Federal and State Update

John D. Halamka MD

May 17, 2012

2

Federal Update

• NPRM recommendations

• QueryHealth

• PopHealth

• Governance RFI - Conditions for Trusted

Exchange, Network Validated Entity

• Care Coordination, Patient Sourced Data,

Quality Measurement hearings

2

1

State Update • House Bill

– Consolidates all health reform responsibilities in new quasi:

Division of Health Care Cost and Quality (DHCCQ)

– Shifts HIT/HIE program funding and responsibility to DHCCQ

– Creates new HIT Council under DHCCQ

• Senate Bill

– Divides health reform responsibilities among 2 quasi’s:

• Health care delivery and financing: Health Care Quality

and Finance Authority (new quasi)

• HIT/HIE: MeHI (existing quasi)

– Bolsters MeHI with $100M in additional funding

– HIT Council membership and chair are changed

1

The Massachusetts Statewide

Health Information Exchange Vision

Berkshire Health

System

Atrius

NEHEN

SafeHealth

Fallon Clinic UMass

Memorial

Statewide HISP Secure Certificate

Management

Web

Portal

Provider/Entity

Directory

Audit

log

BIDMC Partners

Direct Gateway

Services

EOHHS NwHIN

MD

MD

MD

MD MD

MD MD

MD

MassHealth DPH

Basic Commonwealth HIE Services

Description

Provider directory

Certificate repository

DIRECT gateway

Web portal mailbox

Repository of physician names, entities,

affiliations, and security credentials

Repository of security certificates for

authorized users of HIE services

Adaptor that transforms messages from

one standard to another without

decrypting the message

Secure, encrypted mailbox for users

without standards-compliant EHR

“Lookup” services

“Message-handling” services

HIE Services

Users will have 2 ways to connect to

Commonwealth HIE

Provider directory

Certificate repository

DIRECT gateway

Web portal mailbox

HIE Services User types

2 methods of accessing

HIE services

EHR connects directly

Browser access to webmail inbox

Physician practice

Hospital

Long-term care

Other providers

Public health

Health plans

Labs and imaging

centers

In general, who will use which method?

EHR connects directly Browser access to webmail inbox

• Hospitals

• Large practices including FQHCs

• Smaller practices on Direct-capable

EHRs (facilitated by Last Mile

Adoption Program)

• Health plans

• Some LTC and VNA

• Labs and imaging centers

• Smaller practices on less capable

EHRs

• Most LTC and VNA

• Behavioral health

Likely to be many webmail at outset, but expect this to shift over time as EHR

penetration grows and national standards get traction

Trust Fabric (Illustrative)

MA HISP

Commonwealth HIE Trust Fabric

MMS

HISP

NEHEN

HISP

AthenaHealth

HISP

New

Hampshire

HISP

Berkshire Health

HISP

- -

Phasing defines Roadmap for Statewide HIE

Program

•Create infrastructure to facilitate data aggregation/analysis

•Will support Medicaid CDR and quality measure infrastructure

•Will support vocabulary translation services (lab, RX)

Increasing cost and complexity

Facilitate

normalization and

aggregation

Enable queries for

records

Information Highway

•Create infrastructure to enable secure transmission (“directed

exchange”) of clinical information

•Will support exchange among clinicians, public health, and

stand-alone registries

•Focus on breadth over depth

Analytics and Population Health

•Create infrastructure for cross-institutional queries for and

retrieval of patient records

Search and Retrieve

Phase 2

Phase 3

Phase 1

Network functions

Send/receive:

• Referral/Consult

• Admission notification

• Post-encounter summary

• Discharge Summary/Instructions

• Lab Order/Results

• Death Notification

• Uniform Transfer Form

• Public health (SS, Imm., ELR)

• Provider address search

Network participants

• Hospitals (inc. labs and imaging)

• PCP or Specialist

• Health plans

• Long-term care facilities

• Other care setting

• Patients*

• Quality Reporting Service *

• Public health*

Phase 1:

Phase 2:

Additional network participants

• More providers and payers and quality

reporting services

• Commercial diagnostic facilities

• Imaging centers

• Labs

Additional network functions

Send/receive:

• Public Health Alerts

• Quality Measure Reports

• Patient-matching service

• Vocabulary normalization service

Additional network participants

More providers and payers

Additional network functions

Search and retrieve:

• Patient record

• Patient consent/authorization

Phase 3:

*single-direction exchange

Statewide HIE Services Overview

19

Simplify User Access and Repurpose New and Existing Components

MMIS Shared Service

Medicaid & Public Health Applications

Syndromic

Surveillance

MMIS

Claims Engine Provider Online

Service Center

MMIS Base Application

CBHI (Children’s Behavioral

Health Initiative )

Immunization Electronic

Laboratory Reports

Statewide HISP

Direct Gateway**

VG Shared Service

AIMS (Access and

Identity Management)

Other Existing

Enterprise Shared

Services

Clinical Gateway (HL7 Interfaces)

AIMS* (Access and

Identity Management)

Provider Directory**

PKI** (Public Key

Infrastructure)

Clinical Gateway* (HL7 Interfaces)

Syndromic

Surveillance

CBHI (Children’s Behavioral

Health Initiative )

HIE Users (Medicaid and non-Medicaid)

Security and Provider

Directory services leveraged

for Statewide HISP

Architecture and usage

patterns identical for all

users

~80K providers already

using Virtual Gateway

EHR (Direct enabled)

Labs (HL7)

Clinical documents (CDA)

XDR or SMTP

EHR (not Direct enabled)

Labs (HL7)

Clinical documents (CDA)

Web

portal

No interoperable EHR

Clinical documents

Web

portal

Building an infrastructure is no guarantee that it will used Need to Build “Network Effects” As Rapidly As Possible

Value of statewide HIE network and services will increase exponentially with the

number of users

Removing adoption barriers is key to increasing number of users

– Up-front cost and difficulty of system integration is significant barrier to

adoption to most users, especially small practices and safety-net

providers

Can address this barrier through a variety of means

•Align all funding streams to maximize opportunities for synergy

•Leverage existing assets

•Build services where the users are

•Lower the cost and ease the difficulty of using the statewide HISP

Complement Infrastructure with Multi-Pronged Adoption Program

MMIS Shared Service

Medicaid & Public Health Applications

Syndromic

Surveillance

MMIS

Claims Engine Provider Online

Service Center

MMIS Base Application

CBHI (Children’s Behavioral

Health Initiative )

Immunization Electronic

Laboratory Reports

Statewide HISP

Direct Gateway**

MMIS Shared Service

AIMS (Access and

Identity Management)

Other Existing Enterprise

Shared Services

Clinical Gateway (HL7 Interfaces)

AIMS* (Access and

Identity Management)

Provider Directory**

PKI** (Public Key

Infrastructure)

Clinical Gateway* (HL7 Interfaces)

Syndromic

Surveillance CBHI

(Children’s Behavioral

Health Initiative )

1. Managed

procurements,

2. Grants, and

PM/technical support

3. Statewide outreach,

recruitment, and

training

Individual interfaces

Ambulatory practices

CAHs

Long-term care

Web portal recruitment and training

Behavioral health

Vendor-specific hubs (or HISPs)

Hospital EHR vendor

Ambulatory EHR vendor

Sub-network hubs (or HISPs)

HIE (eg, SafeHealth)

Hospital network

(e.g., Berkshire)

CMS SMHP/MMIS (infrastructure) ONC Cooperative Agreement (last-mile services)

Synergies

with REC

Budget estimate for Phase 1 projects and source of funds

Preliminary

Aligning Resources for Statewide HIE Services

ONC Cooperative

Agreement

$12.6M

CMS SMHP/MMIS

$17.1M (Phase 1)

MA Chapter 305

$11.9M

ONC Challenge

Grants

$3.4M

Matching funds for

ONC HIE programs

Matching funds for

CMS FFP

Infrastructure program for

Statewide HIE Services

Adoption program for

Statewide HIE Services

Leverage programs as

relevant for adoption and

infrastructure

SMHP/MMIS funds can be

used only for infrastructure PIN priorities and

user adoption

Private funds

~ $472K annual

(O&M)

Project schedule and updates

Initiative Completion date

1) Develop new approach and confirm with stakeholders Completed Oct 2011

2) Submit APD-U and SMHP to CMS with MoUs Completed Nov 2011

3) EHR/HIE Vendor Roundtable Completed Dec 2011

4) Network Users Roundtable – Eastern MA Completed Jan 2012

5) Network Users Roundtable – Western MA Completed Jan 2012

6) Confirm availability of State Share for APD Completed Jan 2012

7) Develop RFR for Medicaid HIE Infrastructure

implementation

Completed Jan 2012

8) CMS approval of APD-U/SMHP; CMS approval of RFR Completed Feb 2012

9) RFR for Phase 1 services released to Infrastructure Vendors Completed Feb 2012

10) Submit updated SOP to ONC Completed March 2012

11) ONC approval of SOP and SOP budget Expected May, 2012

12) Infrastructure Vendor selected and under contract Late May, 2012

13) Go-live for phase 1 “Information Highway” (Direct Gateway) Oct 15, 2012

14) Go-live for Last Mile program Oct 15, 2012

15) Go-live for phase 1 Public Health Gateway (CBHI, SS) Dec 14, 2012

MA HIE Solution Recap 1. Developing a statewide HIE (Open access HISP) leveraging Medicaid infrastructure and 90/11

HITECH and MMIS FFP funds

– Phase 1 (Push), Phase 2 (Analytics), Phase 3 (Query)

– Build is not enough, need to address last mile connectivity

– HIT ONC Grant not suitable for development of HIE infrastructure. Focusing HIT ONC

grant monies for the last mile adoption

– Leveraging Medicaid funded infrastructure would reduce incremental costs and assist in

sustainability

2. Developed a cost allocation model that envisions usage fee for non Medicaid users

3. MoU signed by organization representing 70 MA hospitals

4. Added a multi-stakeholder governance (24 member Advisory committee) and over 100

members for 5 workgroups

5. Developed State Medicaid Health Plan (SMHP), Implementation Advance Planning Document

(IAPD) and ONC Strategic & Operations Plan (SOP) using a transparent process - with multiple

rounds of stakeholder review

6. Cost allocated between funding sources (SDE HIT Grant, Impact Grant, HITECH, MMIS, State

funds, private funds)

7. Confirmed state share for 90/10 participation

8. Over 110 use cases supported by Phase 1 targeted to go live starting in late 2012