RICK SCOTT
GOVERNOR
Better Health Care for all Floridians
ELIZABETH DUDEK
SECRETARY
Florida Health Information Exchange
Return on Investment Calculator
Introduction to Florida HIE Services
The Florida Health Information Exchange (Florida HIE) offers several services that enable the
secure, electronic exchange of health information for health care providers and health plans
throughout the state. The Florida HIE also offers a cost effective approach to meet the federal
requirements for electronic health information exchange (HIE) in transitions of care as part of the
meaningful use of electronic health records (EHRs).
The Florida HIE has been established by the Agency for Health Care Administration (Agency)
and implemented by Harris Corporation, under contract with the Agency. Florida HIE services
include:

Patient Look-Up (PLU)/Hybrid PLU
Using this service, providers query for patient health records made available for patient look-up
by other participating health care organizations and data sources. This service enables both
discovery of patient records and clinical document exchange. The Florida HIE also enables
stakeholders to leverage and access the functionality of the eHealth Exchange operated by
Healtheway Inc. (formerly NwHIN).
Hybrid Patient Look-Up (PLU) services allow providers that do not have an EHR system to have
access to the PLU service. It can also be used by providers that have an EHR system but are not
yet connected to a hospital or healthcare system that would provide access to the Florida HIE.

Trust Service/Direct Secure Messaging
Direct Secure Messaging (DSM) is a service that encrypts electronic messages and allows for the
secure transmission of emails and attachments. The Trust Service enables connections with
other entities that have implemented secure messaging consistent with national standards. These
connections enable providers to exchange secure messages with additional providers in Florida
and in other states. Trust Service participants also have access to a participant directory where
they can search for another Trust Service participant’s email address.

Event Notification Service
The Event Notification Service (ENS) delivers alerts about medical encounters in a participating
hospital or other facility to a permitted recipient with an existing relationship to the patient.
Permitted recipients include health plans (which forward information to a primary care provider)
or an ambulatory health care provider identified by a participating hospital (ENS Plus). The
service provides alerts when patients are discharged from a hospital, emergency department, or
urgent care, for care coordination and quality improvement.
2727 Mahan Drive, MS#16
Tallahassee, Florida 32308
Visit AHCA online at
AHCA.MyFlorida.com
The service is offered to commercial, Medicaid, and Medicare health plans in Florida. There are
no fees to hospitals for participation in the health plan service. There is a fee for hospitals that
participate in ENS Plus.
Florida HIE Value Proposition
The Florida HIE offer participants flexibility for incremental implementation, local control,
predictable costs, access to interstate electronic HIE, and clear policies regarding participation
and permitted uses.

Flexibility: Meeting Providers’ Needs
The Florida HIE is designed to meet the immediate and future needs of health care providers for
the exchange of electronic health records for patient care. Florida health care providers have a
choice of participating in one or more HIE services as fits the needs of their organization or
practice. Participation is entirely voluntary and participants are free to terminate a service with
notice at any time.

Local Connections and Control
The PLU service has been implemented in a federated approach, meaning that no patient data is
held in a centralized database by the Florida HIE. The PLU service also does not employ a
centralized master patient index (MPI). Patient health records and the MPI reside with the local
health care provider or other data sources.
Similarly, the ENS does not maintain a centralized database other than the member or patient
rosters provided by subscribers for matching to data source identifiers. Further, data sources
control availability to health plans and ambulatory health care provider subscribers.
Health care organizations can elect one of three Trust Service options for choice of connections.
The Trust bundle with or without DSM can be selected by an organization or health information
service provider (HISP) that wishes to send direct messages to other HISPs in the trust bundle
and/or to DSM accounts. A DSM only connection would be selected by an organization or HISP
wishing to send direct messages to DSM accounts without the need for exchange with
organizations in the trust bundle.

Predictable Costs
The Florida HIE has developed a plan for sustainability through subscription fees charged to
participants. Subscription fees are set to generate sufficient revenues to cover maintenance costs
and future technical development. The Agency supports the governance of the Florida HIE
through in-kind services.
Participant costs vary by the services selected. Individual services have been priced to support
sustainability as utilization of the service increases. The Agency will monitor costs and revenues
2
to determine if prices can be lowered as adoption increases. The Florida HIE Price List is posted
on the Florida HIE website at: https://www.florida-hie.net/resources.html.

Mitigating HIE Risks
Subscription agreements for both PLU and DSM services set forth the policies and procedures of
the respective services. The, use of the PLU service is limited to treatment and public health
reporting as authorized by law. The restrictions on use of the PLU service mitigate risks to
participants. DSM’s permitted purposes encompass treatment, payment, and health care
operations.
The Agency has studied the regulatory environment of HIE and has addressed applicable law
systematically. The Health Information Exchange Legal Work Group also advises on emerging
issues relating to legal policies for HIE and periodically reviews changes in the agreements. The
assistance of Florida HIE participants and their expertise in resolving issues and determining
policy related to HIE privacy and security is essential to mitigating risks.
Florida HIE agreements include the PLU Subscription Agreement and eHealth Exchange
Addendum, DSM Subscription Agreements and ENS Addendums, General Participation Terms
and Conditions, and Trust Service Agreement.
These documents are posted at:
https://www.florida-hie.net.

Adoption
The value to participants will increase with greater adoption and participation. The Florida HIE
will connect with a variety of organizations to achieve a statewide HIE and work with
stakeholders to address unique local needs and priorities. Adoption statistics are reported on the
Agency’s website at: http://www.fhin.net/content/kms/index.shtml.
The outreach strategy for PLU is to onboard large organizations that can establish the foundation
for robust HIE in Florida. Smaller organizations have the option of integrating with a PLU
participant or using the Hybrid PLU Service.
The Florida HIE also encourages the participation of HISPs that bring value through connections
with Florida facilities and providers. The adoption plan for the ENS service is to incrementally
add data sources which will encourage health plan participation and support of the Florida HIE.
Value Determination Strategy
Health information technology (health IT) holds the potential to increase the efficiency, cost
effectiveness, quality, and safety of our health care system. 1 Studies conducted by the RAND
Corporation and the Center for Information Technology Leadership (CITL) have estimated that
approximately $80 billion in net annual savings nationally is possible through the use of health
IT.2 Some common return on investment metrics include:
1
2
HIE Economic Sustainability Panel: Final Report, NORC, University of Chicago, April 2009
Evidence on the Costs and Benefits of Health Information Technology, Congressional Budget Office, May 2008
3





Avoided duplicated or inappropriate diagnostic tests
More cost-effective use of prescription drugs
Improved productivity of nurses and physicians
Reduced length of hospital stays/admissions
Lower administrative costs
There are many overlapping factors and complexities that make true financial returns on
investment in health IT difficult to prove. There are two broad categories of potential HIE
savings to consider:
1) Savings by more efficient exchange of information for coordination of care;
2) Savings by increasing the amount of information exchanged to improve coordination
of care and health outcomes.
To complete the process of value determination, a model tailored to the individual participants’
view is needed to allow participants to plug in data specific to their costs, patient population, and
workload so they can calculate the value specific to them for participating in HIE.
The Iowa Office of Health Information Technology has developed a basic set of tools for
calculating return on investment for those participating in the implementation of EHRs and the
exchange of health information.3 The ROI tools have been modified and expanded as applicable
to the exchange services offered by the Florida HIE.

Return on Investment Worksheets
The enclosed return on investment worksheets may be helpful for some providers to assess the
potential cost savings associated with implementing an EHR system and signing up to participate
in the Florida HIE. The following worksheets, developed for illustrative purposes only, are
based on return on investment studies from around the nation:








Meaningful Use
EHR interfaces
Readmissions
Paper and transcription
Chart pulls
Fax
Repeat Emergency Visits
Quality Metrics
If you have a success story you would like to share with other Florida HIE participants, please
send to: floridahie@harris.com.
3
Acknowledgements to the Office of Health Information Technology, Iowa Department of Public Health
4
Return on Investment Worksheet: Meaningful Use
The Florida HIE works closely with hospitals and other health care providers to enable them to
meet the federal meaningful use requirements for electronic HIE in transitions of care. The
Florida HIE is connected to the eHealth Exchange so that Consolidated Clinical Document
Architecture (CCDA) that is shared through the PLU service can be used to meet the transitions
of care requirements. Providers that query CCDAs through the Hybrid PLU service enable PLU
participants to augment electronic exchange for transitions of care.
The Trust Service/DSM offers an approach that does not require participation in PLU. Providers
using a certified EHR can HISP connect to the Florida HIE trust bundle and/or DSM to send
CCDAs to other participants and the Trust Service provides Message Delivery Notifications that
can be used to document delivery. While DSM cannot be used to launch a message for
meaningful use, receipt of messages in DSM can be used by the sending provider for this
purpose.
The worksheet below is an aide to calculate the costs of using the Trust Service/DSM for
comparison with other solutions.
Incentives
Estimated annual incentive:
Annual revenue:
$
Trust Bundle costs
-
$ 7,500
DSM transactions ($25,000 X 1, 2, or N)
-
$
Net revenue:
$
Penalty
Estimated annual penalty:
Annual cost savings:
Trust Bundle costs
-
$ 7,500
DSM transactions ($25,000 X 1, 2, or N)
-
$
Net savings:
5
$
$
Return on Investment Worksheet: EHR Interfaces
The Florida HIE provides HIE for disparate EHR systems. Generally, providers with an existing
EHR system must pay an extra fee (e.g., $5000 - $40,000) to their EHR vendor to establish an
interface with another organization. Rather than paying for an interface with each data trading
partner (e.g., referral provider, hospital, lab, public health department), providers can establish
one connection with the HIE and essentially be connected to many data-trading partners at once.
PLU can connect treating providers such as hospitals, physicians, and county health departments.
Number of hospitals communicated with:
Number of physician offices or clinics
communicated with:
+
Number of laboratories communicated
with:
+
Number of pharmacies communicated
with:
+
Number of home health agencies
communicated with:
+
Number of long-term care settings
communicated with:
+
Total number of connections:
Average annual interface cost from EHR
vendor:
X $
Cost without HIE:
Annual cost of HIE:
Cost saving:
6
$
-
$
$
Return on Investment Worksheet: Readmissions
The Florida HIE can provide access to continuity of care documents (CCD) or CCDAs through
PLU and alerts to primary care providers through ENS. Primary care providers can retrieve
clinical documents using a Hybrid PLU service. A recent study in Connecticut estimates a 25%
reduction in potentially preventable readmissions due to the availability and use of an HIE.4
Number of admissions annually:
Percent of admissions that are Potentially
Preventable Readmissions (PPRs):
X
Number of annual PPRs:
Percent reduction of PPRs due to HIE:
*Adjust for local ENS/PLU uptake:
Low, use 0-10%
Medium, use 10-20%
High, use 20-25%
X
Cost of an admission:
X $
Cost savings potential:
Any additional costs to effect change
$
-
Net cost savings potential:
Percent uncompensated care:
Uncompensated cost saving:
4
25%*
$
$
X
$
Connecticut Statewide Health Information Exchange (HIE) Financial Sustainability Study Final Report: Recommended Funding
Methods and Formulas for HIE Financial Sustainability, December 7, 2010
7
Return on Investment Worksheet: Paper and Printers
The Florida HIE facilitates the exchange of electronic health information. Providers using EHRs
can reduce expenditures required to support a paper-based system. These costs include but are
not limited to paper supplies, filing systems, and dedicated office space required to store paper
charts or reports. HealthBridge, based in Cincinnati, estimated a savings of $0.41 per report with
the elimination of paper delivery of reports.5
Storage
Square footage for record storage:
Rent per square foot:
X $
Annual rent for record storage:
Percent reduction in volume of paper
records after implementation:
$
X
Annual storage cost savings:
$
Delivery
Number of reports per year:
Savings per report (costs of postage,
paper, printers and personnel, based on
detailed time and material studies):
X
Annual delivery cost savings:
Allocated costs for HIE
Net delivery cost savings:
5
HealthBridge, http://www.healthbridge.org
8
$0.41
$
-
$
$
Return on Investment Worksheet: Chart Pulls
The Florida HIE provides an alternative to manual chart pulls. Providers using PLU or Hybrid
PLU will be able to query and retrieve documents rather than having to make a phone call to
another provider and request the patient chart be pulled and sent via fax. A 2006 article in the
Journal of Healthcare Information Technology estimates a 35% reduction in chart pulls in the
first year after EHR implementation. George Washington University Medical Faculty Associates
estimated a first year savings of $81,551 after factoring in staff time for each chart pull.6
Number of chart pulls each day:
Minutes spent per chart:
X
Minutes spent pulling charts each day:
Number of work days per year (e.g. 250):
X
Minutes pulling charts each year:
Reduction in chart pulls or based on post
implementation study of practice/facility:
X
35%
÷
60
Time savings due to HIE
implementation (minutes):
Divide by 60 to determine time savings in
hours:
Time savings due to HIE (hours):
Average hourly administrative rate:
X $
Annual cost savings potential:
Allocated costs for HIE alternative
Net cost savings:
6
$
Stephen Badger, Journal of Healthcare Information Technology, Vol. 19, No 2, 2006
9
Return on Investment Worksheet: Fax
The Florida HIE enables an alternative form of secure communication between providers using
the Trust Service/DSM or PLU services. The University of Iowa initiated a HIE pilot project
with a participating hospital in 2010. Early results show the potential for a 40% reduction in the
amount of time needed to process faxed health information (e.g., average handling time was
reduced from 10 minutes to 6 minutes).7
Items faxed per day, pre-implementation:
Work days per year (e.g. 250):
X
Items faxed annually:
Time to process each fax (in minutes):
X
Divide by 60 to determine time spent
processing faxes in hours:
÷
60
X
40%
Hours spent processing faxes each
year:
Reduction in time spent processing faxes
or based on post-implementation study at
facility, health plan or practice:
Hours saved from and/or PLU:
Average hourly administrative rate:
X $
Annual cost savings:
Allocated costs for HIE
Net annual cost saving:
7
$
-
$
$
University of Iowa Hospitals and Clinics, email message to Iowa e-Health, March 3, 2011
10
Return on Investment Worksheet: Repeat Emergency Visits
The Florida HIE offers the ENS to hospitals and health plans which includes notifications of
emergency department visits. Analysts at the Boston Consulting Group estimated, with
secondary data, that 13% of repeat emergency department (ED) visits were potentially
avoidable.8 The Wisconsin-Institutes for Discovery reported a benefit to providers as well as
payers in decreased emergency department visits due to reduced expenditures on Medicare and
Medicaid patients that are not fully compensated.9
Number of ED visits annually:
Percent of ED visits that are repeated:
X
Number of repeat ED visits:
Percent reduction of repeat ED visits due
to HIE:
*Adjust for local DSM/PLU uptake:
Low, use 0-5%
Medium, use 5-10%
High, use 10-13%
X
Cost of an ED visit
X $
Cost saving potential:
Additional costs to effect change:
$
-
Net cost saving potential:
Percent uncompensated care:
Uncompensated cost saving:
8
13%*
$
$
X
$
Boston Consulting Group, Rhode Island Quality Institute: Business case for Health Information Exchange, 2008.
Srikrishna Sridhar, et. al., Optimizing financial effects of HIE: a multi-party linear programming approach, American Medical
Informatics Association, 2012.
9
11
Return on Investment Worksheet: Quality Metrics
The Florida HIE services enable the electronic exchange of medical record abstracts and other
documentation for quality metrics. Both health plans and health care providers incur substantial
costs to collect and compile quality metrics required for accreditation and certification. Health
care providers need practical, incremental solutions.10 Phone calls related to quality metrics
reporting coordination could be reduced if HIE were widely adopted. These savings do not
include savings in FAX and printer costs. These savings also do not include reductions in time
required for chart abstracting due to EHR generation of metrics.
Number of quality metrics related phone
calls each day:
Minutes spent per phone call:
X
Minutes spent making phone calls each
day:
Number of work days per year (e.g. 250):
X
Minutes making phone calls each year:
Reduction in phone calls or based on post
implementation study of practice/facility:
X
80%
÷
60
Time savings due to HIE
implementation (minutes):
Divide by 60 to determine time savings in
hours:
Time savings due to HIE (hours):
Average hourly administrative rate:
X $
Annual cost saving potential:
Allocated HIE costs
Net cost savings
10
$
-
$
$
CHIME comments in response to AHRQ Request for Information on Quality Measurement Enabled by Health IT,
August 23, 2012.
12