1. 1 Created by and for the local healthcare community, OneHealthPort solves information exchange and workflow problems shared across healthcare organizations. Clinical Information Exchange in Washington State – A Report from the Front Lines October 25, 2016 Presented by Sue Merk, EVP of Innovation OneHealthPort 2016 NW Technology Conference

2. 2 Standards and the Changing Role of Intermediaries 2 For HIEs the goal should not be to perpetuate old, cost intensive connectivity models, it should be to propagate Standards, and ultimately enable trading partners to communicate in a more “loosely coupled” manner at much lower cost Community connectivity vs point-to-point Web Services vs Deep interfaces XML vs flat files Focus on a few standards vs try to do everything

3. 3 The Reality of HIE Vendors don’t want HIEs in the middle – prefer to do it themselves Practices are looking for help from their vendors Vendors can’t know every market – focus on MU There are still too many standards – we’re not all on the same page There is still more talking than doing Compliance issues always come first

4. 4 The HIE – The “Pipe” Most straightforward component for OHP –In place for 5 years Primary challenge revolves around protocols – more than one choice – OHP trying to support multiple options –XDS.B with activator or cert, XDR (Direct), AS2 Variations across vendors, size/sophistication, readiness –Protocol choice today may not be choice tomorrow –Opportunity to educate and inform

5. 5 A Tale of Two HIEs NRAA HIEOneHealthPort HIE Key business driverCMS payments based on quality data reports – 3 year base started in 2012 Meaningful Use - no requirements for HIE until 2014 TransactionCCD via HealtheWay to CMSRegistry reports to DOH – SS, ELR for hospitals Timeline to onboard3 months – 1,000 facilities3 years – 100 hospitals (1,400 facilities) and 16 health plans Critical Mass20122014 Additional transactionsNew patient enrollment, Death notice, detailed error reports, new ESRD C-CDA Admission Discharge Notices, C- CDA, ORU, ADT Transactions/month1.2 million transactions/month700,000 transactions/month 5

6. 6 HIE Maturity Curve – NRAA HIE NRAA HIE - started with quality reporting in custom CCD to CMS Worked on data quality for five years Added additional documents and transactions with CMS Collaborated as an industry on a detailed End Stage Renal Disease C-CDA Considering next investment – collecting their own data for risk-bearing arrangements – use of the CDR

7. 7 Lessons Learned about HIE Adoption happens when clear business drivers prioritize resources. Trying to be all things to all customers rarely works – OHP narrowed focus to things that are sustainable –Offering an Exchange –Promoting standards –Setting the vision for use of web services –Adding a Clinical Data Repository (CDR) with Sponsors 7

8. 8 The CDR Is… A longitudinal patient record to assist consumers and practitioners at the point of care An aggregation of clinical data to support advanced analytics and population health management An interoperability strategy to accelerate adoption and use of standardized clinical info exchange

9. 9 True Interoperability Standards ITI-41 to push messages to the CDR ITI-47 (PDQ) to query for a patient or record identifier to include patient identifier before data submission ITI-18 – Stored Registry query – ask about records in the repository ITI-55 – (XCPD)Cross Community Patient Discovery ITI-38 – Cross Community request for list of documents available on a patient ITI-39 – Cross Community request for a document by identifier (found in ITI-38 response)

10. 10 C-CDA Delivery Options C-CDA via AS2 XDS.b (ITI-41) via AS2 XDS.b (ITI-41) via certificate exchange Direct Message Clinical Data Repository

11. 11 CDR High-Level Data Flows Hospital Clinics Providers Trading Partners push C-CDA to the HIE and receive Acks or Naks from the CDR Reads data message header, adds ITI-41 wrapper and routes to CDR CDR picks up data from the HIE and sends Ack or Nak back to Trading Partners. Data is recorded in the CDR Audit Log CDR

12. 12 EHR Vendor Role Vendors play a critical role in supporting providers’ ability to meet C-CDA data contribution requirements. Ensure C-CDA meets file format conformance against national standard. Work with provider to classify data as N, R or V. Allow parameters to be set by provider to trigger data submission per Sponsor specifications. Automate C-CDA data submission process to the CDR.

13. 13 With the CDR, the state is investing once to “fix the plumbing,” the return on that investment – low cost access to a blended data set – will be shared by many parties in many ways – some of which we haven’t even thought of yet

14. 14 The CDR Components The key to it all – the provider and the patient generate an encounter which is recorded in an EHR and exported in a standards compliant manner – ultimately, the same EHR will be used to query the CDR or other providers in order to view their patient data The “pipe” – connecting the point-of-care with the repository The “box” – where the data is stored, matched with patient ID and optimized for access by providers at the point of care Data is aggregated for presentation in report form or dashboards and population analytics HIE POINT OF CARE OUTPUT Repository User Community

15. 15 The Point of Care OHP has worked with providers and EHR vendors –Raising awareness of CDR requirements –Introducing the C-CDA –Sharing updates and insights on protocols and other standards –Listening to problems –Brainstorming solutions with HCA and vendors –Refining the model OHP’s effort – Some numbers –9 provider webcasts (240 attendees) –10 technical webcasts (266 attendees) –4 new “update” web casts for changes (154 attendees) –90+ one-on-one meetings –Many other group meetings –32 EHR vendors involved –36 provider orgs with 1,387 facilities currently engaged in CDR on- boarding work

16. 16 At the Point of Care, Our Work Balances… Social Engineering Technical Engineering

17. 17 Removing Barriers… Investing in multiple protocols Taking the EHR Vendors “out of the box” solutions and doing the extra work centrally Policy decisions to delay data classifications and directory requirements 1 2 3

18. 18 Phase Two: Quality Reports Quality reports and data analytics provided by the sponsor. Practice and practitioner can log into a secure reporting portal to get a variety of reports on performance and quality measures. Population analytics and metrics set by the sponsor. No automation envisioned initially. Someday may want to download data to vendor or practice analytics tools.

19. 19 Phase Three: Query for Records Once the CDR has had 6-12 months to aggregate clinical data on individual patients. Query the Clinical Portal for community clinical records before each patient visit. The vendor provides automation to batch or transaction query for records to simplify use of the community record. XDS.b and XCA queries will be supported. If the EHR does not store the required sponsor identifier, it can be queried using a PIX or PDQ transaction with the CDR. A secure portal option is available from first day for manual record checking until automation can assist the practice.

20. 20 Authenticate connections Use Provider Directory to route messages Facilitate exchange of standard data Host API/web services API Directory Standards Propagation Query using API C-CDA Response to API Query Clinic Hospital Query/Response using a Web Service/API leverages standard APIs to facilitate any organization capable of starting a query to any organization able to respond to a query on a shared patient. The Clinical Data Repository will accept and respond to queries with a C-CDA Web Services/APIs for requesting Clinical Documents or other business transactions Query/Response Clinical Data Repository

21. 21 C-CDA Preparation and Timeline MilestoneTarget Completion Date Configure message header (including set-up of tables and other automation functionality) to meet C-CDA constraints for submission to the CDR. April – June 2016 Test C-CDA messages for format conformance; correct errors to ensure format is compliant with national standard. Test harness available for use during initial testing and for troubleshooting messages that fail CDR production processing. June 2016 Set-up HIE connectivity for data submission to CDR. June 2016 Build automation for routine C-CDA submission process. June – October 2016 Test submission of C-CDA messages to CDR (end-to-end testing in HIE user acceptance testing (UAT) environment). August – October 2016 Move C-CDA data submission production CDR and roll-out capability to all customers. October 2016 - February 2017 Develop and test CDR query capability. October - December 2016 Roll-out CDR query capability to all customers. January 2017

22. 22 Software as a Service Mis-Adventure Sandlot failed in March 2016, since that point OHP has: –Committed to honor its obligations to Sponsors, Co-sponsors –Been on a crash course to understand the operational details of the CDR –Engaged with the provider and EHR vendor community to enable exchange of C-CDAs –Spent a bunch of time and money on: o Software o Services o Consulting o Staff –Made significant progress

23. 23 Lessons Learned on SAAS What is your recovery plan if your SAAS vendor fails suddenly? Have you ever tested your ability to get software out of Escrow and do anything with it? –Iron Mountain – 6 week effort Do you know how your data will be handled in the event of an outsourced failure? –Define destruction or return of data in policy and require the vendor to verify the process

24. 24 Recovering the Repository Software – largely built on ICW and Mirth software –Clinical Portal App for viewing individual patient records Software –Executed agreement with ICW Without Sandlot in the middle, OHP is gaining deeper understanding of ICW capabilities and challenges Hardware and services –Executed arrangement with Sunguard AS for Infrastructure as a Service (IaaS) –Sungard is huge hosting service worldwide –Sungard manages everything but the applications –OHP retains responsibility for managing applications –Sunguard has all the desirable certifications – ISO, SOC, HIPAA, etc. –Sunguard has technical depth

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