# Presentation: 089039

## State-Level HIE Considering Key Governance Roles and Implications 

- Lynn Dierker
- Rachel Block
- NHIN-HISPC-SLHIE Joint Conference
- May 1, 2008

## Considering Statewide HIE Key Questions

- What is the distinct value for state level HIE activity?
- Is there a state level “approach” or model for implementing HIE?
- How do state level efforts relate to achieving widespread interoperability?

## SLHIE Project Focus 

- Clarify the state level roles and functions necessary to support HIE
- Assess roles and functions in different state environments and at multiple levels (i.e., local, state, regional, national)
- Determine points of commonality, divergence across approaches
- Assess models and identify implementation framework/pathways
- Governance and accountablity
- Policy
- Technical design and roadmap to interoperability
- Costs and resources needed to provide functions
- Financing approaches to support functions

## State Level HIEAn Evolving Landscape

## Governance Research Key Considerations and Influences

_**Considerations**_
- Sources of authority
- Business models
_**Influences**_
- Governance...........................AHIC 2.0
- Privacy and Security.................HISPC
- Technical Implementations.........NHIN
- Standards..................................HITSP
- Network Certification.................CCHIT
_**Alternative Visions of the Future**_
*Chaotic conversion of competitive interests*
*Guidance through coordination & alignment*

## HIE Governance FunctionsWhere the Rubber Meets the Road

- Privacy protections – confidentiality in practice
- Rising public concerns
- The confidentiality of health records
- Consumer empowerment
- Accountability for managing secure and effective HIE practices
- Need to balance public policy concerns with practical realities of HIE development
- Confronting the realities of how oversight of data access, use and control will be effectively carried out.

## Realizing the Promise of Interoperability State level HIE Functions 

_**Priorities for state-level HIE **__***organizational ***__**roles**_** **
- Consistent application of HIE policies, practices and interoperability standards
- Redefining relationships and degrees of collaboration vs competition to achieve HIE social benefit
- Accountability for appropriate controls over data access, use and control
- Mobilization of data from diverse sources

## SLHIE Framework

- Public and private sectors will _**share**_ data, financing commitments, participation in governance, and development of  certification and roles to leverage resources for common good.

**SLHIE**
**Public-Private**
**Partnerships**

**Public-sector**
- Participants

**Private-sector**
- Participants

**Providers** using HIE to improve quality, efficiencies, reduce errors.
**Payers** and **purchasers** using secondary data for quality and safety initiatives.
**Research organizations** using secondary data to accelerate and improve health treatments.

**Public** **providers** using HIE to improve quality, efficiencies, reduce errors.
**Medicare/Medicaid** using secondary data for quality and safety initiatives.
**Public health entities** using secondary data to accelerate and improve health treatments.

## States and State-Level HIEDefinitions and Distinctions

***“******States”-****** ***commonly refers to*** ***state *government* roles and responsibilities (health care policy, regulation and oversight, public health, public insurance programs i.e. Medicaid, public employees)
***“******State-level health information exchange” -***  refers to organized *state-level *efforts ranging in structure and development but with common features related to health information and advancing interoperability
***Key dimensions: ***
- Serving statewide public policy goals for improving health care quality and cost-effectiveness
- Entity with a statewide scope for advancing HIE
- A multi-stakeholder public-private partnership as a governance structure

##  “Governance” vs Government

**State-level HIE “governance”  **
- Convene diverse statewide stakeholders
- Lead and coordinate consensus-based efforts
- The statewide roadmap for interoperability (strategies, relationships, timelines for the particular characteristics of a statewide landscape)
- The policies, procedures and practices related to data use, access, and control; privacy and security.
**State-level HIE governance entity**
- Sits between state government and the health care sector
- Any configuration of HIE networks or RHIOs, agencies, and relevant medical trading areas
- Mission to facilitate compliance across diverse interests and organizations
- Prevailing laws and regulations and sound data management practices
- Neutral and skilled resource serving all stakeholders

## Governance Research FindingsTwo Roles, Three Functions

**Governance Research Findings**Two Roles, Three Functions

**Coordination**
**Function**

**Convening**
**Function**

**Operational**
**Functions**

- State-level
- HIE

- Governance Role

- Technical Operation Role
- (Optional)

## HIE Roles, Functions & Business ModelsAnalytic Framework

| SLHIE Role | Governance
 |  | Technical Operations
(Optional) |
| --- | --- | --- | --- |
| Function | Convening | Coordination | Operating |
| Tasks |  Establish trusted platform for education, negotiation and decision-making

 Advocate on behalf of local stakeholders to advance statewide HIE

 Inform policy development to advance statewide HIE

 Facilitate consumer input

 Track, assess & distribute information on HIE efforts |  Establish and maintain technical roadmap

 Facilitate alignment with local, interstate, regional, & national strategies

 Promote consistent application of effective statewide HIE policies & practices

 Facilitate collaborative development of public policy options & ongoing health care reform efforts |  Own or manage contracts for hardware, software, & technical capacity to facilitate statewide HIE:
infrastructural components (e.g., MPI, RLS), 
applications (e.g., clinical messaging, eRx, EHR), 
services (e.g., implementation guides, standards, workflow optimization)
 |

**HIE Roles, Functions & Business Models**Analytic Framework

**Notes:**
Universal agreement that convening stakeholders and coordinating statewide health information exchange was a critical role for SLHIEs.

Nearly all aspire to operate or oversee the operations of a statewide health information exchange.

Less consensus on the scope of authority and specific functions regarding the coordination and operation of statewide health information exchange.

Significant agreement that state-level HIEs should be independent entities that qualifies for tax exempt status, have multi-stakeholder board consisting of both public and private entities, and have defined relationships with state government.

## Key Findings Organizational Roles - Models

- Migration to two distinct and key organizational HIE roles *at the state level *
**Governance**:
- _Neutral convening_: Structure for engaging stakeholders in statewide mission to build HIE for healthcare quality, cost-effectiveness
- _Coordination_: Mechanism to facilitate collaboration across diverse interests
- Development and implementation of a statewide HIE roadmap
- Consensus-based HIE data sharing policies and practices to ensure confidentiality protections
- Facilitate lowest cost HIE development serving statewide stakeholders
**Technical operations**:
- State-level technical functions (owned and/or managed) to facilitate statewide HIE
- Variable technical models, approaches

## FindingsTrends Across States

- State-level HIE governance role is primary
- Ensure that HIE develops as a public good (beyond silos, corporate interests)
- Serves all statewide stakeholders and data needs
- Reduces technology investments and other costs for all participants
- State level HIE governance entity is a *public-private partnership entity *
- Sits *between* state government and the health sector and industry
- Involves state government, but independent of state government
- Addresses public and private sector interests, blends investments
- Mechanism for coordination of HIE policies and practices
- State governments play important roles
- Designating authority to a state level HIE governance entity
- Providing resources: start up and ongoing
- Leveraging public programs, policy levers to create incentives for HIE
- State-level Governance facilitates various evolving statewide technical approaches
- Size, market characteristics, resources,
- Stages of development

## Organizational Models and Developmental Pathways

**Notes:**
Emphasis what we are seeing about these models.

After two years of study, we are seeing some trends emerge.  This year we took a look at how states are configuring roles and responsibilities among state government, independent public-private partnerships and the range of HIE that are operational or planned.

We have described some of the dug deeper to see implications on how to address accountability.

Florida...7 RHIOs being funded by state
Michigan....9 medical trading areas, RHIOs being supported with state funds in each
New York...more than 20 projects some of which will emerge as RHIOs
* Questions that still remain?  They own operate and manage, what are the implications....

## Governance Examples of Sources of Authority

| State Level HIE Initiatives |  | Authority to Serve as
Governance Entity |  |  |  | Authority to Provide Technical Operations |  |
| --- | --- | --- | --- | --- | --- | --- | --- |
|  |  | Executive Order | Legisl | State contracts (e.g., HISPC) | Other | Contracts AHRQ SRD | Contracts Services |
| AZ | Arizona Health-e Connection |  |  |  |  |  |  |
| MA | MHDC |  |  |  |  |  |  |
| RI | Rhode Island Quality Institute |  |  |  |  |  |  |

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**Notes:**
Key Findings:

1. State-level HIE representatives emphasized that sources of authority and the mechanisms used to confer authority are heavily influenced by local practices and practical considerations. For example, the degree to which state governments utilize executive orders, rules and regulations, and contracts varies significantly from state to state. Amongst the Project Steering Committee, there was no consensus as to which source(s) or mechanism(s) of authority would be the most effective across all states.

2. While consolidating these authorities within a single organization has been proposed as a means for streamlining coordination efforts, some stakeholders expressed concerns about conferring control of privacy and security issues to entities that also have operational responsibilities. 

AZ....Medicaid Transformation Grant calls for 1.3 M to develop linkages to ensure Medicaid HIE will connect with Arizona Health-e Connection  and others.

MA...Collaboration of leading stakeholders, since 1978 serving as the neutral forum and its authority based on stakeholders continued participation.

RI... Given official destination, received award in October.  Haven’t signed a contract.  State will try to transfer as much as state AHRQ contract

## New York as a Case Study

- Independent non-profit state level HIE governance entity
- Not technical operations (currently)
- Large state population
- Strong state government leadership and collaboration
- Illustrates relevance of findings and recommendations from State-level HIE Consensus Project

## Building Blocks NY Health IT Strategy 

- Promote collaboration at state and regional levels
- Support development of RHIOs
- Link to national strategy and standards (focus on interoperability)
- Use infrastructure to expand reach, lift all boats
- Privacy and security are essential to public trust
- Support strategic uses of health IT – high-yield benefits from reducing inappropriate utilization and increasing use of preventive services
- Sustainability hinges on payer involvement

## NYeC Goals

- NYeC will galvanize health care systems improvement by promoting broad use of health information technology through a comprehensive and coordinated state policy agenda that:
*Stimulates coordinated and collaborative efforts* among health care stakeholders to identify and overcome barriers to widespread HIT adoption and use to *enhance evidence-based practice by clinicians, as well as consumer engagement in health maintenance and management *
- Advances health care *performance measurement, public reporting and improvement* supported by HIT
*Improves public health* through effective prevention and management of chronic disease, as well as stronger public health surveillance and emergency response capabilities
*Ensures accountability *by measuring and evaluating HIT impact on health care systems, payers, providers, and consumers

## NY Health IT Strategy Tools to Implement 

- Coordinated policy leadership at state level through State DOH
- NY eHealth Collaborative established to drive collaborative implementation efforts
- HEAL-NY grants for state and regional initiatives promoting HIT and HIE
- NY HISPC forging stakeholder consensus on policies and procedures to protect privacy and security, and ensure consumer access and engagement
- HITEC statewide academic consortia partnering with stakeholders and RHIOs to standardize evaluation measures and methodologies

## Statewide Public-Private Partnership & Collaboration Process – 

**Governance & Policy Framework for New York’s Health IT Agenda**

**Department Of Health**

**New York eHealth Collaborative Board  **

- Policy & Operations Council (RHIOs, HSPs, CHITAs)

- Education & Communication Committee

- Projects

- Strategic Partner Initiatives
- Financial Sustainability
- HITEC – Evaluation
- Consumer Advocacy Coalition

- Privacy & Security

- Collaborative Work Groups

- Implementation

- Feedback

**Policies & Standards**

- Clinical Priorities
- Medicaid
- Quality Reporting
- Public Health
- Connecting NYs and Clinicians

*Governance*

*Work Structure & Project Management *

- EHR Collaborative

- Protocols & Services

## Collaboration Priorities

- Statewide and Regional Governance
- Technical Requirements for Interoperability
- Components to Sustainability
- Value Proposition at Clinician and Consumer Levels
- Cumulative Effect – Can We Bend the Curve
- Continued Investment in Infrastructure
- Ensuring trust through affirmative consent and privacy protections

## Important State-level Challenges and Opportunities 

- Relationship of state level progress to federal strategies, governance and resources
- Sustainable infrastructure – need for government to do what it can, but rely on independent non-profit governance
- Levels of stakeholder engagement to achieve real data sharing
- Perspectives from Steering Committee (and other states)
- Pivotal time
- Voice with AHIC, NHIN
- SLHIE Project’s role and value
- Peer learning
- Real time identification of emerging issues, trends, models
- Organized perspectives and voice of state-level HIE perspectives

## Implications for AHIC Priority Recommendations

- Permanent AHIC must sufficiently inclusive and empowered
- Agenda to link strategies for HIE development with *health care transformation agenda (secondary use, quality, transparency)*
- Synergy between nationwide and state level HIE governance
- State-level HIEs key stakeholders in permanent AHIC
- Design formal mechanism for state-level HIE participation
- Public-private state-level HIE entities engaged in all aspects of AHIC work
- Reflect HIE readiness across diverse statewide environments
- Incorporate all state-level perspectives in its mission and activities
- Serve as vital laboratories for informing, vetting and advancing AHIC priorities.

## Information and Additional Resources

- State-level HIE Consensus Project
- _[www.staterhio.org](http://www.staterhio.org/)_
- Lynn Dierker, RN, Project Director
- _[Lynn.dierker@ahima.org](mailto:Lynn.dierker@ahima.org)_
- New York eHealth Collaborative
- Rachel Block, Executive Director
- Rblock@uhfnyc.org