Sunday, January 31, 2010

Access to preventive care for children

Is the Medicaid safety net strong enough to care for America's neediest children? Despite that many believe Medicaid to be a "ghetto" for healthcare, it does not necessarily provide less effective coverage for children, as a recent excellent article in American Medical News explains:
According to the 2007 National Survey of Children's Health. Based on nearly 92,000 interviews, it found that in 36 states, children in Medicaid and CHIP were as likely or more likely than privately insured kids to have had at least one preventive health care visit over a 12-month period.

"That's what I would expect," said Jay E. Berkelhamer, MD, past president of the American Academy of Pediatrics. Medicaid's advantage lies in the fact that the federal government requires it to cover a standardized package of preventive care benefits for children called the Early Periodic Screening, Diagnosis, and Treatment program. It includes immunizations and dental, vision and hearing screenings. By contrast, private insurance coverage for children is "all over the map," Dr. Berkelhamer said.

But regardless of how strong it is now, some lawmakers and governors have said the public safety net would stretch too thin if the program were expanded to cover millions more people, because states can't afford it. And counting on states to help foot the bill would force them to cut other spending, such as for education, Sen. Orrin Hatch (R, Utah) said late last year. "The last thing we need right now is for Washington to impose more liability on the states."
There is also the issue of reimbursement. Medicaid pay was 72% of Medicare rates and 66% of primary care rates in 2008. This can create a significant burden on a practice that has a high ratio of Medicaid patients.

Children enrolled in Medicaid and the Children's Health Insurance Program in 2007 were less likely than privately insured kids to have a medical home or access to specialists or mental health care. When it came to accessing preventive care, however, publicly insured children did slightly better than those with private coverage.

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Source: Child and Adolescent Health Measurement Initiative, 2007 National Survey of Children's Health, Data Resource Center for Child and Adolescent Health (


Friday, January 29, 2010

Breakthrough Heart Scanner Will Allow Earlier Diagnosis

An innovative cardiac scanner will dramatically improve the process of diagnosing heart conditions.

The portable magnetometer* is being developed at the University of Leeds, with funding from the Engineering and Physical Sciences Research Council (EPSRC) playing a key role.

Due to its unprecedented sensitivity to magnetic fluctuations the device will be able to detect a number of conditions, including heart problems in foetuses, earlier than currently available diagnostic techniques such as ultrasound, ECG (electrocardiogram) and existing cardiac magnetometers. It will also be smaller, simpler to operate, able to gather more information and significantly cheaper than other devices currently available.

Another key benefit is that, for the first time, skilled nurses as well as doctors will be able to carry out heart scans, helping to relieve pressure on hospital waiting lists. The device will also function through clothes, cutting the time needed to perform scans and removing the need for patients to undress for an examination. It could also be taken out to a patient’s home, leading to a reduction in the use of hospital facilities.

Large scale magnetometers have been used for some time for things like directional drilling for oil and gas, on spacecraft for planet exploration and to detect archaeological sites and locate other buried or submerged objects. What has prevented them being used for identifying heart conditions is their size and high cost along with the specialist skill needed to operate them. Using them to examine a patient would involve containing the person within a magnetic shield to cut out other electrical interference.

Field of expertise: the laboratory-scale magnetometer (the large vertical tube towards the left) is now being miniaturised for clinical use (also pictured is student Nick Lewty, who is looking at the output of results from a scan using the magnetometer).
“The new system gets round previous difficulties by putting the actual detector in its own magnetic shield,” said Professor Ben Varcoe who is leading the research team.
“The sensor placed over the area being examined lives outside the shielded area and transmits signals into the detector. The sensor head is made up of a series of coils that cancel out unwanted signals and amplifies the signals that are needed. So the tiny magnetic fields produced by a person’s heart can be transmitted into the heavily shielded environment. What we’ve been able to do is combine existing technology from the areas of atomic physics and medical physics in a completely unique way.”

Like all parts of the body, the heart produces its own distinctive magnetic ‘signature’. The research team has demonstrated that their magnetometer – developed as part of their work in the area of quantum physics – can reveal tiny variations in that signature. Studying these variations can, in turn, reveal the presence of a cardiac condition. The team is now working on miniaturising the magnetometer for widespread medical use. The device could be ready for use in routine diagnosis in around three years.

“Early detection of heart conditions improves the prospects for successful treatment. This system will also quickly identify people who need immediate treatment,” says Professor Varcoe. “But our device won’t just benefit patients – it will also help ease the strain on healthcare resources and hospital waiting lists.”

The device is expected to be particularly effective at detecting ischaemia, a condition where blood supply to an area of the body becomes inadequate due to a blockage of the blood vessels. It could also shorten surgical procedures for people suffering from arrhythmia – a very common condition where the patient has an irregular heartbeat. Currently, the condition is corrected by surgery which can last several hours. Much of the time is spent trying to identify which heart node needs to be cauterised. Scanning the heart with the new device during the operation would offer a much quicker way of pinpointing the correct node, reducing the length of the whole procedure by 80%.

The team working on the magnetometer has included specialists in electronics, precision measurement and optical fibre technology, as well as physicists. The instrument also has potential to be adapted to detect abnormalities in other organs, such as the brain.

The original research project from which the clinical magnetometer is a spin-off was called ‘Creating Long Chain Entanglement Using a Phase Sensitive Micromaser’; this initiative received EPSRC funding of just over £450,000. An EPSRC-funded graduate student at the University of Leeds, Melody Blackman, is now playing a key role in developing the miniaturised version of the original magnetometer for clinical use.

The breakthrough is all the more remarkable as it came about quite unexpectedly. According to Professor Ben Varcoe, the team behind it was working on a very different area of research. “We were undertaking quantum physics research into Schrödinger's cat paradox – a paradox first put forward to challenge assumptions made by Einstein in his Special Theory of Relativity,” says Professor Varcoe. “We used laser spectroscopy** as part of this work but noticed that the results contained some noise, which we identified as a very weak magnetic field. So we developed a highly sensitive magnetometer to help us understand this noise source. But when I attended a conference in Australia, it came to my attention that the magnetometer could also contribute to healthcare.”

*A magnetometer is an instrument that measures magnetic fields.

** Spectroscopy is the study of the interaction between radiation and matter. In laser spectroscopy, pulsed lasers are used to excite the molecules contained in the matter, and this enables the interaction to be observed.
Quantum physics is the study of ‘quanta’. As described by what is known as quantum theory, quanta are discrete, indivisible units of energy.
Other spin-offs from EPSRC-funded quantum physics work at the University of Leeds include a new type of cryostat that can cool anything placed in it down to 0.3°C above absolute zero (minus 273°C). This cryostat can be used in many applications, including semi-conductor processing and X-ray spectroscopy. Cheap to run and easy to handle, it eliminates the need to use large vats of expensive, difficult-to-handle coolants (e.g. liquid helium).

The quantum physics work could also lead to the development of a new breed of ultra-powerful quantum computers which work much quicker than conventional computers. They could also prove particularly useful in securely encrypting financial and other sensitive data transmitted between banking institutions, for example.

The Engineering and Physical Sciences Research Council (EPSRC) is the UK’s main agency for funding research in engineering and the physical sciences. The EPSRC invests around £850 million a year in research and postgraduate training, to help the nation handle the next generation of technological change. The areas covered range from information technology to structural engineering, and mathematics to materials science.

January HIT Policy and Standards Meetings

I thought it might be helpful to provide a list of the recent ONC meetings...

The HIT Policy Committee and its workgroups met this month. Below are links to the meeting materials and audio of the meetings.

HIT Policy Committee Meetings:

January 13 - HIT Policy Committee

January 25 -Information Exchange Workgroup
January 28 – Meaningful Use Workgroup Audio coming soon...

The HIT Standards Committee and its workgroups also met this month. Below are links to the meeting materials and audio of the meetings.

HIT Standards Committee Meetings:

January 20 - HIT Standards Committee

January 26 – Privacy & Security Workgroup
January 26 – Implementation Workgroup
January 27 – Clinical Quality Workgroup

Tuesday, January 26, 2010

Audio from FACA meetings

Many of you know that I have been following closely the meetings of the HIT Policy and Standards Committees and their various workgroups. I have struggled at times to keep up with the monstrous amount of work produced by these bodies. I have emailed and spoken with staff from the ONC and the Altarum Institute (which contracts to provide the webcast for the meetings) to try to prompt the timely posting of audio files and meeting summaries. This would obviate the desire to post very rough draft and inaccurate transcripts. The ONC this week released the following press release:
HIT Policy and Standards Committee Workgroups' Deliberations to be Made Publicly Available

In the interest of transparency, starting in January 2010, the Office of the National Coordinator for Health IT (ONC) is making available to the public the HIT Policy Committee and the HIT Standards Committee workgroups’ deliberations.

All workgroup meetings will be available via webcast; for instructions on how to listen via telephone or Web visit (Note that the majority of the workgroups’ meetings will be available both via phone or web, except when indicated otherwise.)

Please check the ONC website for additional information as it becomes available since any last minute additions or modifications to previously announced workgroup meetings cannot always be published in the Federal Register to provide timely notice.

In addition, audio files (.mp3) of FACA Committee meetings and the workgroup meetings will be available on the ONC website within 24 to 48 hours following the conclusion of each meeting. A draft transcript of the meetings will be available within 5 to 8 business days. All transcripts will be marked and considered “draft” until they are reviewed and approved by the committee or workgroup members.

Contact Person: Judy Sparrow, Office of the National Coordinator, HHS, 330 C Street, SW, Washington, DC 20201, 202-205-4528, Fax: 202-690-6079, email: Please call the contact person or visit the ONC website for up-to-date information on these meetings.
I am very pleased at these efforts at transparency. Provided the files are available I will try to create pages that make it easy to download or stream the audio of the meetings, and post meeting summaries and draft transcripts as they are available. I have updated the recent post on the Privacy and Security Workgroup meeting to include the newly released audio. Now all we need is an app that will make the mp3 files available on the iPhone...

Friday, January 22, 2010

Ahier unplugged

For almost a year now I have been sipping from the firehose of data flow built around blogs, Twitter, YouTube, readers and plenty of email. It has been very interesting to watch ripples from the ebb and flow of events and information as they make their way across our collective consciousness. I have had access to the most brilliant minds in the world (you know who you are ;-) and some fascinating conversations. Many of the people I communicate with regularly I have yet to meet in real life, yet with some of you I have felt a very strong kinship.

In the morning I will be taking a trip into some of the beautiful wilderness areas around my home. Last year I would usually bring along my blackberry, my iTouch, my laptop and many of my little toys and gizmos which I could use. Sometimes I had to tether my laptop to my blackberry to set up a very spotty hotspot, and sometimes I was stuck using Twitterberry. Sometimes I was out of cell range for many hours. This time I am leaving it all behind!

I will be completely out of touch for four days without even my cell phone. This should be a good time for me to do some writing (with real pen and paper!) and to relax and think. I'm sure I will miss reading all the tweets, blog posts and articles that I gobble up every day. And when I get back it may take me a while to catch up with what everyone has been up to, but I'm actually looking forward to being off line for a while. So thank you for all of your data, information, challenging arguments and hilarious interactions. Have a great weekend and enjoy life...

Privacy & Security Policy Workgroup Meeting

The Privacy & Security Policy Workgroup met on January 22. 2010. The agenda and rough draft transcript of the meeting is below. I have gone through the transcript and it is fairly accurate so I am going to post it. I had hoped that we would start seeing meeting summaries and audio files from the meetings posted sooner, but that process is going to take some time to implement. It is not my intention to misquote anyone and please remember that this is a very rough draft transcript. I will provide a link to the audio of the meeting, official meeting summary and then transcript when then are available.


UPDATE - Audio is now available:

1/22 Privacy & Security Policy Workgroup Meeting Audio

Since the audio is available I have taken down the rough draft transcript so that only the most accurate information available is posted.

HIT Standards Meeting Audio

The audio for the HIT Standards Committee meeting on January 20, 2010, has been made available in an expedited and transparent manner since there were technical difficulties at the beginning of the meeting. A draft transcript of the audio is being finalized and will be posted no later than Wednesday, Jan. 27.

Part I

Part II

The meeting materials are here:

Thursday, January 21, 2010

What now for Health Reform?

Now that the special election in Massachusetts is over President Obama has his work cut out for him trying to achieve passage of health reform legislation. "The mega-bills are dead. If we didn't see what happened Tuesday night, we have blinkers on," Democrat Michael Arcuri of New York told the AP following a House Democratic Caucus meeting. And it's very unlikely the House will pass the Senate version unchanged. "I don't see the votes for it at this time," House Speaker Nancy Pelosi said.

But wait a minute... Was the election in Massachusetts really a referendum on health reform. As Rasmussen Reports data shows in polling data from the election, 56% of Massachusetts voters named health care as the most important issue. That suggests it was a big issue, but Democrat Martha Coakley actually won among those voters by a 53% to 46% margin. So this may not actually be a repudiation of the goals of health reform, but more of the costs associated with it and the process used to try to push it through. As Kevin Pho, M.D. said on his blog:
A piece of advice to my progressive friends. The best way to win over doctors is to take medical malpractice seriously. More than a few will gladly accept a single-payer system if explicitly paired with comprehensive liability reform. Even with the most conservative, non-partisan, CBO estimates, fixing the malpractice system will save $54 billion over 10 years, which is not insignificant.
The healthcare system in the United States badly needs reform, but this bill is certainly not the best we can do. And it's still possible to move ahead on health reform taking an incremental approach. There will need to be some efforts to compromise and a series of pared down packages that each can be debated on their own merits. Senator Brown voted for the health reform in Massachusetts and there are sure to be smaller packages that can get through the process. And for those on the far right cheering the election of Brown, I suspect that there will be some disappointment ahead as it becomes clear that he is much more moderate an they might like. But if the progressive wing in liberal America is not paying close attention to what has happened in recent elections in Virginia, New Jersey and now Massachusetts then 2010 will be a very bad year for their agenda.

HIT Standards Committee - December 18

The ONC has promised to make efforts to post the complete presentation in a more timely manner. I'm looking forward to having podcasts available the day after each meeting.
Below is the bookmarked presentation, transcript and audio from the December 18, 2009 HIT Standards Committee meeting:

Wednesday, January 20, 2010

Coming soon to the ONC

These are the HIT Standards Committee and HIT Policy Committee workgroup meeting scheduled for this month. Hopefully we will see meeting materials posted before the meetings are webcast, and we may some day actually have the audio recordings available as a podcast. Now that would be government as a platform.

Standards Committee Workgroups

Implementation Workgroup Meeting
January 26, 2010
10:00 a.m. to 12:00 p.m. (noon)/Eastern

Privacy & Security Standards Workgroup
January 26, 2010
3:00 p.m. to 5:00 p.m. /Eastern

Clinical Quality Workgroup
January 28, 2010
2:00 p.m. to 4:00 p.m. /Eastern

Policy Committee Workgroups

Privacy and Security Policy Workgroup
January 22, 2010
10:00 a.m. to 12:00 p.m. (noon)/Eastern Time

Information Exchange Workgroup
January 25, 2010
9:00 a.m. to 1:00 p.m./Eastern Time

Meaningful Use Workgroup
January 28, 2010
10:00 a.m. to 12:00 p.m. (noon)/Eastern Time

HIT Standards Committee 1/20 Meeting

HIT Standards Committee met on January 20, 2010. The meeting materials are below and hopefully we will see a draft transcript and the audio portion of the meeting available soon.

I will be updating this post as more material is available.

Requirement to Provide Patients an Electronic Copy of Their Record

The proposed rule on meaningful use will require that patients are provided with an electronic copy of their health information (including diagnostic test results, problem list, medication lists, and allergies) upon request. This must also be accomplished within 96 hours of the information being available to the provider. The relevant section from page 1857 of the proposed rule published in the Federal Register states:
Electronic access may be provided by a number of secure electronic methods (for example, PHR, patient portal, CD, USB drive). Timely is defined as within 96 hours of the information being available to the EP either through the receipt of final lab results or a patient interaction that updates the EP’s knowledge of the patient’s health. We judge 96 hours to be a reasonable amount of time to ensure that certified EHR technology is up to date. We welcome comment on if a shorter or longer time is advantageous.
Using patient portals and personal health records are probably the best way to accomplish this. CD's and flash drives could present serious security problems. The aggressive time frame (96 hours) makes providing this information to the patient via a patient portal or PHR the most probable way many providers and EHR vendors will seek to meet this criteria. I recommend the Robert Woods Johnson Foundation Feature: The Power and Potential of Personal Health Records as a great resource to learn everything you ever wanted to know about PHR's (and then some).

Many of the major EHR vendors have PHR/Patient Portal solutions integrated into their offerings:





NHIN Workgroup 12/16

Below is the bookmarked presentation, transcript and audio from the December 16, 2009 HIT Policy Committee NHIN Workgroup meeting:

Tuesday, January 19, 2010

Primary Care Hospital Based Providers & Meaningful Use

It will be interesting to see the comments on the meaningful use proposed rule. One are that I see as troubling is the definition of hospital-based eligible providers (EP)s under this rule. CMS estimates that 12–13% of family practitioners would be considered hospital-based under the proposed definition of hospital-based EP, and therefore would not be eligible for the EHR incentive payments. CMS is rightly concerned that hospital investment in their outpatient primary care sites is likely to lag behind their investment in their inpatient EHR systems.

This is the relevant portion of the proposed rule from page 1905 of the proposed rule published in the Federal Register:
We seek comment as to whether EPs are using qualified EHR of the hospital in ambulatory care settings.

As noted previously, the statute provides that hospital-based EPs, ‘‘such as a pathologist, anesthesiologist, or emergency physician,’’ are those EPs that provide substantially all of their Medicare-covered professional services in a ‘‘hospital setting (whether inpatient or outpatient).’’ Because the HITECH Act does not define the term ‘‘hospital setting,’’ we looked to existing statutes and regulations that define and describe hospital settings for guidance in defining ‘‘hospital setting’’ for purposes of this proposed rule. We welcome comments on alternative approaches to interpreting the meaning of ‘‘hospital setting.’’

First, section 1861(e) of the Act defines the term a ‘‘hospital’’ to mean an institution that ‘‘is primarily engaged in providing, by or under the supervision of physicians, to inpatients (A)
diagnostic services and therapeutic services for medical diagnosis, treatment, and care of injured, disabled, or sick persons, or (B) rehabilitation services for the rehabilitation of injured, disabled, or sick persons.’’ Therefore, we propose that EPs that practice primarily in inpatient hospital settings, as referenced in section 1861(e) of the Act, be considered hospital-based EPs.

Because the parenthetical after the term ‘‘hospital setting’’ in the statutory definition of hospital-based EP specifically refers to both inpatient and outpatient hospital settings, we believe the term ‘‘hospital setting’’ should be defined to also include the outpatient setting. So although a ‘‘hospital’’ is an institution that primarily provides inpatient services, we propose to define the term ‘‘hospital setting’’ for purposes of the Medicare and Medicaid EHR incentive payment programs to also include all outpatient settings where hospital care is furnished to registered hospital outpatients. For purposes of Medicare payment and conditions of participation, it is CMS’s longstanding policy to consider as outpatient hospital settings those outpatient settings that are owned by and integrated both operationally and financially into the entity, or main provider, that owns and operates the inpatient setting. For example, we consider as outpatient hospital settings all types of outpatient care settings in the main provider, oncampus and off-campus provider-based departments (PBDs) of the hospital, and entities having provider-based status, as these entities are defined in § 413.65.

Obviously this policy would deny a huge segment of providers from participating and will actually dis-incentivize the adoption of EHR systems in affiliated physician practices. If the hospital is paying for the physicians’ EHR and no one is eligible for stimulus funds, then a hospital will be inclined to make ambulatory EHR a much lower priority. How will the costs of implementing meaningful use of certified EHR technology by hospital affiliated physician practices be recouped by hospitals? Since the hospital incentive payments are completely separate from the physician practice payments, there is little incentive for cash strapped hospitals to spend scarce capital resources on ambulatory EHR systems.

Monday, January 18, 2010

Tying Light in Knots

Research reported in Nature Physics.

The remarkable feat of tying light in knots has been achieved by a team of physicists working at the universities of Bristol, Glasgow and Southampton, reports a paper in Nature Physics this week.

Understanding how to control light in this way has important implications for laser technology used in wide a range of industries.

Dr Mark Dennis from the University of Bristol and lead author on the paper, explained: “In a light beam, the flow of light through space is similar to water flowing in a river. Although it often flows in a straight line – out of a torch, laser pointer, etc – light can also flow in whirls and eddies, forming lines in space called ‘optical vortices’.

“Along these lines, or optical vortices, the intensity of the light is zero (black). The light all around us is filled with these dark lines, even though we can’t see them”.

Optical vortices can be created with holograms which direct the flow of light. In this work, the team designed holograms using knot theory – a branch of abstract mathematics inspired by knots in everyday life, such as those that occur in shoelaces and rope. Using these specially designed holograms they were able to create knots in optical vortices.

This new research demonstrates a physical application for a branch of mathematics previously considered completely abstract.

Professor Miles Padgett from Glasgow University, who led the experiments, said: “The sophisticated hologram design required for the experimental demonstration of the knotted light shows advanced optical control, which undoubtedly can be used in future laser devices”.

“The study of knotted vortices was initiated by Lord Kelvin back in 1867 in his quest for an explanation of atoms”, adds Dennis, who began to study knotted optical vortices with Professor Sir Michael Berry at Bristol University in 2000. “This work opens a new chapter in that history.”

Please contact Cherry Lewis for further information.

Further information:

The paper: Isolated optical vortex knots by Mark R. Dennis, Robert P. King, Barry Jack, Kevin O’Holleran and Miles J. Padgett. Nature Physics, published online 17 January 2010.

This research was funded by the Leverhulme Trust and Mark Dennis is a Royal Society research fellow.

Knotted light
Knotted light

The coloured circles represent the hologram, out of which the knotted light emerges.

In a light beam, the flow of light through space is similar to water flowing in a river.

Mark Dennis


MLK's Living Memorial

On October 29, 2009 Secretary of the Interior Ken Salazar signed a permit allowing construction of the Martin Luther King, Jr. Memorial on the National Mall.

"Dr. King is one of America’s greatest heroes - a Nobel Peace Prize winner who inspired America to live up to the meaning of its creed of freedom, justice and opportunity for all people,” said Secretary Salazar. "It is fitting and appropriate that we honor Dr. King’s extraordinary life and legacy with a memorial here on the National Mall, alongside the timeless landmarks of American democracy and freedom. May this sacred ground help us draw strength from Dr. King’s courage, dedication and sacrifice, and inspire us to always seek a more perfect union."

"Where so many other great American heroes are honored, it is time to honor Martin Luther King Jr. right here in the nation's front door," Salazar said.

King's only surviving sibling, Christine King Farris, 82, said she was moved to tears when she saw a video depicting the memorial plaza and towering statue of her brother, nestled among Washington's famous cherry blossoms. She said King would have been humbled.

"I think he would say, 'No, don't do this for me,' but we have to do it because generations yet unborn need to know about Martin Luther King Jr.," she said.

Ed Jackson talks about the construction of the Martin Luther King Memorial near the Tidal Basin of the National Mall in Washington, D.C. Construction of the memorial began December 28th, 2009, after 13 years of planning, fundraising, and legal issues.

For more on the Martin Luther King, Jr. Memorial go to

Saturday, January 16, 2010

Closer Look at the Destruction From the Haiti Earthquake

Disturbing images of the devastation in Haiti...

Join together to help Haiti

Politics have no part in humanitarian aid in times of disaster. I'm very proud to see our country rise up and respond to the tragedy in Haiti. It will take a massive effort on all fronts. Let's all join together to make a difference.

But you have to be careful. There are scams out there. The Whitehouse has some recommended ways you can help. Help for Haiti: Learn What You Can Do

Get Information about Friends or Family

The State Department Operations Center has set up the following phone number for Americans seeking information about family members in Haiti: 1-888-407-4747 (due to heavy volume, some callers may receive a recording). You can also send an email to the State Department. Please be aware that communications within Haiti are very difficult at this time.

The Federal Response

Check out the links below to find out how each federal department and agency is responding to the earthquake in Haiti.

Neuroscience research goes deeper into the brain

Although we’ve learned more about the brain during the past decade than in the rest of the history of the world, the way the body’s most important organ works still remains much of a mystery.

This video highlights the work of some of the two dozen faculty members at UC Davis’s Center for Neuroscience. Established in 1990, the center unites researchers from several disciplines to conduct basic research on such questions as how the brain builds and loses memory, and how the visual system develops.

Their work helps brain surgeons develop new techniques, and provides important insights into debilitating diseases and disorders like Alzheimer’s disease, schizophrenia and age-related vision loss.

“The basic scientists bring this very important and fundamental understanding to the M.D.s, so that they can then translate that into clinical health,” says center neurologist Charles DeCarli, a professor of neurology in the School of Medicine. “And the better integrated it can be, the more effective treatments will emerge.”

For example, Kim McAllister, an associate professor of neuroscience, physiology and behavior, and her students are studying the cellular and molecular mechanisms of how brain cells connect with one another in the cerebral cortex, an area of the brain that plays key roles in higher-order functions like memory, language and awareness.

And Charan Ranganath, an associate professor of psychology, is using advances in neuroimaging technology to determine how memory is affected by the tiny strokes that many people suffer as they age. Often these strokes are so minor that a person is unaware of them, but the damage they wreak on memory shows up in Ranganath’s images.

By treating such risk factors as hypertension and diabetes, Ranganath says, people can dramatically lower their chances of suffering these strokes and the memory loss that goes with them.

Paul Pfotenhauer is the broadcast specialist for UC Davis News Service. Ken Zukin is a videographer with Ken Zukin Productions.

Friday, January 15, 2010

HIE: Privacy & Security

This video from Oregon HISPC is pretty interesting:

HISPC Reports on State Law, Business Practices, and Policy Variations
Conducted during 2009 as part of the Health Information Security and Privacy Collaboration (HISPC), the following compendium of 5 reports detail variations in state law, business practices and policy related to privacy and security and the electronic exchange of health information. For quick reference, several reports contain aggregate findings tables in their appendices. Summaries of each report are below.

This report analyzes state laws that are intended to require health care providers (specifically, medical doctors and hospitals) to afford individuals access to their own health information and to identify potential barriers to the electronic exchange of health information. Specific state law provisions examined: scope of medical records to which patients are afforded access, format of information furnished, deadlines for responding to requests, fees for furnishing copies, record retention laws and access to records of minors.

This report identifies and analyzes the impact and variation of state laws related to e-prescribing. The report addresses state laws related to the e-prescribing of controlled and non-controlled substances as well as topics such as record keeping and content requirements, out-of-state prescriptions, and generic substitution laws.

  • Perspectives on Patient Matching: Approaches, Findings, and Challenges [PDF - 629 KB]
    This report analyzes various approaches to matching patients to their health information in the context of electronic health information exchange. Current and potential methods for matching patients to their health records are discussed, challenges to performing patient matching such as scalability and ease of use are analyzed, and the types of information some HIOs use to match patients to their health records is described.

Thursday, January 14, 2010

State HIE Cooperative Agreement Program Webcast

The HITECH Act authorizes the establishment of the State Health Information Exchange Cooperative Agreement Program to advance appropriate and secure health information exchange (HIE) across the health care system. The purpose of this program is to continuously improve and expand HIE services to reach all health care providers in an effort to improve the quality and efficiency of health care. Cooperative agreement recipients will evolve and advance the necessary governance, policies, technical services, business operations, and financing mechanisms for HIE over a four-year performance period. This program will build from existing efforts to advance regional and state level HIE while moving toward nationwide interoperability. See: Funding Opportunity Announcement: State Health Information Exchange Cooperative Agreement Program

The ONC held a Technical Assistance Call on January 5, 2010 for the State HIE Cooperative Agreement Program. These are the slides from the webinar, audio and the transcript is included below.

Webinar Audio Part 1, Part 2, Part 3, Part 4

This webinar was conducted by Kelly Cronin. She is a director in the Office of the National Coordinator for Health Information Technology and has been involved in establishing and evolving the national agenda for HIT. Over the last 6 years, she has had several roles in the Department of Health and Human Services to advance the adoption of interoperable health IT, as a senior advisor to the National Coordinator and the Administrator of the Centers for Medicare and Medicaid Services and the Executive Director of the Council for the Application of Health Information Technology.

Prior to ONC, Ms. Cronin directed patient safety initiatives at the Food and Drug Administration and coordinated the drafting of the Patient Safety and Quality Improvement Act while working for the House Energy and Commerce Health Subcommittee. Her work experience also includes health policy analysis, health services research, and clinical trial coordination. She holds a masters degree in Public Health from George Washington University (GWU), is a lecturer in the Department of Health Policy and a doctoral candidate in the School of Public Health and Health Services at GWU.


Coordinator: Good afternoon and thank you all for patiently holding. I would like to remind all parties that your lines are on a listen-only mode until the question and answer segment of today’s conference call. Also, today’s call is being recorded. If you have any objections please disconnect at this time. I will now turn the call over to Kelly Cronin, Director of State and Community Programs. Ma’am you may proceed.

Kelly Cronin: Hello everyone, thanks for joining us today. We are excited to kick off the new year with some updates for you all about what’s going on with ONC and some of our recent activities that are relevant to all of your efforts with respect to the state HIE program. And we - just to give you a brief overview of the agenda for today, in the next two hours we’re hoping to cover a lot and allow for a good amount of time for some discussion and Q&A.

But we will start off in the first 20 minutes or so giving you an update on some of the recent announcements, the funding opportunity announcements that you have been seeing from the office. As you can tell folks have been very busy on this end, as busy as you are on your end in announcing some more programs with the HITECH funding that we have.
We’re going to give a brief update on the regulation, the notice for proposed rulemaking for meaningful use just to let you know about that is out there and how you can be contributing to the public comment process as well for the interim final rule on (centers and) regulation.
And that will be part of the presentation that Doug Fridsma who is our acting director for interoperability and standards will give on the Nationwide Health Information Network and try to get everyone more up to speed about what’s going on with the NHIN and our standards work in general.
And then we really wanted to spend a good chunk of the time today to get you oriented to what’s going on with technical assistance and give you sort of an update on sort of what all will be available in the way of technical assistance and walk through a bit of the toolkit that we released in December to familiarize you if you haven’t had the time just to peruse and sort of see what’s out there already.

But we think there is a lot of valuable resources that will be helpful to you so we want to spend a good amount of time today trying to orient you towards that.
And then we imagine there’s probably a lot of questions and a lot of ongoing work that you’re doing that you may want to be bringing up and we’ll have opportunities at a few different points in the next two hours to try to answer your questions and address any concerns you might have.
So with that we’ll get started with some updates. So just to let you know, we’ve - you already know the Regional Extension Center’s funding opportunity announcement is out there as long as the state HIE funding opportunity announcement and we’re far enough along with both of those programs in terms of, you know, completing objective reviews at least for the regional centers the first round of applications and we’ll - you can go to the next slide.

We are now going to be going into a second round of applications with the attempt to try to really administer all of the funding over the next few months. So as you know the original SOA had three rounds of funding. We’ve now condensed that into two rounds of funding. So the full applications are going to be due on January 29 with the second round.
We already have preliminary applications that were due on December 22 which are being reviewed and processed now. So mostly wanted to update you on the timeline with that since that is a significant change in how the program was going to be administered initially.

One of the big announcements we had over the last six weeks was related to the Beacon Community Cooperative Agreement program. I think many of you have already been actively working on your efforts maybe perhaps with the regions in your state or maybe some of the smaller states are interested at a state level. But the intent is to provide funding to communities to build and strengthen their health IT infrastructure and exchange capabilities to demonstrate the vision of meaningful use of health IT.
And I’ll talk a little bit more about this in a minute but in terms of our upcoming deadlines, we have a letter of intent that’s due this Friday by 12:00 midnight and we know a lot of people are working on those right now. And then we have our application deadline I believe is February - I think it’s February 2 although we have February 1 on this slide.

We will be going through a very - an expedited process to do objective review and awards for that program as well. Similar to the other programs, it will be a competitive process and we anticipate that 15 communities will be awarded.

And then we also had a recent announcement - funding opportunity announcement on a strategic health IT advanced research project, the SHARP program. This is research that’s focused on achieving breakthrough advances for well documented problems that have really impeded adoption.

So it could be those related to security or cognitive supports or network platform architectures or perhaps those related to secondary use or enhanced use of data from electronic health records. The application deadline for that program is January 25. Letters of intent are also due on January 8.

So I think you may know of some activities or some entities that are interested in these - in this particular program but we have been hearing from many of you that there’s probably more direct overlap with the Beacon Community Cooperative Agreement program. Next slide.

And then we’ve had a series of funding opportunity announcements related to workforce development -- one pertaining to curriculum development centers and another related to community college consortia to educate health IT professionals and then a program assistance for university-based training. All of these have application deadlines in January and letters of intent are due this week. So also a lot of activity going on with workforce in parallel with these other efforts.

I think that many of you have been trying to collaborate across states on some of these opportunities and we’ve been trying to facilitate that to the extent we can and would be happy to continue to do that although we know that you’re probably - if you are involved with this you’re probably - the efforts to submit the letters of intent are probably rapidly coming to a close. Next slide.

And again this is - the final workforce opportunity is competency examination for individuals completing non-degree training. We recognize that it’s also important to have some, you know, type of certification or recognition of someone’s competency as a part of an overall workforce development effort so this is addressing that need. And I think everyone’s here to really learn more about what we’re doing with our HIE program so we don’t need to elaborate on that. Next slide.

So just to recap on this timeline for the regional centers since many of you are involved with either this application process or partnering with those in your state centers that are submitting applications in cycle 2, we already have received the preliminary apps for cycle 2. We’re expecting the full applications by the end of January, going through objective review, and then really expecting to have all the awards issued for both round 1 and round 2 by the end of March.

So there’s going to be a lot happening in parallel with both the state HIE program, the Beacon program, and the regional center program in terms of the processing of cooperative agreements and issuing them over the next two to three months. Next slide. You can skip this, I don’t think we need to go over it.

So this just gives you a summary. For those of you who are involved with multiple things, this might be a helpful point of reference in terms of all the due dates. And I have to say we should apologize to all of you who are involved with multiple efforts and have been working over the last few weeks furiously on all of them.

We share your pain and I think in the end, you know, know that there is such urgency around this work that we hope that our accelerated efforts to administer these programs and get the money out will yield some positive results as quickly as possible. But we do recognize we’re loading people up and we really appreciate your patience with that process.

Just a little bit more about the Beacon program, we are using some of the statutory authority under Section 3013 - 3011 for this program which really focuses on strengthening health IT infrastructure and exchange capabilities. And ultimately we really want to demonstrate the vision for the future where everyone is meaningful users and we have a widespread exchange and able to really show measurable improvement in healthcare quality, safety, efficiency, and population health.

And there are metrics specific to cost, quality, and population health that each community will be proposing through the application process and there will be an expectation that there will be demonstrated improvements within a 30 month period. So it’s a fairly short timeframe to achieve those kinds of improvements, hence the need to really focus on communities that are already advanced in their EHR adoption rates and have existing capacity or capability to exchange information.

So if those of you who have gotten into this opportunity announcement, you probably recognize the fact that we are really selecting and looking for communities that have a baseline adoption rate that is well above the mean. We have recent figures from an adoption survey that indicates that our adoption rate has gone up quite significantly, still in the 20s, but we’re looking really for communities that are in the range of 35% as opposed to - 30% to 35% as opposed to the average across the nation.
We will be as I mentioned awarding 15 non-profit organizations or governmental entities. They could be tribes as well. So there’s a definition in the SOA on who are the eligible awardees.

And we expect that there’s not only going to be a lot of important lessons learned and accomplishments within these 15 communities but that they will generate lessons learned that will be more broadly applicable to the state efforts in general and to a diverse set of communities so that we would hope to and plan to include both rural and urban, low SES, you know, a wide variation of populations and geographies to demonstrate that these types of improvements and advanced use of health IT and exchange are feasible in a wide range of types of communities.

This program is funded, the grants will be a total of $220 million. There will be an additional $15 million that will be available for technical assistance and to also do a national level program evaluation. So we’ll obviously need to be coordinating tightly with our technical assistance program that we’d like to provide to all of you and in many cases your communities might benefit from both of those technical assistance efforts. Next slide.

I think we’ve already covered the SHARP so I’m just going to try to keep going through here and the same with workforce because I think there’s probably more interest in our other agenda items today.

Just to give you an update on sort of on where we stand overall with trying to execute our awards, we really want to try to be getting as many awards out as possible over the next two months. So we really need to be working with our grants management team and our grants management specialists to accelerate this process as fast as possible.

We recognize that many of you have already been contacted about your budgets and are working actively with our grants management specialists for their due diligence process that leads up to the issuance of the notice of awards.
And I think we’ve also made an effort in the last two weeks really prior to the holidays to contact all of you and let you know sort of the status of things. While we have not been able to offer a lot of precision on dates because we’re really dependent on our grants management specialists and our grants management officers to really do a lot of that work and they’re working as fast and as furious as possible to get the work done. They are doing this in parallel with the other large programs we’re kicking off.

So if you have questions about specific dates in which you will be getting your awards or anything about that process, we would encourage you to talk to us offline about that and we’ll try to address any questions or concerns you might have. Go to the next slide.

Just to give you an update on sort of what we’re trying to do, and we’ll touch more on this when we talk about technical assistance and the toolkit. But there’s several different ways that we want to be providing you with sort of ongoing information.

I mean, clearly our program team and the set of project officers and managers that will be involved in this program are going to have a lot of one-on-one contact with you all in trying to work as partners with you to let you know about resources that are available to - for you to complete the strategic and operational plans in ways that will be, you know, consistent with the funding opportunity announcement and many other thinking that’s going on the ONC end. And then we also are going to have the state HIE toolkit and a whole technical assistance team that will be able to support you in that process.

And another thing to just kind of keep in mind which can inform perhaps your priority setting or other activities that you plan as a part of your planning process is what’s being required or proposed really under the NPRM for meaningful use with - as they refer to stage 1.
While there isn’t a lot of specificity of stage 2 or stage 3, I think the funding opportunity announcement sort of gives you sort of the suite of HIE services that are going to be required under the program and you can marry that up with what’s being proposed in the NPRM for your planning purposes.
We’re also going to have a lot of ongoing discussions in our federal advisory committees, the health IT policy committee, and the standards committee. There has been an existing information exchange workgroup that has come out with lab recommendations that some of you have been involved with that I think are going to be quite helpful to our overall effort so we can update you on that perhaps moving forward since some of the potential action items coming out of those recommendations could be quite helpful to everyone.

And then there’s a new nationwide health information network workgroup that you’ll hear more about in a bit but that - they’re taking on a lot of important work starting in November and in December. And we’ll be advancing recommendations in March on some new directions and sort of updated thinking with respect to the NHIN. So all of these things collectively will be helpful to you in your planning process for those of you who are still there.

And again just to let you know, you’ve probably heard this already but the interim final rule on the initial set of standards implementation specifications and certification criteria was issued last week, December 30, and there is a request for comment which will be open for 30 days. So it’s - 60 days, sorry. And we would encourage you all to take a look at that and respond as applicable.

The notice for proposed rulemaking on meaningful use which has been much awaited was also published on December 30. Again this is an NPRM which is different from an interim final rule. There will be again a comment period that will allow for CMS to consider a variety of comments before they propose a final regulation later this year.

So if you’d like to - if you don’t have the links the links are here. Again there is a lot of complicated but important information relevant to health information exchange and your efforts in these regulations so we would hope that you could find the time to not only really read them and analyze them but contribute to the comment process. And we’re likely going to be working with CMS on an opportunity to talk about these regulations more.
We don’t have anything on the calendar yet but we’ll be following up with you in the near term about how we can organize perhaps even a joint call between state health IT coordinators and the Medicaid directors since you’ll be working so closely with them on this effort. So that’s just - that’s the brief update on this end. And why don’t we stop for some questions and answers and then after a few minutes of that we’ll then transition to Dr. Doug Fridsma?

Coordinator: Thank you. If anyone would have a question at this time please depress Star 1. You will be prompted to record your name. Your name is required to ask a question. Please be sure your line is unmuted when you record your name. Again, Star 1 should you have a question please. One moment for the first questions to register. One moment for our first question. Our first question comes from (Jenny Smith). Your line is open.
(Jenny Smith): Hi Kelly, I just wanted to ask you a little bit about the Beacon program in relation to the state HIE. The - our organization is the state designated entity for the state HIE cooperative agreement and we’ve also submitted an application for the (Rec) and obviously those tie very closely to Beacon. And we have two communities in Louisiana that meet the requirements from an EHR adoption perspective for Beacon and so we’re looking at potentially submitting applications for one or both of those.
And I wanted to get your perspective on us as an organization being the lead applicant for one of those Beacon grants. I guess what’s your thought on applying for both, us as the lead applicant submitting applications for both communities within the same state or even just being a lead for one or the other? Is your recommendation that should come from an organization who’s coordinating the (Rec) or the HIE or, you know, just your thoughts across the board on that.

Kelly Cronin: Yeah, I mean, we’re neutral in terms of, you know, who actually applies. As long as you’re eligible and if you have non-profit status you would be eligible to apply. I think on a practical level you probably need to think about where would the dedicated staff and executive leadership come from.

Because one of the things that’s really emphasized in the funding opportunity announcement is the importance of collaboration and governance and really having community wide participation and buy-in and a lot of collective concerted efforts to achieve the community goals that are set.
So I think you may just want to think about the practical issues of staffing, leadership, and the full engagement that’s needed on a community level. But yeah, technically you’re - you would be - I am - from what I understand about your organization you would be an eligible applicant.
There is also -- just for everybody’s knowledge -- specific requirements to work with the state health IT coordinators and make sure that they are engaged and fully supportive of any applicant for the Beacon community program. And certainly anyone who is an awardee would also be expected to work collaboratively with the state health IT coordinators so that these would be really synergistic efforts across the program.
And then there’s also a reference in the Beacon SOA about the importance of practice redesign and care coordination. And the availability of the services that regional centers will offer are really critical to making sure that EHR adoption and implementation is done in a way for the non-adopters in those communities where they can really achieve, you know, quality improvements and workflow redesign and, you know, the kinds of efficiencies and improvements in quality that the program is looking to achieve.
(Jenny Smith): Thank you Kelly, I appreciate all the work you all are doing up there. I know you are just as busy as we are.

Kelly Cronin: It’s a collective pain.

Coordinator: Our next question comes from (Jeff Blair). Your line is open.
(Jeff Blair): Hello Kelly, this is (Jeff) in New Mexico, really amazed at all the work that ONC has done. In the interim final rule, it had a paragraph that mentioned that there will be an additional - it wasn’t clear to me, it said ruling so I wasn’t clear whether it would be an NPRM or another interim final rule for HIT certification. And it didn’t indicate when that would be coming so maybe I’ll just phrase the question in terms of ballparks. Are you trying to get that available to us within the next 30 days or within the next 90 days?

Kelly Cronin: Yeah (Jeff), I think Doug Fridsma is much closer to that so I think he can best address it.

Doug Fridsma: Yeah so thanks again for your question. I think - you’re absolutely right, there is an NPRM that’s going to be coming out that will address certification. The IFR gives the criteria for certification but then as you know there is an entire process involved with how that certification would work, who would be certifying authorities, who is responsible for sort of managing that process.

All of that will be coming out. I’m not sure exactly of the date, I know people are working on it right now. I’m not sure that a date has been selected. I don’t believe we will have something out within 30 days and beyond that I’m not really sure.

(Jeff Blair): Thank you.

Coordinator: Our next question comes from (Beth Nagel). Your line is open.
(Beth Nagel): Hi, this is (Beth Nagel) from Michigan. I was hoping that you could give just a bit more clarification around the timelines for the state HIE cooperative agreement funding. Though I was contacted before the holidays, it’s really the first time I had seen that slide with the timeline and the term I guess rounds 1, 2, and 3 noted.

Kelly Cronin: Yeah (Beth), we are trying to process all the awards as fast as possible and there are grants management specialists that have been assigned to different states and they’re working on the budget reviews and trying to figure out, you know, if the cost allocation has been appropriate and they have sort of a whole due diligence process that they’re going through.

And in order to organize their work they have sort of planned to tackle all the awards coming but it’s safe that made it through the adjusted review process that are going to be getting awards and you have all been contacted about that. They are processing that as quickly as possible.
And we every day have sort of new things that are coming up that they are trying to work with us on in terms of, you know, working with software applications to process the awards and all the technical details around it which makes it very difficult for us to say with any degree of certainty exactly when you can expect, you know, the monies to be available to you. But if you have a specific question about Michigan’s award we can try and address that offline.

(Beth Nagel): Yeah that would be great, thanks.

Coordinator: I have no further questions at this time.

Kelly Cronin: Okay great so with that I’ll turn it over to Dr. Doug Fridsma. Again he is our acting director of interoperability and standards.
Doug Fridsma: Well thank you so much Kelly. I’m delighted to be able to present and talk a little bit about the technical architecture and the National Health Information Network or NHIN and really how that fits into some of the state HIE programs. Slide.

So first what I’d like to do is just give you an overview of the approach that we’ve taken with the Nationwide Health Information Network for those of you who may not be entirely familiar with it and talk a little bit about both what it is now and some of the ongoing activities that are being planned and developed over the course of the next couple of weeks to months.

So just briefly, the Nationwide Health Information Network or NHIN is a collection of standards, protocols, legal agreements, specifications, and services that are really all of the things that you need or at least we hope that you need to securely exchange health information over the Internet. So it’s not just the technology but it’s the standards that are used, it’s the protocols for the data exchange, the legal agreements that help with that, specifications about that, as well as the services and the infrastructure that enables that secure exchange.
So in many ways the NHIN is aimed to provide a common platform for health information exchange across a lot of different entities so that we can achieve the goals of the HITECH Act.

And we hope that at the end of the day having this infrastructure in place will allow health information to follow the consumer so that it’s available wherever that patient might be to help with clinical decision making, to put the use of information beyond direct patient care, and to improve public health.

Now the NHIN didn’t start with the passage of the HITECH Act. It - in its initial pilot implementation the NHIN provided - provides a vehicle for large and/or very technically sophisticated organizations to securely exchange electronic health information on this common platform across a lot of different diverse entities.

Now it’s important to recognize that when the NHIN was first conceived it really was intended to connect health information exchanges and these network of networks.
But in fact what we have been doing and have been evaluating is with the passage of the HITECH Act and the focus now on meaningful use, we realize that the NHIN will have to accommodate a broad range of different kinds of applications from simple local applications for example a healthcare provider communicating a prescription to a pharmacy to much more complicated interchanges that have nationwide participants, lots of different attendant network facilities and tools, and also to include consumers who may wish to have access to their health records from their local caregivers or the like.
So as we have been - forgive us just a moment. So as we have been going forward, not - this is okay.

Kelly Cronin: I don’t know what just happened.

Doug Fridsma: Excuse us just a moment. Give us just a moment, we’re - I guess we’ve lost the slide presentation but we’ll get that back on. There we go, now we’re back.

So what we’ve been doing over the course of the last couple of months is really trying to take a look at the NHIN and make sure that it aligns with the needs of the states, it aligns with the needs of meaningful use, it aligns with some of the new standards for interoperability that are coming out through the IFR and the NPRM.

And so we’ve been working very closely with the federal advisory committee. They have been holding public meetings, they have been having comment periods throughout this process. And in November the HIT policy committee formed the NHIN working group.

They have had a couple of meetings since that time and their goal is to really provide recommendations on the policy and technical framework that will really allow us to leverage the work that’s been done in the NHIN and make sure that it aligns with the needs that we have for meaningful use and standards.

The first meeting was on November 20. They have had public hearings on directory services in December. The next meeting is actually scheduled for January 7 to talk about authentication and certificates. And all their activities can be found at the URL that’s listed there below off of the Web site and tracked that down to the policy committee.
This particular group, just to give you a sense for the kinds of things that they have been working on, there has been a lot of work that has been ongoing with kind of defining what the NHIN is and what are its necessary services. They are also going to be working on governance and this is one of their charges is to come up with a strategy for how NHIN governance should be done.

This is some of the - a timeline that sort of describes what kinds of things need to happen. And so in the course of the next couple of months there is going to be increasing discussion about how to take the NHIN and the operational features of that and be able to provide governance structures around that.

And they’re also working on some of the trust fabrics or what are the things that we can provide that will help states and people that are trying to achieve meaningful use meet the requirements that we have for data exchange around the trust and trust fabric that’s there.
As it stands there is currently a limited production pilot that has an interim governance structure, there is an NHIN technical committee that’s focusing on architectural and technical issues and there is an NHIN coordinating committee that has the authority to establish and maintain policies and legal agreements.

This all is under review. I think there has been tremendous amounts of good work that has gone on within this governance structure and all of that work is going to be reviewed by the NHIN working group since they are at this point legislatively mandated to come up with what that governance structure should look like, leveraging again the work that’s gone on in the limited production pilots.

The other thing I mentioned was the importance of trust. I think it’s important to recognize that we can’t overestimate the importance of trust when we think about both the future and potential successes of the NHIN and data exchange.

Of course the level of trust that is necessary will vary depending on the uses and participants. And so when we think about the fabric of trust or the layers that we have there, there are some people who may wish to use NHIN for simple exchanges of information that don’t require all sorts of rigorous agreements to exchange that data.

So we recognize that that’s something that needs to be supported and that needs to be part of the NHIN fabric of trust. But even within those situations I think it’s important to recognize that this doesn’t mean that there’s no layer of trust or there’s no sort of agreement.
But when we send information, even if say we were sending emails, you know, the sender of that information must be confident that they have the address of the right recipient so that it’s going to the right person; that the receiver of the data is the intended person that you actually, you know, that address is actually associated with the person that you’re sending it to; and that when you send it that nothing gets changed or altered in that transmission.

Clearly as you begin to exchange more sensitive information or that there becomes increasing complexity in the kind of information that you’re using, there may be additional layers of that trust that are going to be important. And it’s going to be important as we move forward that we get input from a wide range of key stakeholders so that as we think about how to support the exchange of information across HIEs, across participants, and across other networks that we have the right degree of trust relationships as well.

Probably the most - the one that you’ve heard the most about when you talk about the NHIN is the DURSA. And the DURSA is a data use and reciprocal support agreement that’s really a comprehensive multi-party trust agreement that has been worked on for a number of probably at least a year to help support the exchange of data among participants that are using the NHIN gateway and the adaptors there.

The DURSA is not meant to be more onerous but in fact it’s meant to help simplify the trust relationships. If what you had to do was create individual agreements from - with everyone that you were going to participate with, it would be very, very difficult to do that if every one had to be custom crafted.
What the DURSA really provides is a multi-party agreement. There’s a lot of sort of key conditions and terms that are used in the DURSA that help support that. But I don’t want to go through all of the different terms and conditions but it’s a multi-party agreement because all of the people who sign it basically agree to the conditions of the DURSA; that people are actually - have that are in production and that they have trust agreements with applicable end users.

They will satisfy privacy and security obligations to keep the information that is exchanged private and secure; that when data is requested it’s only for sort of permitted purposes which includes in flight treatment, related to payment, other sorts of public health reporting for example would all be included.

And it goes on and talks about other responsibilities, duty to respond to requests for data; the conditions around the future use of the data; and then duties requiring requesting and responding participants particularly with things like breach notification, dispute resolution, and liability risk.

So the DURSA is an important part of the NHIN. It’s one part of many of the components and it’s meant to really help to simplify people that are engaged in lots and lots of kind of multi-party agreements.
I think it’s important to note that already there have been key participants who have signed this agreement including the Veterans Administration. And so organizations that have data exchange needs with the VA certainly should think about and review the DURSA since as a signatory to the DURSA the VA is participating in the NHIN in that way.
The other thing I think that’s important to recognize is we have talked a bit about some of the technology, we’ve talked a little bit about the trust that is a key part of the NHIN. But the NHIN also has been working very hard at the use of standards and so the NHIN references, leverages, and utilizes the approved standards. And so certainly the standards that are coming out of the IFR and are defined within the NRPM for meaningful use are all things that are being incorporated within NHIN.
I think it’s also important to note that since the IFR came out just in December, many of the standards that are currently incorporated with the NHIN reference work that has been done by HITSP or the HIT Standards Panel. And so many of those existing standards again which served as input to the development of the standards within the IFR have already been incorporated in the fabric of the NHIN specifications as well.
I think the other thing is that there are a variety of different components within the NHIN with regard to the technology. NHIN specifications define what’s called an NHIN gateway which has different kinds of functionality in it that an NHIN participant can use and can support. Those specifications are again consistent with many of the HITSP standards and will be with the IFR and the standards that are coming out with that as well.
The gateway is actually fairly lean. There’s not a lot of complexity to it. It defines the messaging security and privacy foundation, it defines some discovery information services as well as extensions to that information services with regard to an information services profile.

There are other components that interact with that as well. The Federal Health Architecture or the FHA has developed connect products that are an adaptor that fits into the NHIN gateway and provides additional functionality. And all of those things, tools, and resources are things that state HIE programs can leverage when it comes to supporting the work that they do.
I have just two more slides here that I want to kind of go through that talk a little bit about what the future holds. And so in 2009 the HITECH Act was passed that mandated by the end of 2009 that we would issue the IFR on standards and interoperability as well as work around meaningful use. In 2011 those - we intend to have meaningful use criteria that will help capture and share data.

By 2013 we hope to increase, essentially raise the bar on meaningful use to have advanced share processes that include things like decision support. And by 2015 we want to again raise the bar so that we’re looking at things that will actually take the data that’s been captured and shared, apply advanced share processing decision support, and actually lead to improved outcomes.

What that translates to in terms of rulemaking and policy is that the preliminary definitions of meaningful use came out in 2009, in August the initial standards were identified. And by - and in December the rule, both the IFR for standards and the NPRM for meaningful use was released.
For those of you who are really - for those of you for whom it’s very important to count the dates, the official publication date of the IFR is going to be January - is going to be coming up in January. I think when it gets published in the Federal Register is the official date of that particular regulation. That’s what starts the clock going. Thirty days after that the IFR becomes essentially a rule or has the force of law.
But there will be a 60 day comment period again beginning when the IFR is published in the Federal Register. So we encourage people to take some time going through the 500 and odd pages for meaningful use and the 200 and some pages for the IFR.

Because it’s really important for us to get feedback about this so that we can incorporate that, make necessary changes to that, and make sure that we can - we have rules, standards, and meaningful use criteria that really achieves the goal that we have which is to improve patient care and to improve the cost effectiveness of care and make it - make the capabilities of our public health system better.

I think I sort of talked through these as well. I apologize. So the - I guess the next thing to talk about is to really take a look at the technical architecture of the NHIN and the state HIE programs and to sort of think about how this applies towards that technical architecture.
I can speak and then I’m going to ask Kelly to sort of jump in if there are things that I have missed or if there are problems that I haven’t addressed or the like. But the statewide strategic operational plans are to describe the technical architecture and the interactions among the stakeholders and the technologies that are there to achieve a state’s strategic objectives.

We recognize that the architecture, you know, reflects really all the components of a very complex system, the relationships and interactions among those components and, you know, whether you’re talking about building a house, whether you’re talking about building software, or if you’re talking about building a system for exchanging information we recognize that you have to have a blueprint or an architecture to sort of do that.
There are lots of moving parts that are - exist within that. And so it’s important that the exchange of information among all the various participants in the healthcare value chain has the necessary technology infrastructure so that those exchanges can occur.

And importantly, alliance with what’s going on at the national health IT level so that those exchanges can be secure, can be interoperable, and can extend beyond sort of the state organization that includes federal partners like Indian Health Service and the Veterans Administration and other agencies.

I think it’s important to recognize that when we talk about exchange it isn’t just exchange that crosses state borders but in fact there are federal agencies and partnerships that you probably have within your state organizations that we need to think about.

We also recognize that many of the states are going to be at different levels of maturity and so we’ll be providing additional guidance with regard to the toolkit and technical architecture initiatives. But I think it’s important that we really want to - we recognize that there’s not one size fits all and that we really have to provide the kinds of support to the states at kind of where you are and help people get to the goals that they have.

So some of the key principles here I think that’s important is that as states are advancing their information exchanges and setting up their infrastructure, it’s important to recognize that all of these things should fit within the larger framework we have for healthcare reform and that includes improving quality of care and patient outcomes, improving cost effectiveness of care, and then enhancing the capabilities of public health. And those should underlie a lot of the work that’s going on.
It’s also important to take a look and make sure that meaningful use is addressed as well. Those things have been defined in the NPRM now and I think these initial slides were developed even before the NPRM came out but that’s out there now and the standards. And so I think it’s important to take a look at that and make sure that in the short term those things are addressed.

The - it’s also important though to not necessarily just focus on 2011 but to look much broader at what’s coming down the pike for 2013 and 2015. So things like clinical decision support and remote monitoring are things that we can anticipate are going to be part of meaningful use. And it’s important as people think about the plans for the states that they think not only about 2011 but develop a comprehensive strategy for how they might get to 2015.

Kelly Cronin: And Doug I just wanted to elaborate too that the areas that are listed on slide 40 that he just mentioned are really what we’re requiring for the program. So as a part of the cooperative agreement these will all be the HIE services that will be expected to be, you know, developed and offered if they’re not already, you know, to providers in your state. And each involve, you know, a different set of, you know, complexities.
It does crosswalk in a large degree with the notice for proposed rulemaking but for example the clinical summary exchange for care coordination, in the NPRM right now it’s in scope for 2011 but it also allows for printing or faxing.
So while it may - your providers in your state may be thinking about what they’re going to, you know, what will be feasible for them and what services will be available to them so will there be HIE capacity that will meet all of your hospitals and physicians within that timeframe is one question. But clearly it would be more efficient to exchange this on a standardized electronic basis as opposed to dealing with faxing or printing. So there’s a value proposition or a business case to be made.
Doug Fridsma: And we can be, you know, it has yet to be written but we can be pretty certain that by 2015 that the use of printing and faxing for the exchange of information is very likely to go away. And so it’s important for the states to recognize that and begin to get ahead of the curve so that they can help the providers achieve meaningful use by getting that kind of infrastructure in place.

It’s important to make sure that, you know, the technical architecture includes the key stakeholders across the state’s value chain and that includes both government and non-governmental entities like labs and health plans and agencies with health related missions. It’s - it will be important to make sure that the architecture is conformant with or interoperable with the national standards and, you know, should allow someone to exchange information with participants within the NHIN.

And the scope includes exchanges not only between health enterprises but includes both within state and across state boundaries. So there are many organizations that fit on the boundaries of states that have to exchange information. That’s an important area. There are going to be federal participants within a state like the VA services again that are going to be important to exchange with and it’s important that the technical architecture include those participants as well.

At a minimum the architecture should describe mechanisms to provide or participate in location services, you know, finding people so that you know where to send the data, you know, be able to look someone up. And certainly this is something that the NHIN working group has spent some time in December on and has taken a look at.

Ensure that, you know, when it’s - when relevant you can find people, that they’re discoverable. It’s critical and it can’t be overemphasized how important trust, security, and privacy are with regard to the services that are provided. And it’s important to integrate Medicaid services and state level registries. Those things are all going to be an important part of the services necessary for the states.

I think it’s also important to recognize that we’ll have a lot of new activities and users that will be joining the existing NHIN so we are hopeful that as states begin to develop their plans for information exchange that they will take a look at the technology that NHIN provides, provide feedback and comments about what is helpful, what are the things and features that they would like, and consider really participating in the NHIN in a formal way so that they can exchange information.
It’s also important to recognize that there are lots of other federal initiatives that are currently participating in NHIN and that includes work with the CDC on biosurveillance, work through the Department of Defense on a virtual lifetime electronic record that is being supported by DOD and DA, and as well as the Social Security Administration using some of the standards and infrastructure in their disability determination process. So there’s a lot of work that’s going on within the technical infrastructure for the Nationwide Health Information Network.

Finally I think just as Kelly has said and I think it’s important to echo is we don’t want to make - we want to make sure that people don’t think only of 2011 but are thinking towards the future with this. And one way to be involved or one way to plan for the future is to be involved in making it and that means participating in the NHIN and being a part of that process. I think that grantees in the state strategic and operational plans are encouraged to address options for future participation.
It could mean that you are participating in planning and implementing the appropriate standards, specifications, and architectures. It could be providing use cases that can be used to support the standards. It can be providing comments to the technical infrastructure and it can be participating in the operational network as well. All of those things will be important.
And based on - the project officers within the statewide strategic and operational plans will evaluate these things based on the evolving NHIN guidance. And, you know, I think the state has a lot - the states have a lot of different places to receive guidance both from ONC, from the state HIE team, through the toolkit, EMS, through the federal advisory committees, and more. We’re really working on trying to create a community that we can reach out to the states and make them a part of the solutions that we’re trying to provide.

So with that, I guess we’ll go to the last slide. We can have some questions and answers then. I don’t know Kelly if you want to just say a few words and frame the questions.

Kelly Cronin: Sure yeah, I mean, I think we’d really like to use this as a time to address any questions or concerns you might have with respect to how the NHIN intersects with your existing or developing plans.
And also I really encourage everyone to start thinking about this as a collaborative process, that we really want your full engagement. Not only in the standards development and, you know, adoption process but really how do we continue to develop the technical infrastructure and services and perhaps even open source tools moving forward that will enable your efforts and to really engage in that process formally or informally.
We want to fully encourage. This is getting back to sort of the overall theme of the program is being a federal state partnership. And the more that you can engage with us, you know, we’ll be able to develop this together and figure it out together over the next months and years.
We are getting some questions online. One was just submitted from (Paul Forlenza). I don’t know if we have any others in the queue.
Coordinator: Let me remind parties, if you would like to ask a question on the phone line, Star 1 please. One moment for our first question on the phone lines. Our next question comes from (Rachel Block). Your line is open.
(Rachel Block): Hi, thanks a lot and thanks, it was really a great presentation. We’ve been involved in the NHIN for the last several years and it’s good to see things progressing. I just wanted to mention one - two things separate but perhaps interrelated which you didn’t explicitly address in your presentation and which I think needs to be part of the NHIN state interaction discussion.

One is that while I think it is a great advance for groups like the VA to participate in the DURSA there are separate legal and policy barriers to accessing and using Medicare and Medicaid data and I really haven’t heard ONC talking about that explicitly.

And as particularly the Medicaid HIE plans move forward and we as a state are trying to coordinate closely with them, we have encountered some issues in terms of having to jump through additional hoops in terms of accessing Medicaid data. And we don’t need to go into a whole long saga about the difficulties of accessing Medicare data but I just wanted to put that out there.
And the second thing is that I think it’s very important as the NHIN discussion progresses to be very sensitive to and aware of the discussions that are going on in terms of sustainability of state efforts relative to health information exchange networks and the governance structure associated with that.
Doug Fridsma: Yeah well I think, you know, those are excellent comments. I mean, clearly there is a lot of alignment that and a lot of work that still needs to be done to make this ability for data about a patient to kind of flow where they are in the system. And I think we still have work to be done on that and I think you’re absolutely right that the Medicare data access policies and requiring extra hoops is certainly something that we need to take a look at and address.

Sustainability of HIE is a real problem and it’s something that again is an issue that I think lots of people struggle with. And I’m hopeful that the kinds of discussions that are ongoing within both the NHIN working group as well as within cooperative members and among the states will help people kind of share that practice and figure out how we can address that. And if there are things that ONC can help, those are the kinds of discussions that we’d like to have so that we can help enable the success of the data exchange.

Kelly Cronin: Yeah I would just add to that. I think we’ve all been struggling with the sustainability issue for a few years now, some for more than that. And while we have some really good ideas and some, you know, sort of policy options that have been fleshed out with respect to payment reform or how direct or indirect subsidies over time might be able to sustain health information exchange.

And certainly I think we know now that there’s perhaps going to be increased demand because of the desire for providers to qualify for these meaningful use incentives. And that certainly creates a better business case in the short term.

We all recognize that the cost of governance, the cost of, you know, establishing these networks and really building out the capacity is not going to be solely a public or private effort. It’s really - it’s a combination of a lot of different actors and really the development of a market that needs to be sustained through ongoing revenue, sources of revenue and, you know, a willingness to pay for different services.
So I think we all need to be working together on how that evolves in preserving - in making sure that we’re preserving the right or the appropriate role for federal government and for state government to, you know, make sure that we’re able to achieve our common goals and not lose sight of them because of, you know, directions that may seem to be, you know, not in keeping with where we want to go. That is, you know, sort of what might the market do without our involvement.

So it’s a tricky question and I think, you know, part of our challenge with it is that we don’t have a lot of specificity around payment reform yet and I think we all collectively since there’s going to be a lot happening at a state level with health reform and at a federal level, and I think we all know that the legislation that’s going through the Congress now is not as focused on payment reform as it is on access and insurance reform.

So we still have, you know, sort of this collective burden to be figuring this out. And so how we coordinate that on a Medicare, Medicaid, and other levels is really important to tie into this. So you can expect that we’ll be actively working on that over the next year or two. And through some of our funding, through the Health IT research centers and other related efforts for this program, we really hope to be fleshing that issue out with more specificity.

And I guess also just to touch base on the legal and policy barriers, (Rachel) we’ve talked a lot about this and know that there are some substantial makings.
There are some common problems with Medicaid data that could be addressed and certainly the Medicare issues have sort of well understood for a while and, you know, might require both legal and operational issues to be addressed before that one gets undone. But I think we need to prioritize those as barriers and really be working together on those as well.
Coordinator: Our next question comes from (Walter Sijanski).

Man: Name not recorded.
Coordinator: Mr. (Sijanski), your line is open.

(Walter Sijanski): Thank you, yeah this is (Walter Sijanski) from California. Dr. Fridsma, thank you for a very informative presentation. I have two questions. I don’t know if you have time to answer two questions but I’ll pose both.
The first is I am involved with the preparation of the technical architecture out here in California and we are curious about and struggling with the appropriate role of the NHIN in our planning.

Specifically is ONC looking for the California technical architecture for HIE to include technologies and standards that have been put forth by NHIN as part of the NHIN technical solution or - and/or is ONC looking for California to have specified mechanisms to operate - interoperate with the NHIN, not necessarily use NHIN technologies internal to California. So that - all that was my first question.

My second question has to do with HITSP. You touched on HITSP briefly. Given that many of us again are in the process or planning to implement HITSP specifications and constructs and so forth, a lot of the work that has come out of HITSP and that very few of those work products were - are mentioned in the IFR as requirements for EHR certification and so forth. Can you give us some guidance on whether we should continue with implementing HITSP work products and what the role of HITSP will be in the future?
Doug Fridsma: So (Walter) thanks so much for that - those comments. With regard to the first comment I guess which is, you know, when we speak about NHIN and interacting, having states interact with NHIN, what do we mean by that? Do we mean the improvement of NHIN inside or do we mean that you need to be able to interoperate with it?

I think what’s important is that, you know, the high level goals that we’ve got which are the free flow of information that is secure and private using Internet as sort of its transport mechanism is what underlies this.
And so whether that’s, you know, clearly to do that there needs to be some conformance to the standards that are listed in the IFR so that people are using common vocabularies and terminologies, people are using common procedures for the protocols that they use, exchange packages have to be consistent. And so at some level you at least need to be speaking the same language and, you know, have the same specifications if you will around that.
For some that - the easiest path to that is actually to take some of the technology or to become a natural participant within the NHIN. For others the easiest way is to take existing tools and infrastructure and make sure that they are conformant and interchanged directly.

I think in many ways we’ve tried to be agnostic as to what the right way to do that is, that way we can kind of drive some innovation and the like. And so I guess an answer to your question is yes. That would probably - that technology and standards as well as just doing interoperability is probably a good way to go.

With regard to your second question which was about HITSP constructs, we were guided in developing the IFR by much of the work that was done in the federal advisory committee. The chair or one of the co-chairs was (John Halanka) who also has been leading the HITSP effort and so they’re although not specifically addressed in the IFR there is a lot of consistency across the standards that were advocated.

I think as we move forward, as we go from 2011 to 2013 and 2015, I think it will be increasingly important to take a look at both the good work that HITSP has done as well as how that work and others is used by the advisory committee and those recommendations presented to the ONC.

I think keeping a look towards the future and the IFR does specify kind of some of the directions that we anticipate going with vocabulary standards and some of the exchange specifications and more will be done through the federal advisory committees to sort of tighten those things down and make sure that we’ve got standards that we’ll support.

What will happen with those existing HITSP standards, those are clearly very, very important to HHS and those are standards that are used very broadly. What we have done with the IFR is tried to establish what we think is kind of the minimum criteria and I think as we move forward to 2013 and 2015 we will increasingly provide more functionality.

Coordinator: Our next question today comes from (Raul Racary). Your line is open.
(Raul Racary): Yes Doctor thank you very much. I really appreciate your time and everyone else’s time in presenting this great webinar today. As a state designated HIE, one of our challenges is making sure that we’re meeting the ONC criteria and have a penetration rate into our state and adoption rate that’s high.

Do you envision at any time incorporating anything within the regulations of meaningful use that more push people towards using a state designated HIE versus something else? One of the things that we’re seeing is a lot of hospital groups that already have developed an HIO are contemplating well if it’s not in the meaningful use regulations why should I do it.
Kelly Cronin: Yeah, I mean, this is a tricky issue, this is Kelly Cronin. We have heard a lot in the last four or five months around the issue of both integrated delivery networks or systems and large hospital systems not necessarily being sort of fully on board with a state based approach to planning and implementing health information exchange.

And unless they see sort of the explicit need to be active participants in whatever is sort of endorsed at a state level because they want - they’ll need to do that to qualify for the meaningful use incentive, they may not play.

So in response to that, I mean, we have tried to send a very strong policy statement through the NPRM that really the direction of health information exchange should not be tied in any way to specific proprietary interests. We’re not talking about change of data within an integrated delivery network or just among hospitals that may share a common platform or EHR. We’re really talking about having a trajectory that will lead to widespread adoption of health information exchange across organization boundaries, across business interests.

So that clear policy goal and the preamble along with some very strong messaging from Dr. Blumenthal in terms of what our overall intent and what our policy direction and what - where are programs are going with HHS to support that, that was really something that came out in December in response to this issue.
So we would hope that through a collaborative planning process that hospitals are going to start to realize the increasing number of requirements related to health information exchange which will have to be met by, you know, a set of HIE services and organizations that can deliver those services that likely go beyond sort of a one provider orientation since a lot of it, the data that needs to be moved in a patient centric manner resides outside the hospital and outside the control of one given provider or proprietary system.

So I think it gets back to sort of the strategic perspective and vision that’s involved that everyone needs to be grounded in. And in many ways state leadership being tied to or being sort of grounded in your policy goals and where you want to go overall with health reform really allows you to engage providers at that level and really think about strategically how are you getting to a patient centric flow of information that really does not - that goes beyond any one given provider’s interests or historical investments and electronic health records or platforms.
Coordinator: Our next question comes from (Paul Forlenza). Your line is open sir.
(Paul Forlenza): Hi, thank you for all your work. Two questions about the data use support agreement that you mentioned. The first is that intended to resolve the differences in privacy regulations, laws between states? And if so I’m not sure how that would work.

And the second is while I understand that the VA has signed that, what we’re hearing from our local VA hospital is that there are internal policies in the VA that do not yet allow them to participate in sharing data outside of their own organization. So I wonder if you knew what the status of that was.

Doug Fridsma: I think you raise some really important points around the DURSA. What we really probably need is to have some of the folks that were involved in the crafting of that. We don’t have any of those folks on the call. But maybe what we can do is take that offline and get back to you with some guidance or to just sort of answer that question.
Certainly there has been a lot of participants across multiple states that have been involved. To what degree it has resolved all of the privacy issues I think is sort of a question. And I’ll just take that offline and we’ll try to get back to you on that.

(Paul Forlenza): Thank you.

Coordinator: Our next question comes from (Archie Banks). Your line is open sir.
(Archie Banks): Hi, this is (Archie). My question was around in crafting the interoperable architecture that will communicate with a national HIE, will states get some assistance in crafting that architecture?
Kelly Cronin: Well we certainly will be available - will be providing some guidance through the toolkit that we’ll be covering in a moment here. And there will be technical assistance provided on a limited basis more on a one-to-one level for some states that are most in need of that type of support.
So we can talk more about that offline if necessary but we are going to be providing resources to everybody that gives more details around how to approach and consider some of the key principles that Doug reviewed earlier with respect to developing an architecture.

(Archie Banks): Great, that was what I was meaning about standards and processes for the architecture. Will that be part of the toolkit, the standards?

Kelly Cronin: Well we will have more information out by we hope by the end of the month about a set of specifications that you can consider in the planning process and the more detailed aspects of the technical architecture.
(Archie Banks): Okay thank you.

Coordinator: Our next question comes from (Jay Duco). Your line is open. Excuse me, I’m sorry, (Jenny) your line is open.

(Jenny Smith): Thanks. One of the question Kelly or actually two questions that relate back to the realms of funding for the HIE grants. For purposes of project planning, we’ve got some events and things scheduled for strategic planning. Can you offer any guidance that would help us determine when we might receive notice of award, I mean, not just for Louisiana but for any state of those three rounds?

And then as a follow-up to that, I know that the funding - the announcement states that funds can’t be used to reimburse for pre-award costs. So I just want to clarify, does that mean that any approved activities that occur after the award is announced, say if the award was announced January 14 if we started January 15 that even though the cooperative agreement may not yet be in place they would still be reimbursable?
Kelly Cronin: Yeah, I mean, technically speaking our SOA says that it has to be sort of, you know, a part of the cooperative agreement which would be, you know, after the date of the issuance. We can follow up with you offline to talk about, you know, how you might plan for that.
(Jenny Smith): Okay.
Coordinator: Our next question comes from (Christian Juliard). Your line is open.
(Christian Juliard): Yes I was wondering again on the technical assistance beyond the online toolkit what opportunities there are for states to access technical assistance, if you could say a little more about that.
Kelly Cronin: Sure. Actually that’s the topic of our next 45 or however much time we have left, 35 minutes. So we wanted to give everybody an overview of what resources will exist and we’ll be, you know, developing a greater capacity to provide technical assistance building off of the cooperative agreement we already have with the (HUMA) Foundation and really the state HIE forum.

We have a technical assistance team around that effort. But we also are in the process of soliciting applications for an additional procurement that will expand the resources that will go into providing technical assistance. So we should have, you know, a pretty robust effort underway over the next several months and clearly there’s a whole set of resources that exist now for you all that we really wanted to focus on today. So if there aren’t any other questions it might be best to really allow for the next 35 minutes to address all of that.

Coordinator: You may go ahead with your presentation ma’am.

Kelly Cronin: Lynn Dierker and Greg Farnham are going to review the next part of the presentation. I think as you know Lynn Dierker has been the project director for the state level HIE consensus project and forum over the last several years. And Greg Farnham has been working closely with ONC in the development of the program and really the shaping of this technical assistance program. And he’s the founder of VIT Leaders, of the Vermont IT Leaders that really was the successful HIE in Vermont.

So with that I’ll turn it over to both of them and they’re going to run through sort of an overview of our technical assistance efforts and then give you a run-through of the toolkit.

Greg Farnham: Okay thank you Kelly, appreciate the time to talk to you all today. We have a great challenge ahead of us and as has already been mentioned on the call today we really mean to have this program be a collaboration between states and the federal government and it’s in that spirit that the TA program has been designed. And we’re waiting for a slide. Okay. Well I’ll keep talking about sort of generally what - give the general overview of the program and then the slides will catch up.
So anyways, through this process that we have designed in the TA program that we’re trying to deliver information to help states move as quickly as possible to reach the objectives of the program. And as you know, currently we’re working through a process of reviewing the strategic and operational plans.

And through that review process we intend to identify and share the success strategies of the advanced stage and also identify areas where additional TA guidance is needed for states that are just starting to develop the capacity needed to support statewide HIE.

The ONC technical assistance program is really defined by the goal of supporting states in their efforts to build HIE capacity for meaningful use and it will include a number of objectives that are - include the program being aligned or targeted rather to stages of development and responsive to state needs and will be aligned to support the HITECH state HIE program, program goals, and milestones across states.

And of course it will leverage the collaborative experience of both the state level HIE program TA, team, staff, and other consultants and collaborators or partners and the ONC program regional officers, consultants, etc.
The TA program will continue to evolve over time to meet the program goals. It is currently being organized to support all states in planning and core capacity building activities. The TA will take the form of being both generally applicable to all states but in some cases as Kelly was just mentioning the TA will become very targeted to address specific and unique deficits identified in state plans and programs.

It is our assumption that most states will be using consulting services to develop and execute plans in each state. We may see the ONC support of TA services targeting areas that states otherwise cannot address via vendors or consultants. Just to give you a couple of examples, ONC will be providing additional guidance on cross cutting issues, barriers, comparative information about emerging best practices, and objective guidance linked to program expectations.

We know that this cannot be a cookie cutter approach to deliver technical assistance so we’re working towards a flexible approach to ensure that the states are on the right road.

So the question of, you know, what types of questions will the TA program be able to address -- to start, and again this will evolve over time but these are some examples. How do I get started? How do I pick a consultant or vendor? What do I do to get an ONC approval of my state plan? What are the best practices across states, you know, and so on. I won’t read them all.

Knowing that we’re limited on time I’m going to - I’ve teamed up with Lynn Dierker who is really been a great partner in putting together this program and I’m going to turn it over to Lynn who will control the slides for the next few slides and then give it back to me and then we’ll do a demonstration of the toolkit.

Lynn Dierker: Thanks Greg. On the next slide what we’ve tried to do is sort of start to get into the various offerings that will be part of a general technical assistance program for the what we’re calling the state leadership forum which is all of the state leaders who are responsible for implementing their strategic and operational plans.

So certainly you’ve heard a lot about the toolkit and hopefully have started to see it as a resource, as an online clearinghouse for resources that can be updated on an ongoing basis. But we obviously are planning to respond to the needs, various stages of development, and various modalities that are going to work and be practical in the really busy, crazy lives of what we’re calling this learning community of state grantees.
So building on what we’ve learned with the state level HIE project in the past and the leadership forum and the input that we’ve received, we’re going to be expanding that and hopefully setting up some sort of multi-faceted program that will be timely, responsive, and address various levels of learning and development planning and implementation that are happening across the state.

So that will include a series of webinars and virtual programs that will enable us as a group to identify timely issues but also take up specific topics and sort of a curriculum of key issues that are really relevant across many states, groups of states, and all states about the domains and about planning implementation.

We are going to have a communications list serve and a chance for an ongoing sort of interaction mechanism between the states for sharing information. I’m going to talk about that a little later as well. Coaching in terms of virtual and on-site consulting, and I’m going to talk a little bit more about that in a minute.

Meetings and roundtable discussions so on particular topics where we know all of us collectively are trying to push the envelope and learn and really identify best practices in these emerging issues such as coordinating across programs with Medicaid, about key thorny issues about financing and sustainability where we really need to be talking and advancing issues. We’ll be doing those activities.

And then a leadership training program that is really going to be focused in terms of this sort of - that whole statewide leadership domain but also bringing together those particular individuals who have a unique responsibility to really carry out the collaborative leadership activities that are necessary for success in implementing these strategic plans.
So on the next slide we sort of try and talk about technical assistance consulting recognizing that we want to help states identify strategies and address issues within across the five domains and support states to meet their milestones and deliverables as required by their cooperative agreements. But we’ve got to walk the line and not directly help states specifically accomplish their deliverables and provide services that they or consultants or other resources within a state’s domain really need to appropriately be carrying out.

On the next slide, the technical assistance consulting activities that the program imagining here are going to include efforts to focus on recommended best practices and to really integrate and bring together all of the good work that’s gone on in the past couple of years through the HITSP project, with the state alliance, a lot of the emerging activities now with NHIN, and really bring that together across this community of state leaders to understand what is emerging as best models.

And then to assist states to develop strategies to address these issues and reach milestones. And we know that the states will group likely by stages of development, states with common characteristics and needs so that we’ll be able to provide advice on direction or resolution of issues; to analyze specific issues and suggest potential solutions as they are emerging; to synthesize different approaches and outline alternatives; and then to on an ongoing basis identify case studies or other states’ efforts to resolve similar issues and to in a real time way bring these to attention where states needs help.

And as we all know, I mean, this is such an emergent work because we’re all learning and things are happening and evolving as we speak. And so we really need to make sure that we have the mechanism to really accelerate the dissemination of what we’re learning and what’s really applicable in different type circumstances.

So on the next slide it’s important to address what technical assistance activities, this consulting that we’ll do can’t really include and won’t include. And some of these are really obvious and in some ways I think, you know, it becomes a little tricky and we’ll be in the business of really talking individually to understand what we can and can’t do as your requests come up.

Developing systems, deploying technologies, giving legal advice, actually helping develop the strategic and operational plans themselves, completing audits, writing data sharing agreements, and really producing for states any of the cooperative agreement deliverables or products which we really can’t be in the business of doing.

So advancing to the next slide, this table is just an illustration of the anticipated technical assistance topics evolving across stages that we know we’ll be in the business of addressing. And in this first year especially there is a big focus on completing plans, on all states really achieving approved plans and being able to proceed to implementation. And then we know that even in the advanced planning and implementation area there is really a range of development and issues that are emerging.
We are as Greg pointed out anticipating that advanced states that are tackling particular development will be on a continuous basis feeding that information back to others.

And we’ll be testing and discussing, you know, what are the issues and applications of approaches in different circumstances and across different states and continuing to build the body of knowledge on these topics that will really build the curriculum, that will build the knowledge base, and will advance us all incrementally in meeting the milestones under our strategic and operational plans. Next slide please.
This slide -- hopefully you can all see all these boxes -- just gives a sense of the timeline and how this work is sort of evolving. I mean, as Kelly has pointed out, there is so much work to do to actually review all of the plans, contact all the states, actually put the cooperative agreements in place.
While this is happening we are obviously in the business of developing the toolkit and additional programming and with the anticipation that as we get the results of the cooperative agreements, where we’re really able to synthesize and analyze the sort of groupings of states and where they are in their developments, what the particular deficits are, areas of focus and priorities that make sense for TA, that we’ll be in essence developing a technical assistance plan for all states, each state knowing what kinds of services and needs you’ll be participating in that can help address your particular milestones. And then having an agreement with the states that you’ll participate and you’ll understand what the technical assistance is.
So roughly, you know, six weeks, as this period of time is happening with the cooperative agreements being put into place we are going to be developing this curricula, we’re going to be asking for your input, we are obviously working on the toolkit.

And then we’ll be deploying a lot of these services which are arrayed on the right hand side of the page. The left side has obviously been launched. In terms of the leadership forum, if any of you have been to the state level Web site you will now see that it’s branded as the leadership forum and it’s now your Web site.

And there will be - there is an archive there of the project resources but there will be a password protected area there where as time goes on and we need to develop information share things before it goes public in a developmental way, we’ll have a place for the forum to have a communication platform. The toolkit has been launched and it’s ongoing. I’ll speak a little bit more about the list serve later.

We want to start a mechanism where we can have a timely and ongoing way for states to be asking questions and we can be responding as a team. We’ll be setting up times for the forum to talk on particular topics and to provide input about needs and issues as they’re coming up and launching the consulting services as we go further into the process of really pulling together all the cooperative agreements and the results of all the plans, milestones, and TA needs.

And then a forum leadership training is tentatively we’re looking at early April for when that would occur. So moving ahead then on the next slide I’m going to turn it back over to Greg so that he can talk a little bit about the toolkit now and this major resource that has been sort of the first big development of our technical assistance program.
Greg Farnham: Okay great, thanks Lynn. As you can see there are sort of multiple vehicles that we’re planning on using to develop to deliver technical assistance, the toolkit being just one of them. And you can now locate the toolkit at

The purpose is consistent with the program goals to provide web-based technical assistance resources that help states accomplish targeted milestones outlined in their plans and cooperative agreements.

As you will see in the demonstration that’s coming up, the tool aligns with state HIE program guidance modules, it offers education, decision making support, and practical tools. We’ve really designed this to be sort of customized to some of the questions that we’ve been hearing to make sure it’s very targeted to meet your needs.

The content again, this is the one version of the toolkit and the content will continue to expand and emerge based on information we’re learning from the field as well as additional guidance coming out from ONC. And we really hope that you will consider it your one stop shop for guidance and support for the program.

So as I mentioned, this is the initial release and it’s focused on planning fundamentals, scheduling a second release at the end of January and we need to integrate as much feedback from the states as possible. So we’d really like to hear from you. We’d like to have you start using the list serve, etc. And that’s - I think now we’re moving into the actual demonstration Lynn.

Lynn Dierker: Right, and I’ll get that toolkit up. So hopefully - there’s a little lag time as we move between the screens but you should be seeing on your screen the state HIE toolkit and this is the home page.
Again as Greg mentioned, you can get to this directly. It’s on its own URL, You can also get to this if you go to the leadership forum Web site because there is a link there to take you to the toolkit. But this does stand alone.

And here on the home page as you can see, we’ve hopefully designed something that is really clear and straightforward, easy to navigate. And you can find here the first set of modules that are part of this first beta release and they include the general planning, governance, technical infrastructure, finance, the Nationwide Health Information Network, and grants management.
So if you go to any one of these modules you’ll find in each module that they have been designed to provide some general information that is foundational about the topic. And that really is a compendium of some of the basics you need to - that anyone would need to understand about what constitutes that subject.

And then we’ve also embedded within the section links to the other areas and resources and other tools that and other modules that support and correlate with that topic. And within each module we have an overview section, a frequently asked questions section, tools and resources examples, and an area for program guidance that’s available from ONC and other federal sources.
So I’d like to sort of illustrate the toolkit and because I know we’re short on time I’m going to take an example of governance which is a really important - someone in an early planning stage thinking that they really need to complete their strategic plan.

And while the toolkit is more geared at this time to fundamentals and planning, it is applicable and we’ve started to incorporate and address the fact that this supports those who are doing initial planning, revising their planning, and it will also be added to on an ongoing basis as advanced topics and additional information come out.

So for anyone who is interested in grant management items that have to do with their actual receiving their cooperative agreement, what’s expected, how are they going to understand the key topics that they need to manage to, you can see that this grants management overview section will have several important topics about terms and conditions, about financial management and cost considerations, allowable costs, post award activities, reporting, and these kinds of topics.

And these will be updated on an ongoing basis so that this will be a vehicle by which ONC can continue to add additional specifics that can be available for you. And each time that happens we’ll use the list serve and we’ll send out, you know, a notice that says there’s - there are updates and we’ll also use our RSS feed on the leadership forum page to alert you to these updates on the toolkit.

So quickly let’s assume that a state is interested in completing their plan and wants to really understand how and what they need to include in a plan. I’m having a little lag time on my computer so I’m going to go a faster route.

In the general planning section there is a planning overview section that includes strategic plan guidelines and operational plan guidelines that outline and correlate with what has been in the SOA, in the fundings announcement. With these guidelines you can find an approach to understanding each of the aspects of a strategic plan that need to be completed.
And I want to emphasize that what we’ve tried to do as a TA team with this toolkit is to not just repeat the SOA but to translate it and to really add to it based on sort of real time guidance for those of you who are in the position of needing to interpret it with your stakeholders to understand what it’s going to mean to you.

So that you can go into the strategic plan guidelines and you can find all of the general components that are required to be in a plan and the domain specific components and broken out with some key points about what needs to be considered in each of these.

And as we get information and sort of best practices that are emerging from the review of all the state plans and we continue to understand these best practices, we’ll be adding them here with more specific direction from ONC with these requirements and standards for what needs to be in plans.
But let’s assume then that you want to look and see all these components of a plan and you want to tackle governance. You want to go in and really understand what is going to be involved in setting up a governance structure.
The governance module is constructed again in an overview, frequently asked questions, resources, examples and case studies, and links to ONC and federal programs documents. We have again attempted to sort of talk to you as the user in terms of understanding what governance is and then understanding what factors you need to consider in terms of implementing governance.
So we’ve tried to highlight as you can see by our little light bulbs really important dimensions that are relevant to governance. And the intention of this overview section is that this information is really helpful for you and your stakeholders to really clearly understand the functionality that needs to be put into place and what it is that you’ll need to operationalize within your state.

So as you look down this section you can see that there are - there’s a lot of information and then there’s - you come to governance structure and key components and you really want to understand well what is it that we really need to consider. What does this mean to put a governance relationship in place?

And so we include here links such as this table which will come up in a minute that you can see here that is an overview of key roles and organizational functions that are related to governance and need to be taken into account.
So this attempts to show that there are certain activities within state government itself, certain functions that are part of a state level government entity regardless of which type it is, where it lives, but they are the kinds of functions that need to be considered, the role that it needs to play.
And then on the far right is a column that says and if there are going to be technical operations based on your technical infrastructure and your health information exchange environment, these are the things you’ll need to also consider when planning for what the governance entity may need to do and take on.

So quickly, I mean, this is a very quick sort of introduction to go back and show you how the site is organized. And this again are in each of the domains. The frequently asked questions, we’ll continue to add to these sections. Right now these links will take you back to the overview area and as we get questions we’ll continue to add information. As we get resources we’ll continue to populate the site and we’ll continue to build these links.

Under resources, each site contains right now an initial set of resources. They may vary. This governance section includes several of the primary reports that have been most recent that are really very helpful. But it also includes a milestone checklist as does each domain module that correlates with the SOA and correlates with the milestones in the cooperative agreements and gives you a tool that you can use to understand your key milestones and the fulfillment criteria that go along with this module.
The governance examples and case studies again include some key approaches and examples. These vary across the domains right now and we will be increasingly adding here as we know that there are many, many examples with different dimensions across the domains that you’re interested in.
And then again during - in the links to ONC and federal program documents we want to make a place here where you can come and you can find again all of the expectations, particular requirements, links to documents -- anything, any formal documents that you may want to see or information is here.
So quickly, I don’t know Greg if you would like to talk a little bit about technical infrastructure -- we just have a few minutes left -- as another type of example that I think is particularly relevant. And then we can perhaps take a few questions.

Greg Farnham: Lynn I think we’re kind of closing in on the hour here so I think we’ve covered - I think the only thing to mention is that, you know, it certainly - you’ve covered it well. I think the point of this conversation was just to point out the framework and get people excited and interested to come and visit the site and provide us with some feedback. And I’m afraid we’re going to lose people at 2:00 so I’d like to maybe stop here and ask if you have any closing remarks and then we can open it up to questions.

Lynn Dierker: I just wanted to say by way of next steps that as you’ve heard we’re very, very interested in your feedback on this beta release, the kinds of resources and tools that you’d like to see.

And what we are going to be doing is as you know we’ve started a list serve and we have a list of the specific contacts in each state, sort of a dedicated, restricted list and then we have a more open list for people who are interested. And we’re going to be using these list serves to do a variety of communications but we’ll be sending out a message to you and asking for your feedback.

And we hope that we’ll start to generate really robust dialog across the state as we share resources. And then we’ll be getting back to you with some scheduling in terms of some webinars, talking about TA needs and plans, and moving forward from there.

Greg Farnham: Great. Are there any questions from the group?

Coordinator: At this time if anyone would have a question please depress Star 1 and please record your name. We do have a question from (Jeff Blair). Your line is open.

(Jeff Blair): Yes, I know the different states are at different degrees now of completing their state HIE strategic and operational plan. But we’re probably among many states that have been receiving calls from consultants and attorneys and others asking if we could release our plan.
In the past we’ve had no problem in making our plan publicly available but we’re waiting until ONC provides some guidance to us with respect opt making our state plans publicly available. So if you don’t have a policy yet could you consider developing a policy for all of us for our state HIE plans in terms of publicly releasing them?

Kelly Cronin: (Jeff) this is Kelly, it’s a great question and one we’ve been talking about for a while now. We think it might be in everyone’s best interest if let’s say in the near term if there are some state plans that are approved by us as a part of this - part of the process of doing implementation awards for those states who submitted completed plans with their application back in October. I think it would be desirable to have those ONC approved plans public as soon as possible.

And we can talk to you about that process and I know there is going to be sort of an imminent conversation with you about the feedback and that process (Jeff) as there is, you know, ongoing discussions with the other states that applied for implementation funding. So I would think there is certainly nothing precluding you from making your plans public at this point. I mean, that’s really your decision.

We’re really interested in trying to get the first round of ONC approved plans public as soon as possible because we think it really would be very helpful to everyone who is still in a point in process to see what has been approved and, you know, the level of detail that’s in the plan and, you know, the overall content and what’s covered.
And in many cases it’s - well in all cases really it’s the states that have been at this for a while and really have advanced activities that are ongoing that really can provide a good set of examples for other states to refer to.

So we’ll probably follow up with everybody, you know, probably through our - the list serve and the toolkit and be posting those plans providing that the applicants or the award user are in agreement. We intend to publicly post everything that’s approved.

(Jeff Blair): Thank you.

Coordinator: We do have another question from (Christopher Sullivan). Your line is open.
(Christopher Sullivan): Yes thanks and thanks for this very interesting seminar. Lynn I had a question for you in terms of financing and technical infrastructure and ongoing with your toolkit. I know the state level of health information exchange steering committee had initiated some rounds of sustainability programs, had some forums.

And it seems that one of the key issues to plan health information exchange for the long term especially in this time of robust economy and everybody starting companies is the whole concept of how to craft a sustainable exchange using the best selection of technology. If we build an infrastructure that really can’t return on its investment then we have a hard road ahead of us.

So I was wondering if the toolkit, if you have plans ongoing to try to work in some more of the sustainability discussion and how that might be aligned with the appropriate selections or decisions made in terms of technical infrastructure and the services provided. Because I think that could be a very, very key element in really creating sustainable health information exchange across the country. Thank you.

Lynn Dierker: You know (Chris), I think you highlighted an important issue. And, you know, when I said there’s sort of a multi-faceted sort of dimension to this technical assistance picture, there are these issues that require us to really stay in dialog to compare what we really know in terms of the - how advanced we’ve been able to get so far in thinking about sustainability. But now to take on these new dimensions and to really think this through in terms of the emerging big picture.
So this is an area where I expect we’re going to have these roundtable discussions. We’re really going to take up these particular topics and do some additional sort of analysis work and bring it back to the forum and, you know, be advancing it that way and definitely adding it to the toolkit.
(Christopher Sullivan): Great, thank you so much.

Kelly Cronin: This is Kelly. There’s one question that was submitted online. Will there be any fees for technical assistance programs or services like the webinars or on-site consulting? We don’t anticipate there to be any fees or charges involved with anything that’s offered through technical assistance.
So just to reiterate, this is not intended to produce deliverables that are part of, you know, what you need to do under your cooperative agreements once they’re issued. But any of the resources and services that are provided through technical assistance would be free of charge. Are there any other questions?
Coordinator: No there are not ma’am.

Kelly Cronin: Okay great. We’re a little bit over time so thank you so much for a helpful call and for all of your questions and comments today. I think actually some of them are probably ones that we really do need to follow up on and perhaps even make available as an FAQ in the toolkit for those who couldn’t participate today or who maybe want some more clarity beyond what we addressed on the phone today.

So we really look forward to working with you over the next several years and again we’ll be trying to address any specific concerns about the date of the awards with you individually since a couple of questions came up about that particular issue. So thank you for calling in today and participating via web and I’m sure we’ll all be in contact in the very near future.
We will also be in touch in the near term about sort of a meeting schedule so you have a better handle on when upcoming webinars might be. We want to have sort of a probably a series of welcoming webinars once you all have received awards.

We want to make sure that you have the appropriate information you’re going to need and an understanding of what your responsibilities will be as a recipient of federal funding and just, you know, what the expectations of the program are. And we’ll also be giving you more specific dates and times on our sort of our kickoff at leadership summit which is tentatively planned for late April.

So expect to hear from us in the near future so that you can start to plan ahead about when we’ll have both WebEx’s and in person meetings over the next several months. So thanks again everyone and again we’ll be in touch shortly.

Coordinator: That does conclude today’s conference. Thank you all for participating and you may disconnect at this time.