HIT Policy Committee

1. HIT Policy Committee Information Exchange Workgroup Micky Tripathi, Massachusetts eHealth Collaborative, Chair David Lansky, Pacific Business Group on Health, Co-Chair October 20, 2010

2. Charge to the IE Workgroup • Breakthrough areas where policy barriers prevent providers and/or states from being effective enablers of broader and deeper health exchange • Specific clinical transactions already identified as important to meaningful use • Critical issues that get unearthed by the over $1.5 billion programs in state-level HIE, RECs, Beacons, and NHIN Direct • IE WG will also act as conduit for state-level policy issues that need HITPC attention • For issues in IE WG charter, Identify and recommend solutions to such issues to HITPC • For issues outside of IE WG charter, navigate to most appropriate HITPC WG(s) and facilitate/coordinate as necessary

3. IE Workgroup Membership Chair: Micky Tripathi, Massachusetts eHealth Collaborative Co-Chair: David Lansky, Pacific Business Group on Health

4. Agenda for today • Provider Directory Task Force • Background • Policy Objectives and Problem Statement • High-Level Principles

5. Three-Month Plan 5

6. Provider Directory Task Force Membership Co-Chair: Jonah Frohlich, California Health and Human Service Agency Co-Chair: Walter Suarez, Kaiser Permanente Name Affiliation Hunt Blair Vermont Medicaid Sorin Davis CAQH Paul Egerman Judy Faulkner Epic Seth Foldy DHS, Wisconsin Dave Goetz Dept. of Finance and Administration, TN James Golden Minnesota Department of Health Keith Hepp HealthBridge Jessica Kahn CMS JP Little Surescripts George Oestreich Missouri Medicaid Lisa Robin Federation of State Medical Boards Steven Stack AMA Sid Thornton Intermountain Healthcare

7. Provider Directories and Health Information Exchange • Health information exchange, especially where a sender conveys an unsolicited communication to a known recipient, occurs today with high frequency • Mostly through fax, phone, mail, andwhere electronic, it happens through a variety of channels: ancillary service networks (e.g., Surescripts, Quest/LabCorps, etc), EHR vendor networks, health information organizations, etc. • Directories – which map human-friendly information to machine-readable information such as a person’s name to a phone number or an internet domain name to an IP address – play a critical role in making exchange easier and more scalable • Most directories are proprietary and local and specific to a particular mode of exchange • Within-organization contact lists and directories of individuals, locations • Network-specific directories (e.g., Surescripts, IDNs, Health plans, HIOs) • The most well-known non-proprietary, cross-organizational directory is the distributed DNS registry system used for internet routing • Health information exchange, particularly Directed Exchange transactions, will continue to grow, regardless of whether any federal- or state-government action is taken on provider directories • A variety of exchange approaches likely to be available to clinicians as ATCB-certified EHRs enter the market and MU incentives kick in • However, adoption speed likely to be hindered by lack of uniform and ubiquitous approach for cross-enterprise, cross-platform exchange • Access to provider directories can play a key role in making exchange more uniform and usable from a user perspective

8. Highlights of September 30th Provider Directory Hearing Four panels: Business Requirements (2), State/Regional Framing and Technical Requirements Common Themes Should distinguish between “entity-level” and “clinician-level” directories Entity-level directories serve automated routing of information among addressable network nodes Clinician-level directories could serve automated or human look-up of information at clinician-level specificity Should support interoperability across states and regions and leverage what works in the market today Align with MU Stage 1 transaction needs but want to be open for Stages 2 and 3 and beyond Should consider role of NHIN Direct Entity-level directories should be first priority First priority should be to focus on a “thin layer of discoverability” for entity-level directories – not at the clinician level (important, but second order) Three key components to focus on for entity-level directories: Defining standard addressing schema Establishing basic discoverability of entity (IP address, services supported by entity) Establishing basic discoverability of entity security credentials Common requirements for entity-level directories should be defined with rigid conformance at national level Clinician-level discoverability is important as well but likely to be more complex Needs to be at individual clinician level Development and implementation could be at sub-national/regional/state level Rigid conformance not required 8

9. Policy Objective and Problem Statement Policy objective • Facilitate rapid increase in secure electronic health information exchange (HIE) throughout our health system Problem Statement • The lack of a consistent approach to cross-organizational provider directories will be a barrier to progress both in “directed exchange” and in health information exchange more broadly • Will also represent a missed opportunity to align multiple activities and combine multiple streams of funding that could yield a lower cost, higher quality service for all (e.g., State-level HIE grants, Beacon grants, Medicaid, Public Health) • Key questions that the IE WG will address: • How can provider directories accelerate information exchange? • What can federal and state governments do to guide directory development to support meaningful use and drive system-wide improvements in care? • What policy actions can be taken to promote creation of provider directories that accelerate secure information exchange? • How can information exchange across state borders and nationwide be accelerated by consistent application and use of provider directories? 9

10. Priority should be given to Provider Directories that facilitate MU Stage 1 transactions Directed Exchange transactions supporting Stage 1 Meaningful Use • PCP to/from Specialist (i.e., problem list, patient summary visit) • Ambulatory Clinician to/from Hospital (i.e., discharge summary; emergency department visit summary; surgical report) • Ambulatory Clinician to/from Laboratory (i.e., lab order, lab result) • Hospital or Ambulatory Clinician to/from Public Health (i.e., reportable lab) Two overarching problems to solve for Directed Exchange for MU Stage 1 • Discovery: • Need to know what messages the recipient is able to consume, what mode of communication to use, and how to identify both the correct recipient and their address for a given mode • Security: • Authentication: Need to verify that the recipient computer has appropriate security credentials • Transport: Need to have a secure means of transporting the message Directly addressable by provider directories Supported by provider directories 10

11. Illustrative Schematic of Directed Exchange TransactionClinical Entity to Clinical Entity Example • In principle, directories can play a role facilitating almost any step of such a transaction • However, in practice, complexity rises dramatically as one tries to encompass more information about endpoints and users • A minimum-level directory is needed to facilitate routing of information among recognized entity gateways • NHIN Direct builds on existing DNS infrastructure, with no provider look-up • NHIN Exchange offers more robust directory services for validated NHIN nodes 11

12. High Level Principles to Consider To Guide Development of Provider Directory Policy Recommendations What initial principles should apply generally to Provider Directories? (From Nationwide Framework) Openness and Transparency – Provider directories policies, procedures and technologies should be open and transparent. Collection, Use, and Disclosure Limitation – Provider directories will support the exchange (collection and disclosure) of health information in a consistent and reliable manner. Data Quality and Integrity – By supporting reliable information exchanges in real time, provider directories will help ensure that complete and accurate data is available to support delivery of care. Safeguards – Provider directories will support the secure exchange of health information. Accountability – Provider directories will help ensure accountability of those involved in information exchanges. What initial principles should apply to our Provider Directory recommendations? Business Processes - Start simple and with what’s needed to support concrete priority business process, not with data Meaningful Use - Focus on requirements for stage 1 MU, but with an eye to supporting Stages 2 and 3 and beyond Agility - Don’t over-design too early, remain flexible to changes in technology and business (e.g., ACOs) Incremental – Start by identifying and clearly articulating the minimum set of directory capabilities and the most straightforward technical model needed to accelerate and enhance secure exchange as identified in current and anticipated Meaningful Use stages Collaboration - Encourage regional/multi-state/national initiatives that leverage purchasing, policy and regulatory opportunities Completeness - Clearly delineate sources and uses and users Security – Protected health information must be transmitted securely, with assurances that actors participating in exchange adhere to a minimum set of standards to protect that information 12

13. Questions For WG’s Next Step: Entity level directoryIssues to be addressed • FUNCTIONALITY • Scope • Entity level • Support NHIN Direct • Aligned with NHIN Exchange • Functions • Support exchanges (routing/query/ retrieve) • Support basic discoverability of entity • Support basic discoverability of entity certificate • Operational issues • Operationalizing the thin-layer entity discoverability • Operationalizing the discoverability of entity certificates • How are services managed/built? • How to motivate entities to keep information up-to-date and accurate? • How integrated does this need to be with Direct implementation? • Centralized or federated? • STANDARDS • What standards need to be established by HIT Standards Committee? (Data elements; Open interfaces; others) • POLICY • Participants - Which entities should be included, listed in directory? • Entity type (i.e. labs, hospitals etc) • Characteristics of entities (i.e. only covered entities and business associates) • Participants in particular exchange activities (i.e., Direct, Exchange) • Roles • Federal Government (build, maintain, define standards)? • State/regional HIE activities and HIOs • Providers, vendors, other participants • What should/does government have jurisdiction over? • Approaches • National-centralized • Federated • Applicability and Enforcement • Requirements to participate, conformance, update, accuracy • Should entities be required to agree to a set of policies before being listed in a directory? Which directories? Which policies? • How will policies be enforced? • Who will recommendations apply to?