An Update on Massachusetts Health Information Exchange

As I've described previously, Meaningful Use Stage 1 was focused on the electronic capture of data into EHRs.  The standards we specified included content and vocabulary but not transport.

Stage 2 will be more focused on Health Information Exchange.  Transport standards will likely be included in the Notice of Proposed Rulemaking.

In order for Health Information Exchange to work, I believe we need
a.  A transport standard which can be implemented consistently for multiple senders and receivers (such as Direct)
b.  A certificate distribution infrastructure to secure the endpoints (such as via DNS)
c.  A directory for routing information between organizations (such as a RESTful API to a SQL database)
d.  Connections to the last mile -  sending/receiving directly into EHRs (such as via XDR/SOAP) or into a standalone web-portal as a short term solution while vendors build transport features into EHRs.
e.  Governance to guide the technology and policies that support the above

On October 17, the Massachusetts HIT/HIE Advisory Committee (think of it as the state equivalent of a Federal Advisory Committee) presented its recommendations to the HIT Council (the governance for Massachusetts HIT activities).   The Advisory Committee asked for the input of 88 stakeholders divided into 5 groups - legal and policy, technology and implementation, finance ad sustainability, consumer and public engagement, provider engagement and adoption.

The state HIE implementation plan we presented:

*Aligns with national interoperability standards and emerging MU stage 2 requirements
*Maximizes State Medicaid Health Plan/Medicaid Management Information System Federal Financial Participation funding,  a 9 to 1 match
*Focuses Medicaid funding on building infrastructure for statewide services, and the ONC Cooperative Agreement HIE funding for last mile implementation

What is last mile implementation?

1. Our regional extension center (REC) will do a pareto analysis of EHR adoption in Massachusetts to identify the most commonly used EHRs.  I believe that 20 EHRs are common but 5 EHRs (eClinicalWorks, AthenaHealth, NextGen, Allscripts, GE Centricity) cover 90% of the providers.   We'll negotiate with those vendors to create the software which is necessary to connect their EHRs to the statewide Direct backbone in 2012.  Yes, we could wait until 2013 when Meaningful Use Stage 2 requires them to implement transport standards, but coordinated procurement now will accelerate HIE integration.

2.  We'll provide System Integrator services to support on boarding of small practices and subnetworks of clinicians to the state HIE backbone.

3.  We'll provide education and training to foster adoption and use of HIE services.

4.  We'll devise grants and subsidies that serve as incentives for HIE adoption

5.  We'll facilitate the addition of value added services to the backbone such as public health reporting, clinical registries, and quality measurement services

As I've spoken with vendors, many have noted that State HIEs tend to build central infrastructure but assume endpoints will connect to it on their own.   My experience is that a centralized project management office and a single coordinated plan is needed to connect the endpoints.  Once every provider, payer and patient is connected, the value proposition of the HIE will increase significantly per Metcalfe's law.

We agreed that by November the Advisory Committee will complete:

*Initial State Medicaid Health Plan Implementation Advanced Planning Documents (IAPD) for review by Advisory Committee workgroups and the Secretary of EOHHS before submission to CMS
*An outline of Statewide HIE Policy Guidance that complements the technology to be built via IAPDs
*A high-level plan for entire project, so that all stakeholders understand what we're creating

I'm extremely optimistic - we have a plan with alignment of support, appropriate funding, and mature technologies that are low risk for failure.   The HIT Council, MeHI,  and Federal government stakeholders are reviewing our recommendations over the next few weeks and we'll seek their approval to move forward in November.

The momentum for Health Information Exchange in Massachusetts is building among payers, providers, patients, government, and industry.   2012 will mark the tipping point that enables us to stop talking about barriers to Health Information Exchange and instead focus on the accelerators.