New ONC-Sponsored Research Advances Health Information Exchange

Health information exchange (HIE) is not easy. ONC has sponsored expert research on various technical and business-related health information exchange topics, because we know that professionals engaged in implementing health information exchange must possess business acumen and technical expertise, on top of policy savvy and many other competencies. Without these skills there are many ways to overreach, or just as perilously, under reach, resulting in failure to maximize the long-term value of services offered through health information exchange.

The ONC-sponsored research will provide health information exchange implementers, policymakers, and researchers with a heightened understanding of several high-impact services that can support the sustainability of health information exchange organizations.

We would like to announce that five new health information exchange research reports are now available on HealthIT.gov. Each provides:

• Background information on core concepts
• Analyses of key challenges and opportunities
• Rich appendices, including up-to-date case studies
• Health information exchange vendor descriptions

To execute this work, ONC contracted with Audacious Inquiry , a health information technology services company. These reports will support the State HIE Program’s grantees as they continue to implement health information exchange, which increasingly includes launching query-based exchanges.

Listed below are the five new HIE reports that are available:

1. REPORT: Query-based Exchange: Key factors influencing success & failure of health information exchange

Perhaps the broadest of the reports, Query-Based Exchange: Key Factors Influencing Success and Failure provides essentially a “how-to” guide for navigating the major business considerations facing an HIE, including a breakdown of what the authors consider to be the determinants of HIE success. These are:

• Data provider distribution
• Data diversity/data saturation
• Breadth/relevance of the user-base
• Utilization rates

The report states that:

“…arriving at the true tipping point for query services that will make a Health Information Organization a clinical necessity is dependent on reaching certain milestones against [these] four interrelated metrics.”

REPORT FINDING: The Number of Patient Record Queries Indicate Success of HIEs

One of the most revealing aspects of this report is a chart contrasting six successful HIEs with two shuttered organizations across nearly 24 data points. One of these data points is the average number of patient record queries per month that each entity is receiving or had received. Those HIEs that are considered successful have figures ranging from 1,548 to 333,333 per month, while the closed HIEs had between 167 and 250 queries per month.

REPORT FINDING: There are Leadership Challenges for Health Information Exchange Vendors

The report also considers specific lessons from the experience of these health information organizations. It details the challenges of hiring and retaining a chief executive who is responsible for strategic vision, sales, marketing, day-to-day operations, and complex technical implementation projects. The research found that on top of all this, the leader might only receive a modest salary relative to her private sector counterparts.

2. REPORT: Health Information Exchange-Driven Notification & Subscription Services.

While health information exchange is not easy, it need not be overly complex. One theme that runs throughout the research is that basic tools can be used to support sophisticated use cases.

The report on HIE-Driven Notification & Subscription Services provides a review of the technical considerations involved in enabling push messages to providers. While these messages are a relatively simple technology, they can be used to support the advanced care coordination requirements of new payment models such as the Centers for Medicare & Medicaid Services’ Accountable Care Organizations. The report uses, as an example, the Indiana Health Information Exchange (IHIE)’s ability to send hospital admission alerts and discharge summaries to primary care providers. Such tools will be essential as hospitals begin to face negative financial incentives for readmissions, such as through CMS’ Readmissions Reduction Program.

The report also touches on how IHIE is developing a pilot that will allow managed care organization case managers, as part of their care coordination efforts, to receive notifications when their members are admitted to a hospital or visit an emergency department.

3. REPORT: Provider Directory Solutions for Health Information Exchanges and Beyond

Another important aspect of health information exchange is provider directories. While they are not glamorous, they are ubiquitous, and they can be highly valuable. On the most basic level, a provider directory is a type of electronic white pages that allows one provider to look up contact information for another provider.

The report on Provider Directory Solutions covers the key concepts associated with the technology. However, it also describes several additional use cases, such as how they can be used for future health benefits exchanges or for state licensing boards. Yet, the report goes even further by supporting the idea that the profit potential of provider directories is likely to go beyond the fundamental requirements of clinical health information exchange. Such considerations are critical for the State HIE Program’s cooperative agreement partners as they seek strategies to attain sustainability beyond the grant period.

4. REPORT: Master Data Management within Health Information Exchange Infrastructures

The report on Master Data Management within HIE Infrastructures explores the technical aspects of the tools that can help HIEs accurately capture and coordinate a patient’s identity. In short, master data management is how two pieces of electronic health information are appropriately merged or kept separate, which is particularly challenging when there are varying levels of data quality on patient identities.

The report also considers how master data management tools can be employed for advanced uses, such as data analytics associated with new payment models or patient centered medical homes.

5. REPORT: Consumer Engagement in Health Information Exchange

The report, Consumer Engagement in Health Information Exchange, provides a solid primer on the challenges and technical aspects of consumer-mediated exchange. This includes the considerations related to identity proofing, identity authentication, and access. The report also presents short case studies on several well-known entities working in this space, including:

• UnitedHealth Group
• Aetna
• Microsoft HealthVault
• Rochester RHIO
• Experian/Symantec

For More Information

This work was overseen by the State HIE Policy Office, which is part of the State HIE Cooperative Agreement Program. ONC plans to release additional reports in the future.

For more information, contact ONC Program Analyst John Rancourt or ONC Program Manager Lee Stevens.

Mostishari Outlines ONC Steps to Improve HIE Governance
Originally posted on ONC Buzz Blog Post on December 20, 2012 by Dr. Farzad Mostashari, National Coordinator for Health Information Technology
Reposted on e-HealthcareMarketing.com on December 22, 2012.

Earlier this year, ONC issued a request for information regarding a potential governance mechanism for the nationwide health information network.  Based on the comments and feedback we received from multiple stakeholders, ONC announced in September that we would not be issuing federal regulations. Instead, we committed to launch a range of activities to support existing governance initiatives and advance governance goals of nationwide health information exchange: increase interoperability, decrease the cost and complexity of exchange, and increase trust among participants to mobilize trusted exchange to support patient care. 

Below, are some of the activities ONC is undertaking to promote emerging good governing practices within and across communities.

• Today, we are issuing a new Funding Opportunity Announcement (FOA). The FOA will allow ONC to work collaboratively with entities already involved in governance of health information exchange to encourage the continued development and adoption of policies, interoperability requirements, and business practices that will increase the ease of electronic health information exchange, reduce implementation costs, and assure the privacy and security of data being exchanged.

• In January, ONC will host an open listening session on governance of health information exchange, to provide opportunities for a wide range of stakeholders to describe their issues, priorities, and critical concerns.

• Building upon this input from stakeholders, the HIT Policy Committee and HIT Standards Committee will hold a public hearing on January 29, 2013, to further discuss the current state of health information exchange.  The hearing will highlight the significant amount of exchange activity that is occurring today and the practices that enabled or impeded it; the health information exchange opportunities and needs of providers as they take on new payment models; the nature and scope of governance policies and practices of entities currently providing governance to different types of exchange communities, the impact of governance on information exchange, and the opportunities to strengthen governance at multiple levels.

• In the first quarter of 2013, the National e-health Collaborative, through our cooperative agreement, will convene key stakeholder governance entities.  These entities, whose decisions establish policies and practices for a given community of exchange partners, will work throughout the coming year to identify key issues and common problems in the governance of health information exchange and the best ways to address them.

• ONC plans to publish a series of governance guidelines for effective and trusted electronic health information exchange.  Through this effort, ONC hopes to guide emerging governance models on the policies and practices that should be considered as part of their approach to governance.

• ONC will also launch a monitoring program to ensure the governance goals are being addressed.

ONC will be holding a technical assistance call on January 7, 2013, at 2:00 pm EST for applicants interested in applying for the FOA.

The overarching goal for ONC remains that the information follow the patient where and when it is needed, across organizational, vendor, and geographic boundaries.  We hope that you agree that we have initiated a robust series of activities to accomplish this goal.  We look forward to your input as we move forward.  It will take all of us to be successful.

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Exemplar Health Information Exchange Governance Entities Program
Total of $800,000 in Funding
Excerpted from FOA issued on December 20, 2012
Executive Summary

The Exemplar Health Information Exchange Governance Entities Cooperative Agreement Program (Program) seeks to support a collaborative exchange within existing private or public sector organizations that have already established governance of health information exchange.  The purpose of the Program is to work with existing governance entities to further develop and adopt policies, interoperability requirements, and business practice criteria that align with national priorities, overcome interoperability challenges, reduce implementation costs and assure the privacy and security of electronic exchange of health information.  By advancing and further developing existing health information exchange governance models, this Program promises to increase the level of secure electronic health information exchange in the nation.  Section 3011(a) of the Public Health Service Act (PHSA) authorizes the Secretary to invest in the infrastructure necessary to allow for and promote the electronic exchange and use of health information for each individual in the United States consistent with the goals of the Federal Health Information Technology Strategic Plan: 2011-2015, and more specifically, support the nationwide electronic exchange and use of health information in a secure, private, and accurate manner. Total funding available for this initiative is $800,000.

I.       Funding Opportunity Description

A.        Background and Purpose

This funding opportunity announcement (FOA) will advance collaboration within private or public sector organizations that have already established governance of health information exchange.  The purpose of the Program is to work with existing governance entities to further develop and adopt policies, interoperability requirements, and business practice criteria that align with national priorities, overcome interoperability challenges, reduce implementation costs and assure the privacy and security of electronic exchange of health information, in a manner consistent with section 3011(a) of the PHSA.  As a cooperative agreement, as opposed to a grant, this award instrument of financial assistance ensures substantial involvement between the Office of the National Coordinator for Health Information Technology (ONC) and the recipients during the performance of the project.

ONC had previously considered proposing the establishment of a voluntary accreditation process for the governance of health information exchange through a rulemaking process. A Request for Information (RFI) solicited feedback on whether ONC should establish this voluntary program and on the specific rules of the road that exchange entities should follow. Several of the responses to the RFI pointed out that there are already organizations engaged in health information exchange governance activities, and that ONC should work with these entities rather than set up a new process and program. Based on these and many other comments received, ONC decided not to pursue a governance approach through rulemaking at this time.  Instead ONC is establishing a robust framework of leadership, guidance, engagement, listening and learning, and monitoring. 

• We will identify and shine light on good practices that support robust, secure and interoperable exchange.
• We will actively engage with entities currently serving in governance/oversight roles to promote emerging good governance practices. 
• We will continue to use our existing authorities and convening powers to create consensus and provide guidance and tools to address specific barriers to interoperability and exchange. 
• We will continue to evaluate how and what consumer protections can be appropriately applied to health information exchange through existing regulatory frameworks. 
• We will continue to monitor and learn from the wide range of activities occurring. 

This FOA will enable ONC to work collaboratively through the cooperative agreement process with existing entities undertaking governance activities for the electronic exchange of health information to encourage them to develop and adopt scalable national policies, interoperability requirements and business practice requirements that reduce the cost and complexity of exchange, obviates the need for cumbersome legal agreements and reduces the cost and complexity of health information exchange, .  The FOA is focused on working with existing governance entities to expand their rules of the road (i.e. policies, interoperability requirements and business practice requirements) for participating organizations.  This work will support and advance the efforts of existing governance entities which will benefit consumers and providers by allowing health information to flow securely between unaffiliated healthcare organizations. 

The cooperative agreement will provide funding to selected governance organizations to collaborate with ONC to:

• Develop and implement policies, interoperability requirements and business practice requirements that will facilitate directed “push” and/or query-based exchange[1] and address operational challenges that are slowing adoption and use of either model of exchange
• Identify potential opportunities to incorporate these solutions in national policy through certification of electronic health records, nationally adopted standards, incorporation into federal policy or additional governance activities

B.        Project Structure and Scope of Services
1.         Approach

ONC will enter into cooperative agreements with up to four awardees whose primary role is providing governance for participants’ directed “push” and/or query-based exchange.  Applicants may address one or both of the exchange models.  ONC is interested in funding at least one applicant that will provide governance for each exchange model.  ONC will work with each awardee through the cooperative agreement process to determine the set of policies, interoperability requirements and business practice requirements that will be addressed under this cooperative agreement.  Once the Exemplar Health Information Exchange Governance Entities cooperative agreement(s) are awarded, ONC will encourage State HIE Cooperative Agreement grantees to participate in the Exemplar Health Information Exchange Governance Entities awardee activities, as appropriate.  Awardees will serve as key partners with ONC in demonstrating potential scalable national rules of the road for the electronic exchange of health information.

2.         General Funding Requirements

Applicants must:

1. Have operational governance for the electronic exchange of health information. This means the applicant has established and implemented policies, interoperability requirements and business practice requirements for participants’ query-based exchange, directed “push” exchange or both. 
2. Support the exchange of health information between unaffiliated healthcare organizations, health information organizations and across multiple vendors’ products. 
3. Have broad representation of stakeholders (i.e. as relevant healthcare providers, health IT vendors, consumers, health information organizations, etc.) in decision-making bodies and processes.   
4. Adhere to principles outlined in Section I.B.5, Principles

3.         National Priority Topics

ONC will work with awardees to develop and implement governance policies, interoperability requirements and business practice requirements addressing the national priority topics outlined below. Addressing these topics will support health information exchange in stages one and two of meaningful use and will facilitate implementation of innovative payment models.  In areas where ONC has existing recommendations from the HIT Policy Committee or the HIT Standards Committee that ONC has considered and decided to implement, or has Standards & Interoperability Framework activities, those will be used as the starting point to develop solutions.

1. Directed “Push”  Exchange Model
   1. End user identity resolution and authentication
   2. Discovery and management of digital certificates
   3. Exchanging certificate trust bundles
   4. Querying provider directories
2. Query-Based Exchange Model
   1. Improving patient matching for a patient record query
   2. Implementing meaningful patient choice to participate in HIE
   3. Determining a treatment relationship exists before a patient record query is executed
   4. Addressing liability concerns

Each applicant will work on national priority topics in their selected exchange model through this cooperative agreement and may also propose additional priority topics.  ONC will work with each awardee to determine the final set of topics each awardee will work on under this cooperative agreement.  If multiple awardees are working on the same or similar topics, ONC may instruct awardees to work together to establish a common solution.