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NIST Health IT Symposium Series

Status, Challenges, and Progress to Date

September 27th, 2012 
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Mission 

To advance the health and wellness of Marylanders by 

deploying health information technology solutions adopted 

through cooperation and collaboration.

Vision 

We will enable and support the Maryland healthcare community 

to appropriately and securely share data in order to facilitate 

care, reduce costs, and improve health outcomes.

CRISP Mission and Vision
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History of National HIE Strategy

 Early national HIE strategy shaped by David Brailer (first US HIT Coordinator 

appointed in 2004 by President Bush) and Santa Barbara HIE experience

 Early strategy was supportive of state and regional efforts setting up federated 

HIE networks, however, ONC remained a poorly funded office within HHS

 Over subsequent Coordinators (including Robert Kolodner) national strategy 

shifted to focus on development of a network of networks linked together 

relying on National Health Information Network standards and policies (NHIN 

itself is not actual infrastructure)

 Under David Blumenthal’s ONC, this strategy led to the development of an 

open source instantiation of the NHIN standards called CONNECT. These 

models largely focused on the concept of query-based HIE - collecting 

encounter records into repositories clinicians could later access.

 Then HITECH happened.....
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HITECH

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About $700M of the HITECH funds went directly to statewide HIEs such 

as CRISP, jumpstarting the efforts

After HITECH, HIE’s positioned themselves as a tool to achieve 

“Meaningful Use”; the business model was to charge providers a fee as 

you help them earn a piece of the new incentives
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Government Mandates
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Meaningful Use and Where HIE Fits Today

 Some HIE effort suffered from the “dog caught-up to the mailman” syndrome

 Across the country, progress of HIE as a reliable infrastructure was uneven. 

Some north-eastern states made good progress, but many states were 

getting nowhere

 As ONC and CMS evaluated where HIE should fit within larger MU strategy, 

they decided to focus on Directed exchange of clinical information, 

analogous to existing workflows ... HIE wouldn’t be required

 The central theme of this decision was avoidance of the technical, legal, and 

relationship complexities of query-based HIE and focus on a simple standard 

(basically secure email) which could be ubiquitously adopted. When paired 

with MU CDA documents, much could happen...

 Supporting transitions in care (relying on CDA templates) through Directed 

exchange is currently the heart of an evolving national strategy
Original CRISP HIE diagram

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HIE

H

RxHub

PBM1

PBM2

PBM3

Sure 

Scripts

Rx1

Rx2

Rx3

PBM4

PBM5

H H

Labs

D D Chart

HRB1

Microsoft 

Health 

Vault

User Interface

Web

Browser

Call

Center

HRB2

Health 

Monitoring 

Devices

Health 

Club

Radiology

Chart

Already started

Planned improvement

RHIO approach

HRB approach
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Maryland HIE Sustainability

 CRISP funding to date has largely been grant based

 CRISP is currently collecting hospital participation fees

 The CRISP sustainability plan calls for operating expenses to be distributed 

across 3 customer-bases; hospitals, payers, and public sources
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High Level Interoperability Challenge

Without mandate, CRISP has found most levels of inbound 

and outbound integration with ambulatory EMRs a difficult 

target to achieve.

1.Transport Interoperability (e.g. VPN, SFTP)

1.Message Interoperability (e.g. CDA, HL7)

1.Semantic (Vocabulary) Interoperability (e.g.LOINC, SNOMED, ICD)

2.Process Interoperability (workflow)

The enemy of interoperability is optionality and lack of 

specificity....what we are doing today is largely widespread 

connectivity, not interoperability....
Updated

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Master Patient Indexing – IBM Initiate

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The Challenge: accurately and 

consistently linking identities across 

multiple facilities to create a single 

view of a patient.

A zero or near-zero tolerance of a 

“false positive” match with a low 

tolerance of a “false negative” match.

Accurate cross-entity patient identity 

management is a critical function for an 

HIE to serve multi-organizational reform 

initiatives
Connectivity Progress to Date

Updated Sept 18th, 2012

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Progress Metric Result

Organizations Live

Hospitals (Total 48) 48

Hospital Clinical Data Feeds (Total 143 - Lab, Radiology, 

Clinical Docs)

86

National Labs 2

Radiology Centers (Non-Hospital) 5

Identities and Queries

Master Patient Index (MPI) Identities ~4M

Opt-Outs ~1500

Queries (Past 30 Days) ~3500

Data Feeds Available

Lab Results ~16M

Radiology Reports ~5M

Clinical Documents ~2M
1. Query Portal Growth

2. Direct Secure Messaging

3. Encounter Notification System (ENS)

4. Encounter Reporting System (ERS)

5. Health Benefits Exchange integration

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Current Focus Areas
The CRISP Query Portal can make clinical 

information available 

• Access must be part of a treatment encounter or 

approved use case

• Web-based application with credentials issued 

by CRISP

• The current workflows are difficult

CRISP Query Portal

Types of Data Available

• Patient demographics

• Lab results

• Radiology reports

• Medication fill history

• Discharge summaries

• History and physicals

• Operative notes

• Consults 

Key Challenge / Lesson Learned: The depth of data, the 

breadth of data, and the geographic diversity of data must be 

significant to reach the “tipping point” in query
Query Portal

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CRISP Infrastructure Overview 
PDMP as Part of Query

 We will be working closely over the coming weeks with our partners, 

including Optum, to evaluate capabilities to support the program

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 DHMH and the PDMP team have been actively 

interested in partnering with CRISP on Maryland’s 

PDMP technology solution

 CRISP can play an important role in ensuring controlled 

dangerous substance (CDS) data is incorporated into a 

single source of external clinical data for providers 

(rather than a stand alone PDMP portal) 

o If Maryland does push ahead with PDMP, we are 

eager to use the CRISP query portal to provide 

access to physicians, believing a two-portal 

solution would be bad for everyone.
Direct Secure Messaging Usages:

• To communicate referrals and visit 

summaries between Ambulatory practices

• To send relevant patient clinical information 

between ambulatory practices and hospitals

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CRISP Direct Secure Messaging

• To make formal medical records requests from Ambulatory 

practices to the hospital

• To receive encounter alerts from CRISP’s Encounter 

Notification System when a patient is hospitalized
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CRISP Infrastructure Components
Encounter Notification Service

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 ENS went live on August 3rd with practices 

at three hospital partners 

o Harbor Hospitals, St. Josephs, GBMC 

and JHCP

 Roughly 6000 messages per month are 

current triggered

 Subscribers submit a patient panel to 

CRISP and identify which types of alerts 

they would like to receive

 Phase 1 notifications only include 

demographic information and the event 

types; including chief complaint and 

discharge diagnosis could increase the 

value of the service significantly
Encounter Reporting Service

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 Inter-hospital readmission reports have been distributed to half of 

Maryland hospitals

 CRISP is working with hospital to address variation admission data 

produced by financial data versus that which we receive from 

registration systems – THIS IS A MAJOR CHALLENGE 

 CRISP has generated a 

series of proof-of-concept 

GIS maps to visualize 

utilization as hot-spots

 This capability could be 

valuable to public health 

officials as well as to 

hospitals 
ERS Mapping

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Health Benefits Exchange Services

CRISP was include in the HBE Level 2 funding request to support 3 

specific services:

1.Provider Information Management

 Partnering with Optum, CRISP will offer a verified provider demographics 

source (fed by the HBE Qualified Health Plans) to enable HBE customers to 

search for plans by providers in the network

2.Master Patient Indexing Services for the All Payer Claims Database

 Relying the Initiate MPI, CRISP can enable insights into member churn 

between QHPs and Medicaid plans as member eligibility status changes over 

time

3.Clinical Summary Care Coordination Service

 Based on a triggering event, CRISP will compile a time-banded summary of 

data (starting with just encounter data) to forward to care coordinators 

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Questions