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A discussion of policy options and alternatives for the sustainability of public health information exchange
A discussion of policy options and alternatives for the sustainability of public health information exchange
A discussion of policy options and alternatives for the sustainability of public health information exchange
A discussion of policy options and alternatives for the sustainability of public health information exchange
A discussion of policy options and alternatives for the sustainability of public health information exchange
A discussion of policy options and alternatives for the sustainability of public health information exchange
A discussion of policy options and alternatives for the sustainability of public health information exchange
A discussion of policy options and alternatives for the sustainability of public health information exchange
A discussion of policy options and alternatives for the sustainability of public health information exchange
A discussion of policy options and alternatives for the sustainability of public health information exchange
A discussion of policy options and alternatives for the sustainability of public health information exchange
A discussion of policy options and alternatives for the sustainability of public health information exchange
A discussion of policy options and alternatives for the sustainability of public health information exchange
A discussion of policy options and alternatives for the sustainability of public health information exchange
A discussion of policy options and alternatives for the sustainability of public health information exchange
A discussion of policy options and alternatives for the sustainability of public health information exchange
A discussion of policy options and alternatives for the sustainability of public health information exchange
A discussion of policy options and alternatives for the sustainability of public health information exchange
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A discussion of policy options and alternatives for the sustainability of public health information exchange

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  • 1. An Examination of Policy Approaches andAlternatives for the Sustainability of PublicHealth Information ExchangeAs State-Level Health Information Exchanges (SLHIEs) seek a path towardssustainability, data transformation may hold the keyby Jeffery R. L. SmithABSTRACT: HITECH was a watershed moment for the promotion of health informationexchange (HIE) in the United States. But it was also a 100-year event, in terms of funding.Three years later, Congress is intensely focused on debt and deficit cutting, and states are notanticipating any out-year funding for their HIE efforts. At the same time, HIO performance vis-à-vis cost savings, clinical outcomes and public health improvement will soon come under heavyscrutiny – by legislators, but also by current and potential HIO participants. The need to provevalue will be paramount, and as most of the HITECH grants were front-end loaded, time isrunning short. Nearly half of the sand has fallen through to the bottom of the hour glass. In theend, there are a few basic concepts that will unlock sustainability: data saturation,interoperability and data transformation. With the first two tasks being supported by healthcaresystem-wide changes, the accomplishment of the third may make or break many statewideefforts.Issue for Analysis Sustainable business models continue to elude most publicly-funded health informationexchanges (HIEs). This paper will examine prevalent revenue drivers among five State-LevelHealth Information Exchanges (SLHIEs) and explore the challenges that lie ahead for healthinformation organizations as the nation’s health information infrastructure matures.Background Health information exchange in the United States has a storied and acronymed history.From the early community health information networks (CHINs) of the 1990s to the regionalhealth information exchanges (RHIOs) of the mid and late-2000s, health informationprofessionals have sought for ways to communicate clinical data across space and time. Today,these networks prefer the simple designation of health information exchange (HIE) or healthinformation organization (HIO). HIOs are often referred to as the noun, whereas HIE is the verb.For our purposes, we can differentiate by saying, HIOs are the legal entities that have beenestablished to allow secure, integrated sharing of clinical information among numerous
  • 2. stakeholders, including clinical partners and public health, through a health informationexchange. The purpose of such exchange is to ensure patient data can accompany them to anycare setting in the country – securely and accurately – so that better health, better healthcare andlower costs can be achieved. The Department of Health and Human Service’s Office of theNational Coordinator for Health Information Technology (ONC) envisions independent HIEswill serve as “nodes” in a “network of networks.”1 The resulting Nationwide Health InformationNetwork (NwHIN) “is a set of standards, services and policies that enable secure healthinformation exchange over the Internet.”2 Historically, HIOs have struggled with business models that allow them to be financiallysustainable after grant money or seed funding is expended. Dr. Julia Adler-Milstein haschronicled the financial challenges of HIOs since 2007 with the help of the eHealth Initiative – anon-profit organization that surveys and tracks health IT infrastructure and is recognized as anauthority on health information exchange. According to Dr. Adler-Milstein, failure rates forHIEs in 2007 and 2008 were about one-in-four and one-in-five respectively.3 Although the 2008report found more operational HIOs (131) than in 2007 (83), they had made little progress inexpanding the types of data being exchanged, leading the author to conclude that HIOs’ “scoperemains limited and their viability uncertain.”4 A number of challenges were identified in the 2007 / 08 reports including a lack offunding, privacy and security concerns of stakeholders, legal or regulatory challenges, concernsabout competitiveness and technical architecture or infrastructure challenges. Funding rankedthe highest concern for HIOs in 2008 and Adler-Milstein’s research suggests that about 17percent of HIOs had sustainable financing in 2008. Since this time, however, the world of healthinformation technology and health information exchange has changed dramatically. ONC and other agencies of the federal government have invested hundreds of millions ofdollars over the last four years to establish a framework that could facilitate both local andnational health information exchange. In 2009, as part of the American Recovery andReinvestment Act, the Health Information Technology for Economic and Clinical Health(HITECH) Act contained $548 million in grant money for exchange. Fifty-six states, territoriesand state designated entities (SDEs) received grants ranging from $4 million to $38 millionthrough the State Health Information Exchange Cooperative Agreement Program. TheCooperative Agreement is a four-year program that requires states to submit operational and2 | Policy Approaches and Alternatives for the Sustainability of Public HIE
  • 3. strategic plans to the ONC, including yearly reporting requirements on financial status andprogram progress. State awardees must also match federal funds at increasingly higher ratesduring the four-year period, beginning with 1 percent in year two and ending at 33 percent byyear four.5 ONC had originally required each state to file a sustainability report by February2011, but the requirement was removed and a new deadline has not been set. Also part of the HITECH Act – and a significant driver of current health informationtechnology adoption – is the Medicare and Medicaid Electronic Health Records IncentivePayments Program. Upwards of $19 billion in federal reimbursement funds is available toeligible hospitals and eligible professionals who demonstrate the “meaningful use” of electronichealth records (EHRs). The meaningful use policy platform is a multi-year program seeking tomodernize health information technology through increased adoption of standardized andcertified EHRs. Meaningful Use is a base-line requirement for receiving incentive paymentsfrom Medicare and Medicaid, and if a hospital or doctor has not become a meaningful user ofEHRs by 2015, their reimbursement rates will be cut. In addition to components of the policythat encourage certain uses of technology, some objectives require the exchange of healthinformation. And as the program moves into its second and third stages (2014 and 2016,respectively) it is expected that increasingly robust exchange will be required to qualify as ameaningful user.Mapping the Current HIO Landscape As explained by the ONC’s “Federal Health Information Technology Strategic Plan 2011– 2015,” the federal government’s health information exchange strategy, “focuses on firstfostering exchange that is already happening today, supporting exchange where it is not takingplace, and creating means for exchange between local initiatives.” When considered alongsidethe benchmark reports by Dr. Adler-Milstein, two reports in 2011 can help us better understandthe HIO landscape and give us an indication of how federal policy is affecting that landscape.HIO Data Points According to various authorities on HIE, between 228 and 255 HIEs / HIOs currentlyexist. The aforementioned eHealth Initiative (eHI) found in their 2011 annual survey that 255“initiatives” are underway across the country and that 12 percent of survey respondents (24)3 | Policy Approaches and Alternatives for the Sustainability of Public HIE
  • 4. indicated they had sustainable business models.6 A common understanding of what constitutes asustainable business model is articulated by the University of Maryland’s Center for HealthInformation and Decision Systems (CHIDS): “A sustainable HIE reflects a situation where all the costs of the HIE operations are funded based on the value generated from HIE (e.g. transaction fees, subscriptions, 3rd party reimbursements) instead of other sources external to the direct value chain (e.g. government 7 grants and subsidies).” This percentage of sustainable HIOs is slightly below the 2008 findings by Dr. Adler-Milstein who indicated roughly 23 of 131 HIOs surveyed were able to “cover operating costswith revenue from entities participating in data exchange.” In fact, an eHI survey found that only18 of the 234 HIOs (8 percent) were sustainable in 2010. While it is important to note the self-reporting nature of the eHI and Adler-Milstein reports, it would seem that sustainability rateshave been rising the last two years, from 8 to 12 percent. However, these numbers are well shortof the 17 percent estimate of 2008 HIOs. Another data point that can be compared over time between the eHI and Adler-Milsteinreports is the percentage of HIOs who were previously pursuing HIE, but no longer pursuing HIE– a failure rate. According to Adler-Milstein, 26 percent of identified organizations fell into thiscategory in 2007 and 20 percent in 2008. eHI has tracked a similar measure, finding that HIOsno longer pursuing HIE between 2010 and 2011 represented a 4 percent failure rate. A different kind of survey surfaced in 2011, one more focused on the vendor marketsurrounding HIE solutions, but it gives us another important view of the landscape. A July 2011survey of HIEs by KLAS, a research firm specializing in monitoring and reporting on theperformance of healthcare vendors, categorized their analysis into public and private HIEs.“Public” HIEs are defined by KLAS to be those efforts that receive a substantial portion of theirfunding from government programs and are obliged to receive financial and organizationaloversight from governmental entities. KLAS found the number of operational public HIEs grewfrom 37 in 2010 to 67 in 2011. Meanwhile, the number of operational private HIEs rose from 52to 161 over the same period.8 This report highlights the amount of growth in health informationexchange over the last year, and much of it can be tied back to federal policies that financiallyand organizationally support HIE. Through the Cooperative Agreement, public HIOs have risenover 80 percent. And one can argue that private sector growth (in excess of 200 percent) over the4 | Policy Approaches and Alternatives for the Sustainability of Public HIE
  • 5. last year can be tied to meaningful use requirements. Anther explanation for such high levels ofgrowth can be tied to federal programs associated with parts of the Patient Protection andAffordable Care Act (PPACA) of 2010. Bundled payments, accountable care organizations,patient centered medical homes, all components of PPACA, require clinical data and claims dataexchange across different settings of care.Sustainability in the Shifting Healthcare Landscape Started under HITECH and bolstered by PPACA, health information technology adoptionand health information exchange have seen massive monetary support from the federalgovernment. In all, close to $30 billion has been made available for health IT-related programsthroughout the federal government. Activities in both the public and private sector reflect ashifting landscape between fee-for-service and pay-for-performance in Medicare and Medicaid.This shift in payment model will impact health information technology (HIT) adoption and HIEuse – something policymakers have acknowledged. Regulators and lawmakers at all levels ofgovernment have sought to make new programs enablers of HIT and HIE, not inhibitors. Andwith many federal programs well underway, states are increasingly trying to align their HITstrategies with federal program funds. All states that received HIE Cooperative Agreement grants must submit and implementONC-approved operational and strategic plans. Most states had some kind of HIT strategy inplace prior to HITECH, however, only a handful had dedicated legislation and funds toimplement that strategy. With the implementation of HITECH and PPACA, state-level strategieshave been accelerated, but most – if not all – are moving forward without clearly definedbusiness models for financial sustainability. To understand how HIO sustainability fits within the context of federal HIT activities,and to serve as a foundation for recommendations, I will examine plans submitted by five states,focusing on their visions for a sustainable statewide exchange program: California, Maine,Maryland, Ohio and Colorado. Two factors of sustainability that warrant inspection are theHIO’s technical architectural and service offerings. Indeed, these two factors are contingentupon several other organizational and environmental factors, such as HIE participant mix,governance model, privacy model and physical (broadband) connectivity. However, these two5 | Policy Approaches and Alternatives for the Sustainability of Public HIE
  • 6. factors should be resultant from the latter list of factors: participants and their views will makedecisions on a preferred privacy model, which will dictate the technical architecture. Serviceofferings will be based, again on participant mix and privacy expectations, but also broadbandpenetration – or connectivity. See Figure 1 in the Appendix for a visualization of theserelationships.Service Offerings Although an HIO’s service offerings and technical architecture present a “chicken andegg” paradigm, emerging best practices suggest a thorough understanding of service needs andwants should come before choosing a preferred technical architecture. Many HIOs aredelineating between “value-add” and “core” services, and there are a set of offerings that arerequired for the ONC Cooperative grants. Some of the services are offered by necessity, such asa record locator service (RLS), and other services, like computerized physician order entry(CPOE) or EHR-lite, are seen as a way to attract participation in exchange. Other services, likeelectronic prescribing (eRx) are considered a value-add service, but ONC has put an emphasis oneRx through its Cooperative Agreement program, requiring states to outline an eRx-specificstrategy. It should also be noted the eRx is itself part of an incentive program the pre-datesHITECH. Appendix B contains a list of core and value-add services offered by the fiveaforementioned states and will be discussed in further detail below.Technical Architecture When discussing a state’s planned technical architecture for HIE, I am referring to theorganization of the state’s technology that will facilitate clinical data exchange. There is a hostof considerations that accompany an HIO’s technical architecture, including data storage,common terminology definitions and messaging and document standards. HIOs have choiceswhen deciding on their technical architecture, but a large portion of that final decision rests onHIO’s participant mix and their stakeholders’ physical connectivity. And in conjunction with theHIOs privacy policies, these factors determine the needed technical architecture to facilitate thedesired service offerings. Data storage is the prime determinant, from a policy perspective, for how the HIO willoperate. Questions around data ownership, patient privacy and data use depend largely on where6 | Policy Approaches and Alternatives for the Sustainability of Public HIE
  • 7. and who stores the data. Three main data storage models have emerged through policy andtechnical breakthroughs in the last several years: Centralized, Federated (also known asdecentralized) and Hybrid (See Figure 2 for a visualization and Figure 3 for a list of pros andcons). A guide published recently for hospital chief information officers and other healthcare ITleaders outlined the characteristics of each model.9 According to the CHIME and eHI “HIEGuide for CIOs,” A centralized approach uses one repository to collect all clinical information. The centralized entity manages and performs the exchange of clinical and administrative data among all the participants in the exchange. In A decentralized (federated) approach, the HIO acts mostly as a coordinator and collaboration facilitator to enable the exchange of information; no actual data is held by the entity serving as the HIO. Healthcare organizations make copies of their clinical information on patients available, storing them on “edge servers” that are accessible to other organizations but protected by firewalls to prevent access to their core data storage systems. With a hybrid approach, elements of both the centralized and decentralized models are combined, and services can be handled centrally by one or more HIOs in an area. Often, the hybrid approach takes the form of a central repository of information with “edge servers” utilized for data storage. These edge servers can be located at stakeholder sites or within the central repository, but are notable for the control that providers maintain over their data. An examination of current trends reveals that most public HIOs are using a hybridapproach based on their stakeholders’ needs and projected revenue streams.10 All the statesexamined in this paper use hybrid models, combining elements of centralized, but predominantlyfederated data storage, except Maine.State Sustainability Strategies States looking towards long-term sustainability are examining a range of financingmechanisms that include transaction fees, subscription or membership fees, general purposerevenues / taxes, and fees per covered life. All of these have corresponding pros and cons andevery state will have to decide what mix and what level of these mechanisms to employ so thatparticipation is not hindered. However, states have also developed unique policies, apart fromthe simple calculations of price structure. OHIO The Ohio Health Information Partnership (OHIP) is the state’s designated entity and isone of three major HIOs in the state. OHIP utilizes a hybrid approach to exchange informationand its sustainability strategy is predicated on a three-tiered revenue model: Meaningful Use7 | Policy Approaches and Alternatives for the Sustainability of Public HIE
  • 8. Revenue Tier, Administrative Revenue Tier and Data Revenue Tier.11 The state first intends tooffer services according to what the EHR Incentive Program requires for meaningful use ofEHRs; then it will offer eligibility verification, coordination of benefits, real‐time claimsadjudication and real‐time payment. In its third stage, the HIO plans to incorporate users ofsecondary data, such as state agencies, into its participant mix. OHIP predicts that, along withpayers and employers, state agencies will pay for aggregated data made available through theexchange. By 2015, OHIP estimates this approach can achieve sustainability with expectedrevenues to cover costs by just under $1.5 million. MAINE Earlier this year, the National eHealth Collaborative (NeHC) profiled twelve fullyoperational HIEs that demonstrate a self-sustaining business strategy to identify common“success factors.”12 The NeHC report finds that only one of the HIEs profiled used a centralizeddata storage approach – HealthInfoNet of Bangor, Maine. HealthInfoNet is Maine’s officialstatewide HIO and its primary reason for centralization is aggregated data. Because Maine has acentralized architecture, it has built a “patient centered clinical database” that HealthInfoNetleaders believe will supplement future changes in healthcare policy. A monthly subscription feeallows HealthInfoNet to offer four bundles of services: (1) view; (2) basic HIE; (3) core HIE and(4) Core HIE + Quality Measure reporting.13 One stakeholder that Maine has yet to successfullyintegrate into the participant mix is payers, which could solidify Maine’s self-sustaining status inthe coming years. MARYLAND Maryland has been fairly proactive in recent years in its policies to adopt health IT. Thestate has had since the late 1970’s a unique all-payor hospital rate setting system that seeks costcontainment in healthcare through rate regulation. According to one estimate, this system hassaved Maryland $45 billion since its inception.14 Through the rate regulation system, Marylandcommitted $10 million in funding for the implementation of a statewide HIE, and in May of2009 established its own EHR incentive program funded by the state’s six largest healthinsurers.15 Maryland has tasked the Chesapeake Regional Information System for our Patients(CRISP) to be its official HIO, and so far, CRISP has secured letters of intent (LOI) from all8 | Policy Approaches and Alternatives for the Sustainability of Public HIE
  • 9. forty-eight of the state’s hospitals to participate in the hybrid model HIE. Like other states,Maryland has identified “use case” services they believe will be needed and valued by HIEparticipants. Specifically, the MD HIE State Plan says the “HIE will use secondary data…toprovide clear societal benefits and benefits to various local, state, and national public healthagencies for the purposes of early identification of communicable diseases and acute or long-term population health threats.”16 The state plan does not speculate how much revenue can beraised by each use case, but collectively, Maryland believes the use cases will yield just shy of $6million in subscription fee revenue in 2013. This is about $1 million short of what the HIOexpects operating costs to be that same year. COLORADO Colorado is the only state in the country that has a Chief Data Officer who reports to thestate CIO and is in charge of taking a statewide view of how data is used, spanning programsfrom juvenile justice and education to healthcare.17 The state selected the Colorado RegionalHealth Information Organization (CORHIO) to serve as the state’s designated HIO. CORHIOwill use a hybrid technical architecture that interfaces closely with a broadband initiative calledthe Colorado Telehealth Network. According to the state plan, “The availability of broadbandaccess is an underpinning to the success of our Statewide Health Information Exchange,” and thestate’s HIE plan is tied to the sustainability of its broadband plan.18 Colorado is alsoaggressively charting a course to develop an “Interagency Data Exchange Model” for all health-related IT programs across the state government. This model foresees a close relationship withCORHIO and would supplement their service offering sometime in the future. In September 2011, CORHIO announced a repackaging of its fee schedule that gaveparticipants a choice of an “integrated” package that allows practices that use EHRs to have HIEdata route seamlessly into their system and the “standard” package, for practices that do not havean EHR, or they have an EHR but would prefer to access HIE data from a stand-alone Webportal. Specific estimates for HIE costs and revenues were not available, but the plan foreseesfinancial sustainability by 2015. CALIFORNIA9 | Policy Approaches and Alternatives for the Sustainability of Public HIE
  • 10. Predictably, California’s geography and population present major challenges to statewidehealth information exchange. Where most states have one to three HIEs operating within theirborders, California has thirteen. As such, California has designated Cal eConnect as the HIOresponsible for tying the other HIEs together as one interoperable network. This will costbetween $1 billion and $2 billion per year, according to California’s projections. The state hasidentified a number of financing mechanism to make HIE sustainable in an interim reportoutlining pros and cons alongside each of the potential participants.19 The state’s HIE plan wassubmitted to ONC in March 2010, where it acknowledged, “The most viable sustainable modelfor HIOs is to have broad based participation where stakeholders are charged fees or duescommensurate with the value they derive from the HIO combined with their ability to payrelative to other stakeholders.”20 It also went on to say, “In the course of doing business, CaleConnect will develop a useful knowledge base, and will consider providing contracted services,either to the State or to HIE participants such as health systems.” It was with this last statementin mind that Cal eConnect’s Business Advisory Group in October 2011 unveiled a framework ofservice offerings around governance, coordination and technical assistance to the state’s HIEsand their participants. Cal eConnect envisions that they could “become the Trusted Entity forpolicy and standards oversight,” help create a “common technical architecture” and help otherHIEs with financial management, performance measurement and facilitate “relationships withother Federal and State entities.”21Common Challenges, Diverse Approaches Administrative simplification, telehealth coordination, aggregated data, and HIE expertise– these are parts of the suggested solutions to the “sustainability question.” Were more HIOsexamined as part of this analysis, it is probable that other solutions would emerge, but theywould likely be variants of these themes. With just over two years left in the program, manyHIOs’ sustainability strategy has not yet been put to the test – federal and state-matching grantsare still covering the bills. Subscription fees and phased service unveilings are the predominantstrategy for those HIOs analyzed in this report and are likely to be the same in other states. Line-item projections about specific revenue drivers aside, there are some common trendsthat can be both cause for optimism and grounds for worry. It is likely that historical challengesthat lead to HIO failure – low levels of data volume and diversity; lack of standards and few10 | Policy Approaches and Alternatives for the Sustainability of Public HIE
  • 11. reasons to track quality measures – may become irrelevant in today’s health policy world.According to a November 2011 Center for Disease Control and Prevention (CDC) report, 34percent of the nation’s office-based physicians used basic EHRs – this number is up from 10.5 in2006.22 Further, the report notes that 52 percent of physicians intend to apply for meaningful useincentives, up 41 percent in 2010. A similar survey on meaningful use intention, conducted bythe College of Healthcare Information Management Executives indicates that 93 percent ofhospital CIOs believe their facilities will qualify for stage 1 meaningful use by 2015.23 Clearly a wave of new health data in the form of standardized electronic health recordshas and will continue to enter the US health IT infrastructure. Likewise, federal policies continueto spur health information exchange. Subsequent criteria under meaningful use will require more robust health informationexchange, for transitions of care and for public health use. Stage 2 meaningful use criteria willsoon be available and recommendations to “raise the bar” for health information exchange havealready been submitted to the ONC.24 Additional programs developed as part of the PPACA –ACOs, Value Based Payments and Bundled Payments, among them – will also require robustexchange, of both clinical and claims data, for quality measurements. Despite the amounts of money being spent to develop HIOs, the 2008 Adler-Milsteinreport found that money upfront may actually be detrimental to long-term success. She foundthat while grants and large cash infusions helped HIOs develop their infrastructure, it alsoallowed them to circumvent stakeholders and potential participants.25 This exclusion problemmay well be exacerbated by the tremendous dollar amounts available to HIOs through HITECH.Additionally, the structure of these grants may be a source of concern. The CooperativeAgreements encourage large, upfront spending, lest the state be stuck with a sizable matchingamount in the third and fourth years of the program. And the ONC’s decision to omit and forgetabout a requirement that every state submit a financial sustainability report is somewhat curious.Implications From the small survey of HIOs above, it’s clear that most of them will look to capitalizeon the growing saturation, standardization and interoperability of health data. All of the statessurveyed are either aligning services to coincide with meaningful use requirements, or at leastconsidering a phased approach that will meet participants’ most basic needs first. This approach11 | Policy Approaches and Alternatives for the Sustainability of Public HIE
  • 12. is likely repeated by other states. But will other states strive, as these will, to make datatransformation a core competency, to give all the data they handle value? A common themethroughout these varied state HIO strategies includes a reliance on “big data” – aggregated poolsof patient data for claims, for clinical outcomes and for disease reporting. While most states’HIOs may not be working with zettabytes of data, the ones analyzed above foresee a future inwhich huge amounts of patient data can: help pay insurers and providers in near real-time (Ohio);gather and submit quality reports (Calif., Colo., Maine, Md., Ohio ); communicate in real-timewith state public health agencies (Calif., Colo., Maine, Md.). It is not clear that these states, orothers planning to offer the same kinds of services, will be capable of delivering. A 2011continuation of the studies done by Dr. Julia Adler-Milstein concludes, “Only 13 RHIOs in thecountry seem capable of supporting stage 1 meaningful use criteria,” and “Of greater concern, wefound no organizations that support the robust data exchange that is probably required to realizethe projected quality and efficiency gains from HIE.”26Recommendations The ONC should re-initiate plans to require financial sustainability reports fromHIOs receiving federal funds through the Cooperative Agreements. It is highly likely that the ONC has a close watch on HIO financials that either reflect orrefute the state plans submitted by HIOs in 2009/10. But by omitting the process of organizingand submitting a financial report, as a requirement to receive funds, the ONC may very well havecommitted a sizable oversight. The act of convening diverse stakeholders in an open forum tosubmit federal reports can go a long way towards ensuring its feasibility. Strategic andoperational plans for projects such as HIE are understandably fluid, but having information onsustainability for each state would be beneficial for individual HIOs and the overall nationaleffort. HIOs need to be realistic in their service capabilities and delivery timelines. Finding ways to derive value from clinical, claims and public health data will prove aworthwhile endeavor, but HIOs need to be realistic in their timelines and capabilities. There is alooming problem in promoting a service that requires a multifaceted technical solution notcurrently in place. There is a definite problem in identifying that service as a core competency,intended to help make your business sustainable. Most state HIEs are using hybrid architectures,12 | Policy Approaches and Alternatives for the Sustainability of Public HIE
  • 13. but hybrid architectures make producing the reports and data composites envisioned by theseHIOs more difficult.Appendix A Figure 113 | Policy Approaches and Alternatives for the Sustainability of Public HIE
  • 14. Figure 2Figure 3 Data Storage Pro Con model Economies of scale, more easily Centralized Data ownership, privacy concerns managed cost control Complex to maintain, many Data stays "on site," individual Decentralized stakeholders and different entity in control of security around (Federated) systems, latency issues arrise core data storage systems when conducting queries Data stored locally and centrally, Complex to maintain; difficult to Hybrid with tight control and limited access perform "big data" analytics on of centralized data populations (Source: Compiled from CHIME, eHI “HIE Guide for CIOs”)14 | Policy Approaches and Alternatives for the Sustainability of Public HIE
  • 15. Appendix BThe following charts were compiled using criteria outlined in eHI’s Health InformationExchange: Sustainable HIE in a Changing Landscape and compiled with author’s analysis ofstate HIE plans.MaineHIE or SDE: HealthInfoNetTechnical Architecture: Centralized HIE Services Core Services Value-Add X Master Patient Index X Medication Reconciliation X Master Provider Index Computerized Physician Order Entry X Record Locator Services EMR-Lite X Clinical Messaging X ePrescribing X Clinical Data Routing X Care Coordination Modules X Longitudinal Patient Record Viewer Administrative Services X HIE to HIE Interoperability X Patient Management Tools X HIE-Related Meaningful Use Support X Quality Reporting13 / 16 HIE ServicesMarylandHIE or SDE: CRISPTechnical Architecture: Hybrid HIE Services Core Services Value-Add X Master Patient Index X Medication Reconciliation X Master Provider Index X Computerized Physician Order Entry X Record Locator Services EMR-Lite X Clinical Messaging X ePrescribing X Clinical Data Routing X Care Coordination Modules X Longitudinal Patient Record Viewer X Administrative Services X HIE to HIE Interoperability X Patient Management Tools X HIE-Related Meaningful Use Support X Quality Reporting 15 / 16 HIE Services15 | Policy Approaches and Alternatives for the Sustainability of Public HIE
  • 16. CaliforniaHIE or SDE: Cal eConnectTechnical Architecture: “Neutral Connectivity model” HIE Services Core Services Value-Add X Master Patient Index Medication Reconciliation X Master Provider Index Computerized Physician Order Entry X Record Locator Services EMR-Lite X Clinical Messaging X ePrescribing X Clinical Data Routing Care Coordination Modules X Longitudinal Patient Record Viewer X Administrative Services X HIE to HIE Interoperability Patient Management Tools X HIE-Related Meaningful Use Support X Quality Reporting11 / 16 HIE ServicesColoradoHIE or SDE: Colorado Regional Health Information Organization (CORHIO)Technical Architecture: Hybrid HIE Services Core Services Value-Add X Master Patient Index X Medication Reconciliation X Master Provider Index X Computerized Physician Order Entry X Record Locator Services EMR-Lite X Clinical Messaging X ePrescribing X Clinical Data Routing X Care Coordination Modules X Longitudinal Patient Record Viewer Administrative Services X HIE to HIE Interoperability X Patient Management Tools X HIE-Related Meaningful Use Support X Quality Reporting14 / 16 HIE Services16 | Policy Approaches and Alternatives for the Sustainability of Public HIE
  • 17. OhioHIE or SDE: Ohio Health Information Partnership (OHIP)Technical Architecture: Hybrid HIE Services Core Services Value-Add X Master Patient Index X Medication Reconciliation X Master Provider Index Computerized Physician Order Entry X Record Locator Services X EMR-Lite X Clinical Messaging X ePrescribing X Clinical Data Routing X Care Coordination Modules X Longitudinal Patient Record Viewer X Administrative Services X HIE to HIE Interoperability X Patient Management Tools X HIE-Related Meaningful Use Support X Quality Reporting15 / 16 HIE ServicesEnd Notes1 Office of the National Coordinator for Health IT, Summary of the NHIN Prototype Architecture Contracts,31 May 2007 http://1.usa.gov/tLvhIw (accessed 16 November 2011).2 Office of the National Coordinator for Health IT, The Nationwide Health Information Network, DirectProject, and CONNECT Software, http://bit.ly/sVtyhw (accessed 19 November 2011)3 Adler-Milstein, J., Bates, D., Jha K., “U.S. Regional Health Information Organizations: Progress AndChallenges” Health Affairs, 28, no. 2 (2009): 483-4924 Ibid.5 Office of the National Coordinator for Health IT, State Health Information Exchange CooperativeAgreement Program Funding Opportunity Announcement http://bit.ly/tPATqz (accessed 3 November2011)6 eHealth Initiative, Health Information Exchange: Sustainable HIE in a Changing Landscape, Oct. 20117 Agarwal, R., Crowley, K., Ramos-Johnson, D., “CHIDS Evaluation Framework for Sustainable HealthInformation Exchange: DC RHIO Current Progress and the Road Ahead,” Robert H. Smith School ofBusiness, UMD, Sept. 20108 KLAS, Health Information Exchanges: Rapid Growth in an Evolving Market, July 20119 College of Healthcare Information Management Executives (CHIME) and eHealth Initiative, The HIEGuide for CIOs, Nov. 2011 available online at http://www.cio-chime.org/hieguide/ (accessed 25 November2011)10 Prestigiacomo, J., “A Hybrid Approach” Health Informatics, August 2011 http://bit.ly/ndOBnT (accessed13 November 2011)17 | Policy Approaches and Alternatives for the Sustainability of Public HIE
  • 18. 11 Ohio Health Information Partnership (OHIP) Ohio State HIE Plan: Strategic and operational plans for astatewide health information exchange, 2010 http://bit.ly/vz1HuJ (accessed 20 October 2011)12 National eHealth Collaborative ”Secrets of HIE Success Revealed: Lessons from the Leaders” July2011 http://bit.ly/tbFMnn (accessed 12 November 2011)13 HealthInfoNet Maine Statewide Health Information Exchange Strategic and Operational Plans: AStrategy to Create an Infrastructure that Preserves and Improves the Health of Maine People July 2010http://1.usa.gov/uIY9fl (accessed 12 November 2011)14 Buntin, J., “Maryland’s All-Payer Answer” Governing March 22, 2011 http://bit.ly/v1Nmf1 (accessed 25November 2011)15 Maryland General Assembly House Bill 706 (HB706) “HR Electronic Health Records - Regulation andReimbursement” 2009 http://bit.ly/u0hszw (accessed 25 November 2011)16 Maryland Health Care Commission, Health Information Technology State Plan FY2010 – FY2013, 2009http://1.usa.gov/uDSnEE (accessed 25 November 2011)17 Smith, J. “Moving Mountains: Sharing data on both sides of the Continental Divide” CivSource, March31, 2009 http://bit.ly/cprfCi (accessed 20 November 2011)18 CORHIO Colorado’s State Health Information Exchange Strategic Plan, October 2009http://bit.ly/sShh0v (accessed 20 November 2011)19 Cal eConnect, California’s HIE Sustainability Development Plan: Interim Report to California Health andHuman Services (CHHS), April 2011 http://bit.ly/rQvDvF (accessed 13 November 2011)20 Cal eConnect, California Health Information Exchange Strategic and Operational Plans March 2010http://bit.ly/sEfSOT (accessed 13 November 2011)21 Cal eConnect, Business Advisory Group Meeting Presentation HIE Services October 5, 2011http://bit.ly/tbUoVO (accessed 13 November 2011)22 US Dept. of Health and Human Services, Centers for Disease Control and Prevention, ElectronicHealth Record Systems and Intent to Apply for Meaningful Use Incentives Among Office-basedPhysician Practices: United States, 2001–2011, Nov. 2011 http://1.usa.gov/t1fc00 (accessed 30November 2011)23 College of Healthcare Information Management Executives, “CHIME Member Meaningful UseReadiness Quarterly Update” October 2011 http://bit.ly/sicEBX (accessed 30 November 2011)24 ONC Health IT Policy Federal Advisory Committee, Stage 2 Meaningful Use Matrix http://bit.ly/sgtEVu(accessed 30 November 2011)25 Adler-Milstein, J., Bates, D., Jha K., “U.S. Regional Health Information Organizations: Progress AndChallenges” Health Affairs, 28, no. 2 (2009): 483-49226 Adler-Milstein, J., Bates, D., Jha, A., “A Survey of Health Information Exchange Organizations in theUnited States: Implications for Meaningful Use,” Annals of Internal Medicine, (2011) 154: 666-67118 | Policy Approaches and Alternatives for the Sustainability of Public HIE

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