Advancing Washingtons Health Information Infrastructure

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Advancing WashingtonsHealth Information
Infrastructure

• HIIAB Board Meeting
• September 16, 2009

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Todays Topics

• Scoping the Opportunities
• The Federal Commitment
• The Lens of Meaningful Use
• Building Sustaining the Health Information
  Infrastructure
• Details and Implications of Federal Opportunities
• Total Cost of Ownership
• Funding Mechanisms
• Advancing Washingtons Health Information
  Infrastructure
• Research Approach
• Key Messages from Stakeholders
• Proposed Recommendations

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The New Opportunity
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Federal Commitment46 Billion in Stimulus Funds
New Incentives for Adoption
Appropriations for Health IT

• 1.2 billion for loans, grants technical
  assistance for
• Regional Extension Centers (598M)
• EHR State Loan Fund
• Workforce Training
• Research and Demonstrations

• New Medicare Medicaid paymentincentives for
  HIT adoption
• 23 billion in expected payments through Medicare
  to hospitals physicians
• 21 billion in expected paymentsthrough Medicaid
• 44 billion expected outlays, 2011-2016

Appropriations for HIE
Community Health Centers
1.5 billion in grants through HRSA for
construction, renovation and equipment, including
acquisition of HIT systems

• 564 million for HIE development
• Funneled largely through States or qualified
  State-designated entities
• For planning and/or implementation

Broadband and Telehealth
4.3 billion for broadband 2.5 billionfor
distance learning/ telehealth grants
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Federal Commitment44 Billion for Incentives
Vision of Meaningful Use To enable significant
and measurable improvements in population health
through a transformed health care delivery
system.
Key Goals -Improve quality, safety,
efficiency -Engage patients their
families -Improve care coordination -Improve
population and public health -Reduce
disparities -Ensure privacy and security
protections
Capture Share Data -Lab Results
Delivery -e-Prescribing -Claims Eligibility
Data -Some Quality Immunization Reporting
Increases volume of transactions most commonly
happening today Infrastructure
2011
Advanced Care Processes Decision
Support -Registry reporting / public health
reporting -Electronic ordering -Home monitoring,
Continuity of Care summaries -Populate PHRs
Substantially steps up exchange Starts to
Aggregate and Apply Data
2013
Improved Outcomes -Access comprehensive data
-Experience of Care reporting -Medical Device
Interoperability
Moves toward relatively routine and regular data
exchange Clinical Management Performance
Improvement
2015
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Building the Infrastructure...The Capacity for
Meaningful Use
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When Infrastructure Will ArriveMeaningful Use
Timeline
Meaningful Use Medicaid Timeline
Medicaid Payments Begin
Medicaid Agency Preliminary Planning
Meaningful Use NPRM
Medicaid Agency Implementation
Jan
July
Nov
Apr
July
Nov
Jan
Apr
2010
2009
2011
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State Medicaid AgenciesCMS Guidance to States
Sept 1, 2009 Medicaid Directors Letter

• States must prepare for the implementation of
  meaningful use, which will arrive as early as
  October 2010.
• States can use a 90 FPP match now to advance
  planning activities.
• To receive federal funding for plans, States must
  comply with 3 criteria
• The State must use funds to administer incentive
  payments, including tracking meaningful use
• The State must conduct oversight of the
  incentive program
• The State advance health IT adoption that
  promotes health care quality

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State Medicaid AgenciesDeveloping Medicaid HIT
Plans

• State Medicaid HIT Plan must promote an
  interoperable electronic health system.
• State Medicaid HIT Plans will include....
• Implementation plan for the Medicaid health IT
  incentive program
• Assessment of states health IT capabilities
• Road map for state health IT initiatives,
  including target implementation dates
• Vision for what states health IT future looks
  like in 2014

State Medicaid HIT Plan must be closely linked
and complement the States MMIS, MITA adoption,
and State HIE Strategic and Operational Plans
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State HIE Program564 Million for Capacity
Building

• 564 Million Total funding from ONC
• Cooperative Agreements- Non Competitive
• 4 - 40 Million per State

State Matching Requirements Begin in FY 2011
Four Year agreements with states or State
Designated Entities (SDEs)
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State HIE ProgramFocus

• States will develop or facilitate the creation of
  a technical infrastructure that supports
  statewide HIE. While states may prioritize among
  these HIE services according to its needs, HIE
  services to be developed include
• Electronic eligibility and claims transactions
• Electronic prescribing and refill requests
• Electronic clinical laboratory ordering and
  results delivery
• Electronic public health reporting (i.e.,
  immunizations, notifiable lab results)
• Quality reporting
• Prescription fill status and/or medication fill
  history
• Clinical summary exchange for care coordination
  and patient engagement

• Implications
• States need to develop the governance, policy,
  technical capabilities
• within the framework of meaningful use,
• that ensures HIE is available throughout the
  state.

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State HIE ProgramEssential Domains

• In its FOA, ONC Identified Five Essential Domains
  for HIE
• Governance
• Finance
• Technical Infrastructure
• Business and Technical Operations
• Legal/Policy
• ONCs Expectations
• States will define objectives, set goals, and
  measure progress within the context of these five
  domains.

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State HIE ProgramClassification of States
ONC will evaluated States based on status of
existing HIE activities
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State HIE ProgramWhere are States Today?
Initial planning
Significant planning efforts required prior to
implementation
Alignment with ONC criteria required prior to
implementation
Operational Plan is in alignment with ONC criteria
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State HIE ProgramTimeline for Applications
State HIE Program Timeline
Apps Due
FOA Released
Funding Available
Deadline for Submission of Operational Plans
Jan
Nov
July
Nov
July
Apr
Jan
Apr
2010
2009
2011
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Building the Health Info InfrastructureCombining
the timelines...
State HIE Program Timeline
Apps Due
FOA Released
Funding Available
Deadline for Submission of Operational Plans
Meaningful Use Medicaid Timeline
Medicaid Agency Preliminary Planning
Meaningful Use NPRM
Medicaid Payments Begin
Medicaid Agency Implementation
Jan
Nov
July
Nov
July
Apr
Jan
Apr
2010
2009
2011
Implications The next four months can be used to
assess options and prepare for implementation.
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Regional Extension Centers598M to Support
Adoption and Use

• 598 Million Total funding from ONC
• Competitive Process at least 70 RECs in
  non-overlapping geographic areas nationwide
• Awards to Range from 1-30 Million per REC
• To Support 100,000 primary care providers in
  aggregate at least 1,000 per REC

Must demonstrate financial sustainability within
4 years
4 year contracts split into 2 year increments
with separate budgets and funding structures
plus ONC has option to renew or drop after first
two years
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Regional Extension CentersTimeline
Full applications due by Aug 3rd
Full applications due by Nov 3rd
Full applications due by March 2nd
Preliminary applications under 2nd cycle due by
Dec 22nd
Preliminary applications under 1st cycle due by
Sept 8th
Preliminary applications under 3rd cycle due by
June 1st
Awardee Selection
ONC releases REC Procurement
Awardee Selection
Awardee Selection
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Building the Health Info Infrastructure Why we
are so busy...
State HIE Grant Application
Anticipated Project Start Date
ONC releases State HIE Procurement

• ONC to release Meaningful Use definition and CMS
  to issue proposed rule by end of December 2009
• 60 day public comment period
• First round of administrative HIT payments could
  be released in Q1 2010

Final Rule issued on Meaningful Use
Anticipated Award Announcements
Letter of Intent due 5pm EST on Sept 11th
Earliest Medicare payments will be made available
Application due by 5pm EST on October 16th
ONC to issue guidance on EHR loan program ONC to
craft Meaningful Use definition
Regional Extension Center Application
Full applications due by Nov 3rd
Full applications due by Aug 3rd
Full applications due by March 2nd
Preliminary applications under 2nd cycle due by
Dec 22nd
Preliminary applications under 1st cycle due by
Sept 8th
Preliminary applications under 3rd cycle due by
June 1st
ONC releases REC Procurement
Awardee Selection
Awardee Selection
Awardee Selection
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Sustaining the Infrastructure
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Health Information InfrastructureThe costs for
building capacity...
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The Market for Health ExchangeWhat currently
exists...

• ONCs Assessment of Current Market...
• "Medicare and Medicaid meaningful use incentives
  are anticipated to create demand for products and
  services that enable HIE among eligible
  providers... . The resulting demand for HIE will
  likely be met by an increased supply of marketed
  products and services to enable HIE, resulting in
  a competitive marketplace for HIE services."

Implications ONC acknowledges that a viable
market for HIE doesnt currently exist.
Stakeholders must develop a governance,
financing, policy and technical infrastructure
that both supplies high-value HIE services and
creates sustainable demand.
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The Market for Health Exchange What resources
can we tap?
Medicaid Managed Care Programs
State HIE Grant
Regional Extension Center
Provider Remittance Fees
Ins Claims Adjudication Fees
Medicaid Admin
Medicaid Incentives
State Rev
Total Available
12 million
TBD
TBD
TBD
TBD
TBD
TBD
TBD
Quarterly 2010-2014
Quarterly 2010-2014
TDB 2011-2016
Annual
Annual
TBD
TBD
TBD
Distribution
Coop Agreement
Coop Agreement
Mechanism
TBD
TBD
Approps
TBD
TBD
TBD
Fiscal Agent
State Agency
State Agency
State
TBD
Providers
TBD
TBD
State
Potential Sub- Recipients
Tech Assist Organizations
All
NA
TBD
TBD
TBD
TBD
TBD
Primary Focus
HIE Capacity
HIT Adoption
Meaningful Use
Some Flexibility
Flexible
TBD
TBD
TBD
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Advancing Washingtons Health Information
Infrastructure
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Analytic ApproachField research comparative
analysis

• Research
• Washingtons plans, reports, legislation,
  RFI/RFPs reviewed by Manatts subject matter
  experts
• Feedback sought on key issues
• Health IT adoption, HIE, Privacy Security,
  Coordination
• Interviews with representatives from
• HIIAB leadership
• State agencies
• Hospitals, clinics and providers
• Payers
• Comparative Analysis
• Common practices and progress in other states.
• Other states strategies to maximize funding
  opportunities.

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Research Results
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Stakeholder FeedbackFour Themes

• 1. Build a Shared Infrastructure
• Identify core services that can be re-used across
  different systems.
• 2. Focus on Defining the Architecture
• Given the complexity, developing a technical
  architecture is critical.
• Define the architecture through a collaborative
  statewide process.
• 3. Clarify Roles and Relationships
• Exchange works when participants trust one
  another.
• Trust is best achieved through definition of
  roles, articulation of authorities, and
  understanding of relationships.
• 4. Enhance Existing Capacity to Address eHealth
  Considerations
• Challenge An ambitious schedule for stimulus
  funding a critical need to find workable
  solutions for health care.

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Recommendation 1 Alignment w/Federal Policies

• Continue building a public-private leadership
  framework based on inclusivity and transparency.
• Create the capacity to coordinate within State
  government and across State programs.
• Clarify the roles, responsibilities, and
  decision-making process for Washingtons Health
  Information Infrastructure.

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Recommendation 2 Statewide Collaborative Process

• Create a collaborative infrastructure to address
  key considerations, assess barriers, and
  recommend policies, practices and solutions.
• Develop policies and procedures for
• Clinical objectives and priorities
• Privacy and security
• Technical considerations
• Financial sustainability
• Facilitate process with subject matter experts
  guided by agreed upon deliverables and
  timeframes.
• Help participants conform with statewide policies
  and deploy technical services in a timely and
  efficient manner.

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Recommendation 3 Clinical Objectives Evaluation

• Create a workgroup charged with defining clinical
  objectives and integrating them into eHealth
  efforts.
• Key tasks include
• Monitor the evolving definition of meaningful
  use to ensure Washington supports providers.
• Define clinical priorities that maximize
  opportunities for improvement in both the quality
  and efficiency of health care.
• Develop clinical requirements, identify workflow
  issues, and advance policy recommendations to
  help drive and test the development of policies,
  protocols and standards
• Help the State track and report progress against
  the agreed upon objectives.

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Recommendation 4 Privacy Security Policies

• Engage in a comprehensive assessment of the
  states privacy landscape.
• Establish a workgroup, as part of a statewide
  collaboration process, to develop common privacy
  and security policies.
• Develop a mechanism to ensure compliance with
  common privacy and security policies developed
  through the statewide collaboration process.

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Recommendation 5 Strategic/Operational Tech
Issues

• Define a technical framework around
  interoperability and concepts of data liquidity.
  
• Ideally, a work group consisting of technical
  experts drawn from Washingtons stakeholders
  would
• Enumerate the critical environmental assumptions
  that the technical architecture must address.
• Define the network boundaries and determine which
  systems will comply with agreed upon statewide
  policies.
• Support implementation of the high-value data
  sets identified in Substitute Senate Bill 5501
  and needed to support meaningful use.
• Identify and support deployment of shared
  services.

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Recommendation 6 Financing Strategies

• Ensure Medicaids meaningful use incentive
  payments support the health information
  infrastructure.
• Leverage Medicaid administrative funding to
  support interoperability.
• Assess the need for an EHR Loan Program.

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Exhibits
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Federal DomainsGovernance
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Federal Domains Finance
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Federal Domains Technical Infrastructure
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Federal Domains Business Technical Operations
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Federal Domains Legal/Policy