The Massachusetts Health Information Exchange Strategy
June 8, 2012
- -
Massachusetts Approach To Statewide HIE Services Funding (pre-Sep 2011)
• Massachusetts
Technology Collaborative
• Massachusetts eHealth
Institute
• HIT Council • MassHealth (Medicaid)
• Secretary of Health and
Human Services
• HIE/HIT Advisory
Committee
ONC
Cooperative
Agreement
CMS
SMHP
ONC
Challenge
Grants
Regional
Extension
Center
Statewide HIT/HIE Adoption
Statewide HIE Infrastructure
SDE
State HIT
Fund
$14M $12M $3.4M $11M
“Coordination”
?
HIE Services in Previous Plan
“…support for Consent management will be started. Initially, the focus will be on provider obtained consent
supporting clinical exchange and reporting. Planning will be started for a statewide service to enable consumers
to manage their own consent preferences”
- MEHI Strategic and Operational Plan, August 30, 2010
- -
Massachusetts Approach To Statewide HIE Services Funding (post-Sep 2011)
• Massachusetts
Technology Collaborative
• Massachusetts eHealth
Institute
• HIT Council • MassHealth (Medicaid)
• Secretary of Health and
Human Services
• HIE/HIT Advisory
Committee
ONC
Cooperative
Agreement
CMS HITECH/
MMIS
ONC
Challenge
Grants
Regional
Extension
Center
Statewide HIT/HIE Adoption Statewide HIE
Infrastructure
SDE
State HIT
Fund
$14M $12M $3.4M $11M $XXM for Phase
1
Complementary
90/10
funding
Private
funding
$472K per
year
Workgroup Structure, Leadership, and Staffing
Legal & Policy
Workgroup
Technology &
implementation
Workgroup
Finance &
sustainability
Workgroup
Consumer and public
engagement
workgroup
Provider
engagement &
adoption workgroup
Co-Chairs:
-Wendy Mariner
-Gillian Haney
Facilitator:
-Ray Campbell
Business Analyst:
-Christina Moran
Co-Chairs:
-John Halamka
-Manu Tandon
Facilitator:
-David Delano
Business Analyst:
-David Delano
Co-Chairs:
-Andrei Soran
-Steve Fox
Facilitator:
-Micky Tripathi
Business Analyst:
- Christina Moran
Co-Chairs:
-John Halamka
-Manu Tandon
Facilitator:
-Micky Tripathi
Business Analyst:
-Mark Belanger
Co-Chairs:
-Jessica Costantino
-Kathleen Donaher
Facilitator:
-Christina Moran
Co-Chairs:
-Michael Lee, MD
-Dirk Stanley, MD
Facilitator:
-Mark Belanger
HIT Council
HIE-HIT Advisory Committee
- -
Various projects can be mapped into phases using criteria
assessing difficulty, market demand, and market gaps
Difficulty
•Are there significant business,
technical, governance, or legal
complexities that need to be resolved
before deploying the service/
Demand for HIE service
•Is there immediate market demand for
the transaction as a statewide HIE
service?
Gap in market today
•Is there a gap in the market today?
•Ready to go
•Move to requirements and RFP
development
•No significant technical or policy
barriers
•Needs governance & business
model development
•Needs scoping and budgeting
•Multiple barriers to tackle
•Needs policy, technical,
governance, and business model
development
•Needs scoping and budgeting
Phasing criteria Phasing HIE projects
Phase 1
Phase 2
Phase 3
Phasing defines Roadmap for Statewide HIE Program (from Sep 19, 2011 HIT Council Presentation)
•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
8
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
High-level Deliverables by Phase (from Sep 19, 2011 HIT Council Presentation)
Phase 1:
Information Highway
Phase 2:
Analytics & Population Health
Phase 3:
Search and Retrieve
Legal & Policy
Workgroup
Technical and
Implementation
Finance and
Sustainability
Consumer & Public
Engagement
Provider engagement
& adoption
•Governance model for statewide HIE
services
•Consent policy for routing services
•Security/policy framework for statewide
services
•Operational model for statewide HIE
services
•Requirements for Phase 1 RFPs
•Financial models for Phase 1 services
•Cost allocation MOUs for Phase 1
services
•Public input on statewide HIE plan
•Consumer participation in functional
working groups
•Provider input on statewide HIE plan
•Provider participation in functional
working groups
•Consent policy for registry and
warehousing services
•Governance model for quality data
infrastructure
•Technical requirements for warehousing
& registry infrastructure
•Requirements for Phase 2 RFPs
•Financial models for Phase 2 services
•Cost allocation MOUs for Phase 2
services
•Public input process on warehousing
and registries
•Consumer participation in functional
working groups
•Provider input on warehousing and
registries
•Provider participation on functional
working groups
•Consent policy for search and retrieve
functions
•Governance model for EMPI/RLS
functions
•Technical requirements of
query/retrieve, EMPI, and RLS
•Requirements for Phase 3 RFPs
•Financial models for Phase 3 services
•Cost allocation MOUs for Phase 3
services
•Public input process on query/retrieve,
EMPI/RLS models
•Consumer participation in functional
working groups
•Provider input process on
query/retrieve, EMPI/RLS models
•Provider participation in functional
working groups
Clinical document type prioritization by Provider Adoption WG
• High-priority and high- to medium-maturity
• Discharge Summary
• Consult Note
• ER Note
• Encounter Summary
• Lab Results
• Syndromic Surveillance
• Immunization Record
• Imaging Results
• Universal transfer form (UTF)
• Referral
• Medical Summary
• Lab/imaging Order
• High-priority and low- to medium-maturity
• Advance directives
• Death notification
• Admission notification
• Request for medical summary
Recommend to Technology and
Implementation WG to identify standardized
approaches for electronic exchange
Recommend to Technology and
Implementation WG to confirm standards and
identify implementation guides
- - Massachusetts eHealth Collaborative
filename © MAeHC. All rights reserved.
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 Completed May 2012
12) Infrastructure Vendor selected and under contract June, 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
Current state of the market favors a network of networks connected via a single statewide open HISP supported by centralized project management
Illustrative example
Berkshire Health
System NEHEN
SafeHealth MD
MD
MD MD Fallon Clinic
UMass
Memorial
Statewide HISP
PKI/certificate mgmt Web
portal
Provider/entity
directory
Audit
log
MD MD
MD
MD MD
MD
BIDMC Partners
Direct gateway
services
EOHHS NwHIN
MassHealth
DPH
Atrius
- - Massachusetts eHealth Collaborative
filename © MAeHC. All rights reserved.
Trust Fabric (Illustrative)
Commwealth HIE
HISP
Commonwealth HIE Trust Fabric
MMS
HISP
NEHEN HISP
AthenaHealth
HISP
New
Hampshire
HISP
Berkshire Health
HISP
Part
ners
HIS
P
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
Generic Process for HIE Transactions
Provider directory
Certificate repository
DIRECT gateway
Web portal mailbox
HIE Services
Sender creates message
Lookup provider information in
Provider Directory
Get certificate information from
Certificate Repository
Encrypt message
Send securely to HIE
HIE processes message and
sends to recipient
Recipient decrypts message and
processes message
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
Five Basic Patterns for HIE Transactions
EHR connects directly
Browser access to
webmail inbox
EHR connects directly
Browser access to
webmail inbox
4a
3
2
1
4a
3
2
1 Webmail-to-Webmail
Webmail-to-EHR
EHR-to-Webmail
EHR-to-EHR (via Direct Gateway)
4b
4b EHR-to-EHR (point-to-point)
Different patterns “touch” different parts of the HIE
Webmail-to-
Webmail
Webmail-to-
EHR
EHR-to-
Webmail
EHR-to-EHR
(via Direct
Gateway)
EHR-to-EHR
(point-to-point)
Certificate repository
DIRECT gateway
Web portal mailbox
Provider directory
4a 3 2 1 4b
“Lookup”
services
“Message-
handling” services
- - Massachusetts eHealth Collaborative
filename © MAeHC. All rights reserved.
VGShared Service
Virtu
al G
ate
wa
y
VG Shared Services
Virtu
al G
ate
wa
y
HIE Users (Medicaid & Non-Medicaid)
Statewide HISP
Direct Gateway**
Medicaid & Public Health Applications
SMHP & MMIS Phase 1: Leverage Existing Infrastructure
Syndromic
Surveillance
MMIS
Claims Engine Provider Online
Service Center
MMIS Base Application
MMIS Users
CBHI (Children’s Behavioral
Health Initiative )
Immunization Electronic
Laboratory Reports
Existing enterprise shared services include:
* Upgrade/Expansion
** New
AIMS (Access and
Identity Management)
Other Existing
Enterprise Shared
Services
Clinical Gateway (HL7 Interfaces)
AIMS* (Access and
Identity Management)
Clinical Gateway (HL7 Interfaces)
PKI** (Public Key
Infrastructure)
Provider Directory**
Syndromic
Surveillance
CBHI (Children’s Behavioral
Health Initiative )
- - Massachusetts eHealth Collaborative
filename © MAeHC. All rights reserved.
Simplify User Access and Repurpose New and Existing Components
MMIS Shared Service
Virtu
al G
ate
way
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
Virtu
al G
ate
way
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
- - Massachusetts eHealth Collaborative
filename © MAeHC. All rights reserved.
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
- - Massachusetts eHealth Collaborative
filename © MAeHC. All rights reserved.
Complement Infrastructure with Multi-Pronged Adoption Program
MMIS Shared Service
Virtu
al
Gate
wa
y
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
Virtu
al
Gate
wa
y
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
Pricing and Participation Principles for Private Contributions Finance and Sustainability WG recommendations
• Fee distribution: HIE private sector customers utilizing these services collectively should pay a share of ongoing operating costs as outlined in the agreements between EOHHS and CMS. For now, and for the foreseeable future, that amount is approximately $450,000 per year.
• Pricing philosophy: Private sector customer fees for entities utilizing these services should be "cost-based" where a share of ongoing operating costs are divided among private sector. It is anticipated that prices will vary for certain distinct customer segments
(to be defined) in a manner still to be determined.
• Fee basis: Private fees should be structured through a subscription model rather than a transaction model. A subscription model encourages HIE service usage and provides
customers with predictable fees.
• Fee mandates: Private funding of statewide HIE services should be on a voluntary basis. No organization should be compelled to pay for HIE services through statutory,
regulatory, or administrative channels.
• Funds administration: EOHHS needs to identify how privately contributed funds will be managed and administered. In particular, private sector fees and contributions need to
be protected from other State uses and policies and governance developed to guide how such funds will be utilized
- - - -
Next Steps
• Contracting complete in June
• Complete policy development and infrastructure build by September, 2012
• Go live October 15, 2012 - the Golden Spike!
• Complete SEE (CDA viewer/editor) application features by December 2012
• Last Mile program ensures providers in the Commonwealth will be ready for Meaningful Use 2014 edition by the October 2013 reporting start date