North Carolina Health Information Exchange Board Meeting Developing an Operational Plan for Statewide HIE in North Carolina May 14, 2010

Project Team Workgroup Facilitation and Coordination Project Management Bernstein Dutton Pawlak Garcimonde Governance Legal & Policy Clinical & Tech Operations Finance Bernstein Belfort Kwan Ray Olberg Pawlak du Pont Apodaca Discussion Document – Not for Distribution 2

Planning Approach Project Deliverables Key Work Product... Statewide HIE Operational Plan Coordinating with... Medicaid Meaningful Use Plan Regional Extension Center Leveraging Other Assets... Beacon Community (Southern Piedmont Community Care Plan) CHIPRA Quality Demonstration Grant NHIN activities Operational and planned HIEs Regional and local quality efforts Discussion Document – Not for Distribution 3

Planning Approach Three Steps...Assess, Engage, and Guide 1. Assess HIE and HIT Resources Review inventories of existing resources Identify needs, requirements, planning horizons Conduct informational interviews with key stakeholders 2. Engage Stakeholders Facilitate an inclusive, collaborative process Provide structured, thorough analysis of all options Update stakeholders on meaningful use incentives, standards and technology trends, federal policies and regulations, and leading practices in other states Support public review and participation 3. Guide Stakeholders to Clear, Actionable Recommendations Guide participants through threshold questions to drive recommendations and development of detailed plans Discussion Document – Not for Distribution 4

Planning Approach Stakeholder Engagement and Workflow Governance Board/Steering Committee Manatt facilitates analysis and track & document decisions Governance Work Group Legal & Policy Work Group Clinical & Tech Operations Work Group Finance Work Group Draft and Final Plans Components of Strategic and Operational Plan Compile Drafts, Feedback, and Public Input Engagement is transparent & inclusive...“stakeholders support what they create” Discussion Document – Not for Distribution 5

Planning Approach Guide Stakeholders...Sample Threshold Question What financing mechanisms should be used to sustain statewide HIE services? Identify Threshold Questions Options Exchange fees (transaction, subscription) Assessments Gain sharing Assess Options, Pros, Cons, Risks Resolution Key consideration...Fed funding insufficient to build/operate statewide HIE Reaching a decision...Authority to execute, practical considerations Resolve Methodology based on planning and operational experiences in nine (9) states Discussion Document – Not for Distribution 6

Work Group Methodology Integration of Key Deliverables Governance Work Group Legal & Policy Work Group Clinical & Tech Operations Work Group Finance Work Group Define roles, decision making authority Identify goals Define measures Identify privacy issues Define options Identify policy/tech requirements Identify clinical/business objectives Define architecture Identify services Detail functions, options Develop high-level costs Collect relevant environment data Define revenue sources Identify funding constraints and timing considerations Implementation Requirements Technical specifications Implementation sequencing Detailed cost estimates Detailed, 4 yr budget Evaluation strategy Discussion Document – Not for Distribution 7

Planning Approach Workgroup Facilitation May June July Aug Identify Key Issues Assess Options Refine Plan Finalize Plan Work Group Activities Work Group Deliverables Membership Charters Clinical/business priorities Use cases Technical architecture Implementation req’ments Sustainability model Budget Operational Plan 1st Draft Completed Operational Plan Clinical/business priorities Use cases Tech architecture Discussion Document – Not for Distribution

Work Group Charters/Deliverables Sample Purpose To develop working cost and business models for sustainable HIE services in North Carolina. Operational Plan Requirements 1. Project Schedule (2010 - 2013) 2. Staffing Plans 3. Cost Estimates 4. Budget for Sustainable Business Model 5. Issues and Risk Mitigation Strategies 6. Controls and Reporting Other Deliverables Short Term Business model, foundational assumptions Inventory of cost drivers and revenue sources Estimated costs for statewide HIE Medium Term Identify possible revenue sources, including tax and subscription models and possible loan funds Detailed plan to build sustainable business model to support HIE services, including budget, available funding sources, and recommendations Long Term Sustainable business model for statewide HIE services Discussion Document – Not for Distribution

Example: Strategic Plan Workgroup Deliverables Governance Description of governance entity, including membership, authority and governance model Description of how state will address HIE accountability and transparency Description of coordination with Medicaid, federally-funded state programs, and other ARRA programs (e.g. broadband) Finance Business plan that enables financial sustainability of HIE governance and operations by 2014 Develop and update project budget Technical Infrastructure Description of how infrastructure will facilitate interoperability Description of technical approach and architecture to be used including HIE services to be offered (if applicable) Review and augment environmental scan of HIE Business & Technical Operations Implementation strategy to address how the state will meet meaningful use requirements Description of incremental approach for HIE services to reach all geographies and providers Identify plan and timeline for NHIN participation Legal/Policy Describe NC and interstate privacy and security issues related to HIE Describe plans to analyze and/or modify state laws Describe development of policies and procedures to foster secure HIE Describe the use of trust agreements (e.g. data sharing and use agreements) Describe how the state will address noncompliance with HIE policies Consumer Engagement Consumer engagement and outreach plan Develop communications and educational materials for consumers, general public, and press 10 Discussion Document – Not for Distribution 10

Example: Operational Plan Workgroup Deliverables Governance Description of coordination and interdependencies with relevant ARRA programs (e.g. REC, broadband, and workforce development) Description of governance and policy structures, including their ongoing development Finance Detailed cost estimate for the implementation of the Strategic Plan Detailed schedule describing the tasks and sub-tasks to be completed, including resources, dependencies, and specific timeframes Description of proposed resolution and mitigation methods for identified issues and risks Staffing plans for the project, including project managers and description of key roles Description of activities to implement financial policies, procedures, and controls to ensure compliance with GAAP and OMB Circulars Technical Infrastructure Description of efforts to become consistent with HHS adopted interoperability standards and certification requirements as part of the planned implementation Description of the technical architecture and how its requirements will ensure statewide availability of HIE among healthcare providers, including plans for protection of health data Description of how the technical architecture will align with NHIN core services and specifications Description of technical solutions to develop HIE capacity and enable meaningful use Business & Technical Operations Project schedule describing tasks and sub-tasks to be completed to enable statewide HIE Identification and description of issues, risks, and interdependencies within the overall project Description of how the state will leverage current HIE capacities Description of state-level shared services and repositories to be leveraged (if applicable) Explanation of standard operating procedures and processes for HIE services will be developed and implemented (not required) Legal/Policy Description of how statewide HIE will comply with applicable federal and state legal policy requirements, including the process for developing and implementing policy requirements Description of interdependence of governance and oversight mechanisms Description of plans for privacy and security harmonization and plans for interstate coordination Address how state will comply with federal requirements for data protection Consumer Engagement Consumer engagement and outreach plan Communication messages and educational deliverables for dissemination 11 Discussion Document – Not for Distribution 11

Progress in North Carolina Governance Considerations Status Discussion, Remaining Questions to Address Vision for HIT and HIE in North Carolina From NC HIE Strategic Plan: The HIE vision for North Carolina is safe and secure access to patient health information which benefits the health, safety, efficiency and quality of care for all – a future in which all residents of North Carolina are afforded ready access to and equal opportunity for accurate and secure health information whenever and wherever it is needed. Objectives for realizing value Promote, facilitate and support the development and implementation of health information exchange systems that provide interoperability among healthcare providers. Promote statewide deployment and use of EHRs, especially among priority providers working with medically underserved populations. Safeguard privacy and security of electronic health information Develop a framework for implementation and sustainability of HIT Conduct robust evaluation of process & outcome at end of years 2 and 4 Develop policy, processes, and technology to support informed consumer engagement in HIE flow. Measures of success No measures were identified in strategic plan. Candidate measures include process and outcome goals for technology adoption and utilization, levels of participation in exchange, achievement of quality and safety objectives, efficiency and cost reduction, etc. Discussion Document – Not for Distribution 12

Progress in North Carolina Governance Considerations Status Discussion, Remaining Questions to Address Governance Body roles North Carolina will identify a non-profit organization that will be responsible for both governance and technical operations. Governance Body charter, by-laws Charter and by-laws need to be developed Roles of key organizations Need to articulate roles, relationships between: NCHICA, Health and Wellness Trust Fund, State government, and anticipated Governance Body Role of regional/community exchanges Decisions need to be addressed regarding the locus of exchange. Across the state, will each region have a single HIOs to coordinate policy and technical implementation? What are the near and long term connectivity options for regions not currently covered by HIO? Statewide policy framework Structure and decision making process for collaborative process to be determined. Workgroup charters and membership needs to be developed. Enforcement Authority and accountability mechanisms, including contracts, regulations, and or accreditation need to be addressed. Agreement as to whether participants in statewide HIE will be required to abide by policies developed through collaborative process Use of Statewide HIE services Will participation in statewide HIE networks be optional? Will there be requirements to use statewide services for access to state gov’t services and data? Discussion Document – Not for Distribution 13

Progress in North Carolina Technical Architecture Considerations Status Discussion, Remaining Questions to Address Technical architectural principles From NC HIE Strategic Plan: The NC HIE architecture must be flexible and adaptable to accommodate existing and emerging HIE implementation scenarios. Given the potential total funding amount available to North Carolina, funding multiple HIE platforms is not feasible. Aligned with “meaningful use” criteria as defined by the federal government. The NC HIE architecture must align with NHIN core services and specifications. The HIE platform will be vendor and technology neutral. Service‐oriented architecture will be in alignment with but neutral to major vendor SOA platforms. Privacy and security services will comply with all HIPAA requirements and applicable federal and state regulations. Community HIOs across North Carolina will be able to exchange health information, as well as connect to the NHIN through the NC Shared HIE Services environment. Access and exchange services will be provided in order to leverage existing statewide information assets such as CCNC INC, PHIN, MMIS, commercial laboratories, and IDNs. Inventory of HIE capabilities Inventory of HIOs and capacities of various exchanges has been outlined in NC HIE Strategic Plan: Additional baseline data on exchange capabilities required to identify gaps and complete needs assessment. Discussion Document – Not for Distribution 14

Progress in North Carolina Technical Architecture Considerations Status Discussion, Remaining Questions to Address Technical service selection and prioritization Candidate selection and prioritization criteria identified in in NC HIE Strategic Plan: (1) the clinical value generated (e.g., quality improvement), (2) the degree of competition for the service, (3) the breadth and depth of potential clients, (4) anticipated net revenue and return on investment, (5) technical difficulty; and (6) costs for service provision. Criteria need to be refined in light of meaningful use and proposed NHIN services and mapped to candidate services Technical service costs Need to develop estimated costs for start-up and ongoing support of candidate services. Technology deployment plan Need to identify technical specifications, detailed phasing, draft RFPs. Discussion Document – Not for Distribution 15

Progress in North Carolina Privacy and Security Considerations Status Discussion, Remaining Questions to Address Privacy vision From HIT Task Force Report: Assure privacy and security of health information; Improve healthcare quality and coordination – behavioral and physical; Improve healthcare safety; Reduce healthcare costs or create efficiencies; Assure the education of NC health professionals (current and future) to incorporate HIT into their practices; Enable individuals, providers, and communities to make the best decisions for improving consumer and population health; and Enable appropriate health services research. Privacy principles Outlined in NC HIE Strategic Plan. Principles need to be agreed upon by new Governance Body. Review of existing NC privacy and security laws and regulations Strategic plan and Operational Plan Status indicates a thorough inventory and analysis needs to be conducted. Discussion Document – Not for Distribution 16

Progress in North Carolina Privacy and Security Considerations Status Discussion, Remaining Questions to Address Scope of privacy and security policies Will privacy and security policies apply to all forms of exchange, ranging from point-to-point to many-to-many? Access Agreement as to whether those involved in health information exchange will be required/allowed to filter certain types of sensitive health. Consent Agreement as to whether consent will be required in order to ready it for exchange by uploading it to a HIO. Discussion Document – Not for Distribution 17

Progress in North Carolina Financing Considerations Status Discussion, Remaining Questions to Address Environmental data In January of 2009, significant initial work was completed by NCHICA as part of their NHIN Trial Implementation Contract to develop a sustainability and business plan for North Carolina. Additional work required to update inventory of revenue resources and mechanisms including providers, payers, population, boarder states, existing HIOs, etc. Cost model Develop total cost of ownership model (over four year period) based on selected HIE services. Revenue model Develop revenue models for the state based on environmental data and high-level assumptions. Updated budget Update ONC State HIE Cooperative Agreement budget. Issues and risk mitigation strategies Develop as required by ONC State HIE FOA. Controls and reporting Discussion Document – Not for Distribution 18

Progress in North Carolina Business and Technical Operations Considerations Status Discussion, Remaining Questions to Address Business requirements Identify and prioritize business requirements for use cases and prioritization of services Clinical requirements Identify and prioritize clinical requirements for use cases and prioritization of services Technical service selection and prioritization Candidate selection and prioritization criteria identified in in NC HIE Strategic Plan: (1) the clinical value generated (e.g. quality improvement), (2) the degree of competition for the service, (3) the breadth and depth of potential clients, (4) anticipated net revenue and return on investment, (5) technical difficulty; and (6) costs for service provision. Criteria need to be refined in light of meaningful use and proposed NHIN services and mapped to candidate services Detailed project schedule (2010-2013) Develop detailed project plan as required by ONC State HIE FOA. Staffing plans Develop staffing plans as required by ONC State HIE FOA. Coordination with state agencies Coordination approach discussed in NC HIE Strategic Plan: Coordination with federal efforts Standard operating procedures Develop as required by ONC State HIE FOA. HIE services should be prioritized with consideration to •Impact on patient experience and outcomes •Ability to support processes that ensure quality of care and patient safety •Ability of the HIE to have a ROI for its services •Technological evolution of providers and consumers There should be a primary focus on core services related to HIE and to support providers’ ability to meet meaningful use criteria Services “redundant” to existing services/capabilities (e.g. claims process) should notbe prioritized Discussion Document – Not for Distribution 19

Discussion Document – Not for Distribution ATTACHMENTS Discussion Document – Not for Distribution 20

Project Implementation High Level Milestones & Activities * Mid-May... Kick-off Meeting - Review Operational Plan requirements - Present timeline, key issues, models, and information needs - Identify Steering Committee * May 24 – June 4..... Work Group Launch - Finalize Work Group charters, membership, launch kick off meetings * June 4 – July 9.... Develop Recommendations - Work Groups meet bi-weekly - June 25...Steering Committee review high-level draft * July 9 - July 30.... Develop Draft Plan for Comment - Jul ??... Transmit First Draft Ops Plan to Steering Committee for review - Jul ??... Release Ops Plan for Comment (7 business days) * July 30 – Aug 23.... Finalize Operational Plan - Jul ??... Transmit Final Draft Ops Plan to Steering Committee for review - Jul ??... Transmit Final Version Ops Plan to Steering Committee for review Discussion Document – Not for Distribution 21