Strategic Planning Session Today’s Goals Get Educated Get Inspired Get Connected Get Involved New Hampshire Health Information Organization © NHHIO. All rights reserved. -2- Agenda Welcome and Introductions – Denise Purington, Board Chair, NHHO - Jeff Loughlin, NHHIO Executive Director The State Perspective – William Baggeroer, Chief Information Officer, NH DHHS Where did we start from – How far have we come? – Mark Belanger, Director of Strategic Advisory Services, Massachusetts eHealth Collaborative Legislative Issues and Concerns – Denise Purington, Board Chair, NHHIO Current State of NHHIO – Jeff Loughlin, NHHIO Executive Director Future of Health Information Exchange – Micky Tripathi, President & CEO, Massachusetts eHealth Collaborative HIE Adoption and Use Case Review – Mary Beth Eldredge, Board Vice Chair, NHHIO Participant Discussion Getting Involved, Getting Connected – Jackie Baldaro, Project Manager, NHHIO Q& A - Closing Remarks New Hampshire Health Information Organization © NHHIO. All rights reserved. -3- Introductions - NHHIO Board of Directors Board Member Representation Board Member Representation Denise Purington CIO Elliot Hospital NHHIO Chair Board Member at Large Hospitals David Briden CIO Exeter Hospital NH Hospital Association Large Hospitals Mary Beth Eldredge IT Director Dartmouth Hitchcock NHHIO Vice Chair Board Member at Large Hospitals Patricia Witthaus IT Director Valley Regional Hospital NH Hospital Association Critical Access Hospitals Kirsten Platte CHAN NHHIO Secretary Bi-State Primary Care Association Dr. Richard Lafleur Anthem BC/BS Board Member at Large Health Plans Carol LaCross CFO - Retired NHHIO Treasurer Board Member at Large Michael Lehrman Catholic Charities Board Member at Large NH Health Care Assoc. Deb Mullen Concord VNA Home Care Association Mark Guptill Community Partners NH Behavioral Health Association Dr. Daniel Waszkowski Derry Medical Center NH Medical Society David Querusio Harvard Pilgrim Healthcare Board Member at Large Health Plans William Baggeroer DHHS Board Member at Large DHHS Dr. Christine Rosenwasser Dartmouth Hitchcock Pediatrics Board Member at Large Physicians Victor St. Pierre Consumer Advocate Board Member at Large Consumers Lorraine Nichols IT Consultant Board Member at Large Vacant Retail Pharmacy New Hampshire Health Information Organization © NHHIO. All rights reserved. -4- Introductions – NH Team NHHIO Staff: Jeff Loughlin – Executive Director Jackie Baldaro – Project Manager Micky Tripathi – Senior Advisor NHHIO Partners: Mark Belanger – Strategic Advisor Nancy Fennell – Regional Extension Center (REC) Director Jaime Dupuis – EHR/HIE Consultant Len Levine – EHR/HIE Consultant Gary Tomlinson – Hospital Consultant Jennifer Monahan – Program Coordinator New Hampshire Health Information Organization © NHHIO. All rights reserved. -5- Introductions Orion Health Partners: Nick Yarker Project Manager Lisa Sherwin Regional VP, Professional Services Group New Hampshire Health Information Organization © NHHIO. All rights reserved. -6- Introductions Large Hospitals and providers Critical Access Hospitals and providers Private practices Home health care, VNA, and hospice Long term care or rehabilitation facilities Behavioral Health NH State entities Surgical centers Legislators Professional Associations Members of the press Anyone I missed? New Hampshire Health Information Organization © NHHIO. All rights reserved. -7- Agenda Welcome and Introductions – Denise Purington, Board Chair, NHHO - Jeff Loughlin, NHHIO Executive Director The State Perspective – William Baggeroer, Chief Information Officer, NH DHHS Where did we start from – How far have we come? – Mark Belanger, Director of Strategic Advisory Services, Massachusetts eHealth Collaborative Legislative Issues and Concerns – Denise Purington, Board Chair, NHHIO Current State of NHHIO – Jeff Loughlin, NHHIO Executive Director Future of Health Information Exchange – Micky Tripathi, President & CEO, Massachusetts eHealth Collaborative HIE Adoption and Use Case Review – Mary Beth Eldredge, Board Vice Chair, NHHIO Participant Discussion Getting Involved, Getting Connected – Jackie Baldaro, Project Manager, NHHIO Q& A - Closing Remarks New Hampshire Health Information Organization © NHHIO. All rights reserved. -8- Agenda Welcome and Introductions – Denise Purington, Board Chair, NHHO - Jeff Loughlin, NHHIO Executive Director The State Perspective – William Baggeroer, Chief Information Officer, NH DHHS Where did we start from – How far have we come? – Mark Belanger, Director of Strategic Advisory Services, Massachusetts eHealth Collaborative Legislative Issues and Concerns – Denise Purington, Board Chair, NHHIO Current State of NHHIO – Jeff Loughlin, NHHIO Executive Director Future of Health Information Exchange – Micky Tripathi, President & CEO, Massachusetts eHealth Collaborative HIE Adoption and Use Case Review – Mary Beth Eldredge, Board Vice Chair, NHHIO Participant Discussion Getting Involved, Getting Connected – Jackie Baldaro, Project Manager, NHHIO Q& A - Closing Remarks New Hampshire Health Information Organization © NHHIO. All rights reserved. -9- Health Information Exchange in New Hampshire Where did we start from – How far have we come? September 20, 2013 Massachusetts eHealth Collaborative - 10 - In 2010 we collectively established a high degree of consensus around five strategies 1. Establish a sustainable organizational, governance, and technical foundation for achievement of long term statewide health information goals 2. Level-set individual providers’ abilities to meet Stage 1 Meaningful Use criteria by facilitating e-Prescribing, lab results delivery, and patient care summary exchange across the state 3. Catalyze the efforts of programs focused on HIT adoption 4. Expand availability of HIE services to providers that do not currently have access to robust capabilities for health information exchange 5. Collaborate with Legislators to define the future policy governing HIE purpose and participants Massachusetts eHealth Collaborative - 11 - NH DHHS, NHHIO, the REC of NH, and many committed volunteers have made steady progress ever since Major accomplishments to date: • The New Hampshire Health Information Organization (NHHIO) is now in place • The NHHIO Board of Directors has been established, has set bylaws, has elected officers, and has formed committees • The Executive Director has been selected and NHHIO has been staffed for operations • The Technical services provider, Orion Health, has been selected and is on board • The contract with NH DHHS has been executed to transfer duties and funding to NHHIO • The Participation Agreement, Policies & Procedures, and pricing has all been finalized and is being used with new members • Technical services have been configured and NHHIO has moved forward with 4 pilot sites (Exeter, Seacoast Mental Health, Elliot, and DPH) • The Legislature has passed legislation allowing public health to participate in NHHIO and for PH reports to be sent via NHHIO – There is recent progress to align the HIE law with HIPAA • Alongside NHHIO and NH DHHS, the REC of NH has helped many of the state’s providers and critical access hospitals implement and use EHRs. • 26 organizations have kicked off with NHHIO and 10+ more are in the pipeline Massachusetts eHealth Collaborative - 12 - Where do we stand? eRx in NH - 2012 eRx in NH - 2012 % of pharmacies participating in eprescribing (Surescripts) 96% % of physicians actively e-prescribing via Surescripts network (SS) 83% % of physicians actively using an electronic health record to e-prescribe via SS network (SS) 76% % of new and renewal prescriptions eprescribed (SS) 0% 64% 20% 40% Massachusetts eHealth Collaborative 60% 80% 100% - 13 - Where do we stand? Lab order/result exchange in NH - 2012 Lab order/result exchange in NH - 2012 % of ambulatory providers able to view lab results electronically (NAMCS) 77% % of hospitals sharing laboratory results electronically with ambulatory providers outside their system (AHA) 73% % of ambulatory providers able to send lab orders electronically (NAMCS) 63% % of labs electronically sending structured lab results to providers outside their organization (UNH) 45% % of hospitals sharing laboratory results electronically with hospitals outside their system (AHA) 0% 28% 20% 40% Massachusetts eHealth Collaborative 60% 80% 100% - 14 - Where do we stand? Care summary exchange in NH - 2012 Care summary exchange in NH - 2012 % of hospitals sharing electronic care summaries with ambulatory providers outside their system (AHA) % of ambulatory providers electronically sharing care summaries with other providers (NAMCS) % of hospitals sharing electronic care summaries with hospitals outside their system (AHA) 0% 27% 22% 20% 20% 40% Massachusetts eHealth Collaborative 60% 80% 100% - 15 - Where do we stand? Care summary exchange with Patients in NH - 2012 Care summary exchange with Patients in NH - 2012 % of hospitals capable of providing patients with an electronic copy of their health information (AHA) 84% % of ambulatory providers able to provide patients with clinical summaries for each visit (NAMCS) 0% 59% 20% 40% Massachusetts eHealth Collaborative 60% 80% 100% - 16 - What other “pain points” should we keep an eye on? 1. Focus first on those gaps we identified originally such as facilitating medication reconciliation and transfers of care 2. Need to stay aligned with and support Accountable Care and Stage 2 Meaningful Use 3. Admission/Discharge/Transfer (ADT) transport and support of real time notifications and alerting. 4. Stay out front with privacy & security issues 5. Help providers avoid building infrastructure and/or interfaces twice 6. Interstate connectivity 7. Address the needs of provider types that were left out of Meaningful Use 8. Facilitate administrative transactions such as prior authorizations, claims eligibility, and claims status 9. Provide translation services (e.g., RxNorm, LOINC mapping) 10.Stay cognizant of market consolidation and adjust accordingly Massachusetts eHealth Collaborative - 17 - What organization types should be prioritized for connection? Importance of exchanging data with stakeholder types (June 2013 survey results n=20) Hospitals 5 Physician Practices 15 4 15 Public Health Agencies 12 Home Health 6 9 9 LTC/SNF 12 Quality Data Reporting 6 8 Case Managers 8 6 9 Veteran's Administration 12 Laboratories 7 Patients 7 Payers 3 8 7 5 medium priority 9 Pharmacies 10 Imaging Centers 9 Out of State Providers 5 5 0 2 high priority 4 4 4 6 8 10 Massachusetts eHealth Collaborative 12 14 16 18 20 - 18 - What are the reasons to join NHHIO? Reasons to Join NHHIO (June 2013 survey results n=17) Satisfy meaningful use requirements 14 Improve care transitions through sending and receiving patient care summaries with outside providers 14 Provide clinicians with a means to more easily access critical patient information from providers outside my organization 14 Support Patient Centered Medical Home information sharing needs 12 Support Accountable Care Organization information sharing needs 11 Send required reports to the Department of Public Health 11 Reduce (consolidate) interfaces my organization has with other organizations 10 Send lab orders to labs outside of my organization 10 Reduce staff time, effort, and cost spent on medical records management 9 Send and receive event notifications 9 Receive lab results from labs outside of my organization 8 0 2 4 Massachusetts eHealth Collaborative 6 8 10 12 14 16 - 19 - Thank you! Mark Belanger Director of Advisory Services Massachusetts eHealth Collaborative 860 Winter Street, Waltham, MA 02451 mbelanger@maehc.org Tel: 781.434.7889 Mobile: 339.223.2051 Massachusetts eHealth Collaborative - 20 - Agenda Welcome and Introductions – Denise Purington, Board Chair, NHHO - Jeff Loughlin, NHHIO Executive Director The State Perspective – William Baggeroer, Chief Information Officer, NH DHHS Where did we start from – How far have we come? – Mark Belanger, Director of Strategic Advisory Services, Massachusetts eHealth Collaborative Legislative Issues and Concerns – Denise Purington, Board Chair, NHHIO Current State of NHHIO – Jeff Loughlin, NHHIO Executive Director Future of Health Information Exchange – Micky Tripathi, President & CEO, Massachusetts eHealth Collaborative HIE Adoption and Use Case Review – Mary Beth Eldredge, Board Vice Chair, NHHIO Participant Discussion Getting Involved, Getting Connected – Jackie Baldaro, Project Manager, NHHIO Q& A - Closing Remarks New Hampshire Health Information Organization © NHHIO. All rights reserved. - 21 - New Hampshire Health Information Organization Legislative Updates Denise Purington Board Chair CIO Elliot Hospital Our Changing Environment ARRA Signed Feb 2009 2009 RSA 332:I PHI Use 2009 ACA Signed Mar 2010 ONC Approves SOP Sep 2010 2010 DHHS begins HIE development Nov 2009 HB489 Creates NHHIO Jul 2011 SB288 DHHS Reporting Jun 2012 2011 NH ACO Pilots Jun 2010 Stage 1 MU 2011 2012 Pioneer ACO Dec 2011 New Hampshire Health Information Organization Stage 2 MU 2013 2013+ PCMH, P4P, ACO 2012 © NHHIO. All rights reserved. - 23 - Healthcare Improvement Goals Better Care Patient Safety Quality Patient Experience Reduce Per Capita Cost Reduce unnecessary and unjustified medical cost Reduce administrative cost thru process simplification Improve Population Health Decrease health disparities Improve chronic care management and outcome Improve community health status New Hampshire Health Information Organization © NHHIO. All rights reserved. - 24 - Health Information Technology Drivers Meaningful Use and CMS EHR Incentive Program Maximizes use of electronic data exchange for efficiency and safety Requires care coordination and patient engagement Requires HIPAA compliant transactions Patient Centered Medical Home Develops closed-loop electronic referral system Encourages patient engagement and participation Maximizes care coordination to eliminate redundancy and waste Accountable Care Organizations Requires effective care coordination and care management Maximizes clinical efficiency and decreases costs Requires HIPAA compliant transactions New Hampshire Health Information Organization © NHHIO. All rights reserved. - 25 - NHHIO Legislative Updates Update Definitions to Fully Align with HIPAA Undefined terms leads to ambiguity and misinterpretation of meaning “Healthcare Services” is not defined in provider definition “Treatment” is not defined under use and disclosure Update Use and Disclosure to Fully Align with HIPAA Variability of transmission methods drives inconsistency and increased cost Allow all parties currently receiving and reviewing PHI to do so using safe, secure and auditable methods Patient engagement increases self-management, self-regulation, and informed decision making process for clinical and cost effectiveness New Hampshire Health Information Organization © NHHIO. All rights reserved. - 26 - NH HIE Facts: (RSA 332-I:2) A health care provider or business associate may disclose an individual's PHI and information about the location of an individual's medical records to a HIE – allows for Electronic Master Person Index (EMPI) (Phase 2) Individual must be given an opportunity to opt out of sharing his/her name, address, and PHI through a HIE – information not sent to HIE, does not prevent public health reporting Only a health care provider, for purposes of treatment, may access PHI in a HIE – does not include patients or payors A HIE must maintain an audit log of health care providers who access PHI – central site will maintain transmission logs When federal certification standards are established, a HIE must be certified to be in compliance with nationally accepted interoperability standards and practices – NHHIO is using Direct standards for message transport SB288 – Authorized reporting to Department of Health and Human Services (DHHS) – AHEDD, Cancer Registry, Immunization Registry New Hampshire Health Information Organization © NHHIO. All rights reserved. - 27 - Legal Language Updates II. In this chapter: (a) The following terms have the same meaning as given in the regulations under sections 160, 262 and 264 of the Health Insurance Portability and Accountability Act of 1996 (HIPAA): (1) Business associate; (2) Use; (3) Disclosure; and (4) Protected health information; and (5) Health care provider (b) "Health care provider'' means any person, corporation, facility, or institution either licensed by this state or otherwise lawfully providing health care services, including, but not limited to, a physician, hospital, office, clinic, health center or other health care facility, dentist, nurse, optometrist, pharmacist, podiatrist, physical therapist, or mental health professional, and any officer, employee, or agent of such provider acting in the course and scope of employment or agency related to or supportive of health care services. New Hampshire Health Information Organization © NHHIO. All rights reserved. - 28 - Legal Language Updates Comment: The current law uses an undefined term of “health care services” in order to define a health care provider. In order to alleviate any ambiguity, and to ensure consistency of interstate communication capabilities with other organizations, we suggest using the standard HIPAA definition of a Health care provider. Section 160 of HIPAA contains the definition of Health care provider. “Health care provider” has the meaning given such term in section 160.103 of title 45, Code of Federal Regulations: Provider of services (as defined in section 1861(u) of the [Social Security] Act, 42 U.S.C. 1395x(u)), a provider of medical or health services (as defined in section 1861(s) of the Act, 42 U.S.C. 1395x(s)), and any other person or organization who furnishes, bills, or is paid for health care in the normal course of business. New Hampshire Health Information Organization © NHHIO. All rights reserved. - 29 - Legal Language Updates 332-I:3 Use and Disclosure of Protected Health Information; Health Information Exchange. – I. Except as provided in paragraph VI, a health care provider, or a business associate of a health care provider, or patient, may transmit an individual's protected health information through the health information organization. Only a health care provider, for purposes of treatment, may have access to Except as provided in section 332-I:4, protected health information transmitted through the health information organization., may only be used and disclosed in accordance with the Health Insurance Portability and Accountability Act of 1996 (HIPAA). New Hampshire Health Information Organization © NHHIO. All rights reserved. - 30 - Legal Language Updates Comment: 1. The current language prevents the transmission to, or the receipt of information from patients that may be required by a variety of clinical improvement and home monitoring programs. 2. By limiting the transmission of data for treatment purposes only, which is also an undefined term, providers will be required to build a variety of alternative conduits for data transmission for care coordination and accountable care reporting. 3. By allowing the data to be utilized in accordance with HIPAA, organizations may utilize the data for care coordination purposes, or it may be de-identified for use by NH Medicaid Manage care plans for population reporting and management activities that are critical for cost saving programs. 4. These changes retain all the original limitations on use of the data for marketing and fundraising activities. New Hampshire Health Information Organization © NHHIO. All rights reserved. - 31 - Questions and Comments New Hampshire Health Information Organization © NHHIO. All rights reserved. - 32 - Agenda Welcome and Introductions – Denise Purington, Board Chair, NHHO - Jeff Loughlin, NHHIO Executive Director The State Perspective – William Baggeroer, Chief Information Officer, NH DHHS Where did we start from – How far have we come? – Mark Belanger, Director of Strategic Advisory Services, Massachusetts eHealth Collaborative Legislative Issues and Concerns – Denise Purington, Board Chair, NHHIO Current State of NHHIO – Jeff Loughlin, NHHIO Executive Director Future of Health Information Exchange – Micky Tripathi, President & CEO, Massachusetts eHealth Collaborative HIE Adoption and Use Case Review – Mary Beth Eldredge, Board Vice Chair, NHHIO Participant Discussion Getting Involved, Getting Connected – Jackie Baldaro, Project Manager, NHHIO Q& A - Closing Remarks New Hampshire Health Information Organization © NHHIO. All rights reserved. - 33 - New Hampshire Health Information Organization Jeff Loughlin Executive Director American Recovery and Reinvestment Act (ARRA) Transforming Healthcare HITECH: Catalyst for Transformation Three-Part Aim: Better Healthcare Better Health Paper Records HITECH Act Pre 2009 2009 EHR Incentive Program and 62 Regional Extension Centers A system plagued by inefficiencies Reduced Costs EHRs & HIE 2014 Widespread adoption & meaningful use of EHRs Health Information Technology for Economic and Clinical Health (HITECH) - Framework Regional Extension Centers ADOPTION Improved Individual & Population Health Outcomes Workforce Training Medicare and Medicaid Incentives and Penalties MEANINGFUL USE Improved Ability to Study & Improve Care Delivery State Grants for Health Information Exchange Standards & Certification Framework Increased Transparency & Efficiency EXCHANGE Privacy & Security Framework 37 HITECH Framework in New Hampshire ADOPTION Improved Individual & Population Health Outcomes MEANINGFUL USE Increased Transparency & Efficiency Improved Ability to Study & Improve Care Delivery EXCHANGE New Hampshire Health Information Exchange Plan June 2010 created multi-stakeholder groups The plan is the result of collaborative planning among over 80 stakeholders 380 stakeholder comments were addressed in the current version The plan continues to evolve as we refine the strategy, obtain broader stakeholder input, and incorporate updated use cases from the field Current strategic plan is posted at http://www.dhhs.nh.gov/hie/strategic.htm New Hampshire Health Information Organization © NHHIO. All rights reserved. - 39 - Establishing Governance HB #489 (July 2011) created the New Hampshire Health Information Organization (NHHIO) NHHIO Governed by a broad community based multi-stakeholder Board of Directors Seven (7) seats named by statute with 10 at-large members 501(c)(3) Public Charity organization status received August 2012 New Hampshire Health Information Organization © NHHIO. All rights reserved. - 40 - NHHIO Board of Directors Board Member Representation Board Member Representation Denise Purington CIO Elliot Hospital NHHIO Chair Board Member at Large Hospitals David Briden CIO Exeter Hospital NH Hospital Association Large Hospitals Mary Beth Eldredge IT Director Dartmouth Hitchcock NHHIO Vice Chair Board Member at Large Hospitals Patricia Witthaus IT Director Valley Regional Hospital NH Hospital Association Critical Access Hospitals Kirsten Platte CHAN NHHIO Secretary Bi-State Primary Care Association Dr. Richard Lafleur Anthem BC/BS Board Member at Large Health Plans Carol LaCross CFO - Retired NHHIO Treasurer Board Member at Large Michael Lehrman Catholic Charities Board Member at Large NH Health Care Assoc. Deb Mullen Concord VNA Home Care Association Mark Guptill Community Partners NH Behavioral Health Association Dr. Daniel Waszkowski Derry Medical Center NH Medical Society David Querusio Harvard Pilgrim Healthcare Board Member at Large Health Plans William Baggeroer DHHS Board Member at Large DHHS Dr. Christine Rosenwasser Dartmouth Hitchcock Pediatrics Board Member at Large Physicians Victor St. Pierre Consumer Advocate Board Member at Large Consumers Lorraine Nichols IT Consultant Board Member at Large Vacant Retail Pharmacy New Hampshire Health Information Organization © NHHIO. All rights reserved. - 41 - NHHIO Architecture and Services CHAN Health Centers Public Health (DHHS) VNA / Homecare Inter-state communications ASCC NH Statewide Network – “Backbone” Phase I: Node addressing Security Provider addressing Audit • Direct Secure Messaging Record Locator Service (EMPI) • Inter-state gateway Phase II: Provider Practices NH Hospital Hospital MD MD MD MD Behavioral Health Diagnostic testing Long-term care SNFs • Relationship Listing Service (RLS) Electronic Master Person Index (EMPI) MD New Hampshire Health Information Organization © NHHIO. All rights reserved. - 42 - Electronic Health Record (EHR) Integration User types HIE Services 3 methods of accessing HIE services Physician practice Provider directory EHR connects directly Hospital Certificate repository EHR connects through LAND Appliance Long-term care Other providers Public health Health plans DIRECT gateway Browser access to webmail inbox Web portal mailbox New Hampshire Health Information Organization © NHHIO. All rights reserved. - 43 - Gateway to access HIEs Across New England ME VT NH NY MA CT R I New Hampshire Health Information Organization © NHHIO. All rights reserved. - 44 - Participant Schedule Participant Implementation Messages current/planned Status September 2013 October 2013 November 2013 2-Sep 9-Sep 16-Sep 23-Sep 30-Sep 7-Oct 14-Oct 21-Oct 28-Oct 4-Nov 11-Nov 18-Nov 25-Nov Production AHEDD, ELR data Exeter Hospital Testing Hospital Discharge Summaries Seacoast Mental Health Center Testing Medical Summary State of New Hampshire Department Public Health Production Recieving AHEDD, ELR Dartmouth Hitchcock Medical Center On boarding AHEDD, ELR data State of New Hampshire Cancer Registry On boarding Receiving Cancer Registry data Cheshire Medical Center On boarding AHEDD data Valley Regional Hospital (CAH) On boarding AHEDD data Pemi Baker On boarding Provider Orders, Medical Summary Androscoggin On boarding AHEDD data, Medical Summary Cornerstone VNA On boarding Medical Summary Central VNA & Hospice On boarding Medical Summary COOS County On boarding Medical summary Catholic Medical Center On boarding Medical Summary Franklin VNA & Hospice On boarding Medical Summary Midstate Health On boarding Medical Summary Community Health Access Network (CHAN) On boarding Medical Summary Frisbie Memorial On boarding Cottage Hospital On boarding Derry Medical On boarding Medical Summary Speare Memorial On boarding AHEDD data, ELR data, Discharge/Medical Summary Home Health & Hospice On boarding Medical Summary Monadnock Family Services Scheduled Medical Summary Access Sports Medicine Scheduled Medical Summary Weeks Medical Center Scheduled AHEDD data, Medical Summary Huggins Hospital Scheduled AHEDD data, Medical Summary Mental Health Center of Greater Nashua Scheduled Medical Summary VNA & Hospice of Northern Carroll County Scheduled Medical Summary Mental Health Center of Greater Manchester Scheduled Gastroenterology PA (GASPA) Scheduled AHEDD data, Discharge Summary AHEDD data, ELR data, Medical Summary Stage 2 Meaningful Use Elliot Hospital Medical Summary New Health Information Organization MedicalHampshire Summary © NHHIO. All rights reserved. - 45 - Participant Schedule Participant Implementation Messages current/planned September 2013 Status 2-Sep 9-Sep 16-Sep 23-Sep 30-Sep Pending Schedule Pending Schedule Pending Schedule Pending Schedule Pending Schedule Pending Schedule Pending Schedule Pending Schedule Pending Schedule Pending Schedule Pending Schedule Pending Schedule Pending Schedule Pending Schedule Homemakers Health Services Memorial Hospital St. Josephs Hospital Southern New Hampshire Medical Center Southern New Hampshire Internal Medicine Concord Hospital Concord VNA Franklin Regional Hospital Littleton Regional Northern Human Services New London Hospital Ammonoosuc Community Health Center West Central Behavioral Health Wentworth-Douglass Legend: Status:Implementing Testing New Hampshire Health Information Organization Production © NHHIO. All rights reserved. - 46 - Can I query the HIE for available records and request the information? Currently, NHHIO does not provide a centralized data repository of patient records for querying and retrieving functions, but is creating a platform for electronic directed secure messaging (DSM). However, through the Relationship List Service (RLS) in phase II, NHHIO providers will be able to see a list of organizations where the patients have some type of record associated and the date of the last encounter. Providers may then reach out to the organization through traditional methods associated with the encounter and request the information to be sent to them. NHHIO will also provide a Healthcare Provider Directory (HPD) of all participating providers and organizations. New Hampshire Health Information Organization © NHHIO. All rights reserved. - 47 - What is the Healthcare Provider Director (HPD) used for? NHHIO is establishing a payload agnostic platform to allow organizations to transmit any type of message, file or document that relates to patient treatment. The message is encrypted and transmitted based on the HPD information available to the HIE. This “To” and “From” addressing information can be manually embedded into the file name of the message, ie. FromAddress..ToAddress[##UniqueIdentifier][#Filename], or as an example, from@sendingOrganization.com..to@receivingOrganizations.com##20130212#JoeBloggs.pdf Or, the “To” and “From” information may also be embedded into the C32 CCD , or CDA document, HL7 or XML message depending on vendor capabilities. The ability to include this information into a local provider directory in your EHR or other source system, or not, will help determine our integration methods with each source system. New Hampshire Health Information Organization © NHHIO. All rights reserved. - 48 - LAND Appliance Device Next Unit of Computing Kit Processor Intel Celeron 847 (1.10 GHz) RAM 8GB RAM (2ea 4GB DDR3 SDRAM) Hard Drive 120 GB SSD (Intel SSD 525) Dimensions 4.59”x4.41”x1.55” New Hampshire Health Information Organization © NHHIO. All rights reserved. - 49 - LAND Appliance NHHIO Participant NHHIO Central Site Orion Health Direct Secure Messaging Deployment Facility EMR/ Interface Engine Messaging LAND Appliance HISP Services Administration Orion Health Monitoring • HIE Gateway – message packaging, transmission, encryption • LAND Appliance uses outbound communication only • Centrally managed and remotely supported • Communicates “up” status to central site • Local “hot-swap” appliances available New Hampshire Health Information Organization © NHHIO. All rights reserved. - 50 - How does the LAND appliance communicate? The LAND appliance periodically pings the central site in order to determine if messages are waiting for retrieval. Communications are outbound only directed to a single IP address through a single Port on the local firewall. Once messages are identified, they are then pulled into the LAND, unencrypted, then delivered to destination. Communication between the participant and the LAND appliance is un-secure. http://www.nhhio.org/sites/nhhio.org/files/media/NHHIO%20Solution%20Diagram.pdf Where is the best placement of the LAND appliance: Local Network vs. DMZ? Since communication between the LAND appliance and your sources systems is not encrypted, we recommend the appliance is placed on your network behind your Firewall which provides continuous security of PHI. Messages are encrypted by the LAND appliance, and remain encrypted until they are received on the Receiver’s appliance, at which point they are safely decrypted. New Hampshire Health Information Organization © NHHIO. All rights reserved. - 51 - How is data in transit secured and encrypted? Data is sent through Orion HISP, following Direct ( http://www.healthit.gov/policyresearchers-implementers/direct-project ) standards, using TLS version 1 transport protocols with PKI certificates, encrypted using AES256 algorithm. Encryption/Decryption takes place within the LAND appliance and messages are not opened or deposited at the central site. Where is the Central Site? System is securely hosted by LogicWorks in a hybrid cloud environment, http://www.logicworks.net/, (SSAE16 certified) with separate database and server instances for NHHIO protected by Cisco ASA5520 firewalls with redundant communication ports and full anti-virus and intrusion detection software. What type of network connectivity is required? NHHIO relies upon participant’s commercial internet connectivity and does not utilize any private networks or dedicated circuits. New Hampshire Health Information Organization © NHHIO. All rights reserved. - 52 - LAND Appliance Integration Methods Description Directory Interfaces Simplified File Exchange Sending Receiving Drop a specially named file into a directory to send the file. ✔ ✖ Simplified CDA Documents Exchange Drop a specially named CDA document into a directory to send the file. Information is extracted from the CDA document and included as metadata for the message. ✔ ✖ Document Exchange using the SendDocuments format The sender creates a specially formatted XML document that contains metadata information and either the file to send, or the name of the file to send. ✔ ✔ Web Service Interface Simplified CDA Documents Exchange Uses a web service to send a CDA document. Information is extracted from the CDA document and included as metadata for the message ✔ ✖ Document Exchange using the SendDocuments format Use a web service and a specially formatted XML document with embedded attachment(s) to send a message. ✔ ✔ Uses an HTTP Post and a specially formatted XML document with embedded attachment(s) to send a message. ✔ ✔ Uses the IHE XDR web service to send messages. This interface is appropriate for systems with full XDR implementations. ✔ ✔ Use an external FTP server and a specially formatted XML document with embedded attachment(s) to send/receive messages. ✔ ✔ HTTP Interface SendDocuments format IHE XDR Interface IHE XDR Interface FTP Client Interface Document Exchange using the SendDocuments Format How do I select an appropriate integration method? With support and guidance from NHHIO and the Orion teams, each participant will need to work with their EHR vendor(s) to determine the best integration method based on the export functions of their system, the ability to include HPD information, and the trigger events for the release of information such as: • Medical Summary / Continuity of Care Document (CCD) / (CDA) • Transfer of Care Summary (TOC) • Progress / SOAP notes • Referral requests / Referral letters New Hampshire Health Information Organization © NHHIO. All rights reserved. - 54 - Agenda Welcome and Introductions – Denise Purington, Board Chair, NHHO - Jeff Loughlin, NHHIO Executive Director The State Perspective – William Baggeroer, Chief Information Officer, NH DHHS Where did we start from – How far have we come? – Mark Belanger, Director of Strategic Advisory Services, Massachusetts eHealth Collaborative Legislative Issues and Concerns – Denise Purington, Board Chair, NHHIO Current State of NHHIO – Jeff Loughlin, NHHIO Executive Director Future of Health Information Exchange – Micky Tripathi, President & CEO, Massachusetts eHealth Collaborative HIE Adoption and Use Case Review – Mary Beth Eldredge, Board Vice Chair, NHHIO Participant Discussion Getting Involved, Getting Connected – Jackie Baldaro, Project Manager, NHHIO Q& A - Closing Remarks New Hampshire Health Information Organization © NHHIO. All rights reserved. - 55 - HIE Trends September 20, 2013 Context 1997 – Healthbridge HIE 1999 – New England Health Exchange Network 2001 – Rhode Island Quality Institute 2003 – Indiana Health Information Exchange 2005 – Vermont Information Technology Leaders 2005 – YouTube 2006 – Maine HealthInfoNet 2006 – Facebook 2006 – Accountable care 2007 – Twitter 2007 – Mad Men 2008 – Breaking Bad 2008 – Android 2009 – Modern Family 2009 – HITECH (Meaningful Use) 2010 – Obamacare 2010 – iPad 2011 – NHHIO HIE is maturing HIE 1.0 hie 2.0 • Focused on “the noun” • Focused on “the verb” • Trying to solve “market failures” • Demand-driven -- trying to meet market needs • Multi-entity governance, but often driven by third-party entities • Strived to solve wide variety of rich use cases through comprehensive interoperability • Complex legal, business, and technical requirements to support rich array of use cases • Tried to tackle policy issues to enable business practices and technology solutions • More tactically focused to meet immediate interoperability needs • Led by any organization that has business need and ability to marshal financial, technical, and organizational resources • Designed to fit within existing legal, business, and technical constraints – technology out ahead of policy in some areas What is driving this transition? Limited successes of the prior model Bottom-up demand -- systems are not interoperable because not enough customers asked for interoperability • Meaningful Use incentives • Value-based purchasing • Market expectations about standards of care • Younger provider expectations about use of technology • Consumer expectations about use of technology Supply-side • EHR certification requirements – common denominator important in a fragmented industry • Technology advancements in cloud services, mobile, broadband, storage, patient-matching capability, etc Industry changing rapidly 70% 60% 50% EHR Adoption National 40% NH Massachusetts 30% Vermont 20% Maine 10% 0% 2008 2009 2010 2011 2012 80% 70% 60% eRX Use ME 50% MA 40% National 30% NH 20% VT 10% 0% 2008 2009 2010 2011 2012 National-level HIOs are most comprehensive HIE implementations, but still quite thin • Over 20 participants (4 federal) as of September 2011 • Over 90,000 transactions conducted • HIE solution based on NHIN standards enabling send/receive and query/retrieve • DURSA covering complete set of exchange patterns • Five provider organizations (Geisinger, Kaiser, Mayo, Intermountain, Group Health) • Complete solution based on NHIN standards enabling send/receive and query/retrieve Massachusetts eHealth Collaborative © MAeHC. All rights reserved. - 61 - EHR vendors with high penetration generating large amount of vendor-specific HIE traffic • Large majority of customers (200+) participating in query-based exchanges • 16,743 providers using query-based exchange • ~1.5 million query-based exchanges per month • Currently CCD/CDA querybased exchange is ~2.2 million records for ~385K unique patients per month • ~2.5 million new CCD records made available on query exchange hubs or sent directly to referral providers per month • ~58.5 million directed exchange transactions per month (including HL7 lab result delivery) • Volume doubled over previous year • Processed over 75+ million lab result records in 2012 • Does not include HL7 directed exchange transactions Source: January 2013 -- Epic, eClinicalWorks, Cerner Massachusetts eHealth Collaborative © MAeHC. All rights reserved. - 62 - Some vendors teaming to standardize cross-vendor HIE capabilities • Nascent collaboration effort among some leading EHR vendors • Creating common infrastructure for directed query capability facilitated by: • Record locator service • EMPI • Patient-controlled consent management Massachusetts eHealth Collaborative © MAeHC. All rights reserved. - 63 - What will drive HIE in the future? MU Stage 1 – get everyone electronic, push transactions that already work (labs, eRX) MU Stage 2 – establish new “push” transactions (provider-to-provider) MU Stage 3 – establish new “query” transactions MU Stage 4? 5? 6? Accountable care? Market forces? HIE Functional Needs Vary With Business Goals Enterprise Integration & Management Population, Risk, and Financial Management Population, Risk, and Financial Management Measurement & Reporting & CDS Measurement & Reporting & CDS Case management & patient access Case management & patient access Case management & patient access Registries & Repositories Registries & Repositories Registries & Repositories Cross-system query Cross-system query Cross-system query Cross-system query Message & document delivery Message & document delivery Message & document delivery Message & document delivery EHR functions EHR functions EHR functions EHR functions IPA/PHO Accountable care entities Independent actors IDN • Business integration • Business alignment • Team-based care • Patient engagement • Performance mgmt • Population mgmt • Utilization mgmt • Case facilitation • Become electronic • Fill in gaps in care transitions Massachusetts HIE Plan Record Locator Service Patient name Local name Institution MRN Last visit date # visits Jones, Jennifer L Jones, Jennifer L Jones, Jennifer Jones, Jenny Hospital A PCP 1234 5678 Dec 3, 2012 Jul 8, 2010 3 12 4. View Patient Relationships (constrained to patients with established relationships) 2. Send demographics to RLS 5. Request patient record Specialist N PCP Y Hospital A 6. Send patient record Y Hospital B Y 1. Consent to Publish Provider Relationships 3. Consent to Search or Retrieve Jennifer L Jones Jennifer L Jones Massachusetts eHealth Collaborative © MAeHC. All rights reserved. - 66 - Massachusetts HIE Plan – Possible Patient Access Options Patient Directory Patient name Local name Certificate Institution MRN Direct address Jones, Jennifer L Jones, Jennifer 34X&)VX Jones, Jenny 34X&)VX Hospital A 1234 Jennifer.Jones@hv.masshighway.net PCP 5678 Jennifer.Jones@hv.masshighway.net Jones, Jennifer L 2. Lookup Patient Address 3c. Notification of RLS Change 3b. View RLS or RLS Audit Log or Manage Consent? Specialist N PCP Y Hospital A 3a. Send Record Y Jennifer L Jones 1. Consent Jennifer L Jones Massachusetts eHealth Collaborative © MAeHC. All rights reserved. - 67 - Conclusions HIE activity is starting to flourish….just not in the way we expected a few years ago Heterogeneity will be the hallmark of HIE activity in the coming years There will not be a “National HIE” – but there are already many of them… Multi-layered HIE modes developing as business practices mature • “B2B”-style patterns to move documents around with light centralized coordination – Direct and Directed Query • “Supply-chain” style patterns with deep integration among very closely aligned entities seeking centralized orchestration for rich applications to support complex uses Most state-level HIEs will not survive, and the survivors will be the ones who: • Focus on customer needs • Tackle the problems that only they can solve • Remain flexible to market changes Agenda Welcome and Introductions – Denise Purington, Board Chair, NHHO - Jeff Loughlin, NHHIO Executive Director The State Perspective – William Baggeroer, Chief Information Officer, NH DHHS Where did we start from – How far have we come? – Mark Belanger, Director of Strategic Advisory Services, Massachusetts eHealth Collaborative Legislative Issues and Concerns – Denise Purington, Board Chair, NHHIO Current State of NHHIO – Jeff Loughlin, NHHIO Executive Director Future of Health Information Exchange – Micky Tripathi, President & CEO, Massachusetts eHealth Collaborative HIE Adoption and Use Case Review – Mary Beth Eldredge, Board Vice Chair, NHHIO Participant Discussion Getting Involved, Getting Connected – Jackie Baldaro, Project Manager, NHHIO Q& A - Closing Remarks New Hampshire Health Information Organization © NHHIO. All rights reserved. - 69 - New Hampshire Health Information Organization HIE Use Cases Mary Beth Eldredge Board Vice Chair DH Director of Regional IT Systems New Care Team Model Extends the Reach and Need for Data ACO PCP eRX Home Health / LTC Acute Care Specialty Care PQRS Patient & Families Diagnostic Testing eHealth Portals Mobile Technology MU & CQM New Hampshire Health Information Organization © NHHIO. All rights reserved. - 71 - EP Meaningful Use – Stage 2 Core Objective: Summary of Care record sent with transitions of care and referrals (CCD) Measure: 1. Sent for more than 50% of transitions of care and referrals 2. 10% sent electronically in Direct compliant format a) Transmitted using CEHRT - Or b) Transmitted via NwHIN participating exchange or ONC established governance mechanism (NHHIO) 3. Conduct exchange test a) Different EHR - Or a) CMS-designated test EHR New Hampshire Health Information Organization © NHHIO. All rights reserved. - 72 - EP Meaningful Use – Stage 2 (cont) Core Objective: Submit immunization data (Dependent on NHDPH) Measure: Submit data Other related Objectives: 1. Core: Secure messaging 2. Core: Patient ability to View, Download, Transmit health information 3. Core: Structured lab data >40% 4. Menu: Syndromic Surveillance data 5. Menu: Cancer and other registries 6. Menu: Imaging results New Hampshire Health Information Organization © NHHIO. All rights reserved. - 73 - Value Propositions Increases care coordination efforts by transmitting structured data elements in care summaries, discharge notes, lab results, history and physicals, etc. Replaces traditional point-to-point communications (unsecure fax, mail, etc.) with electronic directed exchange streamlining workflow in the practice setting Provides consistent method for private, secure and auditable transmissions of protected health information (PHI) Streamlines Public Health reporting to the State with connections for AHEDD, electronic lab reporting, cancer care registry and immunization registry Uses national standards to allow providers and hospitals to comply with multiple incentive and quality programs Eliminates the creation and management of multiple point-to-point connections for results delivery and information sharing New Hampshire Health Information Organization © NHHIO. All rights reserved. - 74 - Dartmouth Hitchcock Use Cases Replacing Faxing between sites DH to DH providers DH to non-DH providers Delivering Lab results to ordering providers Referral Requests / Referral Information from referring providers NCCC Outreach Clinics – dual documentation in local record and DH record New London Hospital, Valley Regional Hospital, Catholic Medical Center, Weeks Medical Center, Littleton Regional Hospital, Cottage Hospital, St. Joseph Hospital CHaD Outreach Clinics – dual documentation in local record and DH record CHaD @Wentworth Douglass, Elliot Hospital Discharges to Home Health agencies and SNF/LTC 40% of DHMC discharges go to post-acute care sites Discharge summaries from local hospitals to DH Clinics Manchester, Nashua, Concord Interstate communication of all the above information Vermont, Massachusetts, Maine New Hampshire Health Information Organization © NHHIO. All rights reserved. - 75 - What are your use cases? New Hampshire Health Information Organization © NHHIO. All rights reserved. - 76 - Agenda Welcome and Introductions – Denise Purington, Board Chair, NHHO - Jeff Loughlin, NHHIO Executive Director The State Perspective – William Baggeroer, Chief Information Officer, NH DHHS Where did we start from – How far have we come? – Mark Belanger, Director of Strategic Advisory Services, Massachusetts eHealth Collaborative Legislative Issues and Concerns – Denise Purington, Board Chair, NHHIO Current State of NHHIO – Jeff Loughlin, NHHIO Executive Director Future of Health Information Exchange – Micky Tripathi, President & CEO, Massachusetts eHealth Collaborative HIE Adoption and Use Case Review – Mary Beth Eldredge, Board Vice Chair, NHHIO Participant Discussion Getting Involved, Getting Connected – Jackie Baldaro, Project Manager, NHHIO Q& A - Closing Remarks New Hampshire Health Information Organization © NHHIO. All rights reserved. - 77 - New Hampshire Health Information Organization Getting Connected Jackie Baldaro Project Manager NHHIO Resources www.nhhio.org On-Boarding Documentation NHHIO On-Boarding Document (~5 week on-boarding project plan) Appendix A – Readiness Questionnaire (updated to identify multiple systems) Appendix B - LAND Form (technical contacts and integration method(s)) Appendix C – Provider Directory Upload File Format (.CSV file to be updated) Appendix D – LAND Appliance Documentation (specifications and integration) NHHIO Solution Diagram (description of technical infrastructure and communications) Available at www.nhhio.org New Hampshire Health Information Organization © NHHIO. All rights reserved. - 80 - HIE Technology Grant Program Reduce barriers to implementation and adoption Financial support for hardware purchases Financial support for software upgrades Financial support for additional staffing needs Award amount based on need justification in application Workflow assistance and guidance from the Regional Extension Center of New Hampshire New Hampshire Health Information Organization © NHHIO. All rights reserved. - 81 - In-Kind “Donation” Tracking NHHIO is responsible for a 25% match against all Federal dollars spent In order to keep participant fees low, NHHIO requests tracking of resources spent by the participants: Internal staff time – meetings, staff training, education & outreach Hardware, software purchases External consulting/integration services Documentation in NHHIO tracking form Participant retains auditable receipts New Hampshire Health Information Organization © NHHIO. All rights reserved. - 82 - On-Boarding Process (i) ~ 5 weeks Week 3-4: 2-3: 1: Participant NHHIOAppliance LAND – completes Orion –installation Participant documentation and Kick-off HIE connection Call • Participant Orion reviews NHHIO Participation installs systems LAND agreement and Appliance architecture andon associated LAN for preliminary addendums guidance ••Technical Orion completes Configure architecture firewallLAND withinformation IPform / Port with information Participation – Integration for Engine NHHIO approval (PKI) • Particpant/Orion Orion configures/delivers Identify system connections test connectivity LAND Appliance with central site • LAND Form contact information • HPD CSV file New Hampshire Health Information Organization © NHHIO. All rights reserved. - 83 - LAND Appliance Integration Process 8) Participant Integration - EHR to LAND Appliance Participant, with assistance and guidance from NHHIO, will need to work with their EHR vendor(s) or internal IT team to develop a process to transport, test and validate messages from EHR system(s) to LAND Appliance. Depending upon the Participant’s integration method, additional network directory set-up work may be required to support file exchange. New Hampshire Health Information Organization © NHHIO. All rights reserved. - 84 - On-Boarding Process (ii) ~ 5 weeks Week 3-4: LAND Appliance Integration • Participant establishes system(s) to LAND Appliance integration method(s) Week 4-5: System testing • Participant establish initial use case(s) for export •• Participant creates test messages for transmissionneeds Integration engine / EHR system(s) configuration Week 5: Move to production •• NHHIO will facilitate receiving participant (directory method) Network security / file share configuration •• Complete acceptance testing validates connectivity •• Orion EHR vendor or other IT resources/programming may be required Review support / help desk methods •• Participant validates results – acceptance testing NHHIO / RECNH can provide integration management assistance • NHHIO dues payment (quarterly) New Hampshire Health Information Organization © NHHIO. All rights reserved. - 85 - Project Contact Information Jeff Loughlin Executive Director c: (508) 326-3944 o: (781) 434-7751 jloughlin@maehc.org Jackie Baldaro Project Manager c: (339) 223-0888 o: (781) 434-7553 jbaldaro@maehc.org New Hampshire Health Information Organization © NHHIO. All rights reserved. - 86 - Agenda Welcome and Introductions – Denise Purington, Board Chair, NHHO - Jeff Loughlin, NHHIO Executive Director The State Perspective – William Baggeroer, Chief Information Officer, NH DHHS Where did we start from – How far have we come? – Mark Belanger, Director of Strategic Advisory Services, Massachusetts eHealth Collaborative Legislative Issues and Concerns – Denise Purington, Board Chair, NHHIO Current State of NHHIO – Jeff Loughlin, NHHIO Executive Director Future of Health Information Exchange – Micky Tripathi, President & CEO, Massachusetts eHealth Collaborative HIE Adoption and Use Case Review – Mary Beth Eldredge, Board Vice Chair, NHHIO Participant Discussion Getting Involved, Getting Connected – Jackie Baldaro, Project Manager, NHHIO Q& A - Closing Remarks New Hampshire Health Information Organization © NHHIO. All rights reserved. - 87 - Conclusion Today’s Goals Get Educated Visit www.nhhio.org for updated information Email nh-hio@maehc.org to get on our distribution Get Inspired Contact us with use cases and leads Get Connected Download our agreements Contact Jackie to set up a kick-off meeting Get Involved Contact your legislators to support HIE expansion Check out our calendar for committee meetings Join us for webinar series and discussions New Hampshire Health Information Organization © NHHIO. All rights reserved. - 89 - Thank You! Thank you for partnering with the New Hampshire Health Information Organization (NHHIO) as we take this important next step in the evolution of health care delivery in the Granite State. New Hampshire Health Information Organization © NHHIO. All rights reserved. - 90 -