3 rd meeting date: july 8, 2010 time: 8:30 am – 11:00 am location: nc hospital association 2400...
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3rd MeetingDate: July 8, 2010
Time: 8:30 am – 11:00 amLocation: NC Hospital Association
2400 Weston Parkway, Cary, NCDial-in: 1-866-922-3257; Participant Code 654
032 36#
North Carolina Health Information Exchange
Governance Workgroup
2Discussion Document – Not for Distribution
Agenda
Topic Leads Time
Roll Call and Housekeeping
Meeting Objectives and Timeline Review
Co-Chairs 8:30 – 8:45
Update on other Workgroup Discussions Co-Chairs & Manatt
8:45 – 8:55
Review of June 23, 2010 Governance Workgroup Key Decisions
Co-Chairs 8:55 – 9:05
Governing Participation in the Statewide HIE Co-Chairs & Manatt
9:05 – 10:35
Governance Domain Section of NC HIE Operational Plan
Manatt 10:35 – 10:45
Next Steps & Open Public Comment Co-Chairs 10:45 – 11:00
3Discussion Document – Not for Distribution 3
New NC Health IT Website Launched
www.healthit.nc.gov
4Discussion Document – Not for Distribution
Meeting Objectives
• To confirm decisions from June 23 Workgroup meeting for recommendation to the board.
• To develop recommendations regarding governance rules for participation in the statewide HIE.
5Discussion Document – Not for Distribution
Stakeholder
Outreach
Operational PlanStrategic Plan
NC Statewide HIE Cooperative Agreement Timeline
State HIE
Grant App.
Letter of Intent Submitted
Sept Oct Nov 09 May 2010 Jun Jul Aug Sep
Strategic Plan Submitted to HHS
Biweekly+ Workgroup Meetings with Monthly Board Meetings
• Convene Advisory Board & Workgroups
• Draft Operational Plan
• Publish Draft Operational Plan for Review
• Engage and educate stakeholders
Submit Operational Plan to HHS
Workgroups Formed & Begin Meeting
Publish Draft Operational Plan for Review/ Comment
Funding Announcemen
t
LaunchPhase 2
NC HIE
Formed
6Discussion Document – Not for Distribution
Drafting of Operation
al Plan
Operational Plan Consensus Recommendations
NC Statewide HIE Operational Plan Development Timeline
Workgroups formed
May 2010 June July Aug Sept
May 14 – initial NC HIE Board Meeting
• Compile NC HIE Board & Workgroup recommendations and decisions
• Draft Operational Plan – iterative process with WG review
• Publish Draft Operational Plan for Public Review
Aug. 31: Submit Operational Plan
to HHS
Governance WG: Confirm governance model, advise on scope of governance, craft recommendations on bylaws and board structure for new entity; develop recommendation for consumer engagement plan approach
Clinical/Technical WG: Recommendations on technical architecture approach for statewide HE, begin prioritization of core and value-added services, begin landscape assessment
Legal/Policy WG: Conduct legal scan for NC laws related to consent for treatment purposes; draft legal principles; conduct legal scan for NC laws related to health information data security; develop recommendations on approach to 4As; develop initial consent approach recommendation under existing lawFinance WG: Develop financial model assumptions; data collection to inform financial models.
Master project planning, develop WG charters and workplans; stakeholder meetings, Legal/Policy WG meetings
Governance WG: Participation policies and enforcement mechanisms for the statewide HIE; develop recommendations on roles of State in public/private partnership; processes for coordination with other ARRA funded programs in the state
Clinical/Technical WG: Development of clinical and business use cases, prioritization for core and value-added services, technical approach
Legal/Policy WG: Finalize consent approach recommendation under existing law; review emerging consent policies in neighboring states and identify barriers; develop recommendations for changes to current law to support data exchange; develop recommendations on breach policy principles and role based access principles; develop security recommendations beyond access.Finance WG: Develop 2-3 financial models based on modeling assumptions and develop process for sustainability planning.
Updates from Other Workgroups
8Discussion Document – Not for Distribution
Technical/Clinical Operations Workgroup – June 23, 2010 Meeting
Discussion • Statewide HIE Approaches• Clinical Functions• HIE Service Analysis
Key Decisions
• The Workgroup advanced a recommendation to pursue a Hosted, Shared Services Approach with the following considerations:
o Ensure the approach aligns with the agreed-upon clinical and technical principles.o Conduct a thorough analysis of each service and the NC HIE landscape to ascertain 1) at what level a HIE service should occur and 2) the value of various services to particular stakeholder groups.
This analysis should reveal which services are best left to the local and regional levels and which services would be ideally hosted for utilization statewide, as well as demonstrate the value proposition for various stakeholder groups for each potential statewide service.
• The Workgroup agreed to define clinical functions then explain how the technical components for HIE support the clinical functions. • The Workgroup agreed to develop an implementation sequence by assessing and prioritizing each HIE service along its clinical and operational dimensions. • The Workgroup recommended that the expanded list of candidate HIE services consider meaningful use implications.
9Discussion Document – Not for Distribution
Finance Workgroup - June 23, 2010 Meeting
Discussion •Review HIE financial modeling approach and come to consensus on key assumptions/drivers
•Discuss characteristics specific to North Carolina that may impact financial modeling
Key Decisions
The Workgroup approved the following key assumptions that will be built into the financial modeling approach: o Governance and operations cost inputs will focus on the State-level HIE and not the governance and operations costs of any Regional Health Information Organizations (RHIOs) or local HIEs.
• This assumption is subject to revision based on the decisions made by the other Workgroups, particularly the Governance and Technical/Clinical Operations Workgroups regarding the recommended model for the statewide HIE structure and related role of regional/local HIEs.
o Costs for participants’ connectivity to the HIE will be based on adoption curves by participant type. o The financial model will exclude participant costs to implement new EHRs or remediate existing EHRs and clinical information systems (CIS), with the exception of Medicaid system implementation/remediation required for HIE and the estimated cost for portion of providers that will connect to the HIE using an HIE-provided EHR Lite. o The financial model will identify additional value-added products/services that can help drive revenue, and will include potential added costs for incremental development and delivery.
10Discussion Document – Not for Distribution
Legal/Policy Workgroup – July 2, 2010 Meeting
Discussion Develop recommendation on Opt-In vs. Opt-Out patient consent framework that assumes the following:
The framework is compliant with current NC law (i.e., Pathway 1) The framework addresses only disclosure of clinical data for treatment purposes
Key Decisions
For Pathway 1 (assuming no change to the existing law), The Policy Subcommittee recommended that the NC HIE adopt an Opt-In Consent Policy for disclosure of clinical data for treatment purposes
The Subcommittee weighed the following considerations:
An Opt-In Model is preferable to a Mixed Model because it does not require that information be filtered out of the patient record.
An Opt-In Model is preferable to a Mixed Model because it allows for one consent policy for all participants, thereby streamlining the consent process and reducing confusion.
An Opt-In Model has the disadvantage of potentially restricting the free flow of patient information to the detriment of patient care.
The full Workgroup stipulated that further discussion is needed around whether the consent is “all or none” and if some data types should be excluded from the exchange to protect privacy.
Review of Key Decisions from June 23 Governance Workgroup Meeting
12Discussion Document – Not for Distribution
Governance Workgroup - June 23, 2010 Meeting
Discussion • NC HIE Strategic Plan Verification• Recommendations on Bylaws• Components of Consumer Communications and Engagement Plan
Key Decisions
• Workgroup confirmed, modified, or rejected key governance decisions included in the NC HIE Strategic Plan.
• Workgroup recommended that the following requirements be written into the NC HIE bylaws:
o The Board must be composed of 15-21 members, not including ex-officio members. o Board members will be selected based on merit-based characteristics, but at all times the following groups must be represented on the Board: Hospital/Health Systems, Providers, Consumers, Employers, and Payers.o Board members will serve three-year terms, terms will be staggered, and no member may serve more than two consecutive terms.o The Board will have the authority to establish advisory groups/committees as it deems necessary. o The Board will comply with 501(c)(3) requirements, including those related to conflicts of interest policy and transparency.
The Board should establish a standing Consumer Advisory Council, tasked with developing a consumer engagement plan among other activities.
The current Workgroups (Governance, Finance, Clinical/Technical Operations, Legal/Policy) should stay intact and continue their work for at least a year.
13Discussion Document – Not for Distribution
Implied Decisions in NC HIE Strategic Plan – Oct. 2009
Approaches from Existing Strategic Plans Accept Modify/Needs Further Consideration
Reject
4. CCNC – “As part of North Carolina’s implementation strategy, this network of providers will be leveraged to convene and organize early community-based HIEs.”Workgroup decided that the issue needed more discussion and recommended that a decision on the principle be tabled and considered again in future Workgroup discussions.
X
5. From Implementation Roadmap section: “Special attention will be given to underserved, small and rural communities to facilitate meaningful use throughout the state, regardless of geographic location.”Workgroup recommended that the statement be modified to show support of participants in underserved and rural communities and recognition that they may face more significant barriers to participation in statewide HIE than other participants in the state.
Suggested Revision: “The NC HIE is committed to developing a system that is accessible to all providers of health care services, including those in rural and under-served communities. The NC HIE recognizes that lack of resources may cause significant barriers to participation and will work to develop multiple pathways for participation.”
X
14Discussion Document – Not for Distribution
Implied Decisions in NC HIE Strategic Plan – Oct. 2009
Approaches from Existing Strategic Plans Accept Modify/Needs Further Consideration
Reject
1. Public/Private Partnership Model to Govern Statewide HIE
X
2.Identify geographic regions to support “Community Health Information Organizations” (or “CHIOs”)Recommended that the statement be modified to reflect NC HIE’s support for those existing regional networks or initiatives that align with statewide and national efforts, and to eliminate reference to geographic regions.
X
3. Under governance model outlined in the Strategic Plan, a representative from each CHIO would hold a seat on the governance bodyRecommended that current board is a self-perpetuating board including representation from Hospital/Health Systems, Providers, Consumers, Employers, and Payers.
X
15Discussion Document – Not for Distribution
Implied Decisions in NC HIE Strategic Plan – Oct. 2009
Roles and Responsibilities of Governance Entity from Existing Strategic Plan
Accept Modify/Needs Further Consideration
Reject
1. Convening, educating and engaging key constituencies, including healthcare and health It leaders across the state.
X
2. Facilitating a two-tiered governance structure for interoperable health information exchange that includes: at the state level setting health information policies, standards and technical approaches, and at the community level implementing such policies by CHIOs.Workgroup decided that the issue needed more discussion and recommended that a decision on the principle be tabled and considered again in future Workgroup discussions.
X
3. Evaluating and establishing accountability measures for North Carolina’s HIT strategy.
X
Governing Participation in the Statewide HIE
17Discussion Document – Not for Distribution
Strategic Approaches for North Carolina Statewide HIE Structure
Range of “qualified organizations” pursuing regional or localized exchange are core structure
Statewide HIE provides statewide policy guidance, core services to enable interoperability
Statewide HIE may provide value-added services that benefit a range of participants to support sustainability.
Statewide Network Comprised of Diverse
Qualified Organizations
Abandon core services focus, leaving the private market to address interoperability
Provide backfills where market fails to assure ‘No provider left behind’
Focus on education, convening, and statewide policy guidance
Clinical/Technical Operations Workgroup advised against this option
Market Determines Structure – Statewide
HIE Backfills
Statewide HIE is primary vehicle for HIE
Statewide HIE builds infrastructure, consolidates HIEs for economies of scale
NC HIEs focus on local governance, adoption
Clinical/Technical Operations Workgroup advised against this option
Statewide HIE is the Market
Divide North Carolina into markets/territories assigned to existing HIEs, new HIEs or the Statewide HIE
Statewide HIE provides governance, manages monopolies for public good
Statewide HIE works with regional HIEs to develop service matrix to avoid duplication and to support joint sustainability.
Regional HIEs given Exclusive Territories –
Statewide HIE Provides Governance, Outreach
18Discussion Document – Not for Distribution
Considerations for Qualified Organization and Territory-Based HIE Models
Allows for a greater level of flexibility – wider range of entities can participate / serve as “on-ramps.”
Complexity could present need for greater level of administrative and technical support.
Policies and procedures would need to be adopted by and monitored across a larger and more diverse participant body.
Potential for more variation in core and value-added service needs.
Qualified Organizations
Allows for greater level of control – limited number of “on ramps.”
Potential cost savings due to fewer “on ramps.”
Could present higher level of risk – failure of one regional entity will impact many providers.
Requires significant stakeholder education and outreach.
Requires developing geographic boundaries and potentially close collaboration among competitors.
Responsibilities for service offerings more readily defined (some owned by Statewide HIE, others by RHIOs).
Territory-Based / Regional HIEs
19Discussion Document – Not for Distribution
New York Regional HIO Model
20Discussion Document – Not for Distribution
The RHIOs Serve as “On-Ramps” for Statewide HIE
21Discussion Document – Not for Distribution
Statewide Network Comprised of Diverse Qualified Organizations and Participants
One Example: Statewide Health Information Exchange NetworkOne Example: Statewide Health Information Exchange Network
RHIO RHIO
Lab Enterprise
Providers Hospital RHCFQHC Labs
PrivateNetwork
PayersPublic Health
Clinic Clinic Labs
Long TermCare
EHR Light
Medicaid
MMIS Clinical EligibilityPaid
ClaimsHospital Lab RHC FQHC
HospitalsPhysicianGroups
Clinics
NHIN GatewayInterstate Connectivity
Hospital Lab RHC
Hospital System
22Discussion Document – Not for Distribution
Complex HIE Landscape in North Carolina
• Multiple efforts and investments made across state in electronic exchange of health information.
• NC HIE Workgroup members have expressed a commitment to leveraging existing efforts to the extent possible.
• Many entities that could serve as data aggregators, for example:– Regional HIEs (WNCHN Datalink, CCHIE, Sandhills, Southern
Piedmont)– Statewide Exchange Services (Public Health Surveillance, NCHEX)– Academic Medical Centers with Faculty Practices– Large, Complex Health Systems – Community Care of North Carolina (CCNC)– Others
23Discussion Document – Not for Distribution
Key Questions for Discussion
• What is a Qualified Organization?• What is the Value of Being Part of Statewide HIE for a
Qualified Organization?• How do Qualified Organizations Join the Statewide HIE?• What are a Qualified Organization or Participant’s
Responsibilities as a Participant in Statewide HIE?• What is the Cost for Qualified Organizations to Participate in
the Statewide HIE?• What Happens if a Qualified Organization or Participant
Withdraws from the Statewide HIE?• How do providers or organizations unaffiliated with a
Qualified Organization connect to the Statewide HIE?• What are a Qualified Organization or Participant’s
Responsibilities as a Participant in Statewide HIE?• How Should Relationships Be Governed?
24Discussion Document – Not for Distribution
What is a Qualified Organization?
• A Qualified Organization is a health care organization or aggregator of organizations that is capable of fulfilling the technical, legal, policy, and procedural obligations defined by the Statewide HIE, and willing to enter a binding contract with the Statewide HIE that specifies these requirements and the legal consequences entailed therein.
• Qualified Organizations may be, but are not limited to:
– Provider Networks• Hospitals• Health systems • Integrated delivery networks (IDNs) • Provider groups • Consortia of providers• FQHCs/RHCs• Public Health • Regional HIOs
– Private Networks• Clearinghouses • Pharmacy • Vendor • Lab enterprise
– Medicaid Network– Payors
25Discussion Document – Not for Distribution
What is the Value of Being Part of Statewide HIE for Qualified Organizations?
• Facilitate satisfaction of meaningful use requirements among Qualified Organizations and Participants
• Increase access to important data at point of care by enabling HIE with organizations outside of a Qualified Organization’s existing network infrastructure more rapidly and at lower cost
• Offer broader referral and care coordination services to its members since they can now send/receive summary clinical information from organizations external to the Qualified Organization or Participant
• Access to North Carolina state government information, possibly including Medicaid data
• Lower development cost of shared services offered through participation in statewide HIE such as MPI, consent management, lab orders and results delivery, medication reconciliation
• Possible electronic access to public health data
• Access to best practices and learnings gathered by the Statewide HIE
• Participation in multi-state/interstate HIE and the NHIN
• Other?
26Discussion Document – Not for Distribution
How do Qualified Organizations Join the Statewide HIE?
• Part governance, part technical:
– Participation agreement/contract with the Statewide HIE, binding them to compliance with the Statewide HIE’s policy guidance and rules?
– Must integrate with and connect to the Statewide HIE
27Discussion Document – Not for Distribution
What is the Cost for Qualified Organizations to Participate in the Statewide HIE?
• Financial models are still under development. Cost considerations may include:
– Upfront connectivity costs
– Membership costs in proportion to the number of participants or the number of transactions
– Staging of costs based on which value-added services, in addition to core services, the Qualified Organization or Participant wishes to utilize
• Overall per participant costs should decrease with broader participation
28Discussion Document – Not for Distribution
What are a Qualified Organization or Participant’s Responsibilities as a Participant in Statewide HIE?
• Agree to send and receive health information to and from participants in accordance with the Statewide HIE’s rules
• Comply with all of the Statewide HIE’s policy guidance and rules
• Enforce the Statewide HIE’s rules with all of its own members and participants, including technology vendors that it employs
• Participation in governance process managed by Statewide HIE (e.g. participation in Workgroups or Advisory Bodies)
• Participation in generation and evolution of technical, legal, and other policy guidance as deemed necessary by governance process
29Discussion Document – Not for Distribution
What Happens if a Qualified Organization or Participant Withdraws from the Statewide HIE?
• Participation in statewide HIE is voluntary
• Withdrawal from participation is subject to reasonable withdrawal rules and processes
30Discussion Document – Not for Distribution
How do providers or organizations unaffiliated with a Qualified Organization connect to the Statewide HIE?
• If the NC HIE decides as policy it must fulfill a commitment to “no provider left behind” the Statewide HIE must offer every provider the opportunity to connect to the Statewide HIE network
• Options to insure every provider has access to at least one qualified organization (for example):
– Requiring that a qualified organization accept any provider that applies – with possible subsidies to the participant or the qualified organization in cases where the costs exceed the provider’s ability to pay
– Requiring that qualified organizations “bring on” a portion of providers who would otherwise lack access to statewide HIE (e.g. 10% of total provider participants)
– Offer a low-cost portal to enable participation in statewide HIE
– Coordination with the Regional Extension Center (REC) to identify small and solo practitioners for alignment with a qualified organization or connectivity via a low-cost portal
31Discussion Document – Not for Distribution
How Should Relationships Be Governed?
• The State would enter into a contract with the Statewide HIE
• The Statewide HIE would enter into a technical services contract (likely through an RFP process) to build a service offering consisting of core services and some value-added services
• The Statewide HIE would “certify” Qualified Organizations; Qualified Organizations will have a participation agreement/contract with the Statewide HIE, binding participants to compliance with the Statewide HIE’s policy guidance and rules
• Qualified Organizations (RHIOs, hospital systems, private networks, Medicaid, others) would be able to connect to the Statewide HIE to access core and value-added services
• Statewide policy guidance would include: – Privacy and security rules – Technical rules– Financial rules – Vendor contract requirements – Ongoing governance structure and participation
NC HIE Governance Domain of Operational Plan
33Discussion Document – Not for Distribution
NC HIE – Governance Domain of Operational Plan
• Combined Strategic & Operational Plan• Structure of Governance Domain in Plan:
– Overview– NC HIE Public/Private Partnership
• Articles of Incorporation• By-laws Recommendations
– Board of Directors– Committees– Workgroups– Conflicts of Interest– Transparency
• Authority and Involvement of the State in the PPP
– Governance of Participation in the NC HIE– Alignment with Other Programs
34Discussion Document – Not for Distribution
Next Steps
Upcoming Meetings– Board Meeting – July 13– Workgroup Meeting – July 22 (note location change: NC IOM)
Questions or Comments? - Contact [email protected]