industry, a 21 3 representative of the Iowa collaborative safety net provider 21 4 network created in section 135.153, a nurse informaticist from 21 5 the university of Iowa, and any other members the department 21 6 or executive committee of the advisory council determines 21 7 necessary and appoints to assist the department or executive 21 8 committee at various stages of development of the electronic 21 9 health information system. Executive branch agencies shall 21 10 also be included as necessary to assist in the duties of the 21 11 department and the executive committee. Public members of the 21 12 advisory council shall receive reimbursement for actual 21 13 expenses incurred while serving in their official capacity 21 14 only if they are not eligible for reimbursement by the 21 15 organization that they represent. Any legislative members 21 16 shall be paid the per diem and expenses specified in section 21 17 2.10. 21 18 b. An executive committee of the electronic health 21 19 information advisory council is established. Members of the 21 20 executive committee of the advisory council shall receive 21 21 reimbursement for actual expenses incurred while serving in 21 22 their official capacity only if they are not eligible for 21 23 reimbursement by the organization that they represent. The 21 24 executive committee shall consist of the following members: 21 25 (1) Three members, each of whom is the chief information 21 26 officer of one of the three largest private health care 21 27 systems in the state. 21 28 (2) One member who is the chief information officer of the 21 29 university of Iowa hospitals and clinics, or the chief 21 30 information officer's designee, selected by the director of 21 31 the university of Iowa hospitals and clinics. IOWA E-HEALTH STRATEGIC AND OPERATIONAL PLAN (JUNE 2012) 115

21 32 (3) One member who is a representative of a rural hospital 21 33 who is a member of the Iowa hospital association, selected by 21 34 the Iowa hospital association. 21 35 (4) One member who is a consumer member of the state board 22 1 of health, selected by the state board of health. 22 2 (5) One member who is a licensed practicing physician, 22 3 selected by the Iowa medical society. 22 4 (6) One member who is licensed to practice nursing, 22 5 selected by the Iowa nurses association. 22 6 (7) One representative of an insurance carrier selected by 22 7 the federation of Iowa insurers. 22 8 3. The executive committee, with the technical assistance 22 9 of the advisory council and the support of the department 22 10 shall do all of the following: 22 11 a. Develop a statewide health information technology plan 22 12 by July 1, 2009. In developing the plan, the executive 22 13 committee shall seek the input of providers, payers, and 22 14 consumers. Standards and policies developed for the plan 22 15 shall promote and be consistent with national standards 22 16 developed by the office of the national coordinator for health 22 17 information technology of the United States department of 22 18 health and human services and shall address or provide for all 22 19 of the following: 22 20 (1) The effective, efficient, statewide use of electronic 22 21 health information in patient care, health care policymaking, 22 22 clinical research, health care financing, and continuous 22 23 quality improvement. The executive committee shall recommend 22 24 requirements for interoperable electronic health records in 22 25 this state including a recognized interoperability standard. 22 26 (2) Education of the public and health care sector about 22 27 the value of health information technology in improving 22 28 patient care, and methods to promote increased support and 22 29 collaboration of state and local public health agencies, 22 30 health care professionals, and consumers in health information 22 31 technology initiatives. 22 32 (3) Standards for the exchange of health care information. 22 33 (4) Policies relating to the protection of privacy of 22 34 patients and the security and confidentiality of patient 22 35 information. 23 1 (5) Policies relating to information ownership. 23 2 (6) Policies relating to governance of the various facets 23 3 of the health information technology system. 23 4 (7) A single patient identifier or alternative mechanism 23 5 to share secure patient information. If no alternative 23 6 mechanism is acceptable to the executive committee, all health 23 7 care professionals shall utilize the mechanism selected by the 23 8 executive committee by July 1, 2010. 23 9 (8) A standard continuity of care record and other issues 23 10 related to the content of electronic transmissions. All 23 11 health care professionals shall utilize the standard 23 12 continuity of care record by July 1, 2010. 23 13 (9) Requirements for electronic prescribing. 23 14 (10) Economic incentives and support to facilitate 23 15 participation in an interoperable system by health care 23 16 professionals. 23 17 b. Identify existing and potential health information IOWA E-HEALTH STRATEGIC AND OPERATIONAL PLAN (JUNE 2012) 116

23 18 technology efforts in this state, regionally, and nationally, 23 19 and integrate existing efforts to avoid incompatibility 23 20 between efforts and avoid duplication. 23 21 c. Coordinate public and private efforts to provide the 23 22 network backbone infrastructure for the health information 23 23 technology system. In coordinating these efforts, the 23 24 executive committee shall do all of the following: 23 25 (1) Develop policies to effectuate the logical 23 26 cost=effective usage of and access to the state=owned network, 23 27 and support of telecommunication carrier products, where 23 28 applicable. 23 29 (2) Consult with the Iowa communications network, private 23 30 fiberoptic networks, and any other communications entity to 23 31 seek collaboration, avoid duplication, and leverage 23 32 opportunities in developing a network backbone. 23 33 (3) Establish protocols to ensure compliance with any 23 34 applicable federal standards. 23 35 (4) Determine costs for accessing the network at a level 24 1 that provides sufficient funding for the network. 24 2 d. Promote the use of telemedicine. 24 3 (1) Examine existing barriers to the use of telemedicine 24 4 and make recommendations for eliminating these barriers. 24 5 (2) Examine the most efficient and effective systems of 24 6 technology for use and make recommendations based on the 24 7 findings. 24 8 e. Address the workforce needs generated by increased use 24 9 of health information technology. 24 10 f. Recommend rules to be adopted in accordance with 24 11 chapter 17A to implement all aspects of the statewide health 24 12 information technology plan and the network. 24 13 g. Coordinate, monitor, and evaluate the adoption, use, 24 14 interoperability, and efficiencies of the various facets of 24 15 health information technology in this state. 24 16 h. Seek and apply for any federal or private funding to 24 17 assist in the implementation and support of the health 24 18 information technology system and make recommendations for 24 19 funding mechanisms for the ongoing development and maintenance 24 20 costs of the health information technology system. 24 21 i. Identify state laws and rules that present barriers to 24 22 the development of the health information technology system 24 23 and recommend any changes to the governor and the general 24 24 assembly. 24 25 4. Recommendations and other activities resulting from the 24 26 work of the department or the executive committee shall be 24 27 presented to the board for action or implementation. 24 28 Sec. 26. Section 8D.13, Code 2007, is amended by adding 24 29 the following new subsection: 24 30 NEW SUBSECTION. 20. Access shall be offered to the Iowa 24 31 hospital association only for the purposes of collection, 24 32 maintenance, and dissemination of health and financial data 24 33 for hospitals and for hospital education services. The Iowa 24 34 hospital association shall be responsible for all costs 24 35 associated with becoming part of the network, as determined by 25 1 the commission. 25 2 Sec. 27. Section 136.3, Code 2007, is amended by adding 25 3 the following new subsection: IOWA E-HEALTH STRATEGIC AND OPERATIONAL PLAN (JUNE 2012) 117

25 4 NEW SUBSECTION. 11. Perform those duties authorized 25 5 pursuant to section 135.156. 25 6 Sec. 28. Section 217.41A, Code 2007, is repealed. 25 7 Sec. 29. IOWA HEALTH INFORMATION TECHNOLOGY SYSTEM == 25 8 APPROPRIATION. There is appropriated from the general fund of 25 9 the state to the department of public health for the fiscal 25 10 year beginning July 1, 2008, and ending June 30, 2009, the 25 11 following amount, or so much thereof as is necessary, for the 25 12 purpose designated: 25 13 For administration of the Iowa health information 25 14 technology system, and for not more than the following 25 15 full=time equivalent positions: 25 16... $ 190,600 25 17... FTEs 2.00 IOWA E-HEALTH STRATEGIC AND OPERATIONAL PLAN (JUNE 2012) 118

*Note: The following legislation is from 2012 (SF 2318) SENATE FILE BY COMMITTEE ON WAYS AND MEANS (SUCCESSOR TO SF 2166) (SUCCESSOR TO SSB 3056) A BILL FOR Senate File 2318 AN ACT RELATING TO THE IOWA HEALTH INFORMATION NETWORK, PROVIDING FOR FEES, AND INCLUDING EFFECTIVE DATE PROVISIONS. BE IT ENACTED BY THE GENERAL ASSEMBLY OF THE STATE OF IOWA: Section 1. Section 135.154, Code 2011, is amended by adding the following new subsections: NEW SUBSECTION. 01. "Advisory council" means the electronic health information advisory council created in section 135.156. NEW SUBSECTION. 001. "Authorized" means having met the requirements as a participant for access to and use of the Iowa health information network. NEW SUBSECTION. 2A. "Exchange" means the authorized electronic sharing of health information between health care professionals, payors, consumers, public health agencies, the department, and other authorized participants utilizing the Iowa health information network and Iowa health information network services. NEW SUBSECTION. 2B. "Executive committee" means the executive committee of the electronic health information advisory council created in section 135.156. NEW SUBSECTION. 3A. "Health information" means health information as defined in 45 C.F.R. { 160.103 that is created or received by an authorized participant. NEW SUBSECTION. 4A. "Health Insurance Portability and Accountability Act" means the federal Health Insurance Portability and Accountability Act of 1996, Pub. L. No. 104=191, including amendments thereto and regulations promulgated thereunder. NEW SUBSECTION. 4B. "Hospital" means licensed hospital as defined in section 135B.1. NEW SUBSECTION. 4C. "Individually identifiable health information" means individually identifiable health information as defined in 45 C.F.R. { 160.103 that is created or received by an authorized participant. NEW SUBSECTION. 5A. "Iowa health information network" or "network" means the statewide health information technology network created in this division. NEW SUBSECTION. 5B. "Iowa Medicaid enterprise" means the Iowa Medicaid enterprise as defined in section 249J.3. NEW SUBSECTION. 5C. "Participant" means an authorized health care professional, payor, patient, health care organization, public health agency, or the department that IOWA E-HEALTH STRATEGIC AND OPERATIONAL PLAN (JUNE 2012) 119

has agreed to authorize, submit, access, or disclose health information through the Iowa health information network in accordance with this chapter and all applicable laws, rules, agreements, policies, and standards. NEW SUBSECTION. 5D. "Patient" means a person who has received or is receiving health services from a health care professional. NEW SUBSECTION. 5E. "Payor" means a person who makes payments for health services, including but not limited to an insurance company, self-=insured employer, government program, individual, or other purchaser that makes such payments. NEW SUBSECTION. 5F. "Protected health information" means protected health information as defined in 45 C.F.R. { 160.103 that is created or received by an authorized participant. NEW SUBSECTION. 5G. "Public health agency" means an entity that is governed by or contractually responsible to a local board of health or the department to provide services focused on the health status of population groups and their environments. NEW SUBSECTION. 5H. "Purchaser" means any individual, employer, or organization that purchases health insurance or services and includes intermediaries. Sec. 2. Section 135.155, subsection 2, unnumbered paragraph 1, Code 2011, is amended to read as follows: To be effective, the Iowa health information technology system network shall comply with all of the following principles: Sec. 3. Section 135.155, subsection 3, Code 2011, is amended to read as follows: 3. Widespread adoption of health information technology is critical to a successful Iowa health information technology system network and is best achieved when all of the following occur: a. The market provides a variety of certified products from which to choose in order to best fit the needs of the user. b. The system network provides incentives for health care professionals to utilize the health information technology and provides rewards for any improvement in quality and efficiency resulting from such utilization. c. The system network provides protocols to address critical problems. d. The system network is financed by all who benefit from the improved quality, efficiency, savings, and other benefits that result from use of health information technology. Sec. 4. NEW SECTION. 135.155A Findings and intent == Iowa health information network. 1. The general assembly finds all of the following: a. Technology used to support health care=related functions is known as health information technology. Health information technology provides a mechanism to transform the delivery of health and medical care in Iowa and across the nation. b. A health information network involves the secure electronic sharing of health information across the boundaries of individual practice and institutional health settings and with consumers. Broad use of health information technology and a health information network should improve health care quality and the overall health of the population, increase efficiencies IOWA E-HEALTH STRATEGIC AND OPERATIONAL PLAN (JUNE 2012) 120

in administrative health care, reduce unnecessary health care costs, and help prevent medical errors. 2. It is the intent of the general assembly that Iowa establish a statewide health information technology network. The Iowa health information network shall not constitute a health benefit network or a health insurance network. Nothing in this division shall be interpreted to impede or preclude the formation and operation of regional, population=specific, or local health information networks or their participation in the Iowa health information network. Sec. 5. Section 135.156, subsection 1, paragraphs a and b, Code Supplement 2011, are amended to read as follows: a. The department shall direct a public and private collaborative effort to promote the adoption and use of health information technology in this state in order to improve health care quality, increase patient safety, reduce health care costs, enhance public health, and empower individuals and health care professionals with comprehensive, real=time medical information to provide continuity of care and make the best health care decisions. The department shall provide coordination for the development and implementation of an interoperable electronic health records system, telehealth expansion efforts, the health information technology infrastructure, the Iowa health information network, and other health information technology initiatives in this state. The department shall be guided by the principles and goals specified in section 135.155 and the findings and intent specified for an Iowa health information network in section 135.155A. b. All health information technology efforts shall endeavor to represent the interests and meet the needs of consumers and the health care sector, protect the privacy of individuals and the confidentiality of individuals' information, promote physician best practices, and make information easily accessible to the appropriate parties. The system network developed shall be consumer=driven, flexible, and expandable. Sec. 6. Section 135.156, subsection 2, paragraph a, Code Supplement 2011, is amended to read as follows: a. An electronic health information advisory council is established which shall consist of the representatives of entities involved in the electronic health records system task force established pursuant to section 217.41A, Code 2007, a pharmacist, a licensed practicing physician, a consumer who is a member of the state board of health, a representative of the state's Medicare quality improvement organization, the executive director of the Iowa communications network, a representative of the private telecommunications industry, a representative of the Iowa collaborative safety net provider network created in section 135.153, a nurse informaticist from the university of Iowa, and any other members the department or executive committee of the advisory council determines necessary and appoints to assist the department or executive committee at various stages of development of the electronic Iowa health information system network. Executive branch agencies shall also be included as necessary to assist in the duties of the department and the executive committee. Public members of the advisory council shall receive reimbursement IOWA E-HEALTH STRATEGIC AND OPERATIONAL PLAN (JUNE 2012) 121

for actual expenses incurred while serving in their official capacity only if they are not eligible for reimbursement by the organization that they represent. Any legislative members shall be paid the per diem and expenses specified in section 2.10. Sec. 7. Section 135.156, subsection 3, paragraph a, subparagraphs (6) and (10), Code Supplement 2011, are amended to read as follows: (6) Policies relating to governance of the various facets of the Iowa health information technology system network. (10) Economic incentives and support to facilitate participation in an interoperable system network by health care professionals. Sec. 8. Section 135.156, subsection 3, paragraph c, unnumbered paragraph 1, Code Supplement 2011, is amended to read as follows: Coordinate public and private efforts to provide the network backbone infrastructure for the Iowa health information technology system network. In coordinating these efforts, the executive committee shall do all of the following: Sec. 9. Section 135.156, subsection 3, paragraphs h and i, Code Supplement 2011, are amended to read as follows: h. Seek and apply for any federal or private funding to assist in the implementation and support of the Iowa health information technology system network and make recommendations for funding mechanisms for the ongoing development and maintenance costs of the Iowa health information technology system network. i. Identify state laws and rules that present barriers to the development of the Iowa health information technology system network and recommend any changes to the governor and the general assembly. Sec. 10. NEW SECTION. 135.156A Iowa health information network == business and financial sustainability plan and participant fees. 1. The board, with the support of the department and the advice of the executive committee and advisory council, shall establish and annually review and update a business and financial sustainability plan for the Iowa health information network. The plan shall include fees to be paid to the department by participants who choose to access and use the Iowa health information network. The participant fee schedule shall be structured using fair share, value=based principles. 2. The department shall update and submit a financial model, including fee schedule, revenue and expense projections, and a budget, to the executive committee and the board for approval on an annual basis. Sec. 11. NEW SECTION. 135.156B Iowa health information network == duties of the department. The department shall do all of the following: 1. Develop, implement, and enforce the following, as approved by the board: a. Strategic, operational, and business and financial sustainability plans for the Iowa health information network. b. Standards, requirements, policies, and procedures for access to and use, secondary use, and privacy and security of health information exchanged through the Iowa health IOWA E-HEALTH STRATEGIC AND OPERATIONAL PLAN (JUNE 2012) 122

information network, consistent with applicable federal and state standards and laws. c. Rules, policies, and procedures for monitoring participant usage of the Iowa health information network and enforcing compliance with applicable standards, requirements, policies, rules, and procedures. d. Policies and procedures for administering the infrastructure, technology, and associated professional services required for operation of the Iowa health information network and the provision of services through the Iowa health information network. e. An annual budget and fiscal report for the business and technical operations of the Iowa health information network and an annual report for the Iowa health information network and the services provided through the Iowa health information network. 2. Provide human resources, budgeting, project and activity coordination, and related management functions to the Iowa health information network and the services provided through the Iowa health information network. 3. Enter into participation agreements with participants in the Iowa health information network. 4. Collect participant fees, record receipts and approvals of payments, and file required financial reports. 5. Apply for, acquire by gift or purchase, and hold, dispense, or dispose of funds and real or personal property from any person, governmental entity, or organization in the exercise of its powers or performance of its duties in accordance with this division. 6. Select and contract with vendors of goods and services in compliance with all applicable state and federal procurement laws and regulations. 7. Work to align interstate and intrastate interoperability standards in accordance with national health information exchange standards. 8. Execute all instruments necessary or incidental to the performance of its duties and the execution of its powers under this division. Sec. 12. NEW SECTION. 135.156C Iowa health information network fund. 1. The Iowa health information network fund is created as a separate fund within the state treasury under the control of the board. Revenues, donations, gifts, interest, participant fees, and other moneys received or generated relative to the operation and administration of the Iowa health information network shall be deposited in the fund. 2. Moneys in the fund are appropriated to and shall be expended by the department only for activities and operations suitable to the performance of the department's duties, subject to executive committee review and board approval. Disbursements may be made from the fund for purposes related to the administration, management, operations, functions, activities, or sustainability of the Iowa health information network. 3. Notwithstanding section 12C.7, subsection 2, earnings or interest on moneys deposited in the fund shall be credited to the fund. Moneys in the fund at the end of each fiscal year IOWA E-HEALTH STRATEGIC AND OPERATIONAL PLAN (JUNE 2012) 123

shall not revert to another fund but shall remain in the fund for expenditure in subsequent fiscal years. 4. The moneys in the fund shall be subject to financial and compliance audits by the auditor of state. Sec. 13. NEW SECTION. 135.156D Technical infrastructure. 1. The Iowa health information network shall provide a mechanism to facilitate and support the secure electronic exchange of health information between participants. 2. The Iowa health information network shall not function as a central repository of all health information. 3. The Iowa health information network shall provide a mechanism for participants without an electronic health records system to access health information from the Iowa health information network. Sec. 14. NEW SECTION. 135.156E Legal and policy. 1. Upon approval from the board, the department shall implement appropriate security standards, policies, and procedures to protect the transmission and receipt of protected health information exchanged through the Iowa health information network, which shall, at a minimum, comply with the Health Insurance Portability and Accountability Act security rule pursuant to 45 C.F.R. pt. 164, subpt. C, and shall reflect all of the following: a. Include authorization controls, including the responsibility to authorize, maintain, and terminate a participant's use of the Iowa health information network. b. Require authentication controls to verify the identify and role of the participant using the Iowa health information network. c. Include role=based access controls to restrict functionality and information available through the Iowa health information network. d. Include a secure and traceable electronic audit system to document and monitor the sender and the recipient of health information exchanged through the Iowa health information network. e. Require standard participation agreements which define the minimum privacy and security obligations of all participants using the Iowa health information network and services available through the Iowa health information network. f. Include controls over access to and the collection, organization, and maintenance of records and data for purposes of research or population health that protect the confidentiality of consumers who are the subject of the health information. 2. A patient shall have the opportunity to decline exchange of the patient's health information through the Iowa health information network. A patient shall not be denied care or treatment for declining to exchange the patient's health information, in whole or in part, through the Iowa health information network. The board shall provide by rule the means and process by which patients may decline participation. The means and process utilized under the rules shall minimize the burden on patients and health care professionals. 3. Unless otherwise authorized by law or rule, a patient's decision to decline participation means that none of the patient's health information shall be accessible through the IOWA E-HEALTH STRATEGIC AND OPERATIONAL PLAN (JUNE 2012) 124

record locator service function of the Iowa health information network. A patient's decision to decline having health information shared through the record locator service function shall not limit a health care professional with whom the patient has or is considering a treatment relationship from sharing health information concerning the patient through the secure messaging function of the Iowa health information network. 4. A patient who declines participation in the Iowa health information network may later decide to have health information shared through the Iowa health information network. A patient who is participating in the Iowa health information network may later decline participation in the network. 5. A participant shall not release or use protected health information exchanged through the Iowa health information network for purposes unrelated to prevention, treatment, payment, or health care operations unless otherwise authorized or required by state or federal law. Participants shall limit the use and disclosure of protected health information for payment or health care operations to the minimum amount required to accomplish the intended purpose of the use or request, in compliance with the Health Insurance Portability and Accountability Act and other applicable state or federal law. Use or distribution of the information for a marketing purpose, as defined by the Health Insurance Portability and Accountability Act, is strictly prohibited. 6. The department and all persons using the Iowa health information network are individually responsible for following breach notification policies as provided by the Health Insurance Portability and Accountability Act. 7. A participant shall not be compelled by subpoena, court order, or other process of law to access health information through the Iowa health information network in order to gather records or information not created by the participant. 8. All participants exchanging health information and data through the Iowa health information network shall grant to other participants of the network a nonexclusive license to retrieve and use that information in accordance with applicable state and federal laws, and the policies, standards, and rules established by the board. 9. The board shall establish by rule the procedures for a patient who is the subject of health information to do all of the following: a. Receive notice of a violation of the confidentiality provisions required under this division. b. Upon request to the department, view an audit report created under this division for the purpose of monitoring access to the patient's health care information. 10. A health care professional who relies reasonably and in good faith upon any health information provided through the Iowa health information network in treatment of a patient who is the subject of the health information shall be immune from criminal or civil liability arising from any damages caused by such reasonable, good=faith reliance. Such immunity shall not apply to acts or omissions constituting negligence, recklessness, or intentional misconduct. 11. A participant that has disclosed health information IOWA E-HEALTH STRATEGIC AND OPERATIONAL PLAN (JUNE 2012) 125

through the Iowa health information network in compliance with applicable law and the standards, requirements, policies, procedures, and agreements of the network shall not be subject to criminal or civil liability for the use or disclosure of the health information by another participant. 12. Notwithstanding chapter 22, the following records shall be kept confidential, unless otherwise ordered by a court or consented to by the patient or by a person duly authorized to release such information: a. The protected health information contained in, stored in, submitted to, transferred or exchanged by, or released from the Iowa health information network. b. Any protected health information in the possession of the department due to its administration of the Iowa health information network. 13. Unless otherwise provided in this division, when using the Iowa health information network or a private health information network maintained in this state that complies with the privacy and security requirements of this chapter for the purposes of patient treatment, a health care professional or a hospital is exempt from any other state law that is more restrictive than the Health Insurance Portability and Accountability Act that would otherwise prevent or hinder the exchange of patient information by the patient's health care professional or hospital. Sec. 15. NEW SECTION. 135.156F Governance review. 1. The governance structure as provided in this division consisting of the department acting on behalf of the board subject to executive committee review and board approval shall continue during the term of the state health information exchange cooperative agreement between the department and the office of the national coordinator for health information technology to address the development of standards, policies, and procedures; dissemination of interoperability standards; the installation, testing, and operation of the Iowa health information network infrastructure; and the evolution of Iowa health information network services to improve patient care for the population. 2. During the final year of the term of the cooperative agreement, the executive committee and the department shall review the governance structure, operations of the Iowa health information network, and the business and financial sustainability plan and make recommendations to the board regarding the future governance of the Iowa health information network. Sec. 16. DETERMINATION OF USE, RELEASE, OR DISCLOSURE OF PROTECTED HEALTH INFORMATION. The department of public health shall review the potential of the use, release, or disclosure of protected health information under this Act for the purposes of research, and shall submit its findings and recommendations to the general assembly within twelve months of the effective date of this Act. Sec. 17. EFFECTIVE UPON ENACTMENT. This Act, being deemed of immediate importance, takes effect upon enactment. APPENDIX B: IOWA E-HEALTH STAKEHOLDERS IOWA E-HEALTH STRATEGIC AND OPERATIONAL PLAN (JUNE 2012) 126

e-health Executive Committee Members Name City Organization Jane Brokel, PhD, RN Riverside Iowa Nurses Association Lee Carmen Iowa City University of Iowa Hospitals and Clinics Rob Frieden Davenport Genesis Health System Jim Green Des Moines Mercy Medical Center-Des Moines Joy Grosser Des Moines Iowa Health System Don Nelson, MD Cedar Rapids Iowa Medical Society / Physician Tom Newton Des Moines Federation of Iowa Insurers Joe Smith Boone Iowa Hospital Association Rural Hospital Representative Michael Wolnerman Des Moines State Board of Health e-health Advisory Council Members Name City Organization Fred Bahls, MD Des Moines Veterans Affairs Medical Center Ted Boesen Des Moines Iowa/Nebraska Primary Care Association Michelle Bottenberg Waukee Iowa Pharmacy Association / Drake University Jane Brokel, PhD, RN Riverside Iowa Nurses Association / University of Iowa College of Nursing Susan Brown West Des Moines Telligen Tom Evans, MD Des Moines Iowa Healthcare Collaborative Randall Hanson, MD Waukee Polk County Medical Society / Physician Leon Hofer West Des Moines Rural Iowa Independent Telephone Association & Iowa Telephone Association Tom Newton Des Moines Federation of Iowa Insurers / Wellmark Blue Cross Blue Shield Dave Lingren Des Moines Iowa Communications Network Roy Park Ankeny Consumer Advocate Dana Shaffer, DO Exira Iowa Osteopathic Medical Association / Des Moines University Kristy Walker Iowa City University of Iowa Hospitals and Clinics Jennifer Vermeer Des Moines Iowa Medicaid Enterprise Meeting materials and minutes from past meetings are available at www.iowahealth.org. IOWA E-HEALTH STRATEGIC AND OPERATIONAL PLAN (JUNE 2012) 127

Membership Prescribed by Legislation (2008) Electronic Health Information Executive Committee 1) Three chief information officers of the three largest private health care systems Chief information officer or designee of the University of Iowa Hospitals and Clinics 2) Representative of a rural hospital selected by Iowa Hospital Association 3) Consumer member of the State Board of Health 4) Licensed practicing physician selected by the Iowa Medical Society 5) Licensed and practicing nurse selected by the Iowa Nurses Association 6) Representative of an insurance carrier selected by the Federation of Iowa Insurers Electronic Health Information Advisory Council 1) Pharmacist 2) Licensed practicing physician 3) Consumer member of the State Board of Health 4) Iowa Medicare Quality Improvement Organization 5) Executive Director of the Iowa Communications Network 6) Representative of the private telecommunications industry 7) Representative of the Iowa collaborative safety net provider network 8) Nurse informaticist from University of Iowa 9) Other members selected: a. Consumer b. Department of Human Services c. Des Moines University Clinic d. Iowa Healthcare Collaborative e. Iowa Hospital Association f. Iowa Medicaid Enterprise g. Iowa Medical Society h. Iowa Osteopathic Medical Association i. University of Iowa Hospital and Clinics j. Veterans Affairs k. Federation of Iowa Insurers IOWA E-HEALTH STRATEGIC AND OPERATIONAL PLAN (JUNE 2012) 128

Stakeholder Organizations Individuals from the following organizations have been involved in the Iowa e-health project by serving as an Executive Committee, Advisory Council, or workgroup member. Provider Organizations - Boone County Hospital - Broadlawns Medical Center - Burgess Health Center - Care Initiatives - Des Moines University Clinic - Genesis Health System - Great River Medical Center - Iowa Clinic - Iowa Health Des Moines (Methodist, Lutheran, Blank) - Iowa Health Physicians - Iowa Health System - Mercy Medical Center - Cedar Rapids - Mercy Medical Center - Des Moines - Mercy Medical Center - Iowa City - Mercy Medical Center - North Iowa - Mercy Medical Center, Catholic Health Initiatives - Planned Parenthood of the Heartland - Trinity Regional Medical Center - University of Iowa Hospitals and Clinics - Veterans Affairs Medical Center - Wheaton Franciscan Health care Professional Associations - American Health Information Management Association - Iowa Collaborative Safety Net - Iowa/Nebraska Primary Care Association - Iowa Health Care Association - Iowa Hospital Association - Iowa Medical Society - Iowa Nurses Association - Iowa Osteopathic Medical Association - Iowa Pharmacy Association - Polk County Medical Society Payers - Federation of Iowa Insurers - Iowa Medicaid Enterprise - Principal Financial Group - Wellmark Blue Cross and Blue Shield Government - Iowa Attorney General's Office - Iowa Communications Network - Iowa Department of Education - Iowa Department of Human Services - Iowa Department of Public Health - Iowa Medicaid Enterprise - Legislators - State Board of Health Educational Institutions - Des Moines Area Community College - Des Moines University (Osteopathic Medicine) - Drake University (Pharmacy) - Eastern Iowa Community College/Scott Community College - Hawkeye Community College - Indian Hills Community College - Kirkwood Community College - Northeast Iowa Community College - Northwest Iowa Community College - University of Iowa (Nursing) - University of Iowa (Engineering) Other - American Health Information Management Association - Consumers - Davis, Brown Law Firm - ecfirst - Genova Technologies - Good Samaritan Society - HITRUST - Telligen - Iowa Healthcare Collaborative - Iowa Network Service - Iowa Telephone Association - Iowa Valley Continuing Education - Planned Parenthood of the Heartland - Rural Iowa Independent Telephone Association Appendix C: Letter of Support from the State Medicaid Director IOWA E-HEALTH STRATEGIC AND OPERATIONAL PLAN (JUNE 2012) 129

IOWA E-HEALTH STRATEGIC AND OPERATIONAL PLAN (MARCH 2011) 130

Appendix D: Letter of Support from the Public Health Department IOWA E-HEALTH STRATEGIC AND OPERATIONAL PLAN (MARCH 2011) 131

Appendix E: Letter of Support from the Regional Extension Center IOWA E-HEALTH STRATEGIC AND OPERATIONAL PLAN (MARCH 2011) 132

Appendix F: Letter of Support from Iowa Nebraska Primary Care Association IOWA E-HEALTH STRATEGIC AND OPERATIONAL PLAN (MARCH 2011) 133

Appendix G: ONC-Required Performance Measures and Reporting Baseline Information provided with the state HIE Cooperative Agreement Application October 2009 Governance 1 What proportion of the governing organization is represented by public stakeholders? 2 What proportion of the governing organization is represented by private sector stakeholders? Baseline Data: October, 2009 18% (5 of 28 e-health Executive Committee and Advisory Council members) 82% (23 of 28 e-health Executive Committee and Advisory Council members) Current Data: March 2010 22% (6 of 27 e-health Executive Committee and Advisory Council members) 78% (21 of 27 e-health Executive Committee and Advisory Council members) 3 Does the governing organization represent government, public health, hospitals, employers, providers, payers and consumers? 4 Does the state Medicaid agency have a designated governance role in the organization? 5 Has the governing organization adopted a strategic plan for statewide HIT? 6 Has the governing organization approved and started implementation of an operational plan for statewide HIT? 7 Are governing organization meetings posted and open to the public? 8 Do regional HIE initiatives have a designated governance role in the organization? Finance Government, public health, hospitals, providers, payers, and consumers are represented. Government, public health, hospitals, providers, payers, and consumers are represented. Not at this time. Yes. Iowa Medicaid is a member of the e- Health Advisory Council, which is a nonvoting membership role. Pending legislation (2011) would provide Iowa Medicaid with a seat on the Board of Directors, which would be a voting membership role. Yes the Iowa Health Information Technology Plan approved by the e- Health Executive Committee in June 2009 No. Development of a State Plan is in progress. Yes. Meeting notices, agendas, and minutes from past meetings are available at http://www.idph.state.ia.us/ehealth. Not Applicable. There are no existing regional HIE initiatives. Yes the Iowa e-health Strategic and Operational Plan approved in May 2010. Yes the Iowa e-health Strategic and Operational Plan approved in May 2010. Yes. Meeting notices, agendas, and minutes from past meetings are available at http://www.iowaehealth.org. During each Executive Committee and Advisory Council meeting, a standing agenda item is set aside for public comment prior to adjournment. Not Applicable. There are no existing regional HIE initiatives. 9 Has the organization developed and implemented financial policies and procedures consistent with state and federal requirements? 10 Does organization receive revenue from both public and private organizations? Not at this time. Not at this time. Yes. As a state agency, IDPH adheres to the financial policies and procedures established by the Iowa Department of Administrative Services, which provide the financial controls for state government. These policies and procedures meet or exceed the requirements of the State HIE Cooperative Agreement Program. Not at this time. IOWA E-HEALTH STRATEGIC AND OPERATIONAL PLAN (MARCH 2011) 134

11 What proportion of the sources of funding to advance statewide HIE are obtained from federal assistance, state assistance, other charitable contributions, and revenue from HIE services? 12 Of other charitable contributions listed above, what proportion of funding comes from health care providers, employers, health plans, and others (please specify)? 13 Has the organization developed a business plan that includes a financial sustainability plan? 14 Does the governance organization review the budget with the oversight board on a quarterly basis? 15 Does the recipient comply with the Single Audit requirements of OMB? 16 Is there a secure revenue stream to support sustainable business operations throughout and beyond the performance period? Technical Infrastructure 17 Is the statewide technical architecture for HIE developed and ready for implementation according to HIE model(s) chosen by the governance organization? 18 Does statewide technical infrastructure integrate statespecific Medicaid management information systems? 19 Does statewide technical infrastructure integrate regional HIE? 20 What proportion of health care providers in the state are able to send electronic health information using components of the statewide HIE Technical infrastructure? 21 What proportion of health care providers in the state are able to receive electronic health information using components of the statewide HIE Technical infrastructure? Unknown at this time. To date, funding to advance state HIE planning has primarily included in-kind staff time from participating public and private organizations. Development of the business and financial plan will offer strategies for securing diverse sources of funding to advance statewide HIE. Not applicable. Not at this time. Not at this time. Yes Not at this time. Not at this time. Not at this time. Not applicable. There are no existing regional HIE initiatives. Not applicable. There is no existing statewide HIE infrastructure. Not applicable. There is no existing statewide HIE infrastructure. State Assistance: General Appropriations: $679,359 (2%) In-kind contributions: $895,104 (3%) Federal Assistance: CMS: $236,010.60 (1%) ONC: $8,375,000 (30%) Additional funding needs: $17,314,526.40 (63%); a business plan is currently being developed Not Applicable. A business plan is currently being developed. Not at this time. The business plan is currently being developed. Yes. Iowa e-health reviews the budget with the e-health Executive Committee at least quarterly. Yes Not at this time. Iowa s Business Plan will include a financial sustainability plan that addresses the need for both short and long-term supplemental funding. No. An HIE vendor contract is pending. Not at this time. Not Applicable. There are no existing regional HIE initiatives. Not Applicable. There is no existing statewide HIE infrastructure. Not applicable. There is no existing statewide HIE infrastructure. IOWA E-HEALTH STRATEGIC AND OPERATIONAL PLAN (MARCH 2011) 135

Business and Technical Operations 22 Is technical assistance available to those developing HIE services? 23 Is the statewide governance organization monitoring and planning for remediation of HIE as necessary throughout the state? 24 What percent of health care providers have access to broadband? 25 What statewide shared services or other statewide technical resources are developed and implemented to address business and technical operations? Legal/Policy Not at this time. Yes. An objective of the Governance and Finance Workgroup is to engage in ongoing evaluation and strategic planning. Unknown at this time. Unknown at this time. Technical Assistance is available through Iowa s Regional Extension Center. Yes. An objective of both the Governance & Finance and the Evaluation Workgroups is to engage in ongoing evaluation and strategic planning. According to provider assessments completed by Iowa e-health in 2010, access to broadband varies by provider type. Response rates for these assessments were low, indicating the need to analyze this data to understand potential trends in broadband access in Iowa. Provider Practice = 6.1% Long Term Care = 25% Pharmacy = 7% Laboratory = 18% Radiology = 9% Home Health Care = 17% None at this time. A contract with an HIE vendor is pending. However, planned HIE services include a statewide provider directory, secure provider-provider messaging, continuity of care document, and immunization history and reporting to the state public health department. 26 Has the governance organization developed and implemented privacy policies and procedures consistent with state and federal requirements? 27 How many trust agreements have been signed? 28 Do privacy policies, procedures and trust agreements incorporate provisions allowing for public health data use? Not at this time. 0 0 Not at this time. Note at this time. Pending the adoption of the current Iowa e-health legislation (2011), administrative rules will be developed. Not at this time. However, pending legislation (2011) will direct the development of policies and procedures to include controls over access to and the collection, organization, and maintenance of records and data for purposes of research or population health that protect the confidentiality of consumers who are the subject of the health information. IOWA E-HEALTH STRATEGIC AND OPERATIONAL PLAN (MARCH 2011) 136

APPENDIX H: ONC TECHNICAL ASSISTANCE REQUEST Iowa e-health looks forward to the availability of technical assistance through ONC. The ONC technical assistance team was established to deliver timely guidance and information to recipients of the State HIE Cooperative Agreement Program. Representatives from the Office of Health IT have already been participating in the technical assistance listserv and webinar series; however more specific guidance, coordination, and one-on-one consultation in the following areas will help accelerate Iowa e-health s planning and implementation activities. 1. Facilitate national coordination and information about when and how federal organizations (e.g., HRSA, CDC, Medicare, Veteran s Affairs, Indian Health Services) will connect to various statewide HIEs. 2. Coordinate information sharing with Iowa and other states about regulations being pursued by other federal agencies (e.g., CMS, DEA, CDC). 3. Clarify expectations and provide a minimum data set for a provider directory. 4. Clarify expectations and provide examples of standard operating procedures for the HIE. 5. Facilitate a learning opportunity to better understand relevant EHR and HIE standards. 6. Summarize planning approaches in other states and provide links to available resources. For example: a. Which states have governance structures that are government-led rather than non-profit? b. Which states have legislation governing the operations of HIE? c. Which states have opt-out patient consent models? d. Which states are operational? e. Which states have a single statewide HIE rather than multiple RHIOs? f. Which states have had success with financial sustainability and collection of fees? How much are different stakeholder groups charged across the nation? g. Link to participation agreements currently used for HIEs in other states. h. Link to on-boarding documentation currently used for HIEs in other states. IOWA E-HEALTH STRATEGIC AND OPERATIONAL PLAN (MARCH 2011) 137

APPENDIX I: ONC FOUR-YEAR BUDGET ESTIMATE Through the State HIE Cooperative Agreement Program, Iowa is eligible to receive $8.375 million. As part of the business and financial sustainability planning process, a five year budget for Iowa e-health is estimated at $27.5 million. The following budget reflects the four-year ONC budget and the state funds that will be used to satisfy the ONC match requirements. Budget Item Personnel ONC - State HIE Program State Funds - IDPH Total 1. State HIT Coordinator (EO 4) 1 FTE $398,358 $398,358 2. IT Project Manager (ITS 5) 1 FTE $266,676 $266,676 3. Program Manager $240,196 $240,196 4. Evaluation Coordinator (CHC) 1 FTE $184,743 $184,743 5. Provider Relation Specialist (ITS 3) 1 FTE $210,653 $210,652 6. Program Assistant (AA 2) 1 FTE $173,770 $173,770 7. Communication Coordinator (CHC) 1 FTE $240,598 $240,598 Total Personnel $1,474,396 $240,598 $1,860,257 Fringe Benefits (30% of salary) $442,319 $72,179 $558,076 Travel 8. In-State Meetings and site visits $16,000 $18,400 $16,000 9. Out-of-State Annual grantee meetings $25,600 $25,600 10. Out-of-state conferences $29,600 $29,600 11. Out-of-state travel to view vendor supported HIE prior to HIE vendor selection Total Travel $71,200 $18,400 $89,600 Equipment 12. HIE Hardware $600,000 $600,000 Equipment Total $600,000 $600,000 Supplies 13. Desktop computers $5,850 $5,850 14. Laptop computers 15. Proxima 16. Office set up 17. Desk Telephones $8,400 $8,400 18. Blackberry Purchase $600 $600 19. Blackberry Charges $7,200 $7,200 20. Toll-free telephone line $7,200 $7,200 21. Conference call capabilities (Citrix) $60,000 $60,000 22. Office Supplies $2,880 $2,880 23. Executive Committee and Advisory Council $4,704 $4,704 Meeting supplies Supplies Total $7,800 $89,034 $96,834 IOWA E-HEALTH STRATEGIC AND OPERATIONAL PLAN (MARCH 2011) 138

Budget Item Contractual ONC - State HIE Program State Funds - IDPH Total 24. Legal Services $346,500 $33,000 $379,500 25. Provider Assessment $10,000 $4,000 $14,000 26. Focus Groups $30,000 $30,000 27. Communication Strategy $98,543 $55,730 $154,273 28. Program Evaluation $167,500 $167,500 29. HIE Development $1,980,000 $1,980,000 30. Ongoing Operations $2,063,526 $2,063,526 31. Population Health Integration $250,000 $80,000 $330,000 32. Business / Financial Model Development $200,000 $200,000 Contractual Total $5,146,069 $172,730 $5,318,799 Other 33. Provider Starter Kit $30,828 $30,828 34. Executive Committee & Advisory Council Meals $10,560 $10,560 35. Meeting space rental $8,800 $8,800 36. Department of Administrative Services Personnel Charges 37. Office Rental Space $16,200 $2,400 $18,600 38. Software $4,000 $4,000 39. Professional Membership: ehealth Initiative 40. Professional Membership: HIMSS / Iowa HIMSS 41. Professional Membership: AMIA 42. Staff development $7,500 $13,700 $21,200 43. Consulting Fees $68,810 $35,490 $104,300 Other Total $111,870 $86,418 $198,288 Direct Charges - Sum of Personnel, Fringe, Travel, $7,853,654 $679,359 $8,533,013 Equipment, Supplies, Contractual, and Other Indirect Charges 26-27.2% of salary is charged on $521,346 $521,346 all personnel funded through a grant In-Kind Contributions (44, 45)- Volunteer time from $895,104 Executive Committee, Advisory Council, and Workgroup Members Four-Year Budget Estimate $8,375,000 $679,359 $9,949,463 IOWA E-HEALTH STRATEGIC AND OPERATIONAL PLAN (MARCH 2011) 139

Additional Information about Budget Items: 1. The State HIT Coordinator will provide high-level coordination across state government and with stakeholders; coordinate with Office of National Coordinator, National Governor s Association, and other federal partners, and coordinate with Regional Extension Centers. The State HIT Coordinator is an Executive Officer 4 classification. 2. The IT Project Manager will work with all aspects of the project to assure that the clinical and business needs are identified and translated to the chosen vendor for the HIE solution. The IT Project Manager is an Information Technology Specialist 5 classification. 3. The e-health Program Manager will manage all activities of the HIE cooperative agreement, ensure timely and accurate reporting to ONC, provide functional oversight to the e-health staff, and coordinate activities of the e-health Executive Committee, Advisory Council, and workgroups. The e-health Program Manager is an Executive Officer 2 classification. 4. The Evaluation Coordinator will coordinate the evaluation process for the project, including writing RFIs and RFPs, and coordinating and monitoring contract activities with selected vendor(s). The Evaluation Coordinator is a Community Health Consultant classification. 5. The Provider Relations Specialist (formerly IT help desk coordinator) will work directly with the HIE vendor and Regional Extension Center to add new providers, develop HIE training and educational materials, and support conducted trainings. 6. The Program Assistant will provide project support, including contract monitoring and reporting and budget reporting, and administrative support for e-health project and staff. The Program Assistant is an Administrative Assistant 2 classification. 7. The Communication Coordinator will coordinate the communication process for the project, including writing RFIs and RFPs, and coordinating and monitoring contract activities with selected vendor(s). The Communication Coordinator is a Community Health Consultant classification. 8. In-state travel will be provided for staff members to attend meetings outside the Des Moines area (e.g., Regional Extension Center meetings, provider site visits, presentations, and privacy and security meetings) as needed. Local travel rates are based on the State of Iowa s reimbursement rate of 39 cents per mile and the actual value of a meal purchase, not to exceed $8.00 for lunch. 9. The grant requires travel of two staff to attend the two-day state HIE leadership conference twice per year. Out of state travel rates are based on the State of Iowa s out-of-state travel reimbursement policy. 10. In order to promote staff development, out-of-state travel will be provided for staff to attend one conference per year to learn smart practices and knowledge that will be instrumental in the statewide HIE. Out of state travel rates are based on the State of Iowa s out-of-state travel reimbursement policy. 11. Out of state travel to view vendor solution [Removed from budget] 12. Based on information received from vendors responding to an RFI in 2009, hardware for a primary and an off-site backup system is estimated at $400,000, plus an additional $100,000 for upgrades and the hardware refresh cycle. The actual hardware costs will be determined upon conclusion of the HIE infrastructure procurement process. 13. Computers will be purchased for two staff members. The cost per computer is based on available state government contract pricing. 14. Laptop computers [Removed from budget] 15. Proxima [Removed from budget] 16. Office set-up [Removed from budget] 17. Desk telephones will be provided for 5 staff members. The cost per year is based on current pricing from the Iowa Communications Network which provides the telephone service. 18. The State HIT Coordinator and Program Manager are responsible for a wide variety of activities, which mandate that they be able to communicate with others at all times and have immediate access to information. The cost per blackberry is based on available state government contract pricing. 19. The monthly service charge for blackberries is based on the average blackberry service fees for other department employees in similar roles. 20. A toll-free telephone line will be established for Iowa e-health to give providers and consumers a single point-of-contact for questions, concerns and comments regarding e-health planning and implementation activities in Iowa. 21. The Office of Health IT conducts a majority of multi-stakeholder workgroup meetings through a web conferencing service, Citrix GoToMeeting. The web conference capability allows stakeholders located throughout the state to participate in meetings without travel expenses. The cost per year is based on the Office of Health IT s portion of a department-wide contract with Citrix. IOWA E-HEALTH STRATEGIC AND OPERATIONAL PLAN (MARCH 2011) 140

22. Supplies will be purchased annually to support day-to-day operations of the Office of Health IT. The monthly cost for supplies is based on the average supply orders in previous months. 23. Supplies will be purchased annually to support the Executive Committee and Advisory Council meetings. The cost per meeting cost for supplies is based on the average supply orders in previous months. 24. The Iowa Attorney General s office will provide legal support in the development of the statewide HIE. This includes data sharing agreements, privacy and security policies and procedures, a comprehensive legislative package, exploration of governance options, and fees to establish a long-term governance structure. 25. A contract was established with the University of Iowa Public Policy Center to conduct an assessment of provider readiness to electronically exchange health information. 26. The Iowa Department of Administrative Services (DAS) was contracted to facilitate provider focus groups. 27. ZLR Ignition will develop and execute a communication strategy. Activities include, but are not limited to, face-to-face regional meetings to gain consumer feedback, program branding, communication plan development, integrated media campaign, promotional materials, privacy and security-specific materials, mailing list server hosting, and website development and hosting. 28. A contract will be established to conduct program evaluation, which will include an on-going provider assessment to determine the process of implementing HIT in Iowa, and an evaluation of the effectiveness of the statewide HIE. The program evaluation must equal 2% of the ONC grant funding total. 29-30. A contract will be established with ACS for the development and ongoing operations of an HIE. 31. A contract will be established to make modifications to various public health systems (e.g., Immunization Registry Information Systems) in order to connect population health with the HIE. 32. A contract was established with Hielix-MEDNET to develop a business and financial model in order to ensure sustainability of the statewide HIE. 33. Upon implementation of the statewide HIE, a Provider Starter Kit will be sent to providers and will include detailed information about the statewide HIE, privacy and security pamphlets, and patient consent forms. The printing and postage estimates are based on the average costs incurred by other department programs of similar size and nature of work. 34. Executive Committee and Advisory Council meetings will continue to be held throughout the project period. There is not enough time in the meeting agenda to break for lunch, so meals are provided for a working lunch. In accordance with Department of Administrative Services State Accounting Enterprise Procedure Number 210.245 executive committee and advisory council members may be reimbursed up to $12 for lunch regardless of where a meeting is held. 35. Executive Committee and Advisory Council meetings are open meetings. Meeting space is needed for the council members, support staff, and the public. The rental fee is based on average government or nonprofit rental rates for meeting space. 36. The Iowa Department of Administrative Services (DAS) charges $600 per state employee per year for personnel services, benefit and payroll administration, and training. The DAS personnel charges are charged to the funding source that supports the personnel fees (i.e., salary). 38. Additional software tools (e.g., Microsoft Project or Publisher) may be needed to support activities of the Office of Health IT. 39. Professional Membership ehealth Initiative [Removed from the budget] 40. Professional Membership HIMSS [Removed from the budget] 41. Professional Membership AMIA [Removed from the budget] 42. In the evolving field of HIT, on-going education for staff members will be vital to sustaining the statewide HIE. Staff development will include: Continuing Education Courses in HIT and clinical training workshops. The annual budget for staff development is based on the average staff development budgets in other department programs of similar size and nature of work. 43. The scope of the Iowa e-health project requires expertise in clinical practice, infrastructure, finance, privacy and security, and governance. It is necessary to contract with subject matter experts in these areas to ensure the success of the statewide HIE. Project consultants will also be utilized to synchronize efforts with Medicaid and other federal, state, and regional efforts. 44. Consultation Executive Committee and Advisory Council Contributions. The 25 council members will provide oversight and guidance of e-health activities in the state of Iowa at an average hourly wage of $72. 45. Consultation Workgroup Volunteer Contributions. Workgroups were established to assist and help guide the activities of the Iowa e-health project. Each workgroup is attended by an average of 10 volunteer members at an average hourly wage of $72. IOWA E-HEALTH STRATEGIC AND OPERATIONAL PLAN (MARCH 2011) 141

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