Moving Forward Florida’s Health Information Exchange October 22, 2014 Florida State University School of Information

History of the Florida HIE 2009 Florida applies for ONC State Health Information Exchange Cooperative Agreement Governance by Not-for-Profit proposed/No organizations identified 2010 awarded HIE Cooperative Agreement Program funding in March Legislature directs issuance of Invitation to Negotiate (ITN) by July/ Agency to provide Governance Harris awarded four-year, $19 million contract in November 2

History Continued 2011 Contract signed in February Direct Secure Messaging Deployed in July 2012 First PLU participant connected 2013 Cooperative Agreement terminated September 30 Event Notification Service pilot November 3

Florida HIE Services Patient Look-Up Service (PLU) – Query model health information exchange – No centralized database Event Notification Service (ENS) – Delivers notifications of admission, discharge or emergency department visits – Health plans subscribe and provide member data Direct Messaging (DM) – Accredited vendor, Inpriva, began work in August 2014 – Users able to exchange with other users of other accredited vendors Hybrid Patient Look-Up Service – Enables PLU access to providers through use of Direct Messaging without requiring PLU onboarding Page 4

Direct Messaging (DM) 5 Florida implementation of Direct standard Allows communication between providers with electronic health records and those without A provider needs to send information to another physician or organization for transition of care of referral A provider needs to send clinical information in response to a request Log on to Direct Messaging and enter DM address of a provider or organization Generate an , desired artifacts, and send An is received at the healthcare provider’s mailbox with a read receipt sent to sender when opened Providers can exchange information across the nation using secure protocols

Patient Lookup Service 6 Florida implementation of Connect standard Electronic retrieval of records from multiple data sources at point of care Patient’s data queried after patient consent Patient matching based on patient demographics Document generation capability Provider needs to access a patient’s clinical records PATIENT CONSENT FORM Patient consent obtained The Provider performs a Patient Lookup Query though interface CONTINUTITY OF CARE DOC(CCD) From list, the provider chooses which clinical records to retrieve and view Hospital Physician Offices Request sent to other participants regionally or statewide

7 Patient Lookup Architecture Nationwide Health Information Network (NwHIN) INFRASTRUCTURE INTERNET Build critical mass by including key state systems and large local HIEs or IDNs

1. Data about patient encounters flow from the hospital data sources into the Event Notification Service. 2. Data are matched to member files uploaded by health plan subscribers 3. If a match is made, an alert is created, sent to the health plan and copied to the hospital. 4. The ENS alert about a member’s medical encounter is received by the health plan 5. Health plan provides notice to the members primary care provider and other case management as appropriate -The service’s flexibility allows for numerous ways to work ENS into a health plans daily processes. 8

Governance Agency sets policy through participation agreements – Public advisory groups review plans, status, and agreements – PLU User Group reviews operational issues HIE vendor operates Florida HIE services and gateway to eHealth Exchange Agency performs PLU and ENS vetting Page 9

Florida HIE Status PLU has eight nodes in production with six in various stages of on-boarding with – 1,950 documents retrieved in September About 80% of Florida hospitals are on-boarding ENS with 26 in production – Health plan participation expected effective January 1 DM started under new contract with almost 300 transferred DSM users; 1,157 transactions in August – New service can provide mailboxes or connect directly with an EHR to provide HISP services Page 10

11 Challenge: States have unique requirements concerning procurement and budgets Lessons Learned: ─ Ensure clear expectations regarding budget authority ─ Federal fiscal year and state fiscal years differ ─ Both federal and state requirements must be met

12 Challenge: Breaking new ground in managing an HIE project Lessons Learned: ─ Make sure roles & responsibilities are well understood within team ─ Ensure report content is geared to non-technical audience ─ Vendor awareness of state rules ─ Understand ONC/Federal reporting requirements, both financial and programmatic ─ Use collaboration tool for data sharing between the customer and vendor teams for transparency

13 Challenge: Being on the front end of changes in technology Lessons Learned : ─ Unfolding federal requirements impact project direction ─ Direct Messaging ─ Meaningful Use ─ Vendor readiness ─ Software as a service is often less expensive

14 Challenge: Standards evolved while project is implemented Lessons Learned: ─ Design system for flexibility ─ Start program Configuration Control Board Process before first release ─ Agile Development Method allows rapid & early development of features ─ Involve customer in prioritization of the requirements ─ Encourage and reinforce realistic tasking ─ Build time in schedule for end-to-end testing ─ Test outside the firewall to ensure external access to the system

15 Challenge: Engage stakeholders and understand competing interests Lessons Learned: Stakeholder acceptance is key to participation and adoption Key stakeholders can sway potential participant perception Goal is full representation of interests of all healthcare related groups

16 Challenge: Unique issues in outreach to participants Lessons Learned: ─ Understand relationship between contracting agency and stakeholders ─ Stakeholders may not be educated on HIEs ─ Use existing communications channels ─ Form key relationships with stakeholders early ─ Most frequent questions are on sustainment cost and security/privacy ─ Develop materials responsive to frequent questions

17 Challenge: Document Everything Lessons Learned: ─ Florida HIE provides infrastructure for transport – still needs to document infrastructure for query, patient matching, document storage, audit processes ─ Node architecture document initiated

18 Challenge: Policy levers can impact project direction Lessons Learned: ─ Federal policy for adoption of Direct Messaging changed impacting state implementations ─ Low Income Pool funding requirement to participate in ENS ─ Contractual requirement for HMOs to engage network providers who use electronic health records

19 Challenge: Speed of adoption hard to impact Lessons Learned: ─ Workflow changes take time ─ Vendor development takes time ─ Competing priorities for participants, ICD-10, EHR adoption, change in ownership ─ cost v benefits for participants

20 Challenge: Each deployment is unique Lessons Learned: ─ Parallel development & deployment require close coordination ─ Evaluate participant facilities for readiness & use test environments if necessary ─ Use a Video tool (such as MeetingPlace, gotomeeting) to avoid having access to partner system, simplifying security requirements ─ Use Webinars to share data on specific technical topics

21 Challenge: Variation in consent models

22 Comparison of Consent Models DefinitionProsCons No Consent (TPO) filtered data Prevents sensitive data from being exchanged Avoids legal requirements of sensitive data Removes important mental health data and others Opt-InAuthorization required for exchange to occur Patients control exchange Some patients will not authorize Opt-OutPatient must actively intervene to prevent exchange usually after notification Exchange can occur immediately after opt-out period ends Requires filtering since sensitive data exchange must be authorized Consent at Point of Care Authorization required of accessing provider Responsibility placed on accessing provider Data sources must be assured of compliance

Florida HIE Consent Policy 23 Direct Messaging– same consent policy applicable to faxing or sending records via courier applies ENS - Health plans have consent for TPO as requirement for enrollment Self pay patients excluded PLU - Patient consent at the point of care Florida law requires explicit consent for certain sensitive data Patient controls who can query for information Activity log allows audit of consent

Lessons Learned ─ Models for query must be consistent across participants ─ Workflow changes to accommodate consent implemented should be complete early in implementation 24

25 Challenge: Designing a sustainability plan Lessons Learned: ─ Reaching critical mass is essential ─ Address the public good question by creating incentives, removing disincentives ─ Effective pricing strategy and organizational structure are key ─ Bring right services to the right stakeholders ─ Align costs with benefits

26 Questions? Heidi Fox