Getting Direct with State Health Information Exchange

I have been working on a contract to help the Office of the National Coordinator (ONC) State HIE Program host a Direct Boot Camp in Chicago, IL on April 12 – 14, 2011. So I spent a few days this week working at the Boot Camp helping the ONC bring states up to speed on the Direct Project. But the Boot Camp went well beyond Direct basics to focus on implementation details to help States who are planning on implementing Direct learn from experiences in the field and take their next implementation steps. The Boot Camp was geared explicitly toward states that are implementing Direct as part of their strategic and operational plans under their cooperative agreement with the ONC. I was pleased to be part of the excellent team of ONC staff and consultants that organized and facilitated the event. The meeting agenda and materials are now posted on the Direct Project wiki and there was some good discussion using the #ONCDirect hashtag on Twitter. There was also some rich discussion during the Q&A portions of each session and I encourage you to read through the session notes available on the wiki.

Much of the impetus for incorporating the Direct Project into their state plans was the result of the Program Information Notice (Document Number: ONC-HIE-PIN-001), known as the PIN, sent to the states on July 6, 2010. One section of the PIN requires the states to:

Set Strategy to Meet Gaps in HIE Capabilities for Meaningful Use — Develop and implement a strategy and work plan to address the gaps in HIE capabilities as identified in the environmental scan with a focus on delivery of structured lab results, e-prescribing and sharing patient care summaries across unaffiliated organizations. Gap-filling strategies might include:

• Policy, purchasing and regulatory actions, such as requiring e-prescribing or electronic sharing of lab results in state or Medicaid contracts with pharmacies and clinical labs.

• Core services to reduce the cost and complexity of exchange including authoritative provider and plan directories and authentication services that would support both simplified and comprehensive interoperability.

• Targeted infrastructure for gap areas such as shared services for small labs or pharmacies, or to serve rural providers, which could utilize both simplified and comprehensive interoperability solutions.

In filling these gaps, the state is not required to directly provide or construct technology infrastructure or services. A key role for states can be to provide leadership and direction to public and private stakeholders. States may also use policy and purchasing levers to extend and enhance existing HIE activities in the state so as to encourage key trading partners such as pharmacies and clinical laboratories to participate in electronic service delivery and to enable providers to meet meaningful use requirements.

States shall also establish a strategy and immediate next steps to address the following over the course of the project:

• Building capacity of public health systems to accept electronic reporting of immunizations, notifiable diseases and syndromic surveillance reporting from providers.

• Enabling clinical quality reporting to Medicaid and Medicare.

To meet these requirements many states have plans to use direct messaging in a phased approach as an onramp towards more robust HIE services. But due to the flexible nature of a cooperative agreement, as opposed to being a straight grant, the states have been working with the ONC to fine tune their plans. Many of these states had their plans approved before the Direct Project was able to provide working code. As the Direct Project has developed, some of the states thinking around deploying direct messaging services has evolved. And there is also continuing maturity in the marketplace, with vendors offering services that have allowed the states to back away from providing centralized services themselves and moving towards a more market based approach.

Therefore, many states that were originally planning to to act as a Health Information Service Provider (HISP) themselves are now moving towards creating a preferred vendor list for HISPSs and monitoring the market to ensure coverage for all the providers in their state. A HISP is an entity that provides services that are required for Direct Project exchange, such as the management of trust between senders and receivers. Using the HISP model, offerings are emerging that provide some of these services:

1. Provisioning of health domain addresses
2. Certification issuance and management
3. Global routing services 

The Best Practices for HISPs posted on the wiki is an excellent document for those interested in knowing more about organization structures that will allow these services to be provided.

There are also states planning to use Direct to help with interstate exchange. This is an area that will need further development, as we weave through the spaghetti of various consent laws around the country, but ultimately getting exchange happening at a broad scale will obviously include interstate exchange. Some of the nation networks being launched, such as AAFP/Surescripts and Verizon presented during the boot camp and helped the states to shape some of their thinking in this area. There was a lot of discussion about Provider Directories as well, which I will leave to a future post. It was a very interesting experience to work with the ONC and the various states to further integrate the Direct Project into their plans and I expect we will see this help to drive further adoption and use of these standards and specifications.

The list below shows the currently approved state specific strategic and operational plans for creating health information exchange capacity. Not all of these states are incorporating Direct Project into their plans.

State	Strategic /Operational Plans and State Summaries	Entity Responsible for Grant	Plan Approval Date
Alabama	Strategic and Operational Plans State HIE Plan Summary	Alabama Medicaid Agency	02/12/2011
Arizona	Strategic and Operational Plans	Arizona Governor’s Office of Economic Recovery	03/18/2011
Arkansas	Strategic and Operational Plans	Arkansas Department of Finance and Administration	02/24/2011
California	Strategic and Operational Plans To view the documents separately click here (easier download)	California Health and Human Services Agency	06/16/2010
Colorado	Strategic and Operational Plans	Colorado Regional Health Information Organization	12/3/2010
Connecticut	Strategic and Operational Plans	State of Connecticut Department of Public Health	03/18/2011
Delaware	State Summary	Delaware Health Information Network	05/17/2010
Florida	Strategic and Operational Plans	Florida Agency of Health Care Administration	02/04/2011
Georgia	Strategic and Operational Plans	Georgia Department of Community Health	03/23/2011
Hawai’i	State Summary	Hawaii Health Information Exchange	02/02/2011
Idaho	Strategic and Operational Plans	Idaho Health Data Exchange	12/07/2010
Illinois	Strategic and Operational Plans	Illinois Department of Healthcare and Family Services	12/10/2010
Indiana	Strategic and Operational Plans State Summary	Indiana Health Information Technology, Inc	01/21/2011
Iowa	Strategic and Operational Plans	Iowa Department of Public Health	01/25/2011
Kentucky	State Summary	Cabinet for Health and Family Services	02/17/2011
Maine	State Summary	State of Maine/Governor’s Office of Health Policy & Finance	08/16/2010
Maryland	Strategic and Operational Plans	The Maryland Department of Health and Mental Hygiene	05/14/2010
Massachusetts	Strategic and Operational Plans	Massachusetts Technology Park Corporation	11/03/2010
Michigan	Strategic and Operational Plans State Summary	Michigan Department of Health	11/29/2010
Minnesota	Strategic and Operational Plans	Minnesota Department of Health	02/24/2011
Mississippi	Strategic and Operational Plans	State of Mississippi	02/24/2011
Missouri	Strategic and Operational Plans	Missouri Department of Social Services	01/25/2011
Nebraska	Strategic and Operational Plans State Summary	Nebraska Department of Administrative Services	11/05/2010
New Hampshire	Strategic and Operational Plans State Summary	New Hampshire Department of Health and Human Services	12/10/2010
New Jersey	State Summary	New Jersey Health Care Facilities Financing Authority	01/13/2011
New Mexico	Strategic and Operational Plans State Summary	LCF Research, New Mexico	01/25/2010
New York	Strategic and Operational Plans	New York eHealth Collaborative	11/22/2010
North Carolina	Strategic and Operational Plans State Summary	North Carolina Department of State Treasurer	11/03/2010
Ohio	Strategic and Operational Plans State Summary	Ohio Health Information Partnership	01/25/2011
Oregon	Strategic and Operational Plans	State of Oregon	12/10/2010
Pennsylvania	Strategic and Operational Plans	Commonwealth of Pennsylvania	3/23/2011
Rhode Island	Strategic and Operational Plans	Rhode Island Quality Institute	12/06/2010
South Carolina	Strategic and Operational Plans	South Carolina Department of Health & Human Services	08/30/2010
South Dakota	Strategic and Opeational Plans	South Dakota Department of Health	02/24/2011
Tennessee	Strategic and Operational Plans State Summary	State of Tennessee	09/17/2010
Texas	Strategic and Operational Plans State Summary	Texas Health and Human Services Commission	11/03/2010
Utah	Strategic and Operational Plans	Utah Department of Health	05/12/2010
Vermont	Strategic and Operational Plans State Summary	Vermont Department of Human Services	10/26/2010
Virginia	Strategic and Opeational Plans	Virginia Department of Health	03/17/2011
Washington	Strategic and Operational Plans State Summary	Washington Health Care Authority	12/10/2010
West Virgina	Coming Soon	West Virgina Department of Health and Human Services	02/12/2011
Wisconsin	Strategic and Operational Plans State Summary	Wisconsin Department of Health and Family Services	12/10/2010
Wyoming	Coming Soon	State of Wyoming Office of the Governor	03/18/2011

Direct Project Boot Camp

As most of you may already know, the State Health Information Exchange Cooperative Agreements Program is designed to promote health information exchange (HIE) that will advance mechanisms for information sharing across the health care system. I've said many times that simply digitizing disparate silos of health information will not move us toward the goals of lower costs, higher quality, and improved clinical outcomes. The appropriate and secure electronic exchange and consequent use of health information to improve quality and coordination of care is a critical enabler of a high performance health care system. The program aims to ensure that every eligible health care provider has at least one option for health information exchange that meets the requirements of the Medicare and Medicaid EHR Incentive Programs, defined by CMS in a final rule released on July 13, 2010. Program awardees will be using their funding to:

• Create and implement up-to-date privacy and security requirements for HIE
• Coordinate with Medicaid and state public health programs to establish an integrated approach
• Monitor and track meaningful use HIE capabilities in their state
• Set strategy to meet gaps in HIE capabilities
• Ensure consistency with national standards

The immediate priority of the State HIE program is to ensure that all eligible providers within every state or territory have at least one option available to meet the HIE requirements of meaningful use in 2011. While it is ultimately the responsibility of each Program awardee to determine the specific role and infrastructure of its HIE, this Program Information Notice (PIN) has outlined six key responsibilities for States and SDEs that must be fulfilled for continued funding through the State HIE Program.

One of the resources resources available to assist states and SDEs in their efforts to establish Health Information Exchange capacity for providers is the Direct Project. The Direct Project was created to specify a simple, secure, scalable, standards-based way for participants to send authenticated, encrypted health information directly to known, trusted recipients over the Internet. The Direct Project has more than 200 participants from over 50 different organizations. These participants include EHR and PHR vendors, medical organizations, systems integrators, integrated delivery networks, federal organizations, state and regional health information organizations, organizations that provide health information exchange capabilities, and health information technology consultants. To assist states in planning to incorporate using Direct I am helping with a Direct Project boot camp in Chicago, Illinois April 12th through the 14th.

Thirty nine states are attending the boot camp, and thankfully without a government shutdown this week, the ONC can provide them with some great support. The boot camp will build upon this to provide real hands on work assisting to incorporate direct messaging into their strategic and operational plans, especially to help fill in the gaps in health information exchange coverage. I'll be sure to provide the relevant information for stakeholders on the Direct Project wiki and may even send out a tweet or two.

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2011 Budget Deal Details

Below are the budget cuts that will be voted on this week. The CR that would fund the government through the rest of this fiscal year is posted under the listing of cuts. The bill includes a total of $1.049 trillion in funding, over $38 billion in reductions from last year’s (fiscal year 2010) levels. This includes the $12 billion in reductions previously approved by Congress and signed into law under the previous three continuing resolutions, as well as nearly $28 billion in additional new spending cuts.

Farzad Mostashari named National Coordinator for Health Information Technology

The Office of the National Coordinator for Health Information Technology has named Farzad Mostashari, MD, ScM to replace David Blumenthal, MD as National Coordinator for Health Information Technology. Dr. Mostashari had been serving as Deputy National Coordinator for Programs and Policy within the ONC since July 2009, while Dr. Blumenthal has been national coordinator since March of 2009.

It is no surprise that Dr. Blumenthal as gone back to academia, since he would have lost his tenure at Harvard had he stayed on at the ONC. Blumenthal has done an outstanding job at launching the many health IT initiatives at the ONC over the past two years, and moving us into the "Era of Meaningful Use." But I actually think that this is a great time for transition to Dr. Mostashari as we move from planning these programs to implementation. And I think it is important that this is not a temporary or interim appointment, but we have a permanent replacement. This is no time for doubt or uncertainty, and Farzad will provide the continuity that is so badly needed.

Some have said that the next national coordinator should have more real world experience in implementing an EHR, and Dr. Mostashari will fit this criteria nicely. I have thought for some time (really since my interview with Farzad back in November 2010) that he would be the best choice for this new role. Moving from planning with a strong leader who casts a vision, to implementation with equally strong leadership who has real world implementation experience and great communication skills. As I told Neil Versel for InformationWeek Magazine, "I think you've got the right leader in the right place at the right time."


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