1. North Carolina Health Information Exchange
Governance Workgroup
1st Meeting
June 9, 2010
8:30 am – 11:00 am
Dial-in: ; Participant Code #

2. Agenda Topic Leads Time Introductions and Objectives Co-Chairs
8:30 - 9:00
Background
Manatt
9:00 - 9:20
Workgroup Overview
Workgroup Charter & Work Plan
ONC Statewide Cooperative Agreement Operational Plan
Co-Chairs & Manatt
9:20 - 9:35
Governance Structure – Public/Private Partnership
Roles and Responsibilities of Governance Entity
Discussion
9:35 – 10:45
Next Steps & Timeline
10:45 – 10:50
Open Public Comment
10:50 – 11:00 2

3. Introductions: Co-Chairs, Staff, and Members
William Bernstein, Manatt
Melinda Dutton, Manatt
Brenda Pawlak, Manatt
Allison Garcimonde, Manatt
Co-Chairs
Ben Money, NC Community Health Association
Tom Bacon
NC HIE
Alan Hirsch, Interim CEO
Steve Cline, State HIT Coordinator
Anita Massey, State Project Manager
Members
Connie Bishop, MSN RN, National & State Baldridge Examiner
Jacquelyn Boyden, Kalish Consulting Group
Janis Curtis, Duke Health System
Dana Gibson, Data Link HIE
Craigan Gray, DHHS DMA
Mark Gordon, Kerr Drugs
Don Horton, LabCorp
Darlyne Menscer, NCMS, Carolinas Healthcare System
Harry Reynolds, IBM
Craig Richardville, Carolinas Healthcare System
Pam Silberman, NC Institute of Medicine
Sam Spicer, New Hanover Regional Medical Center
Craig Souza, NC Healthcare Facilities Association 3

4. Expectations of the NC HIE Workgroups
Participants have been nominated and invited to participate by the NC HIE governing board co-chaired by Secretary Lanier Cansler and Mr. Charlie Sanders for your expertise in your field and your commitment to improving health care quality, access, and affordability for all North Carolinians.
Workgroup members are asked to draw on their expertise and perspective from across industries sectors with an eye toward supporting the greater goal of a statewide resource for North Carolina.
Workgroups are expected to be multi-stakeholder, nonpartisan and all discussions, meetings and decision-making processes to be fully transparent.
Workgroups are asked to consider multiple stakeholder group perspectives when working toward solutions.
Workgroups will be asked to make consensus-based recommendations to the NC HIE governing board. In cases where consensus is not reached, the workgroup is expected to put forth a balanced, fair consideration of the pros and cons of an issue.
Workgroup members are expected to respect the opinions and input of others and to engage in fair meeting conduct to work toward consensus recommendations.
Workgroup members are strongly encouraged to attend meetings in person whenever possible.
Public stakeholder input is encouraged.
Will start each meeting with a list of objectives
Based on Workplan, these will help us arrive at the decisions we need. 4

5. Meeting Objectives: Key Decisions
Clear Understanding of Our Charge and Tasks
Confirmation on Public/Private Partnership Model for Governing Entity
Consensus on Roles and Responsibilities of Governing Entity and recommendations to NC HIE Board
Understanding of Upcoming Issues Tasked to Workgroup
Will start each meeting with a list of objectives
Based on Workplan, these will help us arrive at the decisions we need. 5

6. Overview of the Context for Statewide HIE6

7. HITECH Funding: HIT & HIE infrastructure
New Incentives for Adoption
Funding for Health IT
$1.2 B for loans, grants & technical assistance for:
Regional Extension Centers ($640M)
Workforce Training ($80M)
Research and Demonstrations
Medicare & Medicaid incentives for HIT adoption
~$31.5 B to $48.1 B total in expected outlays*
Funding for HIE
Community Health Centers
$1.5 B in grants through HRSA for construction, renovation and equipment, including acquisition of HIT systems
$564 M for Statewide HIE Development
States receive between $4M & $40M
$220 M for “Beacon” Community Program
15 HIEs receiving between $10-$20M
Broadband
USDA/RUS has announced that they will use approximately $2 billion to provide grants while the remaining funds will be used to provide up to $7 billion in loans, for a potential total investment in rural broadband of $9 billion.
Broadband and Telehealth
$4.3 B for broadband & $2.5 B for distance learning/ telehealth grants
*(North Carolina providers estimated to receive $750 M to $1 B) 7
Discussion Document – Not for Distribution 7

8. North Carolina Health IT Awards
ARRA:
State HIE Cooperative Agreement: $12.9 million
Medicaid Meaningful Use Planning: $2.29 million
Regional Extension Center: $13.9 million NC AHEC (North Carolina Area Health Education Centers UNC Chapel Hill)
Beacon Community: $15.9 million Southern Piedmont Community Care Plan
Health IT Workforce Community College Consortia Program (non degree programs): $10.9 million Pitt Community College
Health IT Curriculum Development: $1.8 million Duke University
University-level Health IT Workforce Training (degree programs): $2.1 million Duke University
Broadband: $28.8 million MCNC / North Carolina Research and Education Network (NCREN)
CHIPRA (non-ARRA): $9.2 million (one of 10 state awards)
Testing medical home for children with special health care needs through three provider-led community-based models
Implementing a model electronic health record format for children 8
Discussion Document – Not for Distribution

9. Meaningful Use Overview Regulatory Definition
In HITECH, Congress specified three types of requirements for meaningful use:
use of certified EHR technology in a meaningful manner (e.g. Electronic Prescribing);
that the certified EHR technology is connected in a manner that provides for the electronic exchange of health information to improve the quality of care; and
that, in using certified EHR technology, the provider submits to the Secretary information on clinical quality measures and such other measures selected by the Secretary.

10. Meaningful Use: Funding Timeline MEDICAID MEDICARE
CMS NPRM and
ONC IFC Released
Dec
Medicaid: hospitals that adopt after
2017 not eligible for incentives
Medicaid incentives begin
ONC Final Rule
Medicaid: non-hospital
based physicians1st yr cost
no later than 2016
Medicaid: non-hospital based
physicians no payments after
2021 or more than 5 yrs. …
CMS Final Rule
for Incentives
Medicare phase down incentive
payments for physicians
Medicare penalties begin
for non-meaningful users
FY15 for hospitals
calendar 2015 for physicians
Medicare (FY2011)
incentives begin
Oct. 2010
for hospitals
Medicare incentives
End 2016
Medicare incentives
begin Jan 2011 for
non-hospital based physicians
Medicare: Physicians who 1st payment
is after 2014 receive no incentives
MEDICARE

11. CMS Vision for Stages: Requirements Scaling Up Over Time
Capturing health information in a coded format
Using the information to track key clinical conditions
Communicating captured information for care coordination purposes
Reporting of clinical quality measures and public health information
Disease management, clinical decision support
Medication management
Support for patient access to their health information
Transitions in care
Quality measurement
Research
Bi-directional communication with public health agencies
Achieving improvements in quality, safety and efficiency
Focusing on decision support for national high priority conditions
Patient access to self-management tools
Access to comprehensive patient data
Improving population health outcomes
For Stage 2, CMS may also consider applying the criteria more broadly to both the inpatient and outpatient hospital settings. CMS expects to propose Stage 2 criteria by the end of 2011.
CMS expects to propose Stage 3 criteria by the end of 2013.

12. Framework of Health Reform: Payment Policy Changes
Reduce Cost of Care
Improve Coordination
of Care
Alter Content
of Care
Stimulate Administrative Efficiencies
HIT Incentives
Limit FFS Payment Updates
Medicare captures productivity gains
FFS becomes less attractive
Encourage creation of new delivery organizations including:
Medical Homes, particularly for chronic care populations
Accountable care organizations
Tie Payments to Broader Units of Service
Hospital and Physician Payment Bundles
Episode-Based Payment Bundles
Improving Scientific Basis of Healthcare Decisions
Based on Comparative Effectiveness Research
Payment Tied to Patient Outcomes
Based on Quality Measures

13. Health Information Exchange: Changing the Paradigm
Today “One-to-One” Exchange
Tomorrow “Many-to-Many” Exchange
Human judgment plays a critical role in determining what information is shared and with whom
Phone conversations between clinicians for purposes of treatment frequently replace the need for physically exchanged information.
Authentication of requests for information is heavily reliant on relationships between organizations or individuals charged with information sharing.
In an environment of ubiquitous electronic HIE, data will be gathered or transferred between multiple entities without benefit of the familiar relationships of the old paradigm.
At the time of collecting the data, verification of the requester and sources will be critical, and may require sophisticated permission and authorization controls.

14. The Health IT / HIE Landscape Is Increasingly Diverse
RHIOs
A health information organization that brings together health care stakeholders within a defined geographic area and governs health information exchange among them for the purpose of improving health and care in that community*
HIOs
An organization that oversees and governs the exchange of health-related information among organizations according to nationally recognized standards*
Hospital
eRx Network
Health Plans, PBMs
Specialists
Primary Care Providers
Labs, X-Rays, etc.
Long Term Care
Affiliated Hospitals
Parent System/Org
RHIO
eRx Network
Health Plans, PBMs
Specialists
Primary Care Providers
Labs, X-Rays, etc.
Long Term Care
Hospitals
Public Health and Other Agencies
Emerging Private Service Providers and Networks
Surescripts, Availity, Navinet, etc,
Private Networks
eRx Network
Health Plans, PBMs
Hospital
Primary Care Provider
Labs, X-Rays, etc.
Specialist
Personal Health Information Repositories and Exchange
MSFT HealthVault, Epic MyChart, Payer PHRs, etc.
EHR Vendor Networks
Epic Everywhere, eClinicalWorks EHX, etc
EHR
eRx Network
Health Plans, PBMs
Hospital
Primary Care Provider
Labs, X-Rays, etc.
Specialist
PHR
eRx Network
Health Plans, PBMs
Specialists
Primary Care Provider
Labs, X-Rays, etc.
Long Term Care
Hospitals
Public Health and Other Agencies
* Source: The National Alliance for Health Information Technology Report to the Office of the National Coordinator for Health Information Technology on Defining Key Health Information Technology Terms, April 28, 2008

15. Multiple Approaches to Patient Engagement
PHR
eRx Network
Health Plans, PBMs
Specialists
Primary Care Provider
Labs, X-Rays, etc.
Long Term Care
Hospitals
Public Health and Other Agencies
Un-tethered PHRs
Google, Microsoft, Dossia, WebMD
“Life long” – tries to replicate home file system
Requires work to collect data from providers
Traction with wellness, cancer, and chronic
Tethered to Payer
Insurance providers offer portals to reduce support cost and for “stickiness”
No longevity, consumer changes insurance every 3 yrs
Comprehensive, all provider data in one place
Predominately used by consumer to understand healthcare spending for budgeting & HSA
Hospital
Providers
Pharmacy
Payer Portal
Tethered to Provider
Most major EMRs have a “patient portal”
Larger providers using portal to reduce admin costs and to drive patient “stickiness”
No integration between providers
Labs
Pharmacy
Other HIT
Provider EMR Portal

16. The NHIN NHIN Direct and NHIN Connect
"There is some mistaken belief that NHIN Direct will enable a path for organizations to connect directly to the federal infrastructure. NHIN Direct is a project that will conclude with a set of service descriptions and specifications, and associated deliverables (implementation guides, reference implementations, etc.), and will not run or enable any services directly.“ * Arien Malec, Coordinator for the NHIN Direct project
NHIN Direct
NHIN Connect 16

17. The NHIN Details on NHIN Direct & NHIN Connect
A project to expand the standards and service definitions that, with a policy framework, constitute the NHIN. The standards and services will allow organizations to deliver simple, direct, secure & scalable transport of health information over the Internet between known participants in support of Stage 1 meaningful use.
Key Deliverables
standards
service definitions
implementation guides
reference implementations
associated testing frameworks.
NHIN Connect
A select group of entities that have agreed to share data across organizations along defined use cases. The software to accomplish HIE to HIE exchange (patient look up, retrieval).
Current Exchange participants
SSA, MedVA, DoD, Kaiser Permanente, VA, CDC
Future potential participants
Beacon Communities, SSA grantees, state HIE 17

18. NHIN Relationship to HIO & HIE
NHIN Connect envisioned to support more complex exchange needs
ONC associates less complex exchange, such as secure routing with NHIN Direct
Success is dependent on EMR and HIE vendor adoption of the technologies and standards into their mainstream products
Source: “NHIN 102: Secure and Meaningful Exchange of Health Information over the Internet,” Doug Fridsma, MD, PhD., March 2010. 18

19. Overview of Workgroup Process and Tasks19

20. Meeting Objectives: Key Decisions
Clear Understanding of Our Charge and Tasks
Confirmation on Public/Private Partnership Model for Governing Entity
Consensus on Roles and Responsibilities of Governing Entity and recommendations to NC HIE Board
Understanding of Upcoming Issues Tasked to Workgroup
Will start each meeting with a list of objectives
Based on Workplan, these will help us arrive at the decisions we need. 20

21. State HIE Cooperative Agreement Goals and Planning Requirements
Goal: Plan and develop the HIE infrastructure to ensure
Widespread interoperability across entire state
Providers and hospitals can achieve meaningful use
Required
Plans
Domains to
Address
Types of
Exchange
Strategic Plan: State’s vision, goals, objectives and strategies for statewide HIE; including plans to support provider adoption
( Submitted to ONC Oct. 09 , to be verified via Operational Plan process)
- Operational Plan: Detailed explanation, targets, dates for execution of strategic plan
-Governance
-Finance
-Technical infrastructure
-Business & Technical Ops
-Legal and Policy
Eligibility & claims transactions
eRx & refill requests
Lab ordering & results delivery
Public health reporting
Quality reporting
Rx fill status/med fill Hx
Clinical sum for care coordination & patient engagement 21

22. Key Strategic Decisions for North Carolina
How will the NC Statewide HIE relate to regional HIEs? (Governance)
What State incentives/tools/levers may be used to quickly facilitate significant participation in the statewide HIE? (Governance)
How will the State ensure that the public interest is protected? (Governance & Legal/Policy)
What core infrastructure and services will be offered? (Clinical/Technical Operations)
How will start up and ongoing costs be financed and sustained over time? (Finance)
What policies will be implemented to protect privacy and security of data and promote trust? (Legal/Policy)

23. State HIE Cooperative Agreement Program: Governance
The statewide HIE should provide governance, leadership, and accountability around the management of the HIE infrastructure, privacy and security, and a mechanism for consumer and provider participation.
The Governance Workgroup will
Develop a governance framework that will ensure broad-based stakeholder collaboration and transparency
Develop and vet governance models to be recommended to the NC HIE Board
The Workgroup will be tasked with ensuring a governance framework characterized by:
Alignment with Medicaid and public health programs
The ability to provide oversight and accountability to protect the public interest
The support of providers statewide to achieve meaningful use

24. State HIE Cooperative Agreement Program: Governance
ONC’s Achievements Expected by 2011
Governance Structure: Establish a governance structure that achieves broad-based stakeholder collaboration with transparency, buy-in and trust.
Goals, Objectives, Measures: Set goals, objectives and performance measure for HIE reflecting consensus among stakeholder groups, accomplish statewide coverage of all providers for HIE meaningful use criteria.
Coordination: Ensure coordination, integration, alignment of efforts with Medicaid and public health programs via efforts with HIT Coordinators.
Oversight and Accountability: Establish oversight and accountability mechanisms to protect the public interest.
Alignment with National Governance: Account for the flexibility needed to align with emerging nationwide HIE governance (as specified).

25. Workgroup Deliverables for Operational Plan
Governance
Recommendation on public-private partnership structure and functions of the governing body
Recommendation on bylaw-related issues for governing body
Recommendation on approach to statewide HIE
Recommendations to ensure alignment with Medicaid and state programs
Recommendations to ensure alignment with ARRA funded HIT and HIE activities in North Carolina
Components of a consumer engagement and outreach plan
Finance
Environmental data collection / provider landscape
2-3 financial model scenarios
Payment flow models
Finance section of NC HIE Operational Plan
Workplan for ongoing sustainability effort
Clinical & Technical Operations
Landscape survey of relevant health IT assets across key stakeholders
Clinical opportunity analysis as relates to NC HIE meaningful use and operational goals
Selected use cases
Straw technical architecture and approach based upon use cases
Description of how the technical architecture will align with NHIN core services and specifications
Legal/Policy
Recommendation on statewide policy framework that protects the privacy and security of health information and that allows for incremental development of polices over time.
Process to harmonize federal and state legal and policy requirements to support HIE.
Recommendations on operational processes to support privacy and security policies and ensure implementation and evaluation of policies
Process to develop a consumer and stakeholder outreach, education and engagement plan.
NC state law scan 25
Discussion Document – Not for Distribution 25 25

26. Meeting Objectives: Key Decisions
Clear Understanding of Our Charge and Tasks
Confirmation on Public/Private Partnership Model for Governing Entity
Consensus on Roles and Responsibilities of Governing Entity
Recommendations to NC HIE Board
Understanding of Upcoming Issues Tasked to Workgroup
Will start each meeting with a list of objectives
Based on Workplan, these will help us arrive at the decisions we need. 26

27. State-level HIE Governance & Technical Operations
In support of a statewide organizing capacity, state-level efforts serve two important and distinct roles:
Governance: A primary role to convene health care stakeholders, promote collaboration, develop consensus, coordinate policies and procedures to secure data sharing, and lead and oversee statewide efforts.
Technical operations: An optional and variable role to manage and operate the technical infrastructure, services, and/or applications to support statewide efforts.
Role
Governance
Technical Operations
Function
Convene
Coordinate
Operate/Manage
Task
Provide neutral forum for all stakeholders
Educate constituents & inform HIE policy deliberations
Advocate for statewide HIE
Serve as an information resource for local HIE and health IT activities
Track/assess national HIE and health IT efforts
Facilitate consumer input
Develop and lead plan for implementation of statewide solutions for interoperability.
Promote consistency and effectiveness of statewide HIE policies and practices
Support integration of HIE efforts with other healthcare goals, objectives, & initiatives
Facilitate alignment of statewide, interstate, & national HIE strategies
Serve as central hub for statewide or national data sources and shared services
Own or contract with vendor(s) for the hardware, software, and/or services to conduct HIE
Provide administrative support & serve as a technical resource to local HIE efforts 27 27

28. Governance: Considerations
Important distinction between state government and statewide governance, which refers to the process to serve the collective interests in the State.
Governance occurs at multiple levels: local, regional, statewide, interstate, and federal. States must define the roles, inter-relationships, and obligations within and across these layers.
Effective governance is built on inclusive and transparent processes that identify and develop practical policies for key decisions.
Accountability can be achieved through a variety of mechanisms, including statutory, regulatory, contracts, self-enforcement.
Should the State-level effort be empowered to sanction/accredit other entities (e.g. local health information exchanges, providers, payers) participation in the exchange of data in a state?

29. Potential Functions of a Comprehensive Governance Entity
Administration
Provides operational and financial oversight, as necessary. Likely overseen by an Executive Director and staff that reports to a Board of Directors. Includes oversight of
Fiscal processing
Legal issues
Contracting
Statewide Collaboration Process
Open and transparent stakeholder process to develop statewide policies and procedures around:
Health Outcomes
Privacy & security
Technology
Sustainability
Evaluation & Accountability
Shared Services
Contract for and manage services to be utilized by all HIEs across the state, for example
Core services
State-level services
Membership
Testing
Monitoring
Adoption Services
Provides support and assistance with adoption and implementation of
Electronic health records (EHRs)
Health information exchange (HIE)
Electronic prescribing (eRx)
Personal health records (PHRs)
Communication and Education
Provides outreach and education tools around HIE activities and its implications to
Consumers
Providers

30. Governance – Continuum of Statewide Coordination
How should HIE be governed in North Carolina?
What are the State’s and private sector’s roles?
Public
Private
Market-Driven Approach
State defers to regions
State Designated Entity (SDE)
Independent entity, with state participation (Public/Private Partnership)
State Led
State government led, supported by collaborative, multi-stakeholder policy process NV IN AZ CO NY RI TN VT MI MN WA DE

31. Governance – Option 1 Option Pros Cons Market-Driven Approach
The State, either directly through a State agency or through a contract with a not-for-profit governance entity, obtains and distributes grant funds through an RFP process to local and regional HIE efforts across the state. Each local or regional HIE effort is responsible for its own policy, governance and operations. Coordination and interoperability across HIEs is dependent upon existing and emerging federal standards.
Direct
Cost effective
Ensures market support
Necessarily self-supported
Most rapid procurement process
No defined structure for building consensus or generating widespread mutual trust
May lack urgency
May leave public health or policy goals unachieved
Experience to date does not demonstrate support for a true market-based approach
Requires mechanism to address coverage gaps
Risks sub-optimal realization of meaningful use dollars
Lacks coordinated strategy

32. Governance – Option 2 (A)
Pros
Cons
Not-for-profit Governance Entity
The State contracts with a not-for-profit governance entity that is responsible for managing the statewide collaboration process, recommending statewide policy and guidance and governing the operations of HIE efforts throughout the state. The not-for-profit governance entity does not operate the HIE directly, but contracts with either one statewide HIE or multiple regional HIEs to provide HIE operations.
Builds consensus and trust in a multi-stakeholder environment
May be removed from State political changes
Multi-stakeholder environment likely improves long-term sustainability
Allows for flexibility
Voluntary self-regulation avoids creating a State bureaucratic process
Facilitates alignment with counties and cities
Creates a new level of organization that may threaten the independence of existing HIE initiatives
Requires immediate initial investment in administrative resources
May require compliance with state procurement law

33. Governance – Option 2 (B)
Pros
Cons
Not-for-profit Governance Entity and Operator
The State contracts with a not-for-profit governance entity that is responsible for managing the statewide collaboration process, recommending statewide policy and guidance and governing the operations of HIE efforts throughout the state. The not-for-profit governance entity is responsible for operating the statewide HIE or shared statewide HIE services.
Facilitates interoperability among HIEs using State services
Builds consensus and trust in a multi-stakeholder environment
May be removed from State political changes
Multi-stakeholder environment likely improves long-term sustainability
Allows for flexibility
Voluntary self-regulation avoids creating a State bureaucratic process
Facilitates alignment with counties and cities
May supplant or require significant modification to existing exchanges with the operation of a single statewide exchange or statewide corer services
Creates a new level of organization that may threaten the independence of existing HIE initiatives
Requires immediate initial investment in administrative resources
May require procurement with state procurement law

34. Governance – Option 3 Option Pros Cons State Led
The State, directly through a State agency, is responsible for managing the statewide collaboration process, recommending statewide policy and guidance and governing the operations of HIE efforts throughout the state. The State does not operate the HIE directly, but contracts with either one statewide HIE or multiple regional HIEs to provide HIE operations.
Elevates priority of State health outcomes
Prioritizes State HIE goals
May build on existing State efforts
Adherence to existing State process and guidelines
Greater likelihood of alignment with other State initiatives
The State has experience implementing complex programs
Creates accountability with the State
Requires State commitment to administrative funding that does not exist today
May be less flexible and unable to respond to immediate needs
State procurement process may lengthen implementation timelines
Some do not support increasing the size of government

35. Meeting Objectives: Key Decisions
Clear Understanding of Our Charge and Tasks
Confirmation on Public/Private Partnership Model for Governing Entity
Consensus on Roles and Responsibilities of Governing Entity
Recommendations to NC HIE Board
Understanding of Upcoming Issues Tasked to Workgroup
Will start each meeting with a list of objectives
Based on Workplan, these will help us arrive at the decisions we need. 35

36. Governance Workgroup Threshold Issues
Consensus Recommendations
Unresolved Questions
Governance Model
Roles & Responsibilities

37. Meeting Objectives: Key Decisions
Clear Understanding of Our Charge and Tasks
Confirmation on Public/Private Partnership Model for Governing Entity
Consensus on Roles and Responsibilities of Governing Entity
Recommendations to NC HIE Board
Understanding of Upcoming Issues Tasked to Workgroup
Will start each meeting with a list of objectives
Based on Workplan, these will help us arrive at the decisions we need. 37

38. Key Issues for Discussion in June & July 2010:
Bylaw-related issues for governing body
Model approaches to statewide HIE
Relationship between public-private partnership entity and state
Alignment with Medicaid and other state programs
Alignment with ARRA-funded HIT and HIE programs in state
Components of a consumer outreach and communications plan

39. Discussion Document – Not for Distribution
Next Steps
Upcoming Meetings
Board of Directors– June 15th
Workgroup Meeting – June 21st
Questions or Comments?
- Contact 39 39
Discussion Document – Not for Distribution