1 st Meeting June 9, 2010 8:30 am – 11:00 am Dial-in:1-866-922-3257; Participant Code 654 032 36#

1. 1st Meeting June 9, 2010 8:30 am – 11:00 am Dial-in:1-866-922-3257; Participant Code 654 032 36#

2. Agenda

3. Introductions: Co-Chairs, Staff, and Members Staff • William Bernstein, Manatt • Melinda Dutton, Manatt • Brenda Pawlak, Manatt • Allison Garcimonde, Manatt Co-Chairs • Ben Money, NC Community Health Association • Tom Bacon NC HIE • Alan Hirsch, Interim CEO • Steve Cline, State HIT Coordinator • Anita Massey, State Project Manager Members • Connie Bishop, MSN RN, National & State Baldridge Examiner • Jacquelyn Boyden, Kalish Consulting Group • Janis Curtis, Duke Health System • Dana Gibson, Data Link HIE • Craigan Gray, DHHS DMA • Mark Gordon, Kerr Drugs • Don Horton, LabCorp • Darlyne Menscer, NCMS, Carolinas Healthcare System • Harry Reynolds, IBM • Craig Richardville, Carolinas Healthcare System • Pam Silberman, NC Institute of Medicine • Sam Spicer, New Hanover Regional Medical Center • Craig Souza, NC Healthcare Facilities Association

4. Expectations of the NC HIE Workgroups • Participants have been nominated and invited to participate by the NC HIE governing board co-chaired by Secretary Lanier Cansler and Mr. Charlie Sanders for your expertise in your field and your commitment to improving health care quality, access, and affordability for all North Carolinians. • Workgroup members are asked to draw on their expertise and perspective from across industries sectors with an eye toward supporting the greater goal of a statewide resource for North Carolina. • Workgroups are expected to be multi-stakeholder, nonpartisan and all discussions, meetings and decision-making processes to be fully transparent. • Workgroups are asked to consider multiple stakeholder group perspectives when working toward solutions. • Workgroups will be asked to make consensus-based recommendations to the NC HIE governing board. In cases where consensus is not reached, the workgroup is expected to put forth a balanced, fair consideration of the pros and cons of an issue. • Workgroup members are expected to respect the opinions and input of others and to engage in fair meeting conduct to work toward consensus recommendations. • Workgroup members are strongly encouraged to attend meetings in person whenever possible. • Public stakeholder input is encouraged.

5. Meeting Objectives:Key Decisions • Clear Understanding of Our Charge and Tasks • Confirmation on Public/Private Partnership Model for Governing Entity • Consensus on Roles and Responsibilities of Governing Entity and recommendations to NC HIE Board • Understanding of Upcoming Issues Tasked to Workgroup

6. Overview of the Context for Statewide HIE

7. HITECH Funding:HIT & HIE infrastructure New Incentives for Adoption Funding for Health IT • $1.2 B for loans, grants & technical assistance for: • Regional Extension Centers ($640M) • Workforce Training ($80M) • Research and Demonstrations • Medicare & Medicaid incentives for HIT adoption • ~$31.5 B to $48.1 B total in expected outlays* Funding for HIE Community Health Centers $1.5 B in grants through HRSA for construction, renovation and equipment, including acquisition of HIT systems • $564 M for Statewide HIE Development • States receive between $4M & $40M $220 M for “Beacon” Community Program • 15 HIEs receiving between $10-$20M Broadband and Telehealth $4.3 B for broadband & $2.5 B for distance learning/ telehealth grants *(North Carolina providers estimated to receive $750 M to $1 B) 7 Discussion Document – Not for Distribution

8. North Carolina Health IT Awards • ARRA: • State HIE Cooperative Agreement: $12.9 million • Medicaid Meaningful Use Planning: $2.29million • Regional Extension Center: $13.9 million NC AHEC (North Carolina Area Health Education Centers Program @ UNC Chapel Hill) • Beacon Community: $15.9 million Southern Piedmont Community Care Plan • Health IT Workforce Community College Consortia Program (non degree programs): $10.9 million Pitt Community College • Health IT Curriculum Development: $1.8 million Duke University • University-level Health IT Workforce Training (degree programs): $2.1 million Duke University • Broadband: $28.8million MCNC / North Carolina Research and Education Network (NCREN) • CHIPRA (non-ARRA): $9.2 million (one of 10 state awards) • Testing medical home for children with special health care needs through three provider-led community-based models • Implementing a model electronic health record format for children 8 Discussion Document – Not for Distribution

9. Meaningful Use Overview Regulatory Definition In HITECH, Congress specified three types of requirements for meaningful use: • use of certified EHR technology in a meaningful manner (e.g. Electronic Prescribing); • that the certified EHR technology is connected in a manner that provides for the electronic exchange of health information to improve the quality of care; and • that, in using certified EHR technology, the provider submits to the Secretary information on clinical quality measures and such other measures selected by the Secretary.

10. Meaningful Use: Funding Timeline MEDICAID CMS NPRM and ONC IFC Released Dec. 30 2009 Medicaid: hospitals that adopt after 2017 not eligible for incentives Medicaid incentives begin ONC Final Rule Medicaid: non-hospital based physicians1st yr cost no later than 2016 Medicaid: non-hospital based physicians no payments after 2021 or more than 5 yrs. 2009 2010 2011 2012 2013 2014 2015 2016 2017….. 2021 CMS Final Rule for Incentives Medicare phase down incentive payments for physicians Medicare penalties begin for non-meaningful users FY15 for hospitals calendar 2015 for physicians Medicare (FY2011) incentives begin Oct. 2010 for hospitals Medicare incentives End 2016 Medicare incentives begin Jan 2011 for non-hospital based physicians Medicare: Physicians who 1st payment is after 2014 receive no incentives MEDICARE

11. CMS Vision for Stages:Requirements Scaling Up Over Time For Stage 2, CMS may also consider applying the criteria more broadly to both the inpatient and outpatient hospital settings. CMS expects to propose Stage 2 criteria by the end of 2011. CMS expects to propose Stage 3 criteria by the end of 2013.

12. Framework of Health Reform: Payment Policy Changes Reduce Cost of Care Improve Coordination of Care Alter Content of Care • Stimulate Administrative Efficiencies • HIT Incentives • Limit FFS Payment Updates • Medicare captures productivity gains • FFS becomes less attractive • Encourage creation of new delivery organizations including: • Medical Homes, particularly for chronic care populations • Accountable care organizations • Tie Payments to Broader Units of Service • Hospital and Physician Payment Bundles • Episode-Based Payment Bundles • Improving Scientific Basis of Healthcare Decisions • Based on Comparative Effectiveness Research • Payment Tied to Patient Outcomes • Based on Quality Measures

13. Health Information Exchange: Changing the Paradigm Today“One-to-One” Exchange Tomorrow“Many-to-Many” Exchange • Human judgment plays a critical role in determining what information is shared and with whom • Phone conversations between clinicians for purposes of treatment frequently replace the need for physically exchanged information. • Authentication of requests for information is heavily reliant on relationships between organizations or individuals charged with information sharing. • In an environment of ubiquitous electronic HIE, data will be gathered or transferred between multiple entities without benefit of the familiar relationships of the old paradigm. • At the time of collecting the data, verification of the requester and sources will be critical, and may require sophisticated permission and authorization controls.

14. The Health IT / HIE Landscape Is Increasingly Diverse RHIO Private Networks Hospital EHR PHR Labs, X-Rays, etc. Labs, X-Rays, etc. Labs, X-Rays, etc. Labs, X-Rays, etc. Labs, X-Rays, etc. Health Plans, PBMs Health Plans, PBMs Health Plans, PBMs Hospital Hospital Specialists Specialists Specialists Health Plans, PBMs Health Plans, PBMs eRx Network eRx Network eRx Network eRx Network eRx Network Affiliated Hospitals Hospitals Hospitals Hospital Hospital Primary Care Providers Primary Care Providers Primary Care Provider Primary Care Provider Primary Care Provider Parent System/Org Public Health and Other Agencies Public Health and Other Agencies Specialist Specialist Primary Care Provider Primary Care Provider Long Term Care Long Term Care Long Term Care RHIOs A health information organization that brings together health care stakeholders within a defined geographic area and governs health information exchange among them for the purpose of improving health and care in that community* HIOs An organization that oversees and governs the exchange of health-related information among organizations according to nationally recognized standards* Emerging Private Service Providers and Networks Surescripts, Availity, Navinet, etc, Personal Health Information Repositories and Exchange MSFT HealthVault, Epic MyChart, Payer PHRs, etc. EHR Vendor Networks Epic Everywhere, eClinicalWorks EHX, etc * Source: The National Alliance for Health Information Technology Report to the Office of the National Coordinator for Health Information Technology on Defining Key Health Information Technology Terms, April 28, 2008

15. Multiple Approaches to Patient Engagement PHR Labs, X-Rays, etc. Health Plans, PBMs Specialists eRx Network Hospitals Primary Care Provider Providers Hospital Pharmacy Labs Pharmacy Public Health and Other Agencies Long Term Care • Un-tethered PHRs • Google, Microsoft, Dossia, WebMD • “Life long” – tries to replicate home file system • Requires work to collect data from providers • Traction with wellness, cancer, and chronic • Tethered to Payer • Insurance providers offer portals to reduce support cost and for “stickiness” • No longevity, consumer changes insurance every 3 yrs • Comprehensive, all provider data in one place • Predominately used by consumer to understand healthcare spending for budgeting & HSA Payer Portal • Tethered to Provider • Most major EMRs have a “patient portal” • Larger providers using portal to reduce admin costs and to drive patient “stickiness” • No integration between providers Other HIT Provider EMR Portal

16. The NHIN NHIN Direct and NHIN Connect NHIN Direct NHIN Connect

17. The NHINDetails on NHIN Direct & NHIN Connect NHIN Direct A project to expand the standards and service definitions that, with a policy framework, constitute the NHIN. The standards and services will allow organizations to deliver simple, direct, secure & scalable transport of health information over the Internet between known participants in support of Stage 1 meaningful use. • Key Deliverables • standards • service definitions • implementation guides • reference implementations • associated testing frameworks. NHIN Connect A select group of entities that have agreed to share data across organizations along defined use cases. The software to accomplish HIE to HIE exchange (patient look up, retrieval). • Current Exchange participants • SSA, MedVA, DoD, Kaiser Permanente, VA, CDC • Future potential participants • Beacon Communities, SSA grantees, state HIE

18. NHIN Relationship to HIO & HIE NHIN Connect envisioned to support more complex exchange needs ONC associates less complex exchange, such as secure routing with NHIN Direct Success is dependent on EMR and HIE vendor adoption of the technologies and standards into their mainstream products Source: “NHIN 102: Secure and Meaningful Exchange of Health Information over the Internet,” Doug Fridsma, MD, PhD., March 2010.

19. Overview of Workgroup Process and Tasks

20. Meeting Objectives:Key Decisions • Clear Understanding of Our Charge and Tasks • Confirmation on Public/Private Partnership Model for Governing Entity • Consensus on Roles and Responsibilities of Governing Entity and recommendations to NC HIE Board • Understanding of Upcoming Issues Tasked to Workgroup

21. State HIE Cooperative AgreementGoals and Planning Requirements • Goal: Plan and develop the HIE infrastructure to ensure • Widespread interoperability across entire state • Providers and hospitals can achieve meaningful use Required Plans Domains to Address Types of Exchange • Strategic Plan: State’s vision, goals, objectives and strategies for statewide HIE; including plans to support provider adoption • ( Submitted to ONC Oct. 09 , to be verified via Operational Plan process) • - Operational Plan: Detailed explanation, targets, dates for execution of strategic plan • Eligibility & claims transactions • eRx & refill requests • Lab ordering & results delivery • Public health reporting • Quality reporting • Rx fill status/med fill Hx • Clinical sum for care coordination & patient engagement • -Governance • -Finance • -Technical infrastructure • -Business & Technical Ops • -Legal and Policy

22. Key Strategic Decisions for North Carolina • How will the NC Statewide HIE relate to regional HIEs? (Governance) • What State incentives/tools/levers may be used to quicklyfacilitate significant participation in the statewide HIE?(Governance) • How will the State ensure that the public interest is protected? (Governance & Legal/Policy) • What core infrastructure and services will be offered? (Clinical/Technical Operations) • How will start up and ongoing costs be financed and sustained over time? (Finance) • What policies will be implemented to protect privacy and security of data and promote trust? (Legal/Policy)

23. State HIE Cooperative Agreement Program: Governance • The statewide HIE should provide governance, leadership, and accountability around the management of the HIE infrastructure, privacy and security, and a mechanism for consumer and provider participation. • The Governance Workgroup will • Develop a governance framework that will ensure broad-based stakeholder collaboration and transparency • Develop and vet governance models to be recommended to the NC HIE Board • The Workgroup will be tasked with ensuring a governance framework characterized by: • Alignment with Medicaid and public health programs • The ability to provide oversight and accountability to protect the public interest • The support of providers statewide to achieve meaningful use

24. State HIE Cooperative Agreement Program: Governance

25. Workgroup Deliverables for Operational Plan 25 Discussion Document – Not for Distribution

26. Meeting Objectives:Key Decisions • Clear Understanding of Our Charge and Tasks • Confirmation on Public/Private Partnership Model for Governing Entity • Consensus on Roles and Responsibilities of Governing Entity • Recommendations to NC HIE Board • Understanding of Upcoming Issues Tasked to Workgroup

27. State-level HIE Governance & Technical Operations In support of a statewide organizing capacity, state-level efforts serve two important and distinct roles: Governance: A primary role to convene health care stakeholders, promote collaboration, develop consensus, coordinate policies and procedures to secure data sharing, and lead and oversee statewide efforts. Technical operations: An optionaland variable role to manage and operate the technical infrastructure, services, and/or applications to support statewide efforts. 27

28. Governance: Considerations • Important distinction between state government and statewide governance, which refers to the process to serve the collective interests in the State. • Governance occurs at multiple levels: local, regional, statewide, interstate, and federal. States must define the roles, inter-relationships, and obligations within and across these layers. • Effective governance is built on inclusive and transparent processes that identify and develop practical policies for key decisions. • Accountability can be achieved through a variety of mechanisms, including statutory, regulatory, contracts, self-enforcement. • Should the State-level effort be empowered to sanction/accredit other entities (e.g. local health information exchanges, providers, payers) participation in the exchange of data in a state?

29. Potential Functions of a Comprehensive Governance Entity

30. Governance – Continuum of Statewide Coordination • How should HIE be governed in North Carolina? • What are the State’s and private sector’s roles? Public Private

31. Governance – Option 1

32. Governance – Option 2 (A)

33. Governance – Option 2 (B)

34. Governance – Option 3

35. Meeting Objectives:Key Decisions • Clear Understanding of Our Charge and Tasks • Confirmation on Public/Private Partnership Model for Governing Entity • Consensus on Roles and Responsibilities of Governing Entity • Recommendations to NC HIE Board • Understanding of Upcoming Issues Tasked to Workgroup

36. Governance Workgroup Threshold Issues

37. Meeting Objectives:Key Decisions • Clear Understanding of Our Charge and Tasks • Confirmation on Public/Private Partnership Model for Governing Entity • Consensus on Roles and Responsibilities of Governing Entity • Recommendations to NC HIE Board • Understanding of Upcoming Issues Tasked to Workgroup

38. Key Issues for Discussion in June & July 2010: • Bylaw-related issues for governing body • Model approaches to statewide HIE • Relationship between public-private partnership entity and state • Alignment with Medicaid and other state programs • Alignment with ARRA-funded HIT and HIE programs in state • Components of a consumer outreach and communications plan

39. Next Steps Upcoming Meetings Board of Directors– June 15th Workgroup Meeting – June 21st Questions or Comments? - Contact anita.massey@nc.gov 39 39 Discussion Document – Not for Distribution