Montgomery County Health Information Exchange Collaborative Strategies for a Person-Centric, Inclusive Maryland Health Information Exchange February 2009 TABLE OF CONTENTS PAGE SUMMARY, FINDINGS, RECOMMENDATIONS Acknowledgements 1 Executive Summary 3 Introduction 3 Advantages in Maryland 3 Summary of Recommendations 4 - Governance 4 - Financing and Business Model 5 - Privacy and Security 6 - Technical Architecture 6 - Community Engagement 7 Transformative Change 7 Background 9 Montgomery County/Prince Georges County Healthcare 10 Environment Study Design and Report Organization 10 Caveats, Cautions, and Assumptions 11 Our Vision of Statewide HIE in Maryland in 2012: Three Years into 13 the Future Guiding Principles for a Statewide HIE in Maryland 13 Implementation Approach for a Statewide HIE 14 Statewide HIE Participant Relationships 15 Use Case Selection and Priority Sequencing 16 Summary of Decision Points, Recommendations, and 17 Rationale Governance Report Decision Points and Recommendations 18 Community Perspectives Report Decision Points and 25 Recommendations Privacy and Security Report Decision Points and 26 Recommendations Technical Infrastructure Report Decision Points and 31 Recommendations Finance and Sustainable Business Model Decision Points & 39 Recommendations Capital Costs Summary for Statewide HIE 42 Financing Approaches for Statewide HIE 42 Conclusion of MCHIE Study Design and Recommendations 43 Overview REPORTS Governance Report Executive Summary 1 Background: The need for State Support of HIE 2 Key Decisions for State-Level HIE Governance 4 - Vision for Statewide HIE 5 - Role of RHIOs and Local HIEs 9 - Relationship Between Governance and Technical 12 Operations - Collaborative Governance Structure 15 - Composition of Governance Entity 19 - Accountability Mechanisms 23 - Measuring and Evaluation Progress 27 - Key Functions and Tasks 32 - Implementation 35 Attachments - Glossary 38 - State-level HIE Governance Approaches in Leading 39 States a) New York 43 b) Tennessee 44 Community Perspectives Report Executive Summary 3 Introduction 4 - Background 4 - Objective 4 - Methodology 4 - Limitations 6 Detailed Findings 6 - Perceived Assets, Benefits, and Utility 6 - Desired Features 8 - Risks, caveats, and barriers 9 - Factors in organizational and individual support of 11 HIE Recommendations 13 - Gaining Buy-In and Support 13 Conclusions 15 Appendices 16 - Focus Group Discussion Guide: English 17 - Focus Group Discussion Guide: Spanish 19 - MCHIE Community Perspectives Questionnaire 21 - Consumer Survey 23 Privacy and Security Report Executive Summary 1 Background on State-Level HIE Privacy & Security 2 Threshold Issues for State-Level HIE Privacy and Security 4 - Governance 4 - Scope of Privacy and Security Policies 6 - Policy Interoperability and Enforcement 8 - Seeking Changes to or Conforming with Existing 10 Laws - Baseline Consent Principles 12 - Data Filtering 14 Attachments - Glossary 16 - State of Maryland’s Comparison of MCRA and 18 HIPAA - Comparative Analysis of Privacy and Security 21 Approaches in Leading States Technical Infrastructure Report Executive Summary 1 MHCC RFA Requirements for Technical Features 2 Background on State-Level HIE Technical Implementation 3 - Technical Components and Key Considerations 3 - Use Case Definitions 8 Threshold Technical Decisions for Maryland Statewide HIE 11 - Technical Design and Implementation Principles 11 - Implementation Approach 14 - Interoperability Standards 21 Use Case Sequencing 24 Cost Modeling 30 Attachments - Glossary 35 - Use Case Details 37 - Existing Capabilities: HIE and Health IT in Maryland 50 - Product Categories, Vendors, Price Ranges 56 Finance and Sustainable Business Report Executive Summary 1 Background on State-Level HIE Financing 2 - Public Good Characteristics of Statewide, 3 Interoperable HIE - Impact of Healthcare Structure and Incentives 3 Threshold Issues for State-Level HIE Financing 4 - Principles to Guide Financing of Statewide HIE 4 - Use Case Selection 6 - Startup Capital 15 - Ongoing Operating Expense 21 - Financing For Governance Process 24 Attachments - Glossary 27 - Detailed Analysis of High-Priority Use Cases 29 - Approaches for Securing Capital Financing 46 APPENDICES Appendix A: Teams and Team Members Governance Community Perspectives Privacy and Security Technical Architecture Finance Appendix B: “Evidence on the Costs and Benefits of Health Information Technology”; Congressional Budget Office, May 2008 MCHIE Statewide HIE Program Summary, Findings. Recommendations Acknowledgements This work could not have been completed without the enthusiastic and generous contributions of so many individuals and organizations. In spite of extensive and numerous obligations, this group worked together to address the complexities, benefits, and strategic planning necessary to bring the benefits of health information exchange to the people of Maryland. Please refer to the appendix that lists the valued participants for Montgomery County Health Information Exchange Collaborative. February 19, 2009 Page 1 of 43 MCHIE Statewide HIE Program Summary, Findings. Recommendations February 19, 2009 Page 2 of 43 MCHIE Statewide HIE Program Summary, Findings. Recommendations Executive Summary Introduction Health Information Exchange (HIE), properly planned, governed, and deployed, has the potential to bring many benefits to the people of Maryland. The structured, inclusive planning approach taken by the state beginning with Senate Bill 251 of the 2005 Maryland General Assembly greatly improves the chances of success compared with failed or stalled efforts elsewhere. The Task Force to Study Electronic Health Records report (December 2007), the Privacy and Security Solutions and Implementation Activities report (September 2008), and the two reports commissioned for the Citizen- Centric Health Information Exchange for Maryland (this report from the Montgomery County HIE Collaborative (MCHIE) and the sister CRISP report) constitute a comprehensive assessment of the national, state and local opportunities and challenges; the identification of critical success factors; and incremental, value driven plans for moving toward a statewide HIE that will benefit every individual However, a word of caution is in order. The health care sector has traditionally lagged behind virtually all other sectors of the economy in the effective use of information technology to improve quality, lower costs, institute process improvements, and make information more accessible for better decision making. Contributing factors include the fundamental complexity of medical science; the complexity of the U.S. health care delivery system; misaligned reimbursement structures; legal constraints and uncertainties that increase costs and delay implementation; costly, complex, and largely incompatible data systems that further complicate exchanging data; high acquisition and operational costs that stress budgets and inhibit adoption; and difficulty in achieving and demonstrating a positive return on investment. The highly decentralized health care delivery system is sometimes a contributing factor as well, in that it can be challenging to achieve economies of scale for a one or two provider practice in a way that is both cost effective for the providers and supported in the most efficient manner. In addition to the legal and financial challenges, considerable skills are required not only to deploy and maintain the required technology, but, more importantly, to integrate the tools into the care delivery process. These skills have historically not been available throughout the health care delivery system in a quality and quantity needed for successful adoption and deployment. To achieve the potentially considerable benefits of a Maryland statewide HIE, governance is a critical, but often neglected activity. For a small practice, community clinic, or individual hospital, the nature of accountability relationships and the requirements to sustain a collaborative framework are a modest to non-existent concern. When creating a statewide exchange, governance must be addressed first. The governance organization must be trusted, representative, transparent, and able to balance the multiple conflicting issues that will inevitably arise in such a venture. Health Information Exchange projects in other states have failed or struggled because of lack of attention to this critical success factor. Effective governance can enhance and accelerate HIE adoption. Poor governance leading to poor adoption and implementation has been shown to lead to failure and a long delay before efforts can be restarted. Advantages in Maryland The State of Maryland brings unique strengths that will serve it well in successfully implementing and benefiting from a comprehensive statewide HIE. First, Maryland is well positioned to create an February 19, 2009 Page 3 of 43 MCHIE Statewide HIE Program Summary, Findings. Recommendations effective public-private partnership to govern and foster HIE by building on the history and capabilities of the Maryland Health Care Commission (MHCC) and the Health Services Cost Review Commission (HSCRC) in fostering and overseeing statewide multi-stakeholder health care initiatives. Second, the HSCRC method for financing health care lends itself both to on-going HIE financing and, more importantly, ensuring that HIE costs actually contribute to improved care and lower costs as HIE projects are designed and implemented. (However, the HSCRC funding mechanism may not be adequate or appropriate