HITSP Real World Sites Health Information Exchanges

1. HITSP Real World Sites Health Information Exchanges Webinar 6 July 9th, 2009 | 2:00 – 3:30 pm (Eastern) Laurance Stuntz, NEHEN Technical Architect, Partner, CSC Jim Younkin, KeyHIE Project Director Noam H. Arzt, PhD, FHIMSS, VITL Consultant

2. Learning Objectives During this 90-minute webinar, participants will: Learn how HITSP products are being used today by NEHEN, KeyHIE and VITL Learn how NEHEN used standards to deliver a sustainable, growing Health Information Exchange (HIE) for administrative and clinical data Learn about KeyHIE adoption of national models and standards in the implementation of an HIE providing timely information for patient care Learn about VITL’s use of standards and success with results delivery, medication history, disease management, and other functions

3. Agenda What is HITSP? New England Healthcare EDI Network (NEHEN) Keystone Health Information Exchange (KeyHIE) Vermont Information Technology Leaders (VITL) Overview of the 2009 Webinar Series

4. To serve as a cooperative partnership between the public and private sectors for the purpose of achieving a widely accepted and useful set of standards specifically to enable and support widespread interoperability among healthcare software applications, as they will interact in a local, regional, and national health information network for the United States. Mission

5. Overview HITSP is a volunteer-driven, consensus-based organization that is funded through a contract from the Department of Health and Human Services Created in 2005 HITSP develops Interoperability Specifications (IS) – documents that harmonize and recommend the technical standards that are necessary to assure the interoperability of electronic health records Production to date:13 IS and 60 related constructs

6. Patients Consumers Employers General Practitioners HITSP Stakeholders • Specialists • Payers • Suppliers • Hospitals • Review Boards • Practice Guidelines • Residential Care Providers • Outpatient Healthcare Providers • Government Agencies Current Participation in HITSP: 724 organizations 800+ individuals Over 25,000 volunteer hours

7. HITSP members agreed that a standard is a well-defined approach that supports a business process and . . . has been agreed upon by a group of experts has been publicly vetted provides rules, guidelines, or characteristics helps to ensure that materials, products, processes and services are fit for their intended purpose is available in an accessible format is subject to an ongoing review and revision process HIT Standardization Standards Harmonization is required when a proliferation of standards prevents progress rather than enabling it.

8. HITSP Interoperability Specifications (IS) Recognized Accepted

9. HITSP Interoperability Specifications (IS) Released / Panel Approved

10. “Meaningful Use” From existing Interoperability Specifications, determine subset required for “meaningful use” as called for in the American Recovery and Reinvestment Act (ARRA) 9

11. ARRA Led to Creation of HITSP Capabilities All based on previous HITSP work

12. NEHEN – New England Healthcare EDI Network Use of HITSP IS Laurance Stuntz - NEHEN Technical Architect

13. Massachusetts Healthcare Information Exchange History 1997: New England Healthcare EDI Network (NEHEN) founded 5 members concentrating on implementation of HIPAA Administrative Simplification 2003: MA-SHARE founded Clinical Data Exchange started in with MedsInfo-ED pilot 2004 – 2005: NHIN Architecture Prototype 2006: Rx Gateway 2008: Discharge Summary Pilot 2009: Clinical Data Delivery June 2009 Clinical (MA-SHARE) and Admin (NEHEN) Merge

14. MA-SHARE / NEHEN Merger Background NEHEN had a strong cost savings focus and has been sustainable through member fees since 1999 MA-SHARE relied on grant and “angel” funding for 2003 – 2008 In 2009, clinical services are mature enough to be sustainable through member fees Organizations decided to merge and form a new not-for-profit for a variety of reasons Economies of scale relative to governance, management, and support Take advantage of shared technical infrastructure Positioning for HIE / Stimulus funding

15. What is NEHEN? • NEHEN is a collaborative, payor and provider-owned solution for healthcare data exchange that has: • 50+ hospitals, 5,000+ physicians, 4.5M+ health plan members • 8 health plan participants • Delivers more than 7 million total transactions per month • Delivers more than $15 billion in claims per year • Delivers more than 100,000 new prescriptions per month • Purpose • Shared development effort / exchange best practices • Coordinated project planning and prioritization • Dedicated exchange technical support • Coordinated exchange testing and implementation • Benefits: • Simplified Administrative Processes • Increased Net Revenue • Reduced Costs

16. Founding Members Provider Members Payor Members Vendor Members Member Overview

17. NEHEN Functions Administrative Information Exchange NEHEN delivers all of the HIPAA administrative transactions with a flat subscription fee, allowing members to use a single, integrated solution for communicating with their payors, at a fraction of the cost of using traditional healthcare clearinghouses Ambulatory and Long Term Care ePrescribing NEHEN provides a utility to link homegrown EMR systems to the SureScripts pharmacy network and other medication history information sources to help providers receive ePrescribing incentive payments Clinical Data Delivery NEHEN connects hospitals, physician practices, and other providers via the HIE to exchange clinical data, including discharge summary and continuity of care documents

18. Capability: Exchange of Administrative Benefits / Eligibility Transactions Harvard Pilgrim NEHEN Contract Affiliates Automatic transmittal Tufts Health Plan Network Health • Hospital or Physician Practice BMCHP NHP • NEHEN Network • Transactions are transmitted to NEHEN eGateways at other members • Providers are directly connected with each payer or via NEHEN Hub NEHEN Reports • NEHEN Database Patient Accounts NEHEN eGateway creates the standard transactions NEHEN Payor Services NEHEN Express Non-NEHEN Payor Non-NEHEN Clearinghouse Provider-side Payor-side

19. Capability: Issue Ambulatory and Long Term Medications (ePrescribing) Secure Internet Payor Prescriber Point of Care Information System Pharmacy (Retail or Mail Order) Dispenser Rx Gateway Data Provider Data Router

20. Secure Internet Capability: Clinical Data Delivery Using CCD Receiver: Payor / Physician / Hospital Sender: Physician / Hospital EMRs and Other Enterprise Systems Interface Engine or Portal Interface Engine or Portal EMRs and Other Enterprise Systems HIE Application Server / Gateway HIE Application Server / Gateway Secondary Local System Secondary Local System CCD Standard Document CCD Standard Document NEHEN HIE Application Server / Gateway CCD Standard Document, HTTP encapsulation Community Participant Locator

21. Capability: Screen Shot Communication of Clinical Data Using CCD

22. Exchange of Administrative Benefit Eligibility Transaction X12 270-271 Eligibility Inquiry and Response Utilizes business rule from CAQH CORE leading to T85 – Administrative Transport to Health Plan for new connections Issue of Ambulatory and Outpatient (ePrescribing) Industry has standardized on NCPDP specifications and SureScripts communication formats Clinical Data Delivery C32 / Summary Documents using HL7 Continuity of Care Document (CCD) Component C83 / Clinical Document Architecture (CDA) Content Modules Component HITSP Capabilities Used by NEHEN

23. Quality Reporting C 38: Patient Level Quality Data Document Using IHE Medical Summary (XDS-MS) Research Reporting C 25: Anonymize General Transaction Delivery C 26: Nonrepudiation of Origin T 16: Consistent Time T 17: Secured Communication Channel T 31: Document Reliable Interchange T 29 : Notification of Document Availability C 44 : Secure Web Connection C 62 : Unstructured Document C 80: Clinical Document and Message Terminology HITSP Constructs Under Consideration for Future Clinical Data Exchange • Maintain Privacy and Security • TP13: Sharing of documents • TP20: Access Control Transaction Package • T 15: Collect and Communicate Security Audit Trail Transaction • TP30: Manage Consent Directives Transaction Package

24. HITSP Solution & Benefits HITSP Descriptions of Use Cases are valuable to help educate members and new participants Plan to leverage components identified by HITSP C32 / C83 concepts relative to the CCD T85 relative to new health plan trading partners (based on CORE) Tracking and planning to implement HITSP constructs as use cases indicate a documented interaction, data format, or transport

25. The Future Currently developing priority and planning for implementation of the following: Expand use of visit/discharge summaries Sending data in support of consultation Sending data in support of quality reporting Integration with personal health records Expanding connectivity to external, non-local trading partners Connectivity to Aetna, United, and other national payors Connectivity to software vendors and hosted EMRs

26. Lessons Learned – HIE Creation and Governance Concentrate on sustainability Pick use cases that save money so that new organizations will willingly fund ongoing operations NEHEN started with administrative exchange and those successes have led to annual budget of > $3MM completely from member contribution Get executive commitment Policy groups must have C-level representation to commit their organizations Organizations must commit tangible dollars or dedicated resources; this can’t be a part time or “volunteer” job Don’t try to boil the ocean Start with small projects Pilot with 2-3 participants Learn from the pilot, adjust, and expand

27. Lessons Learned – Standards HITSP Constructs provide value in organizing concepts and linking to recognized standards NEHEN has tended to take pieces of the Interoperability Specifications rather than implement them in whole cloth NEHEN experience supporting both clinical and administrative workflows points to a need for common transport specifications T85 starts down this path, but needs to be extended to data-agnostic transport Tracking the common data transport model under development by the Security, Privacy and Infrastructure Technical Committee It will be important to simplify the presentation of HITSP concepts and make them accessible to non-experts

28. KeyHIE Use of HITSP IS Jim Younkin - KeyHIE Project Director

29. KeyHIE® June 2009 H H H H H H H • Twelve member organizations • - hospitals, clinics, skilled care, home health, LTC • Data from 7 hospitals / 42 clinics • Used in three emergency departments • 2.5+ million patient records in MPI • 130+ Users • 317,000+ Patient Authorizations

30. KeyHIE® Implementation Strategy Leverage systems and data sources already in place to avoid high start-up costs (MPI, web-portals, etc.) Build incrementally: 4 phases Adopt national models and standards Initially: Connecting for Health Now: IHE and HITSP

31. KeyHIE® History

32. KeyHIE® Implemented Use Cases/Capabilities Portal access to regional data sources Emergency department physicians, nurses, staff Primary care and specialty practices Case managers Regional link from Electronic Health Records (EHRs) Laboratory results sent to external EHR

33. KeyHIE® Use of HITSP Standards Current C 62 Unstructured Document T 15 Collect and Communicate Security Audit Trail T 16 Consistent Time T 17 Secured Communication Channel TP 13 Manage Sharing of Documents TP 22 Patient ID Cross Referencing (equivalent) TP 30 Manage Consent Directives (equivalent) C 35 HITSP EHR Lab Result Terminology Component C 36 HITSP Lab Result Message Component Planned T 23 Patient Lookup by Demographics C 37 HITSP Lab Report Document Component C 48 Encounter Document Using IHE Medical Summary (XDS-MS)

34. Demographics – HITSP TP22 (equivalent)

35. Patient Authorization– HITSP TP30 (equivalent) • Opt-in • No authorization, no access • Authorization at each organization • Real-time authorization • Patient education • Rigorous information security practices

36. Encounters (Record Locator from “Connecting for Health”)

37. Clinical Documents – HITSP TP13, C62

38. Standard Lab Coding – HITSP C35

39. KeyHIE® Successes Community Master Patient Index with 2.5+ million patients KeyHIE portal live in April 2007 Now receiving data from seven hospitals and 40-clinics 4.7+ million encounters recorded annually 317,000+ patient authorizations signed by June 2009 Began document repository in October 2008 82,000+ documents published by June 2009 97% of labs from one hospital now file electronically to EHR

40. Lessons Learned Technical readiness of communities to use HIE standards Patient authorizations RFP development Operational costs (e.g. MPI maintenance) Value to case managers HITSP allows rapid deployment

41. Document Store Selection Process Started with participants in HIMSS interoperability showcase Contracted with IHE-vetted professional to navigate RFP process Developed requirements Request for Proposal sent to vendors… IHE “certified” for PIX and XDS Registry/Repository Hosting capabilities Grant-related time constraints Got solid responses from 7 vendors

42. Document Store Requirements Provide and Register Documents (any content) Query and Retrieve Documents Interface set up with Registry / Repository Document Sources Document Consumers Integrate with KeyHIE Infrastructure CMPI, RLS, Network

43. KeyHIE® Future More Stakeholders: • Emergency Departments • Case managers (Medical Home) • PCPs • Home Health • Long Term Care / Assisted Living • Emergency Responders More Documents: • Laboratory Results • Medication Lists • Consults • Pathology Results • Allergies • Problem Lists • Patient Summaries (Continuity of Care Documents) • Electrocardiogram Tracings (EKGs)

44. Contact Information Jim Younkin – Project Director, KeyHIE IT Program Director, Geisinger Health System jryounkin@geisinger.edu This project was supported by grant number UC1HS016162 from the Agency for Healthcare Research and Quality, and in part, under a contract with the Pennsylvania Department of Health, Harrisburg, Pennsylvania. The department specifically disclaims responsibility for any analysis, interpretations or conclusions. Edward G. Rendell, GOVERNOR.

45. VITL – Vermont Information Technology Leaders Use of HITSP IS Noam H. Arzt, PhD, FHIMSS, VITL Consultant

46. Background: What is VITL? A non-profit public-private partnership located in Montpelier, VT Started by VAHHS (hospital association) Incorporated on July 22, 2005 Declared by Vermont Legislature to be only statewide RHIO 11 member board of directors representing various stakeholder groups – physicians, hospitals, insurers, employers, state government, and consumers Awarded non-profit status by IRS in March 2009

47. VITL’s Projects and Services Developed original Vermont Health Information Technology Plan Health Information Exchange Network Build secure interfaces to data sources/sites Provide data, storage and messaging Data normalization and matching services for Department of Health’s Blueprint for Health (Chronic disease management/medical home project) and immunization information system Results delivery for lab tests, radiology reports Electronic health record adoption and clinical transformation Medication history service E-prescribing adoption incentive program

48. Functions Results Delivery Hospitals are connected to the VITL HIE to send HL7 messages containing results to EHRs. Local lab codes translated to LOINC standard. Medication Histories for Emergency Departments Medication data from Pharmacy Benefit Manager (PBM) databases is obtained through the SureScripts network and routed to hospital emergency department through the VITL HIE. EHR Grant Program Independent practices receive grants to acquire EHRs, redesign workflow, and connect to the VITL HIE. Public Health Registries VITL connects practice EHRs to public health registries, including immunization reporting, health maintenance tracking, and others. Clinical Data Sharing VITL connects hospitals, physician practices, and other providers via the HIE to exchange clinical data, including continuity of care (CCD) documents.

49. Continuity of Care Document Data Sharing Example

50. HITSP & IHE Standards Used HITSP C32 IHE XDS-MS Medical summary HITSP TP22 IHE-PIX Patient lookup by ID Future HITSP C37 IHE XD*-Lab Lab data exchange HITSP TP23 IHE-PDQ Patient lookup by demographics HITSP TP30 IHE BPPC Consent HITSP T17 IHE ATNA Secure node XDS HITSP TP23 IHE XDS Document storage/ retrieval HITSP T15 IHE ATNA Audit logging HITSP T14 HL7 V2.4 Exchange lab results HITSP T16 IHE CT Consistent time