1. What’s New in ONC?
The Office of the National Coordinator for Health Information Technology Panel:
Insight into Emerging Policy
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2. Agenda
Vision for Meaningful Use John Glaser Standards and Certification Carol Bean Policy Activities Jodi Daniel Nationwide Health Information Network – Future Direction John Glaser State Grants Kelly Cronin Health IT Extension Program Rachel Nelson Nationwide Health Information Network Ginger Price
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3. John Glaser, PhD Senior Advisor to the National Coordinator
OFFICE OF THE NATIONAL COORDINATOR
John Glaser, PhD Senior Advisor to the National Coordinator
Vision for Meaningful Use
Slides that follow are from a draft set of recommendations made by a Work Group of the HIT Policy Committee on June 16, 2009 3
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4. Achievable Vision for 2015
Prevention, and management, of chronic diseases
A million heart attacks and strokes prevented
Heart disease no longer the leading cause of death in the US
Medical errors
50% fewer preventable medication errors
Health disparities
The racial/ ethnic gap in diabetes control halved
Care coordination
Preventable hospitalizations and re-admissions cut by 50%
Patients and families
All patients have access to their own health information
Patient preferences for end of life care are followed more often
Public health
All health departments have real-time situational awareness of outbreaks
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5. HIT-Enabled Health Reform Achieving Meaningful Use
2009
2011
2013
2015
HIT-Enabled Health Reform
Meaningful Use Criteria
HITECH Policies
2011 Meaningful Use Criteria (Capture/share data)
2013 Meaningful Use Criteria
(Advanced care processes with decision support)
2015 Meaningful Use Criteria (Improved Outcomes)
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6. Improve Quality, Safety, Efficiency 2011 Objectives
Capture data in coded format
Maintain current problem list
Maintain active medication list
Maintain active medication allergy list
Record vital signs (height, weight, blood pressure)
Incorporate lab/test results into EHR
Document key patient characteristics (race, ethnicity, gender, insurance type, primary language)
Document progress note for each encounter (outpatient only)
Use CPOE for all order types
Use electronic prescribing for permissible Rx
Implement drug-drug, drug-allergy, drug-formulary checks
Manage populations
Generate list of patients by specific conditions (outpatient only)
Send patient reminders per patient preference
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7. Improve Care Coordination 2011 Objectives
Exchange key clinical information among providers of care Perform medication reconciliation at relevant encounters
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8. Summary
Journey to a transformed health system requires meaningful use of transformation-capable HIT
Migration of HIT readiness from current situation to fully HIT-enabled ecosystem will evolve over time
Proposed MU criteria for 2011 and beyond provides escalating capabilities, balancing urgent need for reform and feasibility of what is achievable
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9. OFFICE OF THE NATIONAL COORDINATOR
Carol Bean, PhD, MLS, MPH Acting Director, Office of Interoperability and Standards
Standards and Certification 9
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10. HHS Interoperability Standards
“Recognized” in
“Accepted” in January 2009
EHR Laboratory Results Reporting (IS01)
Biosurveillance (IS02)
Consumer Empowerment (and Access to Clinical Information via Network, IS03)
Emergency Responder EHR (IS04)
Consumer Empowerment and Access to Clinical Information via Network (IS05)
Quality (IS06)
Medication Management (IS07)
Personalized Healthcare (IS08)
Consultations and Transfers of Care (IS09)
Immunizations and Response Management (IS10)
Public Health Case Reporting (IS11)
Patient-Provider Secure Messaging (IS12)
Remote Monitoring (IS77)
Updates to IS02, IS03, IS04, IS05
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11. Eight Technology Priority Areas for HIT in ARRA
Privacy and Security
HIT Infrastructure
Certified Health Record
Disclosure Audit
Improve Quality
Individually Identifiable Health Information (IIHI) Unusable
Demographic Data
Needs of Vulnerable
Source: John Halamka
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12. Tiger Teams Focus Areas: Business Cases vs Use Cases
A new EHR Centric Interoperability Specification to meet ARRA requirements
Security, Privacy & Infrastructure
Quality Measures
Data Architecture (Element, Template, and Value Set)
Exchange Architecture and Harmonization Framework
Clinical Research
Tiger Team membership 232 technical experts
Source: John Halamka
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HITSP – enabling healthcare interoperability

13. New Paths to Certification: In Brief (CCHIT Concept)
Certified EHR Comprehensive [EHR-C]
Rigorous certification of comprehensive EHR systems that significantly exceed minimum Federal standards requirements
For providers who seek maximal assurance of EHR compliance and capabilities
Certified EHR Module [EHR-M]
Flexible certification of Federal standards compliance for EHR, HIE, eRx, PHR, Registry and other EHR-related technologies
For providers who prefer to integrate technologies from multiple certified sources
Certified EHR Site [EHR-S]
Simplified, low cost certification of EHR technologies in use at a specific site
For providers who self-develop or assemble EHRs from noncertified sources
Source: “Town Call: New Paths to Certification ©CCHIT
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14. Mapping Current CCHIT Programs to the New Paths (CCHIT Concept)
EHR-C
Ambulatory and Inpatient EHRs
Child Health, Cardiovascular, Enterprise add-on
EHR-M
Emergency Department, other specialties and settings under development
Stand-alone ePrescribing
PHRs
Health Information Exchanges
EHR-S
Ambulatory or Inpatient internally developed EHRs
Source: “Town Call: New Paths to Certification ©CCHIT
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15. Jodi Daniel, JD, MPH Director, Office of Policy & Research
OFFICE OF THE NATIONAL COORDINATOR
Jodi Daniel, JD, MPH Director, Office of Policy & Research
Policy Activities 15
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16. American Recovery and Reinvestment Act of 2009 (ARRA)
Policy Activities
American Recovery and Reinvestment Act of (ARRA)
Established two Federal Advisory Committees
Requires the Secretary to promulgate regulations related to the electronic exchange of health information.
Provides incentives to eligible providers who are meaningful users of certified EHRs.
Two step process
Added Privacy Protections
Established two Federal Advisory Committees
HIT Policy
HIT Standards
Requires the Secretary to promulgate regulations
Standards, Certification Criteria, and Implementation Specifications
Two Step Process
Certified EHR (which is also qualified) and
Meaningful Use
Added Privacy Protections
Increased HIPAA penalties
Allows OCR to keep a portion of the recovery
Applies penalties to Business Associates
Breach Notification 16
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17. Policy Activities
The Nationwide Privacy & Security Framework for Electronic Exchange of Individually Identifiable Health Information
Draft Model Personal Health Record (PHR) Privacy Notice & Facts-At-A-Glance
Reassessing Your Security Practices in a Health IT Environment: A Guide for Small Health Care Practices
HIPAA Privacy Rule Guidance Related to the Privacy and Security Framework and Health IT 17
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18. Other Policy Areas Policy Activities NHIN DURSA development
Consumer preferences
Privacy and Security
501(c)(3) status for Health Information Organizations
Anti-Fraud and health IT
CLIA and the electronic exchange of laboratory data
Other Policy Areas
NHIN
DURSA development
Multiparty agreement
Assumes participants in production
Establishes authority for interim governance
Developed as part of ongoing NHIN activities
First iteration was a Test Data DURSA
Applies to “test data” (not PHI) for Trial Implementations
Executed by all participants in Trial Implementations in September 2008
Production DURSA
Initial draft Production DURSA – December 2008
Revised draft for limited production – June 2009
Initial version of production DURSA – limited production – January 2010
Large, diverse multi-stakeholder team assembled to develop this agreement through a set of contracts and grants and with active engagement of Federal agencies.
Consumer preferences
NHIN Cooperative is exploring technical capabilities to support consumer preferences, and permissions.
Analysis under way to identify possible approaches for consumer preferences supported through the NHIN.
Privacy and Security
Information is securely exchanged among participants in the NHIN – supported through the NHIN architecture and secure protocols.
From a policy perspective – the NHIN Cooperative is working to establish a trust model that works within the current legal and policy framework, but that also enables and fosters health information exchange based on a nationwide basis. 
In addition, the NHIN Cooperative is developing:
-A white paper that articulates how the NHIN addresses the 8 principles in the HHS Privacy and Security Framework
-A set of NHIN participant security requirements – to identify the types of safeguards that participants agree to support as a condition of participating in the NHIN.
501(c)(3) status for Health Information Organizations
Medical Identity Theft/ Anti Fraud
CLIA guidance to allow for the electronic exchange of laboratory data
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19. John Glaser, PhD Senior Advisor to the National Coordinator
OFFICE OF THE NATIONAL COORDINATOR
John Glaser, PhD Senior Advisor to the National Coordinator
Nationwide Health Information Network Future Direction 19
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20. Nationwide Health Information Network Future Direction
The NHIN is a set of conventions that provide the foundation to the exchange of health information that supports meaningful use. The foundation includes technical, policy, data use and service level agreements and other requirements that enable data exchange, whether between two different organizations across the street or across the country.
The NHIN foundation supports both the local and nationwide exchange of health information. The foundation does not distinguish between the two.
Health information exchanged should be enabled for all clinical information systems including at the edge systems (EHRs, PHRs, etc.) (not quite sure of the definition of an edge system).
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21. Nationwide Health Information Network Future Direction
ONC will maintain overall responsibility for the governance of the NHIN, the development and management of the foundation and the demonstration of new components of the foundation.
ONC will identify an organization to assume operational responsibility for CONNECT and the core set of NHIN-wide infrastructure.
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22. Kelly Cronin Director, Office of Programs and Coordination
OFFICE OF THE NATIONAL COORDINATOR
Kelly Cronin Director, Office of Programs and Coordination
State Grants 22
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23. Section 3013: State Grants to Promote HIT
A program to facilitate and expand the electronic movement and use of health information among organizations according to nationally recognized standards.
Information exchange to improve the quality of health care is a requirement for the meaningful EHR use incentives.
Depending on maturity of efforts re: health information exchange, a state or state designated entity will be eligible for either a Planning grant or an Implementation grant.
Planning grants will assist states in developing a roadmap to implement statewide health information exchange consistent with the meaningful EHR use criteria.
Implementation grants will assist states with acting on approved roadmaps to build statewide health information exchange capacity consistent with meaningful EHR use criteria.
Planning and implementation should be done in coordination with Medicaid to ensure the direct relevance and support for meaningful use of EHRs.
ONC intends to award grants to all states and territories that submit qualified applications.
The program is in support of MU and they’ll be an expectation that HIE capacity will be developed overtime to enable information exchange among eligible professionals and providers in a way that qualifies them for Medicare and Medicaid meaningful use incentives.
This makes coordination across the State grant and Medicaid programs at the state and federal level critical to success.
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24. Planning and Implementation Grants
Planning and Implementation grants should be pursued in the public interest and be consistent with the National Coordinator’s plans.
Federal – State partnership is key!
Funds shall be used to facilitate and expand HIE according to nationally recognized standards and to:
Enhance broad and varied participation.
Assist in identifying state or local resources to support a nationwide effort.
Complement other federal grants and programs.
Provide technical assistance to overcome barriers to exchange.
Promote effective strategies to support exchange in underserved communities.
Assist patients in utilizing health information technology.
Encourage clinicians to utilize Regional Extension Centers for technical assistance.
Support public health agencies authorized use of and access to health information.
Promote use for quality improvement, including reporting on quality measures.
The Secretary shall ensure continuous improvement based on annual evaluation and implementation of lessons learned.
Funding will be tied to approaches that lead towards the greatest improvement in quality of care, decrease in costs and the most effective authorized and secure HIE.
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25. Qualified State Designated Entities (QSDE)
States may appoint a QSDE to carry out the work specified in Section A QSDE should meet the following criteria:
Be designated by the state as eligible to receive awards.
Be a not-for profit entity with broad stakeholder representation on its governing board.
Demonstrate that one of its principal goals is to use information technology to improve health care quality and efficiency through the authorized and secure electronic exchange and use of health information.
Adopt non-discrimination and conflict of interest policies that demonstrate a commitment to open, fair and non-discriminatory participation by stakeholders.
A QSDE should consult with and consider the recommendations of:
Health care providers
Health plans
Patient or consumer organizations
HIT vendors
Health care purchasers/employers
Public health agencies
Health professions schools
Universities
Clinical researchers
Users such as clerical staff
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26. OFFICE OF THE NATIONAL COORDINATOR
Rachel Nelson, MHA Special Assistant to the Deputy National Coordinator
Health Information Technology Extension Program 26
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27. Health Information Technology Extension Program
National Health Information Technology Research Center (HITRC) Regional Centers Offering Direct Technical Assistance to Providers
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28. HITRC (National Research Center)
Supports efforts to adopt, implement, and effectively use health IT:
Offers Technical Assistance & Educational Resources
Develops or recognizes best practices
Incorporates input from Federal agencies, health IT users, others as appropriate
Serves as resource and forum for knowledge and best-practices exchange
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29. Regional Centers
Individualized technical assistance to providers seeking to adopt and effectively use health IT to exchange information within appropriate policy frameworks Technical Assistance with product selection, workflow changes toward achieving meaningful use – including helping with provider in-house work to connect to health information exchange infrastructure, and in effectively leveraging electronic health information and health information technology to improve quality of cares
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30. Ginger Price Program Director, Nationwide Health Information Network
OFFICE OF THE NATIONAL COORDINATOR
Ginger Price Program Director, Nationwide Health Information Network
Nationwide Health Information Network 30
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31. The Nationwide Health Information Network
NHIN
RHIOs and HIEs
Personal Health Records
Federal Agencies
Integrated Delivery Networks
Community Health Centers
Registries and Repositories
The Nationwide Health Information Network
The NHIN provides:
Common legal framework for information sharing
Common infrastructure necessary for network security and connectivity
Specifications for interoperable services
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32. NHIN Architectural Principles
Highly distributed: Patient health information is retained at the local health information exchange level
Local autonomy: Each HIE must make their own determinations with respect to the release of patient information
Focus only on inter-organizational health exchange: The NHIN does not attempt to standardize implementations of the NHIN services and interfaces, only the communications between HIEs
Use public internet: The NHIN is not a separate physical network, but a set of protocols and standards that run on the existing internet infrastructure
Platform neutral: The NHIN has adopted a stack (web services) that can be implemented using many operating systems and programming languages
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33. Nationwide Health Information Network
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34. Nationwide Health Information Network Standards and Services
Messaging, Security and Privacy Foundation
NHIN Services
NHIN Profiles
Messaging
Message Transport
Services Definition
Security
Public Key Infrastructure
Encryption
Digital Signature
Authorization Framework
Requestor Authentication
Requestor Authorization
Discovery Services
Subject Discovery
Authorized Case Follow-up
Query for Documents
NHIE Service Registry
Information Exchange Services
Retrieve Documents
Query Audit Log
Health Information Event Messaging
Consumer Preferences Profile
Store and exchange consumer preferences for sharing of personal health information
Other Profiles in Development
GIPSE (Biosurveillance)
Profiles describe how to implement services for a specific domain like consumer preferences for information sharing or biosurveillance Services describe specific interfaces (web services) used between HIEs to discover and exchange health-related information Messaging, Security and Privacy Foundation describes the underlying protocols and capabilities necessary to send and secure messages between NHIE
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35. “ ” NHIN 2008 Results However beautiful the strategy,
you should occasionally look at the results..
Sir Winston Churchill
Demonstrated Technical Capability
Created a Set of Initial Interoperable Specifications
20+ disparate organizations participating in the NHIN Cooperative
Laid foundation for data usage agreements
Completed Trial Implementations
Started limited production pilots in 2009
We have the building blocks… .
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36. NHIN Cooperative Participants
Private HIEs
State-Level HIEs
Provider Orgs / IDNs
Federal
Entities
CareSpark
Delaware Health Information Network
Cleveland Clinic
CDC
Community Health Information Collaborative
New York eHealth Collaborative
Kaiser
CMS
HealthLINC (Bloomington)
North Carolina Health Care Information and Communications Alliance (NCHICA)
DoD
HealthBridge
IHS
Indiana
(Regenstrief Institute)
West Virginia Health Information Network (WVHIN)
NCI
Long Beach Network for Health
NDMS
Lovelace Clinic Foundation (NMHIC)
SAMHSA
MedVirginia
SSA
Wright State University VA
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37. Lessons Learned from the NHIN Trial Implementations
More directed activities with shorten cycles for work products
Created processes and teams like the Specifications Factory
The testing tools must be matured and processes automated.
Providing Reference Implementation and automated test tools and scripts
Baseline the foundational services of the NHIN
Need a stable platform that will not require retooling for 18 – 24 months
Large IDNs and federal data are significant attractor for private Health Information Exchange entities
SSA, VA, Kaiser Permanente, DoD
An executable DURSA is needed to avoid complexity of point to point.
The Data Use and Reciprocal Support Agreement (DURSA) developed by the NHIN DURSA Team and the ONC Office of Policy and Research recently entered Federal clearance. The DURSA pragmatically addresses the agreements needed to exchange health information on the NHIN under conditions that exist today.
Need a governance structure for real health information to flow
Governance includes strategic direction, representational oversight, and operating policies and procedures, and enforcement mechanisms
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38. Demonstration Projects
NHIN limited production pilots are critical to the success of demonstrating how standards and specifications are implemented as working operational solutions for health information exchange.
MedVirginia and SSA entered into the first limited production pilot in February, 2009.
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39. SSA – MedVA Pilot Results
weeks
Currently processing approximately 75% of predicted load
Starting with one provider network (Bon Secours) in February
Approximately 3200 SSA eligibility requests for Bon Secours last year
In discussions with 4 more provider groups to come online in 2009
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40. Demonstration Projects
Other organizations planning to demonstrate health information exchange later this year: HealthBridge Indiana Health Information Exchange Kaiser Permanente Department of Veterans Affairs Department of Defense Centers for Disease and Prevention
The next NHIN pilot project demonstrations will include onboarding the pilot partners into the NHIN trusted community, performing conformance testing and interoperability testing, issuing a digital certificate, and adding them into the NHIN service registry.
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41. NHIN and CONNECT
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42. To learn more about the Nationwide Health Information Network:
Go to and look for: Nationwide Health Information Network Interested? We’d like to hear from you at
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43. CONNECT Seminar Presentations are Available for Download Online at http://www.connectopensource.org
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