Rachel Block NY eHealth Collaborative Coordination of State and Federal Policies for Health IT Implementation: A Postcard from NY Rachel Block NY eHealth Collaborative

Historical Context for Health IT Policy Key Elements in New York’s Health IT Strategy Key Health IT Elements of Federal Stimulus Legislation

Strong Imperative for Health Care Reform US health care very costly and performs poorly compared to other countries Many studies and commissions have called for system changes to: Improve public health Improve quality and safety Manage cost and care more effectively

Health Systems Change Requires Broad Use of Health IT To Err is Human (IOM) Crossing the Quality Chasm (IOM) High Performance Health System (Commonwealth Fund) Other countries (UK, Canada, Germany)

Health IT Is Necessary but Not Sufficient Health information exchange is essential complement to health IT: Incentive to use health IT Track care across continuum, hand-offs Empower consumers and families Create longitudinal information Strengthen public health surveillance

Key Concepts in Health Information Exchange Interoperability of health information systems would facilitate exchange Broad acceptance and use of certain policies is required Technical standards: data structure, communications Clinical imperatives: quality, safety, care management Protections re access and use: consent, disclosure of breach Security policies: audit, authorization, authentication Governance and accountability Financing and incentives

Framework for New York’s Health IT Strategy “Cross-Sectional” Interoperability APPLY Clinician/EHR Consumer/PHR Community AGGREGATE & ANALYZE Clinical Informatics Services Aggregation Measurement Reporting ACCESS Statewide Health Information Network – NY (SHIN-NY) 7 7

What will get us “there” in NYS? Policy alignment Support of increased adoption of certified and interoperable EHRs in all care settings Increased adoption of patient/consumer programs including secure PHRs Coordination of care, including medication management, across care settings Disease prevention, early detection and other public health initiatives Monitoring and ongoing support of implementation to ensure safety and success Sustainable reimbursement models to promote HIT 8

Governance and Accountability Public trust is key underpinning for these systems Need authority, structure and means to set policy, monitor use, enforce standards Federal government has established some policies and mechanisms but not comprehensive Establish organizational capability and accountability at state and regional levels

Governance and Organizational Components: Policy Development and Implementation Framework HITEC Create evaluation tools Assess sustainability Measure progress NYS Dept of Health Fund health IT Oversee contracts Enforce regulations NYeC Statewide collaborative process Deliberate & decide policies Assist RHIOs/CHITAs $ $ Evaluation tools, other resources Funding and contractual obligations Implementation guides, tools, other resources State Statewide Health Information Network for NY (SHIN-NY) RHIO RHIO RHIO RHIO RHIO CHITAs CHITAs CHITAs CHITAs Region Patients Providers Payers Purchasers Patients Providers Payers Purchasers Patients Providers Payers Purchasers Patients Providers Payers Purchasers Patients Providers Payers Purchasers Local RHIO: A governance entity that oversees HIE in its region CHITA: A collaboration supporting adoption of health IT

Statewide Collaboration Process DOH NYeC Board Governance/ Oversight Policy & Operations Council Collaborative Work Groups Implementation Clinical Priorities Privacy & Security EHR Collaborative Protocols & Services NHIN Project HEAL Projects CDC Project MSSNY Projects Policy/Standards Education & Communication Committee Cross-Cutting Activities Financial Sustainability Work Group Consumer Advocacy Council HITEC 11 11 11

Policies Governing Access to and Use of Data Current law and practices protects privacy and confidentiality – need to translate and adapt to health care enabled by HIE –consent, review of disclosures, notification and remedies for breach Policies Governing Disclosure and Use – Treatment, Public Health, Research, etc

Data definitions and record structure Technical Standards Data definitions and record structure Product certification requirements Strategy for connectivity Hard coded interface specifications versus… Open source, service oriented architecture as in what we use for the internet

Policies and Standards for Technical Security Authentication of users (clinicians, consumers) Authorization (role-based rights to access patient data) Audit (tracking disclosures)

Vision for New York’s Health Information Infrastructure Costly, High Risk and non-Interoperable EHRs Interoperable EHRs Clinician EHR Pharmacies Radiology SHIN-NY Hospitals Labs Government/ Medicaid Consumers Payers

Grouped Physician Offices Service Oriented Architecture Model Hospital system Pharmacy SureScripts Rx Hub Health Plan Lab Rad Documents Results Reporting eRx & Med Hx EHR Patient Centric Multiple Clinics (CHCs & FHQCs) Clinician EHR EHR EHR Clinician EHR EHR Clinician EHR SHIN-NY** EHR EHR EHR Grouped Physician Offices EHR EHR EHR EHR DOH Node EHR EHR EHR EHR Medicaid UPHN Integrated Child Health Record EHR EHR EHR EHR NYS Department of Health 16 16 16 16

Clinical Imperatives for HIE Clinical uses structured around “use cases” which cross walk to technical requirements Continuum of care – medication management Safety and efficiency – e-prescribing Quality Improvement – quality measures for decision support and public reporting Population health surveillance and management

Clinical Priorities: Definitions, Requirements and Applications Define clinical priorities that best demonstrate critical areas and opportunities for improvement in both the quality and efficiency of health care for New Yorkers Demonstrate and communicate the value of interoperable health IT adoption and effective use to clinicians and other stakeholders Develop clinical requirements, identify workflow issues, and advance policy recommendations to help drive and test the development of policies, protocols and standards for NYS Health Information Infrastructure Clinical Scenarios that illustrate value proposition Create scenarios based on use cases and subgroup priorities 1 2 3 4 Workflow requirement documents and narratives to support clinical practice redesign Clinical requirements document to guide technical development and implementation: Hone value proposition for increased patient safety, improved quality, efficiency and decreased cost; Identify and prioritize clinical data types & elements, features and functions & CDS Provide detailed workflow analysis, including charts and narratives Reimbursement requirements document Identify and prioritize reimbursement requirements to support sustainability Coordinate with other Workgroups (EHR Collaborative, Protocols/Services, Privacy & Security) Reconciliation relies on cross-continuum data Coordination with NHIN projects Promote e-prescribing in context of advancement to a full EHR with CDS Prioritization of clinical needs for financial incentive models Medicaid / Medication Management Quality Reporting PHR and medication management crossover Emergency services and coordination (DNR) Patient education and decision support Patient identification and consent Current PHR product readiness Continuity of care record with the PHR Secure patient-clinician clinician-clinician interaction Additional patient data sources including Telemedicine Connecting NYers and Clinicians Public Health Integrating current public health data sources –coordinated input High priority to deal with projects already out Bi-directional data flow through the Universal Public Health Node Access to public programs as an issue for public health Coordination with other efforts – CDC and NHIN Statewide quality standards Locus of aggregation Key data elements/specifications CDS across care settings Intersection with medication management Physician adoption/trust

EHR Collaborative – Comprehensive System of Adoption Support Services Knowledge-sharing Policies & Standards Products & Services Convene and share best practices and lessons learned among participants and users Recommend common policies, standards, and technical approaches among HEAL projects Recommend statewide services to reduce the cost and/or increase the quality and consistency of EHR adoption and support Value-Oriented Project Management Readiness assessment & planning Vendor selection and contracting Practice transformation & workflow planning System deployment & implementation Reporting, decision support, and performance measurement Inter-operating with internal and external systems Post-implementation support 19 19

Federal Stimulus Legislation: Multiple Areas of Focus Appropriations for Health IT & HIE New Incentives for Adoption New Medicare and Medicaid payment incentives to providers for EHR adoption $20 billion in expected payments through Medicare $14 billion in expected payments through Medicaid ~$34 billion in gross expected outlays, 2011-2016 $2 billion for loans, grants & technical assistance: HIE Planning & Implementation Grants EHR State Loan Fund National Health IT Research Center & Regional Extension Centers Workforce Training New Technology R&D Broadband and Telehealth $4.3 billion for broadband & $2.5 billion for distance learning/ telehealth grants Directs ONC to invest in telehealth infrastructure and tools Directs the new FACA Policy Committee to consider telehealth recommendations Comparative Effectiveness $1.1 billion to HHS for CER Establishes Federal Coordinating Council to assist offices and agencies of the federal government to coordinate the conduct or support of CER and related health services

Details about Available Funding/Programs

Medicare and Medicaid EHR Adoption Incentives Funding mechanism(s) Federal Incentive Payments State matching payments (for admin costs) Payment Agent Medicare carriers and contractors State Medicaid agencies Payment Recipients Hospitals and physicians Hospitals, physicians, NPs,dentists, mid-wives, third-party entities promoting EHR adoption State Medicaid agencies for program admin Amounts for Hospitals $2 million base amount Plus increases for annual discharges, number of inpatient days attributable to Medicare, and charges attributable to Medicare $2 million base amount Plus increases calculated using similar methodology as Medicare incentive (eligible entities include Acute Care and Children’s Hospitals) Amounts for physicians & other health professionals Up to $44,000 in Medicare reimbursements Over 5 year period Up to $64,000 Over a 5 year period covering up to 85% of eligible implementation costs Providers must demonstrate “Meaningful Use of Certified EHR Technology” to receive payments

Key Concepts in Federal Stimulus and Alignment with NY’s Strategy HIE Infrastructure SHIN-NY: Governance, Policy and Technical Components Planning and Implementation Grants for State HIE Plan NYeC = state designated entity Regional Extension Centers EHR Service Bureau, CHITAs Loan Fund Dormitory Authority 23 23

Framework for NY’s Health Information Infrastructure Definition of “Meaningful Use” of EHRs Crosswalk to NY Strategy Framework Framework for NY’s Health Information Infrastructure Three Components Uses EHR in a meaningful manner, which includes electronic prescribing as determined to be appropriate by the HHS Secretary Uses EHR that is “connected in a manner” that provides for the electronic exchange of health information to improve the quality of health care, such as promoting care coordination (in accordance with law and standards applicable to the exchange of information) Submits information on clinical quality measures and other measures as selected and in a form and manner specified by the Secretary Statewide Health Information Network Clinical Informatics Services Clinician/EHR 24 24 24 24