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Coordination of State and Federal Policies for Health IT Implementation:

A Postcard from NYRachel Block

NY eHealth Collaborative

Historical Context for Health IT Policy

Key Elements in New York’s Health IT Strategy

Key Health IT Elements of Federal Stimulus Legislation

Strong Imperative for Health Care Reform

• US health care very costly and performs poorly compared to other countries

• Many studies and commissions have called for system changes to:– Improve public health– Improve quality and safety– Manage cost and care more effectively

3

Health Systems Change Requires Broad Use of Health IT

• To Err is Human (IOM)

• Crossing the Quality Chasm (IOM)

• High Performance Health System (Commonwealth Fund)

• Other countries (UK, Canada, Germany)

4

Health IT Is Necessary but Not Sufficient

• Health information exchange is essential complement to health IT:– Incentive to use health IT– Track care across continuum, hand-offs– Empower consumers and families– Create longitudinal information – Strengthen public health surveillance

5

Key Concepts in Health Information Exchange

• Interoperability of health information systems would facilitate exchange

• Broad acceptance and use of certain policies is required

– Technical standards: data structure, communications– Clinical imperatives: quality, safety, care management– Protections re access and use: consent, disclosure of breach– Security policies: audit, authorization, authentication– Governance and accountability– Financing and incentives

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Framework for New York’s Health IT Strategy

ACCESS ACCESS

AGGREGATEAGGREGATE&&

ANALYZEANALYZE

APPLYAPPLY

Statewide Health Information Network – NY (SHIN-NY)

Clinical Informatics Services

Aggregation Aggregation MeasurementMeasurement ReportingReporting

“Cross-Sectional” Interoperability

Clinician/EHR Consumer/PHR Community

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What will get us “there” in NYS?

• Policy alignment• Support of increased adoption of

certified and interoperable EHRs in all care settings

• Increased adoption of patient/consumer programs including secure PHRs

• Coordination of care, including medication management, across care settings

• Disease prevention, early detection and other public health initiatives

• Monitoring and ongoing support of implementation to ensure safety and success

• Sustainable reimbursement models to promote HIT

Clinical Practice/Delivery Model

Reimbursement Model

Patient Engagement

Health Information

Model

Governance and Accountability

• Public trust is key underpinning for these systems

• Need authority, structure and means to set policy, monitor use, enforce standards

• Federal government has established some policies and mechanisms but not comprehensive

• Establish organizational capability and accountability at state and regional levels

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Governance and Organizational Components: Policy Development and Implementation Framework

NYS Dept of HealthFund health IT

Oversee contractsEnforce regulations

NYeCStatewide collaborative process

Deliberate & decide policiesAssist RHIOs/CHITAs

Implementation guides, tools, other resources

RHIO

PatientsProvidersPayers

Purchasers

Loca

lR

egio

nSta

te

RHIO

PatientsProvidersPayers

Purchasers

Funding and contractual obligations

$

HITECCreate evaluation toolsAssess sustainability

Measure progress

$

RHIO

PatientsProvidersPayers

Purchasers

CHITAs

Evaluation tools, other resources

Statewide Health Information Network for NY (SHIN-NY)

CHITAs

RHIO

PatientsProvidersPayers

Purchasers

CHITAs

RHIO

PatientsProvidersPayers

Purchasers

CHITAs

CHITA: A collaboration supporting adoption of health ITRHIO: A governance entity that oversees HIE in its region

Statewide Collaboration Process

NYeC Board

Clinical Priorities

Privacy & Security

EHR Collaborative

Protocols & Services

Policy & Operations Council

DOH

NHIN Project

HEAL Projects

CDC Project

MSSNY Projects

Collaborative Work Groups Implementation

Education & Communication Committee

Consumer Advocacy CouncilFinancial Sustainability Work Group

Go

vern

an

ce/

Ove

rsig

ht

Po

licy

/Sta

nd

ard

sC

ross

-Cu

ttin

g

Act

ivit

ies

HITEC

Policies Governing Access to and Use of Data

• Current law and practices protects privacy and confidentiality – need to translate and adapt to health care enabled by HIE –consent, review of disclosures, notification and remedies for breach

• Policies Governing Disclosure and Use – Treatment, Public Health, Research, etc

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Technical Standards

• Data definitions and record structure

• Product certification requirements

• Strategy for connectivity– Hard coded interface specifications versus…– Open source, service oriented architecture as

in what we use for the internet

13

Policies and Standards for Technical Security

• Authentication of users (clinicians, consumers)

• Authorization (role-based rights to access patient data)

• Audit (tracking disclosures)

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Vision for New York’s Health Information Infrastructure

Costly, High Risk and non-Interoperable EHRs

Interoperable EHRs

Immunization

Public health

Medicaid

Health Plans

Hospitals

Pharmacies

Labs

Clinicians

Consumers

Clinician EHR

Radiology clinics

Immunization

Public health

Medicaid

Health Plans

Hospitals

Pharmacies

Labs

Clinicians

Consumers

Clinician EHR

Radiology clinics

Clinician EHR

SHIN-NY

ConsumersPayers

Government/Medicaid

LabsHospitals

Pharmacies Radiology

1616

Medicaid UPHN

RadLab Documents

Hospital system

Results Reporting

DOH Node

NYS Department of Health

Service Oriented Architecture Model

Clinician EHR

Clinician EHR Clinician

EHR SHIN-NY**

Integrated Child Health Record

EHR

EHR

EHR

EHR

EHR

EHR

EHR

Multiple

Clinics

(CHCs

&

FHQCs)

Pharmacy Health Plan

eRx &Med Hx

SureScripts RxHub

EHREHR EHREHR

Grouped Physician Offices

EHR EHR EHREHR

EHR EHR EHR EHR

Clinical Imperatives for HIE

• Clinical uses structured around “use cases” which cross walk to technical requirements– Continuum of care – medication management– Safety and efficiency – e-prescribing– Quality Improvement – quality measures for

decision support and public reporting– Population health surveillance and

management

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Clinical Priorities: Definitions, Requirements and Applications

Clinical Scenarios that illustrate value proposition•Create scenarios based on use cases and subgroup priorities

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1. Reconciliation relies on cross-continuum data

2. Coordination with NHIN projects

3. Promote e-prescribing in context of advancement to a full EHR with CDS

4. Prioritization of clinical needs for financial incentive models

1. Reconciliation relies on cross-continuum data

2. Coordination with NHIN projects

3. Promote e-prescribing in context of advancement to a full EHR with CDS

4. Prioritization of clinical needs for financial incentive models

Medicaid / Medication Management Quality Reporting

1. Statewide quality standards

2. Locus of aggregation

3. Key data elements/specifications

4. CDS across care settings

5. Intersection with medication management

6. Physician adoption/trust

1. Statewide quality standards

2. Locus of aggregation

3. Key data elements/specifications

4. CDS across care settings

5. Intersection with medication management

6. Physician adoption/trust

1. PHR and medication management crossover2. Emergency services and coordination (DNR)3. Patient education and decision support4. Patient identification and consent5. Current PHR product readiness6. Continuity of care record with the PHR7. Secure patient-clinician clinician-clinician

interaction8. Additional patient data sources including

Telemedicine

1. PHR and medication management crossover2. Emergency services and coordination (DNR)3. Patient education and decision support4. Patient identification and consent5. Current PHR product readiness6. Continuity of care record with the PHR7. Secure patient-clinician clinician-clinician

interaction8. Additional patient data sources including

Telemedicine

Connecting NYers and Clinicians Public Health

1. Integrating current public health data sources –coordinated input

2. High priority to deal with projects already out

3. Bi-directional data flow through the Universal Public Health Node

4. Access to public programs as an issue for public health

5. Coordination with other efforts – CDC and NHIN

1. Integrating current public health data sources –coordinated input

2. High priority to deal with projects already out

3. Bi-directional data flow through the Universal Public Health Node

4. Access to public programs as an issue for public health

5. Coordination with other efforts – CDC and NHIN

Coordinate with other Workgroups (EHR Collaborative, Protocols/Services, Privacy & Security)

Define clinical priorities that best demonstrate critical areas and opportunities for improvement in both the quality and efficiency of health care for New Yorkers

Develop clinical requirements, identify workflow issues, and advance policy recommendations to help drive and test the development of policies, protocols and standards for NYS Health Information Infrastructure

Workflow requirement documents and narratives to support clinical practice redesign

Clinical requirements document to guide technical development and implementation:• Hone value proposition for increased patient safety, improved quality, efficiency and decreased cost;•Identify and prioritize clinical data types & elements, features and functions & CDS •Provide detailed workflow analysis, including charts and narratives

Reimbursement requirements document•Identify and prioritize reimbursement requirements to support sustainability

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Demonstrate and communicate the value of interoperable health IT adoption and effective use to clinicians and other stakeholders

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EHR Collaborative – Comprehensive System of Adoption Support Services

Knowledge-sharing

Convene and share best practices and lessons learned among participants and users

Policies & Standards

Products & Services

Recommend common policies, standards, and technical approaches among HEAL projects

Recommend statewide services to reduce the cost and/or increase the quality and consistency of EHR adoption and support

Value-Oriented Project Management

Vendor selection and contracting

Practice transformation & workflow planning

System deployment & implementation

Post-implementation support

Reporting, decision support, and performance measurement

Inter-operating with internal and external

systems

Readiness assessment & planning

Federal Stimulus Legislation: Multiple Areas of Focus

Appropriations for Health IT & HIE

New Incentives for Adoption

$2 billion for loans, grants & technical assistance:

• HIE Planning & Implementation Grants

• EHR State Loan Fund

• National Health IT Research Center & Regional Extension Centers

• Workforce Training

• New Technology R&D

New Medicare and Medicaid payment incentives to providers for EHR adoption

• $20 billion in expected payments through Medicare

• $14 billion in expected payments through Medicaid

• ~$34 billion in gross expected outlays, 2011-2016

$4.3 billion for broadband & $2.5 billion for distance learning/ telehealth grants

• Directs ONC to invest in telehealth infrastructure and tools

• Directs the new FACA Policy Committee to consider telehealth recommendations

Broadband and Telehealth

Comparative Effectiveness

$1.1 billion to HHS for CER

• Establishes Federal Coordinating Council to assist offices and agencies of the federal government to coordinate the conduct or support of CER and related health services

Details about Available Funding/Programs

En

titl

em

en

t F

un

ds

Ro

ug

hly

$

34

B i

n g

ros

s

ou

tla

ys

Medicare Payment

Incentives

Medicaid Payment

Incentives

Physicians/Dentists

• Acute care hospital • Children’s hospitals

Incentives through Carriers

Incentives through States• Nurse Practitioner• Midwife

FQHC

Req

uir

es

“Mean

ing

ful”

us

e o

f E

HR

CMS

CMS & States

ProgramFunding Distribution

Agency Use of Funds Fund Recipients / Beneficiaries

Ap

pro

pri

ate

d F

un

ds

$2

B

Workforce Training Grants

New Technology Research and Development

Grants

Medical Health Informatics

EHR in Med School Curricula • Higher Education• Medical School• Graduate schools

Health Care Information Enterprise Integration Research

Centers• Federal Gov’t Labs

HHS, NSF

NIST, NSF

Health IT Extension Program

Health IT Research Center

Regional Extension Centers Least Advantaged Providers

• Non-profit

ServicesONC

HIE Planning and Development

EHR Adoption Loan Program

Planning Grants

Implementation Grants

Loan Funds for States

Loan Funds for Indian Tribes

State Designated Entity

States

HC Providers

Loans

ONC

ONC

Indian Tribes

Medicare and Medicaid EHR Adoption Incentives

Medicare Medicaid

Funding mechanism(s)

Federal Incentive Payments Federal Incentive Payments

State matching payments (for admin costs)

Payment Agent Medicare carriers and contractors State Medicaid agencies

Payment Recipients

Hospitals and physicians Hospitals, physicians, NPs,dentists, mid-wives, third-party entities promoting EHR

adoption

State Medicaid agencies for program admin

Amounts for Hospitals

$2 million base amount Plus increases for annual

discharges, number of inpatient days attributable to Medicare, and charges attributable to Medicare

$2 million base amount Plus increases calculated using similar

methodology as Medicare incentive

(eligible entities include Acute Care and Children’s Hospitals)

Amounts for physicians & other health professionals

Up to $44,000 in Medicare reimbursements

Over 5 year period

Up to $64,000

Over a 5 year period covering up to 85% of eligible

implementation costs

Providers must demonstrate “Meaningful Use of Certified EHR Technology” to receive payments

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• HIE Infrastructure– SHIN-NY: Governance, Policy and Technical

Components

• Planning and Implementation Grants for State HIE Plan– NYeC = state designated entity

• Regional Extension Centers – EHR Service Bureau, CHITAs

• Loan Fund– Dormitory Authority

Key Concepts in Federal Stimulus and Alignment with NY’s Strategy

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Definition of “Meaningful Use” of EHRs Crosswalk to NY Strategy Framework

Three Components• Uses EHR in a meaningful manner,

which includes electronic prescribing as determined to be appropriate by the HHS Secretary

• Uses EHR that is “connected in a manner” that provides for the electronic exchange of health information to improve the quality of health care, such as promoting care coordination (in accordance with law and standards applicable to the exchange of information)

• Submits information on clinical quality measures and other measures as selected and in a form and manner specified by the Secretary

Framework for NY’s Health Information Infrastructure

Statewide Health Information Network

Clinical Informatics Services

Clinician/EHR