1 OHIP HIE State Plan - Amazon S3 · 2.6.2 Technical Architecture ... Appendix D – EHR Request...

2010

Ohio Health Information Partnership 7/31/2010

HIE State PlanStrategic and operational plans for a

statewide health information exchange

Approved January 25, 2011

Primary Contact: Fred Richards, CIO/COO 614.664‐2600 [email protected]

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TABLE OF CONTENTS

Table of Figures [Tables] .............................................................................................................................. vi

Table of Figures [Diagrams] ........................................................................................................................ vii

Table of Appendices .................................................................................................................................... vii

1 STRATEGIC PLAN ........................................................................................................................................ 1

1.1 Introduction ................................................................................................................................... S ‐ 1

1.1.1 Creation of OHIP ..................................................................................................................... S ‐ 1

1.1.2 Ohio’s Efforts For Health Reform ............................................................................................ S ‐ 2

1.1.3 Executive Summary ................................................................................................................. S ‐ 5

1.2 HIE Development and Adoption .................................................................................................. S ‐ 12

1.2.1 Vision ..................................................................................................................................... S ‐ 12

1.2.2 Goal ....................................................................................................................................... S ‐ 12

1.2.3 Objectives.............................................................................................................................. S ‐ 12

1.2.4 Primary HIE Drivers ............................................................................................................... S ‐ 13

1.2.5 Environmental Scan .............................................................................................................. S ‐ 16

1.2.6 Proposed HIE Model ............................................................................................................. S ‐ 34

1.3 Federal and State Coordination ................................................................................................... S ‐ 48

1.3.1 Regional Extension Center Services ...................................................................................... S ‐ 48

1.3.2 Federally Funded, State Based Programs ............................................................................. S ‐ 54

1.3.3 Public Health ......................................................................................................................... S ‐ 57

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1.3.4 Broadband Initiatives ............................................................................................................ S ‐ 63

1.3.5 Medicaid Coordination ......................................................................................................... S ‐ 67

1.3.6 Medicare Coordination ......................................................................................................... S ‐ 74

1.3.7 Participation with Federal Care Delivery organizations ........................................................ S ‐ 77

1.4 Governance .................................................................................................................................. S ‐ 78

1.4.1 Collaborative Governance Model ......................................................................................... S ‐ 78

1.4.2 Governance Structure ........................................................................................................... S ‐ 79

1.4.3 Staffing Structure .................................................................................................................. S ‐ 81

1.4.4 Stakeholder Involvement ...................................................................................................... S ‐ 83

1.4.5 State Government HIT Coordinator ...................................................................................... S ‐ 84

1.4.6 Accountability and Transparency .......................................................................................... S ‐ 85

1.5 Finance ......................................................................................................................................... S ‐ 86

1.5.1 Sustainability ......................................................................................................................... S ‐ 87

1.5.2 Summary of Costs and Revenues .......................................................................................... S ‐ 88

1.6 Technical Infrastructure ............................................................................................................... S ‐ 94

1.6.1 Request for Information ....................................................................................................... S ‐ 94

1.6.2 Technology Development Principles ..................................................................................... S ‐ 95

1.7 Business and Technical Operations ............................................................................................ S ‐ 100

1.7.1 Implementation .................................................................................................................. S ‐ 100

1.7.2 Project Management .......................................................................................................... S ‐ 103

1.8 Legal/Policy ................................................................................................................................ S ‐ 106

1.8.1 Privacy and Security ............................................................................................................ S ‐ 106

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1.8.2 State laws ............................................................................................................................ S ‐ 108

1.8.3 Policies and Procedures ...................................................................................................... S ‐ 109

1.8.4 Trust Agreement ................................................................................................................. S ‐ 110

1.8.5 Oversight of Information Exchange and Enforcement ....................................................... S ‐ 112

1.8.6 Consent Toolkit and Educational Campaign ....................................................................... S ‐ 113

1.8.7 Securing Health Data .......................................................................................................... S ‐ 113

2 OPERATIONAL PLAN ............................................................................................................................. O ‐ 1

2.1 Introduction to Operational Plan .................................................................................................. O ‐ 1

2.1.1 Project Plan ............................................................................................................................ O ‐ 1

2.1.2 Risks and Mitigation Strategy ................................................................................................ O ‐ 1

2.2 Coordination with Other ARRA Programs ..................................................................................... O ‐ 4

2.2.1 Regional Extension Center ..................................................................................................... O ‐ 4

2.2.2 Coordination with Medicaid, Medicare and Federally Funded, State‐Based Programs ........ O ‐ 6

2.2.3 Participation with FCDOs and Coordination with Other States ............................................. O ‐ 7

2.3 Governance ................................................................................................................................... O ‐ 7

2.4 Finance .......................................................................................................................................... O ‐ 9

2.5 Cost Estimates ............................................................................................................................. O ‐ 10

2.5.1 Staffing Plans ........................................................................................................................ O ‐ 11

2.5.2 Controls and Reporting ........................................................................................................ O ‐ 14

2.6 Technical Infrastructure .............................................................................................................. O ‐ 15

2.6.1 Standards and Certification ................................................................................................. O ‐ 15

2.6.2 Technical Architecture ......................................................................................................... O ‐ 18

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2.6.3 Technical Deployment ......................................................................................................... O ‐ 19

2.7 Business and Technical Operations ............................................................................................. O ‐ 19

2.7.1 Current HIE Capacities ......................................................................................................... O ‐ 19

2.7.3 Standard Operating Procedures for HIE .............................................................................. O ‐ 24

2.8 Legal/Policy ................................................................................................................................. O ‐ 25

2.8.1 Establish Requirements ....................................................................................................... O ‐ 25

2.8.2 Privacy and Security Harmonization .................................................................................... O ‐ 25

2.8.3 Federal Requirements .......................................................................................................... O ‐ 25

TABLE OF FIGURES [TABLES]

Table 1 Ohio Health Care Statistics ........................................................................................................ S ‐ 17

Table 2 OHIP Board of Directors ............................................................................................................ S ‐ 81

Table 3 OHIP Projected HIE Revenues and Expenses ............................................................................ S ‐ 90

Table 4 OHIP Revenue Model Assumptions .......................................................................................... S ‐ 93

Table 5 Proposed Core Infrastructure Services Implementation Model ............................................. S ‐ 101

Table 6 Projected Risks and Mitigation Strategies .................................................................................. O ‐ 2

Table 7 Federal, State and OHIP Committee Alignment ......................................................................... O ‐ 8

Table 8 OHIP HIE Budget ....................................................................................................................... O ‐ 10

Table 9 OHIP Staff (Current and Planned) ............................................................................................ O ‐ 12

Table 10 Summary of HIE Services by Existing HIOs in Ohio ................................................................. O ‐ 23

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TABLE OF FIGURES [DIAGRAMS]

Diagram 1 Primary HIE Networks In Ohio (Source: 2010 EHR/HIE Survey) ........................................... S ‐ 23

Diagram 2 HIE Business Model .............................................................................................................. S ‐ 35

Diagram 3 ‐ Major Payers and Managed Care Plans in Ohio ................................................................. S ‐ 47

Diagram 4 OHIP Regional Partners ........................................................................................................ S ‐ 50

Diagram 5 Broadband Coverage with Physicians by Zip Code ............................................................... S ‐ 65

Diagram 6 Broadband Coverage with Hospitals by Zip Code ................................................................ S ‐ 66

Diagram 7 National Level Repository Narrative ..................................................................................... S ‐ 75

Diagram 8 Project Management Coordination .................................................................................... S ‐ 104

Diagram 9 Project Management Reporting Structure ......................................................................... S ‐ 105

Diagram 10 Key Responsibilities of OHIP Board and Advisory Committees ........................................... O ‐ 8

TABLE OF APPENDICES

Appendix A – Health IT Regulatory, Certifications and Other References1

Appendix B – EHR/HIE Survey Tool

Appendix C – Regional Partners

Appendix D – EHR Request for Proposal (RFP)

Appendix E – HIE and REC Committee Members

Appendix F – HCCQC Health IT Task Force

Appendix G – Stakeholders Who Submitted Letters of Support

Appendix H – HIE Request for Information (RFI)

1 See Appendix P, Amendment #15

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Appendix I – HIE Project Plan2

Appendix J ‐ HISPC Model Permission Form

Appendix K – HIE White Paper3

Appendix L – Behavioral Health Subcommittee Information4

Appendix M – EPrescribing Task Force Members5

Appendix N – Privacy and Policy Committee Members6

Appendix O – OHIP Financial Policies and Procedures7

Appendix P – HIE State Plan Amendment Table

Appendix Q – HIE Implementation Model8

2 See Appendix P, Amendment #12 3 See Appendix P, Amendment #16 4 See Appendix P, Amendment #13 5 See Appendix P, Amendment #2 6 See Appendix P, Amendment #11 7 See Appendix P, Amendment #14 8 See Appendix P, Amendment #17

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1 STRATEGIC PLAN

1.1 INTRODUCTION

As the state‐designated entity (SDE) to lead health information technology (HIT) development for Ohio,

the Ohio Health Information Partnership (OHIP) is pleased to submit its health information exchange

(HIE) State Plan to the Office of the National Coordinator (ONC) under the State Grants to Promote

Health Information Technology Planning and Implementation9 grant.

This plan outlines the strategic and operational direction to develop a statewide HIE for the purposes of

improving the healthcare quality, outcome and experience for the citizens of Ohio. By facilitating timely,

secure and accurate exchange of health information:

Patients will be better positioned to become true partners in managing their health;

Providers will be able to gain a more holistic view of healthcare needs;

Adverse treatment practices can be avoided; and

The healthcare system as a whole can address current costly and inefficient administrative and

clinical practices.

While OHIP and its stakeholders have invested a great deal of effort in the development of this plan, it is

recognized that the healthcare environment is highly dynamic and subject to rapid evolution in the

areas of clinical advancement, workforce, public policy, funding and technology. Therefore, the

approach outlined in this document is conceptual and will evolve with ongoing strategic guidance from

ONC, stakeholders and consumers as tasks are completed and deliverables are met. The one constant is

the consensus for the need to remain fluid and agile as we progress with this important scope of work to

achieving improved health quality and outcomes for Ohio.

1.1.1 CREATION OF OHIP

In September 2009, Governor Ted Strickland designated OHIP as the SDE to lead the implementation

and support of health information technology (HIT) initiatives established by the American Recovery and

9 Appendix A, Reference # S15

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Reinvestment Act (ARRA)10 throughout Ohio. To help cultivate these programs, OHIP has created a two‐

pronged mission:

Support the adoption and meaningful use of electronic health records (EHRs) by Ohio’s health

care providers through regional partnerships with industry experts to provide outreach,

educational, technical and quality improvement services.

Facilitate and develop a statewide HIE that improves the timeliness and efficiency of data

exchange while ensuring patient privacy for the purposes of advancing the safety, quality,

accessibility, availability and efficiency of health care for citizens of Ohio.

In support of its mission, OHIP completed submission of two ARRA Health Information Technology for

Economic and Clinical Health (HITECH) grants in October and November 2009. The State Grant to

Promote Health Information Technology Planning and Implementation11 provides funding to states or

state‐designated entities for the development of statewide HIEs. The Health Information Technology

Regional Extension Center (REC) program12 offers funding to entities to provide education, outreach and

technical assistance to help providers in their geographic areas to select, successfully implement and

meaningfully use certified EHR technology to improve the quality and value of health care. In addition,

the state’s 2010‐11 biennial budget allocates $8 million in non‐general‐revenue funds to the Ohio

Department of Insurance (ODI) to support OHIP’s efforts. ODI will work with OHIP to oversee the use of

this money and the application for federal resources.

1.1.2 OHIO’S EFFORTS FOR HEALTH REFORM

Historically, Ohio has endorsed multiple initiatives to improve the quality and efficiency of our

healthcare system, including:

Healthy Ohio13 – Healthy Ohio is a program managed by the Ohio Department of Health (ODH)

to improve the health of all Ohioans by creating a better quality of life, assuring a more

productive workforce and equipping students for learning about their health, while increasing

the efficiency and cost‐effectiveness of medical services. Healthy Ohio’s three core program

areas are:

10 See Appendix A, Reference # R2 11 See Appendix A, Reference # S15 12 See Appendix A, Reference # S14 13 See Appendix A, Reference # S16

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- Health promotion;

- Disease prevention; and

- Health equity.

Health Information Privacy and Security Collaboration (HISPC)14 – Ohio participated in a

nationwide effort led by RTI International to identify the state and federal laws that create

barriers to information exchange within and between states, and to recommend solutions to

overcome those barriers. A summary of the HISPC findings for Ohio and other midwestern states

is available in a final report produced in July 2009 (see

http://hispc.pbworks.com/f/Intrastate_Interstate_FinalReport_20090911.pdf)

House Bill 125 Advisory Committee on Eligibility and Real‐Time Claim Adjudication15 – The Ohio

General Assembly instructed an advisory committee to report its findings and recommendations

for legislative action to standardize eligibility and real‐time claim adjudication transactions

between providers and payors. The committee convened its first meeting in July of 2008 and

held monthly public meetings through December of 2008. The charge of the committee was to

study and recommend standards to enable providers and payors to communicate electronically

with each other regarding patient insurance eligibility. The committee also was asked to address

the challenges involved with real‐time claim adjudication and present any possible solutions. A

copy of the committee’s final report is available at

http://www.insurance.ohio.gov/Legal/Documents/hb125‐finalreport.pdf.

Medicaid Information Technology System (MITS)16 – Beginning in 2004, Ohio embarked upon an

initiative to replace its Medicaid Management Information System (MMIS) with the newly

released Medicaid Information Technology Architecture (MITA). Key components of MITS are in

place, including front‐end support for managing the exchange of administrative transactions

between trading partners and an enterprise service bus (ESB). Use of the system for production

claim adjudication is targeted for early 201117. This new framework will position Medicaid to

work with OHIP in exchanging permissible information with HIE stakeholders, both for the

efficiency and effectiveness of patient care and population health purposes.

The Health Information Partnership Advisory Board (HIPAB) – In 2007, the Governor convened a

workgroup of healthcare stakeholders who produced a list of high‐level recommendations

14 See Appendix A, Reference # R16 15 See Appendix A, Reference # S5 16 See Appendix A, Reference # S13 17 See Appendix P, Amendment # 6

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regarding HIE adoption, governance, finance and exchange. The committee’s interest in HIT

adoption was very high and many of the participants continued as engaged stakeholders of OHIP

following its formation.

The Ohio Health Care Coverage and Quality Council (HCCQC)18 ‐ Following its initial creation by

an Executive Order from Governor Ted Strickland, the Ohio General Assembly established the

HCCQC in July of 2009. The council was designed to improve the coverage, cost, and quality of

Ohio’s health insurance and healthcare system and includes four task force workgroups:

- Payment reform;

- Patient‐centered medical homes (PCMH);

- Consumer engagement; and

- Health IT.

Ohio’s Implementation of State and Federal Health Care Reforms19 ‐ On March 23, 2010,

President Barack Obama signed The Patient Protection and Affordable Care Act20 (PPACA) into

law. One week later, he signed The Health Care and Education Reconciliation Act of 2010, which

made numerous changes to PPACA. The healthcare reforms in this legislation aim to expand

healthcare coverage to millions of Americans, which will require a number of changes to health

insurance products and the regulations that govern them. There are more than a dozen key

provisions that are scheduled to take effect in 2010, including:

- The creation of a national high‐risk pool program for people with pre‐existing conditions

that cannot buy insurance on their own;

- Tax credits for small businesses that obtain health coverage for their workers; and

- Assistance for Medicare beneficiaries with high drug costs who fall within the drug

benefit’s coverage gap or “doughnut hole.”

Other provisions will continue to take effect through 2014, when major reforms to expand

access to health coverage are fully implemented. The federal reform measures complement the

reforms to state law, as passed in the 2010‐2011 State of Ohio budget. Those within the state

who are currently analyzing the federal legislation are determining the required next steps so

that Ohio takes full advantage of all of the opportunities and resulting benefits. Ohio has

designated state team leads for every provision of the bill and looks forward to working with the

18 See Appendix A, Reference # S12 19 See Appendix A, Reference # S11 20 See Appendix A, Reference # R22

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US Department of Health & Human Services (HHS) as further guidance and regulations are

crafted.

Additionally, Ohio has three participants in the National Health Information Network (NHIN),

numerous operational HIEs and several of the nation’s top‐ranked hospital systems in the

country. Through these efforts, Ohio has invested both time and resources in advancing HIT to

increase the safety and quality of care delivery and to reverse the trend of rising healthcare

costs. While many efforts are underway, there are still many areas where additional HIT

resources are needed.

1.1.3 EXECUTIVE SUMMARY21

Ohio is ready to build on its Regional Extension Center (REC) structure, which is providing assistance now

to physicians, hospitals and other healthcare providers to meaningfully use electronic health records

(EHRs). The creation and implementation of a statewide health information exchange (HIE) will allow the

secure, virtual sharing of patient information both within Ohio and across the nation. OHIP is pleased to

submit this State Plan to the Office of the National Coordinator (ONC) under the State Grants to

Promote Health Information Technology Planning and Implementation. This plan lays out the strategic

and operational goals, objectives, deliverables and deployment plan to create an HIE platform that can

improve the delivery of health care to 11.5 million Ohioans.

1.1.3.1 GOVERNANCE AND STAKEHOLDER COLLABORATION

Ohio’s strength lies in the collaborative creation of OHIP, the state‐designated entity (SDE) founded by

medical and healthcare partners who have a vested, critical interest in the use of EHRs and the creation

of an HIE infrastructure. OHIP is a private, nonprofit organization. Founders include top leadership from

the Ohio State Medical Association, the Ohio Osteopathic Association, the Ohio Hospital Association,

BioOhio and the State of Ohio. The leaders of this nonprofit organization serve as the Executive

Committee on the 15‐member OHIP Board, also made up of information technology, medical, hospital,

behavioral health and health insurance leaders. Ohio is one of six SDEs that also is a Regional Extension

Center (REC) awardee, so its governance involves experts who have a local, grass‐roots interest in the

integration of EHRs into an HIE infrastructure.


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The board’s diverse membership means medical and healthcare communities across Ohio have clear

representation, and these leaders have the clout to create and implement an HIE that their

organizations will use. For instance, the Cleveland Clinic, United HealthCare and a member of AARP sit

on the board, all representing different perspectives and issues. Two committees – the Regional

Extension Center Committee and the Health Information Exchange Committee – form the umbrella for

various subcommittees and workgroups in such areas as privacy and behavioral health, and other areas

as needed.

All of these committees and workgroups involve active and committed professionals who will eventually

use the HIE system. The governance of OHIP involves a medley of partners with an interest in ensuring

everyone who wants to be part of the HIE gains access to it. This means that a small, rural hospital in

Appalachia, or a clinic in an impoverished neighborhood in Toledo, or a home healthcare worker at the

bedside of an elderly farmer can gain access to the HIE across the state. Because OHIP itself is a

nonprofit, its staff remains a neutral and trusted source to coordinate efforts in health information

technology (HIT) under the direction of the OHIP board and its committees.

The 17‐member HIE Committee helped write this State Plan, which reflects the perspectives, visions and

tactical strategies of diverse board members. This HIE Committee also includes representatives in

hospital administration, health plans, medicine, public health, information technology, and rural,

university and urban hospitals. . A subset of the HIE committee members will evaluate and select the

HIE vendor and ensure the infrastructure is secure, streamlined, integrated and cost effective. As part of

the State Inter‐Agency Council (SIC) comprised of 17 state agencies and boards, government writers

also shared how an HIE could potentially save the State of Ohio time and money by finding efficiencies in

the exchange of clinical information, claims payment, licensing, record keeping and federal reporting. In

addition, OHIP is engaged in a large statewide effort, the Health Care Coverage and Quality Council,

which involves 30 public and private representatives whose task is to improve the quality and cost of

health care in Ohio.

The diversity on the OHIP board, its committees and workgroups, and the cooperation of state

government agencies, ensures Ohio’s plan is not only collaborative, but represents the best ideas of

Ohio’s experts on how to provide better health care to Ohioans through technology.

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1.1.3.2 ENVIRONMENT AND TIMING

While Ohio utilizes sophisticated HIT – the Cleveland Clinic, Premier Health Systems, HealthBridge,

among others – it lags behind other states when it comes to actually sharing that information statewide.

Traditionally, Ohio has had HIEs and networks function in isolation, a bifurcated system where regions

handled their own patient health information. A significant catalyst for change occurred with the influx

of 2009 American Recovery and Reinvestment Act funding and financial incentives, followed by an

additional $8 million in non‐general revenue state funds. These monies led to the formation of OHIP to

help physicians and hospitals create the technological infrastructure for the meaningful use of EHRs.

Simultaneously, HealthBridge – an existing HIE – also received federal funds and covers a tri‐state area

that includes Cincinnati and southwestern Ohio. OHIP’s intent is not to compete with existing

infrastructures, but rather, create systems that can interact and integrate with one another.

Although Ohio might have been conservative in its approach in developing a statewide HIE, timing has

allowed OHIP to incorporate two important factors in its planning process that may not have been

available to other early adopter states. These factors include linking recent ONC announcements

regarding strategic, national direction for HIE with the significant HIT investments already made by

medical and hospital communities in the state so that investments going forward are leveraged and

aligned with the current national vision.

Between 2008 and 2014, Ohio will have spent an estimated one billion dollars in private monies for HIT.

This tremendous investment and involvement of hospitals allows Ohio to leverage the existing health

information organizations (HIOs) and hospital infrastructures so that medical and healthcare

professionals within those communities can exchange information. The intense interest of doctors,

hospitals and health plan leaders to talk in real ways about how to create a statewide HIE and deploy it,

exemplifies the spirit of collaboration in Ohio and shows that the timing is right.

Many of Ohio’s doctors and healthcare professionals have not yet embraced EHRs and new HIT. A 2010

OHIP survey of 2,000 of Ohio’s 25,342 physicians shows that 45 percent still are entirely paper‐based or

use only a practice management system. EHR use among behavioral health providers is low – at 20

percent. Of the physician offices and hospitals that do have EHRs, about 70 percent have been certified,

but not under the new national standards. While Ohio has five of the top 10 largest hospitals in the

country, more than 50 percent of physicians are either practicing alone or in small group practices with

two or three physicians. The challenge for OHIP’s REC is to reach out to independent and small‐group

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physicians to help them implement EHRs. Ohio’s ultimate goal is to assist 6,000 providers and physicians

throughout the EHR adoption process.

As for exchanging information and records, only 48 percent of hospitals, 23 percent of physician offices,

and five percent of behavioral health entities use a primary HIE network to exchange data. The majority

of these 16 networks are hospital‐based, where exchange is primarily limited to affiliated organizations

or common system platforms. There are four networks that are either university or regionally based, but

desire the capability to exchange information on a statewide or national level with a broader range of

providers, labs, health plans and pharmacies. The survey shows that when physicians currently exchange

data, it is largely for administrative purposes or to support the exchange of lab orders or results. The

statewide HIE would integrate existing networks and expand their range of exchange capability

geographically, by type of data exchanged, and among providers and payors involved in a patient’s

continuum of care.

1.1.3.3 HIE DEVELOPMENT AND DEPLOYMENT

The vision for the HIE is that it is sustainable, secure, and allows physicians and other healthcare

professionals access to patient authorized health information. But ultimately, the more altruistic vision

is to improve the overall level of health care provided by providers in Ohio.

The four drivers for OHIP’s HIE development strategy include:

Helping physicians achieve meaningful use within the ONC incentive timeframe;

The use of national standards for interoperability and frameworks;

Balancing core services with regional flexibility; and

Ensuring that the HIE is sustainable.

Core services will include how to look up patients, how to find a physician, lab, or entity using the HIE,

and how to locate where patient records are in the state. Patients will need to provide consent so that

their records can be exchanged electronically and only authorized users will be able to access those

records.

OHIP’s initial deployment strategy for the HIE is to reach out to 200 key technology partners and

healthcare entities so that 80 percent of Ohio’s population potentially could be reached by the end of

the first year. This strategy allows physicians to achieve meaningful use within the ONC’s timeframe and

take advantage of the Medicare/Medicaid financial incentives. These 200 “touch points” will become

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both participants and users of the HIE. This opens the door of opportunity to improve patient diagnosis

and coordination of care.

OHIP’s integration strategy will move providers and vendors from basic data exchange functionality to

full standards‐based capability aligned with the national standards. OHIP will define a technical model,

clarify integration standards necessary to connect to the statewide HIE, and offer tiered connectivity

options for providers to participate in the HIE at a level compatible with their existing architecture. Not

all users of the HIE will be at the same level of sophistication. This tiered connectivity approach will

offer: web portal access through the provider’s browser; access to a shared repository to facilitate data

exchange; and the ability to access records on demand while the data remains at its original source.

During the first phase of deployment, OHIP will work with its five preferred vendors to ensure

integration capability. In addition, the HIE will connect with Ohio hospital EHR market leaders, regional

health information organizations, pharmacy and lab market leaders, and other ambulatory EHR vendors.

During Phase II of deployment, federally qualified health centers, major health insurance companies and

Medicaid managed care plans will be included in this strategic integration outreach. Public Health will

also participate in the HIE.

1.1.3.4 TECHNICAL INFRASTRUCTURE FOR STATEWIDE HIE SERVICES

OHIP intends to create a trusted HIE platform that ultimately enables the secure exchange of patient

information electronically and in real time. The HIE will not be a centralized repository or huge database;

instead, it will be a hybrid model that maximizes access to data while retaining that data at the original

source whenever possible.

Ohio is very fortunate to have many knowledgeable and actively engaged stakeholders interested in

OHIP’s technical development strategy, who have been very clear and consistent in their message to

OHIP regarding their desires for infrastructure design. These messages have been the foundation of

OHIP’s technology principles and development strategy and include:

A sustainable technical infrastructure that connects and leverages existing HIE activity as

well as links providers, health plans, labs, pharmacies and other healthcare stakeholders

currently not connected;

Desire for a hybrid model (i.e., only persist data within the HIE necessary to facilitate

exchange);

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Desire for discovery and location services that streamline the identification of trusted

sources both inside the state and across state borders;

Clear and consistent use of federally endorsed interoperability standards where defined

and, where not defined, the standard is set by OHIP;

Assurance of the privacy and security of patient data consistent with Ohio and federal laws;

A recognition of the rapidly evolving standards environment and the need to select an

innovative and easily adaptable technical platform;

A recognition of the incremental interoperability among stakeholders (i.e., the varying

degree of technical capability of stakeholders);

A recognition that the historically separate administrative and clinical data flows are

blending together and will have significant impact on the future cash flow of providers; and

The strong desire for execution, action and deliverables.

These messages have formed these action steps for OHIP toward the development of a statewide HIE

infrastructure:

Release of Request for Information (RFI) in First Quarter 2010

Selection of 8 HIE vendors to participate in Request for Proposal (RFP) process in April 2010

Completion of HIE State Plan in July 2010

Release of RFP in September 2010

ONC Approval of State HIE Plan in December 2010

Selection of HIE vendor in January 2011

Implementation of core services in June 2011

OHIP and its stakeholders are anxious to begin and want ONC’s support to execute this strategy in a

timely manner.

1.1.3.5 PRIVACY AND POLICY

Because of the sensitivity of exchanging health information, one of the most prestigious law firms in

Ohio, Bricker and Eckler LLC, has worked alongside OHIP since its foundation in fall 2009. The firm’s

lawyers have provided legal advice and have assisted in the creation of contracts, RFPs for the preferred

EHR vendor program, end‐user contracts and other legal documents. These attorneys continue to

provide guidance as Ohio prepares to implement the statewide HIE.

OHIP’s original Privacy and Security Committee redefined itself as the Privacy and Policy Committee

after several meetings when members realized the complexity of Ohio’s statutory and case law related

to privacy alone. The Privacy and Policy Committee, where many legal experts sit at the table, is

handling the patient privacy and policy issues surrounding the HIE. The OHIP HIE Committee will provide

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guidance on the technical security of the infrastructure and will receive monthly updates from the

Privacy Committee on evolving policies.

During Phase I, the committee reviewed the work of the Health Information Security Privacy

Collaboration (HISPC) and also completed a comprehensive assessment of Ohio privacy case law to

determine legal issues involved in the creation and implementation of an HIE. Phase II will be a review of

Ohio and federal law, as well as best practices from other states, to develop a standard “consent”

solution. The committee is writing a white paper that includes a legal analysis of privacy and

foundational policies for the HIE, which will include consent forms, business associate agreements, and

participant agreements for the full board’s approval in December. The paper will then be sent out to all

stakeholders for comments and feedback. OHIP will create an educational toolkit on consent and privacy

for physicians, providers and the public as part of an awareness campaign about the exchange of patient

health records.

1.1.3.6 OHIP’S SUSTAINABILITY STRATEGY

OHIP will leverage federal grant money to offset the initial build‐out and core services of the statewide

HIE to encourage stakeholder participation. Concurrently, OHIP will use its REC program to expand

provider EHR adoption, directly increasing the possible user base of the HIE. As the HIE attains a critical

mass of users, additional, value‐added services will be phased in, so they can be purchased by current

users and secondary data users who may not require bi‐directional functionality.

To reduce costs for hospitals, providers, payors and patients, OHIP intends to sustain the HIE through

innovations in eligibility verification, coordination of benefits, real‐time claims adjudication and real‐

time payment. To provide value‐added services, OHIP sees significant opportunities arising from the

convergence of three historically separate provider processes: timely identification of disease‐specific

treatment protocols, clinical documentation workflows and administrative workflows to secure

payment. In the past, providers followed entirely separate electronic or manual processes to perform

these three functions, all of which were analyzed for errors retroactively. Until recently, technology was

not widespread enough to support a more sophisticated set of protocols using timely clinical and

administrative data to ensure better outcomes for both the patient and provider.

For example, through the statewide HIE, OHIP envisions the real‐time capability to validate clinical data

against treatment protocols, benefit coverage and payor edits to achieve a 99 percent propensity for a

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provider to be paid on a first pass. More importantly, the on‐demand merging of clinical and

administrative data flows allows patients to obtain point‐of‐service authorization and a clear

understanding of the cost of treatment. Deployed in an “open model” that supports all payors and

providers throughout the state, these future workflows also align with healthcare reform models such as

accountable care organizations and PCMHs.

It is this future vision that has driven OHIP to select a sustainability strategy that incorporates the clinical

and administrative exchange services further described within the HIE State Plan.

1.2 HIE DEVELOPMENT AND ADOPTION

1.2.1 VISION

OHIP’s vision is to create a secure, sustainable HIE that guarantees the protection of all patient records,

enables providers to access necessary, patient‐authorized health information and improves the overall

level of health care provided across the State of Ohio.

1.2.2 GOAL

The goal of OHIP is to create a trusted and sustainable statewide HIE, offering a value‐added, integrated

and seamless structure for enabling the exchange of health information to improve measureable health

outcomes for Ohioans.

1.2.3 OBJECTIVES

Promote Ohio providers’ ability to reach meaningful use, improving the quality of health care

delivered;

Provide a financially sustainable HIE that is not reliant on long‐term public or grant support;

Provide a technical architecture that ensures private and secure exchange of health information

with regional health information organizations (RHIOs), HIEs located in other states and with

disparate EHR systems using federally‐endorsed standards and integration protocols;

Develop a governance structure that is able to operate in a manner that is fair and efficient for

all stakeholder groups throughout the state;

Harmonize Ohio laws and regulations encompassing the exchange of health information with

national standards and requirements; and

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Provide de‐identified and aggregate clinical health data in an administratively efficient manner

to address population health issues in Ohio.

1.2.4 PRIMARY HIE DRIVERS

There are four primary drivers influencing OHIP’s strategy for statewide HIE adoption. These drivers are

fundamental to the planning process regarding the development of a statewide HIE:

Meaningful Use

National Standards Development

Sustainability

Balancing Core Services with Regional Flexibility

1.2.4.1 MEANINGFUL USE

The term “meaningful use” describes a set of objectives that providers must accomplish to demonstrate

that they are using their certified EHR software in a meaningful way. The measures that are used to

gauge meaningful use are meant to improve

healthcare quality, efficiency, and patient safety.

Additional payments will be available to eligible

providers who meet these objectives through the

Medicare or Medicaid programs beginning in 2011 to

further incentivize the adoption of EHRs.

The milestone stages are defined in the Medicare and

Medicaid EHR Incentive Payment Program Final Rule22.

Some of these objectives require providers to

exchange information securely between two unaffiliated, but authorized and consenting parties, for the

purpose of care coordination23.

Consistent with the requirements of the federal planning grant, OHIP is in the process of creating a

trusted, integrated statewide HIE infrastructure that will enable providers to reach meaningful use

objectives with HIE implications in the timeframes directed by ONC. To support this goal, OHIP must

22 See Appendix A, Reference # R18 23 See Appendix A, Reference # S3

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establish core support services that will facilitate, not replicate, the exchange of data between trusted

partners. These services will identify trusted partners, locate the necessary data, identify the consumer

preferences for sharing that data and enable the exchange in a secure and standard manner.

NATIONAL STANDARDS DEVELOPMENT

OHIP recognizes that ONC has been active in introducing new interoperability frameworks to support

long‐term strategies and directions for HIE. These frameworks involve harmonizing many previous and

current national efforts to create standard exchange protocols to facilitate HIE within and across state

boundaries. To quote Dr. David Blumenthal, National Coordinator of Health Information Technology, “To

make meaningful use possible, including the necessary exchange of information, we need to meet

providers where they are and offer approaches that are feasible for them to support meaningful use.”

Some of the past and present national standards development efforts include:

National Health Information Network (NHIN)24 – The NHIN is a set of open standards, services

and policies that intend to accelerate the use of the Internet for secure and standard transport

of health information to improve health care. This framework includes multiple parts:

- NHIN Exchange: a group of public and private entities that have agreed to a common

framework;

- NHIN Connect: an example of the open source technology layer required to perform the

exchange of health information;

- NHIN Direct: a pilot project to develop a set of protocols designed to simplify the “push”

of health data between two trusted parties; and

- The Data Use and Reciprocal Support Agreement (DURSA): a contract that provides the

legal framework governing participation in NHIN exchange.

National Information Exchange Model (NIEM)25 – The NIEM is a framework developed by the

Department of Homeland Security and currently used by the Department of Justice (DOJ) and

several other federal agencies to send information with standardized data semantics and

structures across domains. Investigation into its possible cross application with HIE is being

24 See Appendix A, Reference #S7 25 See Appendix A, Reference #S8

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considered through a series of 11 private contracts to possibly further harmonize and clarify

current HIE implementation standards.

Health Information Technology Standards Panel (HITSP)26 – HITSP paved the way for a great deal

of standards development for HIE before being disbanded. This was achieved by designating a

series of priorities for exchange (i.e., use cases) and producing related, highly detailed

interoperability specifications. HITSP brought together many existing standards development

organizations (SDOs), government bodies, consumer groups and professional associations to

complete this work, which could be leveraged to develop a more streamlined set of protocols

for structured data exchange.

Certification Commission for Health Information Technology (CCHIT)27 – Founded in 2004, CCHIT

was created to assist providers with the purchase of EHRs, by certifying them based upon

required functionality, interoperability and capabilities. Since 2006, the CCHIT has voluntarily

certified EHR vendor solutions using criteria developed through a consensus‐based process

engaging diverse stakeholders.

National Institute of Standards and Technology (NIST)28 – As noted in the Health IT Standards

and Certification Final Rule, ONC separates the notions of testing and certification of EHRs into

two parts. Testing relates to tools and procedures that will be used to provide objective data

about EHR solutions, which will then be evaluated during the certification process. Since the

NIST has significant experience in the development of similar testing tools and procedures for

other industries, ONC is seeking input from them as it relates to the testing process for EHRs.

Integrating the Healthcare Enterprise (IHE) 29– The IHE leveraged and organized a number of

integration standards by clinical domain, providing a technical framework for application of the

specifications developed through HITSP. Examples of clinical domain profiles published by the

IHE include cardiology, pathology and radiation oncology.

All of these development efforts boil down to one important factor for OHIP to consider in developing

its HIE model: Change is a constant. This is a basic premise in OHIP’s development strategy and will be a

fundamental driver in the selection of our future HIE vendor partner.

26 See Appendix A, Reference # S4 27 See Appendix A, Reference # C1 28 See Appendix A, Reference # S9 29 See Appendix A, Reference # S6

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SUSTAINABILITY

The notion of how to sustain a statewide HIE beyond core ARRA funding has been the single most vetted

topic through the OHIP stakeholder engagement process. The good news is OHIP and its stakeholders

wholeheartedly concur that the statewide HIE’s ability to add value to the existing HIE environment in

Ohio is a critical consideration in establishing the priorities of OHIP.

Much has been written about the notion of sustainability in HIE; however, few models are proven,

particularly in the context of recent national standards development activity. Are there HIE services that

are both desirable and sustainable at the statewide level as national standard protocols progress? OHIP

believes the answer to that question is “yes” and elaborates further on the proposed sustainability

model in the Proposed HIE Model (S‐34), Finance and Sustainability (S‐86) sections of the strategic plan.

BALANCING CORE SERVICES WITH REGIONAL FLEXIBILITY

While recognizing that the majority of data exchange occurs within a community, OHIP plans to pursue

an HIE development strategy that provides core infrastructure services to allow for statewide or

interstate exchange, while maintaining support for community‐based exchanges as desired. This

concept is consistent with OHIP’s REC regional partner approach, which was designed to engage

stakeholders at a community level in establishing priorities, providing strategic direction and

encouraging HIT adoption.

1.2.5 ENVIRONMENTAL SCAN

1.2.5.1 OHIO’S HEALTH CARE SYSTEM

Currently, there is no single RHIO supporting exchange services statewide today; however, Ohio is home

to numerous nationally acclaimed universities, hospital systems and RHIOs that engage in administrative

and clinical HIE. To understand Ohio’s healthcare environment, it is important to acknowledge Ohio’s

substantial size in terms residents, healthcare providers and payors as well as their geographic

distribution.

Table 1 provides basic Ohio metrics regarding the number of residents, estimated healthcare coverage

levels, physicians, hospitals, ancillary providers and health plans in the state.

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Table 1 Ohio Health Care Statistics

Reference Value Source

Total Residents (2009) 11,542,645 http://quickfacts.census.gov/qfd/states/39000.html

- % Under 5 years 6.5% http://quickfacts.census.gov/qfd/states/39000.html

- % Under 18 years 23.8% http://quickfacts.census.gov/qfd/states/39000.html

- % 65 years or older 13.7% http://quickfacts.census.gov/qfd/states/39000.html

Coverage Estimates (2008)

- % below poverty level 13.3% http://quickfacts.census.gov/qfd/states/39000.html

- % Medicaid enrollment 18% www.statehealthfacts.org

- % Medicare enrollment 16% www.statehealthfacts.org

- % uninsured 21% http://grc.osu.edu/ofhs/

Total Physicians 25,342 http://www.med.ohio.gov

- Priority Primary Care (MDs) 8,113 http://www.med.ohio.gov

- Priority Primary Care (DOs) 1,387 http://www.med.ohio.gov

Hospitals 225 http://www.odh.gov

- Critical Access Hospitals (CAHs) 34 http://www.odh.gov

- Rural Hospitals 33 http://www.odh.gov

Health Information Organizations 16 OHIP’s EHR/HIE 2010 Survey

- Hospital‐Based 11 OHIP’s EHR/HIE 2010 Survey

- University‐Based 2 OHIP’s EHR/HIE 2010 Survey

- Regional HIOs 3 OHIP’s EHR/HIE 2010 Survey

Special Population Providers

‐ Behavioral Health Providers 549 http://mentalhealth.samhsa.gov

‐ FQHCs 3530 http://www.ohiochc.org

‐ VA Medical Centers 5 http://www.visn10.va.gov/Health_Care_Services.asp

‐ DoD Medical Facility 1 http://www.wpafb.af.mil/units/wpmc/index.asp

HIE Program Information Notice (PIN) Identified Organizations

- Local Health Departments 130 http://www.odh.gov

- Laboratories (CLIA) 10,639 http://www.odh.gov

- Pharmacies 2,165 http://pharmacy.ohio.gov/

- Health Insurance Providers 300 http://www.odi.gov

Geographically, Ohio’s healthcare community is not centralized, but rather dispersed among Ohio’s

primary metropolitan areas (Cincinnati, Cleveland and Columbus) as well as secondary metropolitan areas

such as Toledo, Youngstown, Akron, Dayton and Athens. Although Ohio’s healthcare system has grown in a


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decentralized manner, due to the close proximity of the communities with each other, there is a significant

amount of patient interchange across them and across state borders where these primary and secondary

cities are located. In addition, hospital systems have been expanding their networks outside their

communities in recent years, and there are an increasing number of providers offering specialty services

that attract patients from outside their typical healthcare community.

1.2.5.2 EHR/HIE SURVEY PROCESS

As noted in Primary HIE Drivers section (S‐13), the ability for providers to achieve meaningful use is a

primary driver of OHIP’s strategic plan. To gauge the current situation of Ohio providers, OHIP conducted a

survey in June 2010 that assessed the current level of HIT adoption and type of assistance needed for

providers to achieve meaningful use.

The survey was administered using an interactive online survey tool31 and was directed to hospitals and

providers of all specialties. The tool was designed to be completed by a practice manager or hospital staff

person with knowledge of both clinical operations and HIT. It directed the respondent to additional

questions based on prior responses to minimize the amount of time necessary to complete the survey.

OHIP used multiple channels to inform providers across the state about the survey. These channels

included:

The Ohio Hospital Association (OHA);

The Ohio Osteopathic Association (OOA);

The Ohio State Medical Association (OSMA);

The Ohio Academy of Family Physicians (OAFP);

The Ohio Academy of Pediatricians (OAAP);

OHIP’s REC Regional Partners (RPs); and

Distribution channels specific to obstetrics and gynecology, internal medicine and behavioral

health.

31 See Appendix B, 2010 EHR/HIE Survey Tool

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1.2.5.3 COMPOSITION OF RESPONDENTS

Despite the number of concurrent demands

on providers and the limited timeframe for

response due to tight HIE and REC deadlines,

the environmental scan yielded responses

from 356 physician offices, hospitals and

behavioral health service providers.

The following items are interesting details to

note about respondents of the survey:

Over half of the responses received were from physician’s offices.

In total, approximately 2,000 physicians

are represented in the responses.

There are high rates of solo practitioners

in Ohio and, when coupled with the

percentage of 2‐5 doctor offices, very

high numbers of small office practices.

A significant number of rural hospitals

responded to the survey indicating

high interest in HIT adoption.

1.2.5.4 EHR/HIE SURVEY RESULTS

For the purpose of the state plan, the survey data was analyzed in the context of meaningful use. To

achieve meaningful use and thereby qualify for related incentive payment programs, providers must:

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Use a certified EHR in a meaningful way (e.g., ePrescribing)

Connect the technology in a way that provides electronic exchange of health information to

improve the quality of care

Submit clinical quality measures to Centers for Medicaid and Medicare Services (CMS)

1.2.5.5 CURRENT USE OF EHRS

Several questions in the survey were created to assess the respondent’s current level of EHR adoption

and progress towards meaningful use.

What is interesting about the data from a

meaningful use perspective is:

Forty‐five percent of respondents are

either entirely paper‐based or use a

practice management system only.

Of those who have EHRs, a significant

number of providers and hospitals are

either actively using or in the process of

implementing certified EHRs. The term

“certified” refers to software that has

been certified by CCHIT.

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Certified EHR adoption rates among behavioral health providers is very low. Reasons for these low

adoption numbers in Ohio are well known and further described in the Coordination with Other

ARRA Programs, Coordination with Behavioral Health section (O‐4) of the operational plan.

Data from the survey indicates an increase in the number of providers and hospitals actively

implementing EHRs. This is encouraging because it shows that providers are not waiting for

implementation of the incentive payment programs to proceed with new health IT investments.

Although a significant

number of physician offices

are using certified EHR

software, a substantive

number are using solutions

that were implemented prior

to 2005. The number of early

adopters is encouraging and

reflects a level of

commitment by Ohio

providers. For vendors who have kept pace with technology changes, this is a good statistic.

However, standards for ePrescribing, interoperability, security and other functionality have

significantly changed over the past five years.

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CURRENT USE OF HIE

The survey also was designed to analyze the current level of HIE adoption in Ohio as well as the primary

network facilitating this exchange. The significance of this data is:

Among entities that have purchased EHRs, high rates of adoption for administrative transaction

exchange such as eligibility and claim information exist. This statistic is not surprising in that,

historically, healthcare organizations have been driven by financial incentives, which existed to

encourage this type of exchange. Until recently, financial incentives minimally existed to

encourage clinical data exchange for purposes of improved patient outcomes.

Although administrative transaction use is high, constituents report that there are many

opportunities for streamlining this exchange as well as improving the quality of data exchanged

to reduce costs and improve the speed and accuracy of the information.

EPrescribing is on the rise in Ohio, although the hospital environment is a bit behind the

physician environment. For more information on this topic, see the Specific HIE Service Issues

section below (S‐27).

There are opportunities to expand the exchange of lab orders/results, immunization data,

clinical summary information (even if only in human readable form) and reportable lab results.

The latter two areas have been historically hampered by a lack of interoperability standards.

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Only 48 percent of hospitals, 23 percent of physician offices and 5 percent of behavioral health

entities are using a primary HIE network in Ohio to facilitate data exchange. These networks are

either hospital‐based, university‐based or regional HIOs and are mapped in Diagram 1 below:

Diagram 1 Primary HIE Networks In Ohio (Source: 2010 EHR/HIE Survey)

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INTEREST IN INCENTIVE PAYMENT PROGRAMS

In addition to reporting their level of

EHR or HIE adoption, respondents

denoted their current intentions

regarding participation in the

Medicare and Medicaid incentive

payment programs. Worth noting is:

Hospitals can choose to

participate in both programs,

if they meet the eligibility

criteria. This would explain the larger percentage of “not sure” responses.

The majority of physician offices expressed interest in the Medicare incentive payment program.

Reasons may include that the majority of physician offices have a larger Medicare patient mix,

there are no minimum volume requirements to participate, and Medicare’s benefits and related

billing/reimbursement program is generally better understood due to less diversity by region or

implications of managed care.

QUALITY REPORTING

Historically, Ohio providers have participated in a wide variety of disparate electronic quality reporting

initiatives spearheaded by the government, provider or hospital associations, accreditation bodies,

payors and other entities with oversight responsibility. A few of the many programs are highlighted in

this document.

One example is CMS’ Physician Quality and Reporting Initiative (PQRI). Stakeholder input indicates that

Ohio provider participation in CMS’ PQRI program is increasing; however, quantitative figures for 2010

participation will not be available until February 2011. Historically, Ohio physicians have been slow to

adopt the Medicare quality reporting process due to concerns about the costs to implement and the

reporting of measures was tied to claim submission. With the recent announcement of CMS’ proposed

rule to align the PQRI program with meaningful use reporting,32 features such as direct integration with

32 See Appendix A, Reference # R6

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EHRs and the unbundling of the process from claim workflows should allow providers to become more

engaged in this process.

Another example is Ohio’s Cancer Incident Surveillance System (OCISS). To assess the burden of cancer

in Ohio, state law requires the reporting of all new cancer cases diagnosed among Ohio residents to

OCISS. Any physician, dentist, hospital, or person diagnosing and/or treating cancer cases is required to

report them to the OCISS within six months of diagnosis. Additional information is collected over the

two‐year period post diagnosis to obtain the most accurate and complete data on each case. Thus,

incidence data for 2002‐2006 was the most recent available at the time of ODH’s Ohio Cancer Facts and

Figures 2009. The percentage of cancer cases diagnosed among Ohio residents that were reported to

the OCISS is referred to as “completeness.” Completeness of case reporting is estimated to be 94

percent for 2002‐2006, based on Ohio mortality rates and the Surveillance, Epidemiology, and End

Results (SEER).

In addition, the American Osteopathic Association’s (AOA) Clinical Assessment Program, which has been

accepted as a CMS registry, is currently being used in all of the AOA‐approved residency programs in

Ohio and has been expanded for use by practicing physicians. This assessment program measures and

compares current clinical practices with evidence‐based practice guidelines representing state‐of‐the‐art

professional standards of care. The AOA has contracted with Applied Health Services (AHS), Inc. in

central Ohio to design and manage the project and provide reports and assistance to participating

programs.

Providers and payors as a whole are looking forward to efforts by ONC and other federal and state

agencies to streamline and standardize quality reporting such that data is more timely, consistent,

accurate, less costly to produce or manage and non‐redundant.

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HIE BARRIERS AND OPPORTUNITIES

In the survey, OHIP also asked respondents what their largest challenges were to using HIE as well as

what they saw as potential opportunities.

The most commonly noted barrier was the historical lack of integration between HIEs and EHR software.

Even those entities that have adopted EHRs with structured integration capability, currently report

receiving the same data in multiple ways (direct integration, fax and email) leaving the physician with

the sense of being barraged with information. Other barriers include privacy and security concerns as

well as lack of knowledge about HIE options. OHIP, as both an HIE and REC service provider, is well

positioned to address these top concerns.

In terms of opportunities for the HIE, the vast majority of survey respondents expressed interest in the

HIE streamlining the exchange of referral and related prior authorization information followed by

disease registry data. Members of OHIP’s HIE Committee concur with these suggestions, but the

business workflows and related policies between providers, patients and payors in the area of referral

and related authorization management are varied and disparate. The policy and workflow issues would

need to be addressed first to sufficiently and effectively automate the process within the HIE. In

addition, improved timeliness of eligibility information and more effective use of referral/prior

S ‐ 27

authorization transactions would be needed, the latter of which is not addressed in any published

standards.

Other suggestions noted:

Further electronic integration with public health for immunization or HIV reporting;

Broader exchange among the behavioral health community including justice system,

Penal system, local boards and state agencies;

Automating patient medical record requests; and

Exchanging imaging and use of telemedicine.

Several respondents noted interest in exchange but a lack of funding was a major concern.

1.2.5.6 SPECIFIC HIE SERVICE ISSUES33

EPRESCRIPTION

BACKGROUND IN OHIO ON EPRESCRIBING

SURESCRIPTS STATISTICS

In addition to the information available through the survey, Surescripts’ reported the following level of

ePrescribing activity in Ohio as of their latest state progress‐reporting period (2009):

Surescripts Statistic 2009 % Change

from 2008

% Physicians Routing Prescriptions Electronically 18% ˄ 5%

% of Patients with Available Prescription Information 75% ˄ 5%

% of Pharmacies Activated for ePrescribing 95% ˄ 7%

% of all Prescriptions Routed Electronically 10% ˄ 5%


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OHIO BOARD OF PHARMACY STATISTICS ON EPRESCRIBING CAPABILITY IN OHIO

As of October 2010, the Ohio Board of Pharmacy (BOP) has tracked the following statistics about retail

pharmacy capability to receive ePrescribing transmissions:

Retail: There are 2,169 retail pharmacies in Ohio. The BOP estimates that approximately 90 percent

of all the pharmacies in Ohio can accept electronic prescriptions, which closely aligns with

Surescripts’ estimates.

Chains: Of the 1,605 chain store pharmacies, all but one are approved by the BOP to accept

ePrescriptions. The one chain pharmacy that is not approved can currently receive ePrescriptions by

fax only and is in the process of obtaining approval to receive ePrescriptions directly into its

computer system.

Individual and Small Chains: Of the 564 pharmacies with 1 – 11 stores, 80 percent or more accept

ePrescriptions.

RESEARCH GRANTS ON EPRESCRIBING IN OHIO

The Ohio University College of Osteopathic Medicine, in partnership with other universities and

associations, received three grants from the Ohio Medical Quality Foundation from 2001 through 2008

to evaluate the impact of ePrescribing on patient safety, patient satisfaction, physician satisfaction and

pharmacist satisfaction. The project included a statewide survey of pharmacists and physicians to

identify perspectives and barriers of ePrescribing. The survey was followed by a prospective study

involving the implementation of ePrescribing in both urban and rural settings to evaluate safety and

attitudes of physicians, pharmacists and patients. The results from all three phases of the project

demonstrated that ePrescribing provided benefits, but not without challenges.

OHIO STATUTES AND REGULATIONS GOVERNING PRESCRIBING AND EPRESCRIBING

In Ohio, physicians are authorized prescribers. Nurse practitioners and physician assistants have

prescriptive authority only when they have taken additional classes and received certification for

prescribing medications. In addition, Ohio pharmacists may substitute generics for brand name drugs,

when available, unless the prescriber expressly indicates on the prescription that substitution should not

occur.

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Ohio Administrative Code (OAC) requires prior approval by the BOP34 of all electronic prescription

transmission systems intended to be used in Ohio. Historically, the BOP’s requirements and certification

process has been independent of CCHIT or other national voluntary certification programs.

OHIO BOARD OF PHARMACY EPRESCRIBING APPROVAL PROCESS

The BOP approves the complete ePrescribing transmission system—both the systems that are used to

originate ePrescriptions in the physician office or hospital setting, as well as the systems used to receive

the prescriptions in the pharmacy setting. To date, the BOP has approved approximately 75 ePrescribing

systems for hospitals and office settings in Ohio (this includes installations that are site‐specific, such as

nine different Epic systems installed through nine different hospital systems and their affiliated hospital

networks). The pharmacy ePrescribing systems approved for use by the pharmacies number around

25.Ohio’s system of ePrescribing approval by the BOP is both unique and more stringent than any

criteria existing in other states. Under BOP’s review, an ePrescribing system must have positive

identification of the user to be on the approved list of vendors. Positive identification can include any of

the following: a) a manual signature on a hard copy (this record must be maintained for three years); b)

a magnetic card reader with a password; c) a bar code reader with a password; d) a thumbprint reader

or biometric method; e) a proximity badge reader with a password; f) a list of randomly generated

questions with a password; g) a printout of every transaction that is verified and manually signed within

a reasonable period of time by the individual who prescribed, administered or dispensed the controlled

drug (the printout must be maintained for three years).

FUTURE OF EPRESCRIBING IN OHIO

Up until 2010, the positive identification requirement was a disincentive for some hospital EHR systems

to implement ePrescribing. Also, if an ePrescribing vendor selected the use of a printout as the method

of positive identification, the follow‐up documentation required after the prescription was written (i.e.,

the printing out, signing and maintenance of records for three years) seemed excessive and contrary to

the intent of ePrescribing.

With the issuance of the DEA Interim Final Rule of Electronic Prescriptions for Controlled Substances (75

FR 16236, March 31, 2010), many of the same issues have arisen at the national level. Due to the DEA

requirement for two‐factor authentication for ePrescribing controlled substances, much of the work

34 See Appendix A, Reference #R19

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done in Ohio will put Ohio in the forefront of ePrescribing. The vendors that have already been certified

in Ohio should be able to meet the DEA standards quickly. Consequently, the BOP has voted to accept

the DEA’s certification standards for ePrescribing for its vendor approval system and not require a

separate approval through the BOP, effective January 1, 2011.

The DEA’s rule also addresses the retention of ePrescriptions. Under the rule, records are to be retained

electronically for a period of two years. The DEA regulations do not allow a paper record to be used to

document positive identification or two‐factor authentication. This should encourage more physicians

and practitioners to adopt ePrescribing.

EPRESCRIBING TASK FORCE IN OHIO

OHIP has created a task force with representatives from the BOP, the Ohio State Medical Association,

the Ohio Hospital Association, the Ohio Osteopathic Association, the Ohio Pharmacists Association,

numerous individual hospital pharmacists and CIOs, physicians and a representative from AARP (see

Appendix M). These groups have met to determine what barriers there are to ePrescribing and what

needs to be done to encourage ePrescribing in Ohio. The task force addressed issues of the BOP review

and determined that aligning Ohio’s EHR review system with the DEA system will create a much more

equitable system for hospitals and physicians in Ohio.

The task force is also in the process of developing education and outreach materials/presentations that

can be offered to prescribers regarding ePrescribing. Many groups are submitting the educational

materials they have developed to use for broader educational programs.

The task force is working on education strategies to teach both physicians/practitioners and pharmacists

about potential errors that can be made using ePrescribing tools and how to minimize those errors.

ELECTRIONICALLY DELIVERED LAB RESULTS

OHIP has identified four major lab suppliers in Ohio representing 70 percent of the current electronic

exchange of lab results today: LabCorp, Quest Diagnostics, MedPlan and hospitals. Both LabCorp and

Quest are currently supporting structured lab result exchange using HL7 v2.x.x as well as the ability to

incorporate these results into a continuity of care document (CCD).

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The difficulty arises with integration necessary to exchange results. The majority of consumers of lab

results have systems that are unique or out‐of‐date, requiring custom interfaces. Interfacing individual

systems together requires time and money. With the hundreds of different interfaces between

physician offices, hospitals and other care delivery organizations, these lab organizations can only

develop so many interfaces per year. In some areas of the state, the only place that performs lab tests is

the local hospital. Referring providers who are not affiliated with the local hospital or do not have robust

EHRs are able to obtain results electronically.

Instead of requiring multiple, costly, point‐to‐point interfaces, OHIP has engaged these lab organizations

to consider offering a single standard integration solution. The integration standards to be used will be

clear, consistent, published and identical to requirements for EHR vendors. This strategy will improve

the availability of lab results among all providers. In addition, lab market leaders report other potential

benefits of integration with the statewide HIE. Currently, they have limited capability to confirm or

validate patient demographics or insurance coverage for self‐insured or highly transient populations.

Additionally, they are challenged to integrate lab orders and results with paper‐based offices. Through

planned administrative exchange functionality and web portal access, OHIP can provide opportunities to

help lab market leaders improve their ability to deliver services.

PATIENT CARE SUMMARIES

Although OHIP’s environmental scan survey indicated currently low levels of CCD exchange,

stakeholders have stated this is the most desired clinical HIE service. Ideally, the information would be

exchanged in a structured manner so it can be easily integrated into the patient’s electronic chart, but

providers are willing to accept it in human readable form to begin care coordination and achieve Stage 1

Meaningful use.

Several of the existing HIE networks in Ohio report being able to exchange a care summary of some type

(discharge summary, emergency room report, CCD, CCR, etc.), most often in human readable form.

Where HIE networks have expressed interest in OHIP’s assistance is:

Broadening the range of care summary exchange beyond the scope of the current HIE networks

(e.g., beyond the HIE network’s geographic region within the state or across state borders);

Facilitating the identification and location of patient care information from trusted sources

beyond their region via discovery and location services;

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Connecting EHRs to allow for more advanced structured integration of care summaries using

clear and common standards;

Facilitating exchange with providers involved in the patient’s care continuum who have limited

connectivity currently, such as behavioral health, long‐term care and home health so that a true

total picture of a patient’s care can be realized.

Leveraging use of a patient care summary to facilitate payment of services to providers by

comparing information with treatment protocols consistent with the patient’s condition

OHIP has adopted the following strategies to broaden the level of exchange:

A Behavioral Health Subcommittee was formed in August 2010 to help behavioral health

providers adopt EHR solutions and have the capacity to fully participate in the statewide HIE

Members of the subcommittee are behavioral health representatives who serve as liaisons to

each of OHIP’s REC regional partners as well as state agency, provider association and county

board association representatives. For more information regarding this subcommittee’s work,

please see Section 2.2.1.1

A representative from Ohio’s AHIMA chapter who has extensive long‐term care experience is a

member of OHIP’s Privacy Council along with two attorneys who specialize in behavioral health.

These experts have been instrumental in addressing special challenges regarding the exchange

of information for these populations in Ohio.

OHIP is engaged in discussions to add two industry representatives to its HIE Committee; one

representing long‐term care and the other representing home health. The committee is

considering specific strategies to deploy mobile applications to home health providers so they

can participate in the HIE in a cost effective and feasible manner.

OHIP is currently preparing an integration statement that will detail all of the standards EHR

vendors must support to connect to the statewide HIE. The integration statement will align with

the Standards and Certification Final Rule, where defined, and where not defined, OHIP will

choose standards consistent with industry standards.

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PAYOR DATA EXCHANGE

Beginning in 2009, Aetna, Anthem Blue Cross and Blue Shield, CIGNA, Humana, Kaiser Permanente,

Medical Mutual of Ohio, UnitedHealthcare and WellCare Health Plans began a one‐year pilot with

Availity to allow for eligibility verification and standardized claims submission through a common payor

portal. This pilot, initiated by the American Health Insurance Plans (AHIP) association, allows for

improved quality metrics reporting, a reduction of redundant testing when records are not easily

available and integration with health plan medical policies for benefit. The goal is to diminish the

administrative burden on both providers and payors. With these eight different insurance plans

involved, this pilot portal will allow payors and providers to exchange eligibility and claims data for

approximately 90 percent of the commercially insured in Ohio.

The payor community supports the transformation of provider record keeping and data exchange from

an historical paper record to an electronic format that allows for standardized reporting, claims

information and an EHR that is calculable and searchable. A great deal of administrative overhead is

currently involved on the part of health plans in obtaining pertinent medical information from providers

pertaining to insured members. An established HIE is viewed as a vehicle to allow for seamless and

automatic transfer of relevant health information without placing an undue burden on providers. Given

a broader adoption of EHRs, the fundamental information infrastructure is created for the adoption of

comprehensive care models, such as the PCMH. The EHR allows for integration of best practices and

clinical pathways, as well as ePrescribing. Future integration with health plan cost data and medical

policies will empower providers to not only make the most clinically appropriate choice, but also the

most cost‐effective one, maximizing the patient’s benefit.

There is also broad support for a standards‐based approach for data exchange and the adoption of a

national protocol standard such as NHIN by payors. The historic limitation of the EHR was a lack of a

standard data format, requiring payors to adopt several different platforms for data transmission. Given

the mobility of members and those who obtain health services in multiple locations and sites across the

country, interoperability with other state and regional HIEs is viewed as important by health plans.

Benefit eligibility integration and coordination of benefits is another important focus for both providers

and payors. Since employment status is a key driver of healthcare benefits from a commercial payor

perspective, HIE integration with employer information is a requisite component from a payor

perspective. Ultimately, employee status verification is a function of the employer, which provides this

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information to the health plan. In addition, many employers conduct wellness programs and provide

biometric screenings. The collected information should be integrated with an employee’s EHR,

empowering providers to act on the results of such screenings.

1.2.6 PROPOSED HIE MODEL

Given the current healthcare environment and related primary drivers, OHIP is seeking to develop a

statewide HIE in a phased manner while acknowledging the need to remain fluid in the planning process,

given the dynamic nature of Ohio’s environment. It is important to note that, while diagrams and

priorities are outlined below, these are conceptual in nature and will be contingent upon many factors

including further ONC guidance, selection of an HIE vendor, deadlines and requirements of the HIE grant

and ongoing stakeholder input.

Diagram 2 depicts the proposed business model, denoting the core support and HIE services OHIP is

proposing35.


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The core support and HIE service priorities contained in this diagram are outlined below. It should be noted that a

major requirement of OHIP’s active procurement process will be to not only identify a vendor capable of

supporting a substantial statewide HIE, but one that demonstrates flexibility, sustainability and innovation in

supporting this type of HIE development model.

1.2.6.1 CORE SUPPORT

Core support refers to the components of the “engine” of the statewide HIE that must be in place to

support future HIE services. Core support includes:

Discovery/Location Services

- Master Patient Index (MPI)

- Master Entity Index (MEI)

Diagram 2 HIE Business Model

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- Record Locator Service (RLS)

Trust Enablement Services

1.2.6.2 HIE SERVICES – PHASE I

Phase I HIE services are those that meet the following criteria:

Necessary to support Stage 1 meaningful use objectives with direct HIE implications,36 direct HIE

implications are those objectives which are not currently supported at the EHR level or through

existing channels;

Necessary to support OHIP’s sustainability plan; and

Services not requiring integration with the new State Medicaid MITS system scheduled to go‐live

in phases beginning early 201137. The state’s administration felt it be important to stabilize the

MITS environment before pursuing integration with the statewide HIE. However, it was

considered feasible and beneficial to consider integration of Medicaid eligibility information

during Phase I of HIE development.

PROPOSED PHASE I HIE SERVICES INCLUDE:

Exchange services required to support Stage 1 meaningful use with direct HIE implications at a

statewide level ;

Community‐based web portal and branding support with access to statewide HIE;

Centralized insurance eligibility verification;

Integration with OHIP’s preferred EHR vendor solutions; and

Centralized mailing address verification service.

1.2.6.3 HIE SERVICES – PHASE II

Phase II HIE services are those that meet the following criteria:

Necessary to support Stage 2 meaningful use objectives with direct HIE implications;

Necessary to support exchange with other states and federal care delivery organizations; and

36 See Appendix A, Reference # S3 37 See Appendix P, Amendment #6

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Services that integrate with state agency systems such that administrative and clinical

efficiencies can be achieved.

PROPOSED PHASE II HIE SERVICES INCLUDE:

Support for Stage 2 meaningful use with HIE implications at a statewide level;

Integration with state level and other registries;

Advanced data aggregation and reporting tools; and

National standards protocol development and support.

1.2.6.4 HIE SERVICES – PHASE III

Phase III HIE services are those that meet the following criteria:

Necessary to support Stage 3 meaningful use objectives with direct HIE implications;

Services that require additional time to stabilize environments or streamline related business

processes before integration can occur; and

Services that may require additional time to address legal or technical development required to

ensure effective implementation and use.

PROPOSED PHASE III HIE SERVICES INCLUDE:

Support for Stage 3 meaningful use with HIE implications at a statewide level;

Other centralized administrative transaction support;

- Centralized coordination of benefits

- Centralized referral, pre‐authorization and certification coordination

- Centralized claim adjudication, remittance advice, and claim status verification

Expanded integration with Medicaid and other state agencies;

Other payor/employer clinical data exchange; and

Consumer PHR integration.

Details regarding the proposed core support and HIE services are further described in the Business and

Technical Operations/Implementation Plan section of the strategic plan.

1.2.6.5 IMPLICATIONS OF RECENT PROGRAM INFORMATION NOTICE (PIN)

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On July 6, 2010, ONC released additional guidance to state HIEs regarding responsibilities, roles and key

deliverables38. In particular, states were instructed to focus on the following three HIE capabilities in the

next year:

ePrescribing – OHIP has included this service in Phase I under the umbrella of support for Stage

1 meaningful use; however, OHIP acknowledges that many stakeholders see this as a function of

the EHR solution (i.e., SureScripts integration with EHR solution) as a first step and the

aggregation of medication history data as a second step via the statewide HIE. OHIP also notes

that shifts are occurring in federal and state regulations related to ePrescription adoption such

as the recent changes to permit providers to prescribe controlled substances electronically 39and

efforts to align the BOP certification program with national standards and certification

requirements. For this reason, OHIP’s strategy is to leverage40 its preferred EHR vendor program

that requires participating vendors to offer ePrescription modules certified by the BOP as well as

standards‐based integration with the statewide HIE. As a second step, OHIP will offer the ability

to exchange prescription data to any HIE participant.

Receipt of structured lab results – This is also a service included in Phase I under the support for

Stage 1 meaningful use and has strong support by stakeholders. During its HIE RFI process, OHIP

evaluated the current standards supported for the exchange of lab data by responding vendors

and will strongly consider this capability in its (RFP process. In addition, ODH is currently

receiving reportable lab information and is working with the Centers for Disease Control (CDC)

to standardize this type of exchange using NHIN protocols.

Sharing patient care summaries across unaffiliated organizations – For Stage 1, it is not a

requirement to exchange patient care summary data via structured integration with an EHR,

but, ultimately, a goal of OHIP’s stakeholders. Universally, support for the exchange of care

coordination data is a high priority among stakeholders and is seen as having significant

potential to improve patient outcomes. Much of this data exists today, however, not necessarily

in consistent data vocabularies or terminology. OHIP sees opportunities in offering initial

exchange of human readable information and data management services that could normalize

and aggregate the data until widespread adoption of interoperability standards among

providers is achieved.

38 See Appendix A, Reference # S17 39 See Appendix A, Reference # R3 40 See Appendix P, Amendment #4

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All of these services are further discussed in the following sections of the strategic plan: Federal and

State Services Coordination, REC services, EHR Preferred Vendor Program (S‐51); Technical

Infrastructure, Request for Information (S‐94), Business and Technical Operations, Implementation (S‐

100).

1.2.6.6 HIE DEPLOYMENT STRATEGY41

The goal of OHIP’s HIE deployment strategy will be to connect as many of the early adopters as possible

to the statewide HIE so that an estimated 80 percent of Ohio’s population can be supported by the end

of the first year of deployment. This strategy not only allows providers to achieve meaningful use

objectives with HIE implications within incentive program timelines, but also creates the opportunity to

truly transform patient outcomes. To achieve this, OHIP sees a number of opportunities to deploy

services in a manner that maximizes early adoption.

For the initial phases of adoption, OHIP will focus on offering discovery, location, trust enablement and

Stage 1 meaningful use services. These deployment strategies are described in order of priority under

Service Phase I Deployment. For subsequent phases of adoption, strategies for deployment are

described under Service Phase II and III.

Since a large part of the adoption strategy is contingent upon OHIP’s integration strategy, a basic

discussion of OHIP’s approach to integration is discussed below.

EHR INTEGRATION STRATEGY

Consistent with the goals of meaningful use, OHIP is pursuing an integration strategy that aligns with

interoperability standards and frameworks endorsed by the ONC to maximize the number of

participating providers in the statewide HIE. Use of endorsed standards lessens confusion and minimizes

the overall cost to healthcare systems by eliminating custom point‐to‐point interfaces. However, OHIP

recognizes the following challenges in achieving this goal:

EHR vendors currently use varying degrees of technology and standards to support connectivity

to and transmission of health information across unaffiliated organizations.


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Since the Standards and Certification Final Rule was finalized in July 2010, many EHR vendors

have not yet upgraded to the endorsed standards and/or achieved ONC certification.

The Final Rule does not mandate definitive standards for all use cases and technology layers.

Addressing these challenges in a cost‐effective manner requires a strategic approach to integration that

acknowledges “incremental interoperability,” (i.e., the progression of providers and vendors from basic

data exchange functionality to full standards‐based integration capability). This approach includes

defining OHIP’s technical model, clarifying integration standards necessary to connect to the statewide

HIE , and offering tiered connectivity options for providers to participate in the HIE at a level compatible

with their existing architecture.

HYBRID MODEL APPROACH

It is important for EHR vendors desiring to connect with the statewide HIE to understand that OHIP has

chosen a hybrid model approach. A hybrid model balances the need to hold data where it is created

rather than centrally, with the need to effectively exchange information among participants of varying

degrees of technology.

Ideally, all health information would be retained at the source and OHIP would simply provide HIE

participants with the discovery and location services necessary to identify the patient, the provider with

whom data is being exchanged and the location of the source data for retrieval at the time of query.

However, since there are varying degrees of capability at the EHR level, OHIP anticipates the need to

accommodate three types of connectivity levels: a) web portal; b) centralized publisher; and c)

federated publisher. A hybrid model is required to offer these connectivity options.

Web Portal Access ‐ This basic connectivity level provides access to the HIE via a web portal

available through the provider’s browser. This type of connectivity would sit side‐by‐side with an

EHR solution or practice management system not yet capable of directly generating structured

query transactions necessary to push or pull information to/from the HIE. Information accessed

through the HIE would not be consumed by the EHR solution, but could be stored or otherwise

recorded depending on the capabilities of the provider and/or their EHR solution.

Centralized Publisher ‐ In this scenario, EHR vendors may have the capability to support required

interoperability standards necessary to achieve structured integration; however, they are not

capable of making data available to the statewide HIE upon a query request without the need to

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persist clinical data centrally. These vendors will need OHIP to provide a data stage or shared

repository to facilitate exchange of data when it is needed. EHR vendors at this technology level

would be considered “centralized publishers” because they cannot provide data in a true

federated configuration.

Federated Publisher ‐ Here,, EHR vendors have the capability to support the required

interoperability standards necessary to achieve structured integration and would be capable of

making data available to the statewide HIE upon query without the need to persist clinical data

centrally. These vendors are referred to as federated publishers (i.e., data will remain at the

source) and are the most likely to be certified market leaders. OHIP’s preferred EHR vendors

would fall into this category.

INTEGRATION CLARITY

In instances where the Final Rule is not definitive, OHIP’s strategy will be to select and publish the

standard to be used for the HIE rather than support multiple standards. This connectivity strategy was

chosen to keep costs competitive, provide clarity and consistency among providers and vendors, and

minimize the opportunity for errors.

OHIP is in the process of developing a detailed integration statement to clearly outline selected

interoperability standards required to connect to the statewide HIE, especially in instances where they

are not defined by ONC and/or a choice in options was offered in the Final Rule. An example of such a

choice is the use of the HL7 CCD or ASTM CCR to exchange patient care summaries. OHIP will select one

option to maintain costs and will base those options on current market support and penetration levels.

Finalization of the integration statement may be dependent on OHIP’s HIE vendor selection; however, it

is OHIP’s goal to complete this work independently. This integration statement will be made available to

all vendors desiring to connect to the HIE.

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SERVICE PHASE I DEPLOYMENT

STRATEGY #1 – WEB PORTAL ACCESS

Target Number of Physicians: 1,000

OHIP’s goal is to focus on early adopters who are capable of structured integration within their EHR

solutions due to the streamline benefits provided; however, OHIP recognizes there are physicians who

have EHR solutions not capable of this type of integration but will have an immediate need for HIE

services necessary to obtain Stage 1 meaningful use objectives. For this reason and because most HIE

vendors offer web portal capability, OHIP views this as an early adoption strategy.

This strategy also offers a community‐level approach for deployment through OHIP’s regional partners,

a desire expressed by stakeholders early in the planning process. By offering to deploy web‐based access

to the statewide HIE through a regional partner website; stakeholders felt physicians would feel a sense

of community‐level adoption and support.

STRATEGY #2 – OHIP EHR PREFERRED VENDOR INTEGRATION


Following a structured RFP process, OHIP’s REC program selected five preferred EHR vendors to provide

discount pricing and several other benefits to providers seeking certified EHR software. One of the

many additional benefits is assurance that the EHR vendor will achieve ONC certification and will meet

the interoperability requirements necessary to integrate with the statewide HIE without additional cost

to the provider.

OHIP is leveraging these discount offerings to encourage early adoption with the statewide HIE as

follows:

‐ OHIP’s regional partners have been provided preferred EHR marketing and pricing materials to use

as they recruit priority primary care physicians through the REC program. These materials highlight

the benefit of connection to the statewide HIE. Of the 6,000 targeted PPCPs within OHIP’s REC

regions, it is estimated that approximately 3,000 of these PPCPs will be interested in a preferred

vendor.

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‐ The online EHR readiness and assessment tool purchased by OHIP, Welch Allyn, will auto‐generate

RFP‘s to one or all five of the preferred EHR vendors based on provider input. This process alone

saves providers hours in EHR selection, evaluation and negotiating steps, facilitating a more rapid

EHR/HIE adoption model.

‐ At this time, all of OHIP’s preferred EHR vendors have achieved ONC general and ambulatory

certification. ONC certification ensures EHR vendors can meet the security, privacy and

interoperability requirements necessary to connect to the statewide HIE.

‐ HIE vendors participating in OHIP’s RFP denoted structured integration capability with at least one

of OHIP’s preferred EHR vendors in their proposals and have been asked to demonstrate that

integration during their oral and use case presentations for each of the top three HIE services

(ePrescribing, structured lab results and patient care summaries). This increases the likelihood that

structured integration with our preferred vendors will be rapidly achievable.

‐ OHIP has obtained each preferred vendor’s detailed integration information and is in the process of

analyzing it to determine commonality in use of standards not defined by the Standards and

Certification Final Rule. This analysis will assist OHIP in completing its HIE integration statement.

‐ OHIP conducts routine web conferences with the preferred vendors to track certification status,

adoption levels, provider and integration issues.

STRATEGY #3 – OHIO HOSPITAL EHR MARKET LEADERS


There are three large hospital EHR vendors who have a significant market share in Ohio, especially

among large integrated delivery networks who are running hospital‐based HIOs. OHIP is in the process

of reaching out to these vendors to successfully integrate with the HIE.

‐ Epic – Epic has been very successful in Ohio installing its system in approximately 80 hospitals with

about 4, 000 physicians. These installations represent about 60 percent of inpatient bed capacity in

Ohio. Epic offers products that allow for the exchange of health information among other Epic users;

however, it has not been able to exchange information outside its network historically other than

via NHIN exchange.

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‐ McKesson – McKesson has been successful in maintaining its customer base in Ohio. OHIP has been

in discussions with McKesson, whose leadership has expressed strong interest in integrating with

OHIP so their customers can reach meaningful use.

‐ Seimans – Seimans has a number of installations in Ohio; however, it does not offer a clinical

exchange product.

‐ Cerner – Cerner has an active presence in Ohio and, in particular, supports a large regional

community hospital in the northern part of the state that is leading adoption efforts among critical

access hospitals.

OHIP’s interim CEO, Dan Paoletti, who is the Vice President for the Ohio Hospital Associations Data

Solutions Division, has been actively educating and engaging hospital representatives in plans for

integration with the statewide HIE.

STRATEGY #4 – REGIONAL HEALTH INFORMATION ORGANIZATIONS

Targeted RHIOs: 4

As noted in Diagram 1 of the HIE State Plan, stakeholders reported 16 HIE networks in the state during

OHIP’s environmental scan survey conducted in June 2010. The majority of these networks are hospital‐

based and will be integrated via Strategy #3; however, there are four non‐hospital‐based HIE networks:

HealthBridge, Collaborating Communities Health Information Exchange (CCHIE), Wright State’s

HealthLink and the Appalachian Health Information Exchange (AHIE).

OHIP intends to provide a conduit for each of these networks to the HIE for statewide trust enablement,

discovery and location services as well as additional wraparound services as noted in the scan analysis. It

is not OHIP’s intent to replace services being offered, but rather complement them and allow them to

reach a broader audience.

As noted previously, HealthBridge is a finalist in OHIP’s HIE Vendor procurement process as well as the

service provider for CCHIE. Communication regarding integration with the statewide HIE is restricted per

legal counsel guidance until the procurement process is complete, which is anticipated by the end of

January 2011. However, OHIP concurs it is critical to integrate with HealthBridge, CCHIE as well as

HealthLink and AHIE, and intends to pursue discussions following completion of our procurement

process.

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These networks represent more than 10,000 physicians and over 80 hospitals. Since these providers are

already being served regionally, it is unclear how many of those physicians also are represented in

hospital system estimates, and OHIP does not list them as targeted numbers.

STRATEGY #5 – OHIO LAB MARKET LEADERS

Targeted Number of Labs: 3

Per commercial payors and hospital sources, LabCorp, Quest and MedPlan (a regional lab) support 70

percent of the electronic exchange of lab results in Ohio today. OHIP met with LabCorp in November

and is in the process of securing its commitment to connect to the statewide HIE. This integration would

include its specialty labs, such as Compunet.

Similar discussions with Quest and MedPlan are being scheduled to begin plans for early integration

with the statewide HIE. Through integration, these lab providers will minimize their costs by not having

to integrate individually with each EHR vendor. All three of these labs are capable of supporting

structured lab integration.

It is estimated that the other 20 percent of lab results are exchanged within hospital system networks

and will be addressed through Strategy #3.

STRATEGY #6 – OHIO PHARMACY MARKET LEADERS

Targeted Number of Pharmacies: 2,165

According to SureScripts, approximately 95 percent of community pharmacies were activated for

ePrescription in 2009. Since SureScripts supports the majority of ePrescription exchanges in Ohio today,

OHIP is reaching out to SureScripts to negotiate both a cost‐effective integration strategy for the HIE as

well as addressing the remaining percentage of paper‐based pharmacies in the state.

OHIP recognizes the need to integrate with hospital‐based pharmacies. Even though they may not be

dispensing large volumes of medication, they are critical in offering a complete view of a patient’s

medication history. Negotiations with hospitals are occurring to determine alternatives for providing this

linkage.

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STRATEGY #7 – OTHER AMBULATORY EHR VENDORS


OHIP has contact information for more than 40 ambulatory EHR vendors who submitted proposals for

the preferred EHR vendor RFP. OHIP will reach out to these vendors who showed early interest to share

its integration strategy so they have adequate time to prepare for integration. In prior discussions,

vendors have expressed enthusiasm to connect to the statewide HIE and are busy obtaining ONC

certification.

‐ Note: Stakeholders indicate significant EHR marketplace confusion over the term “certification”.

Historical certification tracks, such as CCHIT’s voluntary program, are being confused with ONC

certification. Some vendors who achieved prior CCHIT certification are not necessarily forthright in

making the distinction between CCHIT voluntary certification status and ONC status when they

approach providers about using their products. There is also a general lack of knowledge about

ONC’s website for tracking ONC EHR vendor certification status and the granularity of certification.

OHIP has added the link to its website and is using education and awareness materials to make

these distinctions more clear.

SERVICE PHASE II DEPLOYMENT

STRATEGY #8 –FEDERALLY QUALIFIED HEALTH CENTERS

Targeted Number of Providers: 500

Currently, eight of Ohio’s 35 FQHCs have fully implemented certified EHRs, with several additional

centers in the queue for completion by spring 2011. The remaining FQHCs anticipate full EHR

implementation by 2013.

One of OHIP’s board members, Jeff Lowrance, is CIO for Ohio Shared Information Services (OSIS), the

health‐care controlled network that provides centralized IT support to the majority of Ohio FQHCs. OSIS

uses a NextGen platform, who is also one of OHIP’s preferred EHR vendors. Through a single integration

of the OSIS NextGen platform, the majority of Ohio’s 35 FQHCs and their related providers will be

connected to the statewide HIE quickly.

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Based on 2009 data, the Ohio Association of Community Health Centers (OACHC) reports there are 27

FQHCs in OHIP’s REC region, who employ approximately 265 providers. Given several recent grant

opportunities, OACHC projects there will be closer to 500 providers statewide in the near future.

STRATEGY #9 – OHIO PAYOR MARKET LEADERS

Targeted Number of Payors: 10

Ohio has five major payors and five major managed care plans operating in the state as noted in

Diagram 3.

Diagram 3 ‐ Major Payers and Managed Care Plans in Ohio

Ohio’s Major Payors Ohio’s Medicaid Managed Care Plans (MCPs)

WellPoint CareSource

Aetna Molina HealthCare of Ohio

CIGNA Centine (Sold as Buckeye Community Health Plan)

Medical Mutual of Ohio UnitedHealthcare (Sold as Unison Health Plan)

Amerigroup Ohio

WellCare of Ohio

Paramount Advantage

One hundred percent of the major payors are exchanging eligibility data electronically. None of the

MCPs are. Since approximately 74 percent of Medicaid consumers are enrolled in managed care, OHIP

see opportunities in facilitating electronic eligibility verification for these organizations.

Two of these payors, Medical Mutual of Ohio and UnitedHealthcare are represented on OHIP’s board.

One of them is a board member of the Ohio Association of Health Plans. They are all very interested in

connecting to the statewide HIE and streamlining their administrative processes as well as providing

treatment costs analysis to providers at the point of service.

STRATEGY #10 – MEDICAID AND PUBLIC HEALTH INTEGRATION

Targeted Number of Local Health Departments: 128

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Both of these large state agencies are committed to integrating with the statewide HIE, since there is

recognition of the potential for significant administrative and clinical savings. Medicaid sees potential in

streamlining eligibility verification, coordination of benefits and reporting. Public Health is anxious to

streamline its existing reportable lab, immunization and syndromic surveillance programs through the

statewide HIE.

These agencies are listed in OHIP’s second phase of deployment for two reasons: a) the planned

implementation of Medicaid’s new claim adjudication system (MITS) in early 2011 and the need to

stabilize that system before integration; and b) the potential for significant restructuring among state

health agencies following the recent change in government administration and budget deficit issues.

Currently, 84 percent of emergency departments in the state are providing syndromic surveillance data

to ODH. That data represents 94 percent of all emergency department visits and is accessible to all local

health departments. For reportable lab results, ODH received 55,000 reports in the first three quarters

of 2010 and is anticipating 100,000 reports in 2011. ODH’s immunization system, Impact SIIS, contains

vaccination records for over 9 million Ohioans, representing more than 80 percent of the state’s

population. Ohio Medicaid estimates 3,000 to 4,000 providers will qualify for the Medicaid EHR

Incentive Payment Program. Since many of these providers may be represented in targeted numbers

listed previously, OHIP did not list them as an additional targeted figure.

1.3 FEDERAL AND STATE COORDINATION

1.3.1 REGIONAL EXTENSION CENTER SERVICES

1.3.1.1 HIE AND REC STRATEGY

There is an inherent relationship between the value of an HIE and the adoption of EHRs. The value of an

HIE is directly related to the number of exchange participants using EHRs. For many healthcare

providers, especially small practices and primary care providers, the cost and effort associated with

purchasing, implementing, and utilizing an EHR is only justified if an HIE is available. Due to this direct

relationship between the HIE and EHR adoption, it is important that these two roles be intimately

related.

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As a recipient of both the State Grant to Promote Health Information Technology Planning and

Implementation and the Health Information Technology Regional Extension Center Program, OHIP is in a

unique position to coordinate both efforts closely. This dual‐service capacity provides a distinct

opportunity for OHIP to engage in HIE outreach and stakeholder involvement through existing,

structured REC channels of communication.

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1.3.1.2 REGIONAL PARTNERS APPROACH

For OHIP to coordinate efforts across the awarded REC region, it created seven multi‐stakeholder groups

called Regional Partners42 (RPs) that are responsible for assisting providers in their areas with the

implementation of certified EHRs and achieving meaningful use. These RPs are a consortia of provider

representatives, hospitals, universities, community colleges, vendors, workforce development and

quality improvement organizations. Each RP has an identified area of service (counties) and has received

REC funding based on the targeted number of priority primary care providers (PPCPs) that have been

identified as requiring assistance (See Diagram 3).

OHIP meets weekly with its RPs to coordinate EHR and HIE adoption efforts, share marketing, outreach

and education materials, discuss best practices and to coordinate resources. The eighth region of the

42 See Appendix C for a list of Regional Partner Primary and Secondary Contacts

Diagram 4 OHIP Regional Partners

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state is supported by HealthBridge, an RHIO that was also awarded a REC grant for 11 counties in

southwestern Ohio as well as northern Kentucky and southeastern Indiana. Since HealthBridge is one of

eight vendors invited to participate in OHIP’s HIE RFP, communication with them is limited to the

procurement process.

1.3.1.3 EHR PREFERRED VENDOR PROGRAM

OHIP will require its RPs to meet established milestones to ensure that providers, regardless of

geographic location, receive the assistance necessary to adopt EHRs and achieve meaningful use. These

four milestones are:

Signed Technical Assistance Contracts;

Documented EHR Go‐Live Date;

Meeting Meaningful Use; and

System Maintenance and Optimization.

To assist with the first two milestones, OHIP issued an RFP43 in April 2010 to select a handful of EHR

vendors to offer robust solutions at a discount to providers. The vendors selected to participate in

OHIP’s preferred EHR program are44:

Sage Intergy Suite 6.0

NextGen Ambulatory EHR v5.6

eClinicalWorks v8.0

Allscripts Professional

eMDs Solution Series v6.3.0

OHIP’s preferred EHR vendors are contractually committed to integrate with the statewide HIE and use

the standards created and adopted by ONC. All of these vendors are currently ONC certified for all

general and ambulatory criteria. In addition, preferred vendors must tie payment terms to the

achievement of milestones and receipt of incentive payments rather than the passage of dates and

adopt warranties protecting the provider from classic vendor implementation or support issues.

43 See Appendix D, OHIP REC EHR RFP document 44 See Appendix P, Amendment #4

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OHIP intends to leverage the preferred EHR vendor program to cultivate the ePrescribing objective for

meaningful use, since most providers use their EHR solutions for this purpose. All preferred vendors are

required to support the ePrescribing capability accordingly. The BOP was represented on OHIP’s

preferred EHR vendor selection team and is working closely with OHIP to ensure alignment with BOP

certification requirements. For more information on additional strategies OHIP is planning to leverage

the preferred EHR program for HIE deployment, see Section 1.2.6.6.

1.3.1.4 REGIONAL LEVERAGE AND FLEXIBILITY

While OHIP has established EHR milestones consistent with the federal Health Information Technology

Regional Center (HITRC) guidance, OHIP does not plan to specify the process by which RPs achieve them.

The goal is to ensure that each region is receiving the same quality of services while allowing RPs the

flexibility to develop delivery models that meet their specific geographic needs.

The goal of OHIP is to deploy HIE services and support in a similar fashion, providing core services

statewide, while supporting the specific needs to develop community‐centered exchange efforts. This

balance of core infrastructure and regional flexibility is important when taking into account the cultural,

market and political differences within healthcare delivery in each region. For example, the way in which

services are delivered in one metropolitan area will be different from the way in which services are

delivered in a rural area and both may differ from how services are delivered in another metropolitan

area. OHIP's strategy would allow different approaches in different regions while still achieving the same

milestones.

Using this structure, OHIP is uniquely positioned to deploy HIE outreach, education and service adoption

across the state in an organized, efficient manner leveraging the expertise, communication channels,

market knowledge and stakeholder relationships of their RPs. Community exchanges desiring additional

HIE infrastructure support can be coordinated through RPs so that close alignment with provider EHR

adoption can occur.

1.3.1.5 IT WORKFORCE DEVELOPMENT

In order to meet OHIP’s goals, Ohio needs a trained and qualified health IT workforce, and yet, there is a

lack of such professionals across the nation. Although there are HITECH grants for institutions of higher

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education to develop and implement an HIT curriculum, these trainees will not graduate from those

programs until half way through OHIP’s goal of having 6,000 physicians meaningfully using EHRs.

SHORT‐TERM WORKFORCE SOLUTION

OHIP has convened a statewide team charged with developing a short‐term solution to the trained

workforce problem. The team consists of staff from several state agencies: Board of Regents (OBR)

(higher education), Department of Development (ODD), Department of Jobs and Family Services

(ODJFS). Also at the table are representatives from community colleges, private career colleges, the REC

RPs, and several professionals who have done EHR implementation before and are considered experts in

the field. The team will work on four areas:

Creating a job description and related curriculum

Developing a student/trainee recruitment plan

Seeking additional funding streams

Determining logistics for delivering the training

OHIP is looking to recruit trainees from several sources. Many qualified Ohioans are out of work and

have some of the skills OHIP is seeking in HIT professionals. Through federal retraining programs in the

state, these people will be recruited and screened for suitability OHIP also will look at students and

recent graduates of some of the allied medical programs in our community colleges.

For funding, OHIP intends to capitalize on the federal retraining funds through Ohio’s One Stops and

Ohio Skills Bank. ODJFS, ODD and OBR have been brought in as partners, realizing that this is a job

creation opportunity. OHIP’s intention is that the RPs, as well as the EHR vendors, will hire these

trainees.

LONG‐TERM WORKFORCE SOLUTION

Cuyahoga Community College was awarded the HITECH Community College Consortium grant for the

Midwest. Representatives from the college are also on the workforce development team. They have

designated four community colleges in Ohio to deliver the curriculum in both classroom settings and

through distance learning. As mentioned above, OHIP is concerned that trainees from this program will

not be available until OHIP has passed the midpoint of the REC and HIE grant cycles, and that is why

OHIP is developing a short‐term solution as well.

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OHIP will remain in regular contact with Cuyahoga Community College as the program develops and will

coordinate with its program to the extent possible with the option of transitioning students from the

short‐term program into that program for further training.

OHIP will also continue to work with OBR to ensure that HIT is included in the current medical

professions curricula in Ohio institutions of higher education.

1.3.2 FEDERALLY FUNDED, STATE BASED PROGRAMS

1.3.2.1 ROLE OF STATE INTERAGENCY COUNCIL

In April 2010, the State HIT Coordinator formed the State Inter‐Agency Council (SIC) to explore

opportunities for leveraging the use of the HIE to meet the state’s health quality objectives and to

improve administrative efficiency. The SIC also serves as the forum for coordinating co‐occurring efforts

across agencies that are involved in federally funded, state‐based programs with HIT implications.

The SIC is comprised of representatives from the state’s health oversight and coverage agencies who

have a good understanding of the data already being collected in their agencies and the potential uses

for streamlining data that will be available through the HIE. The council’s task is to address the use of

health information from two perspectives: Policy and Operations. On a policy level, the SIC will work to

identify how each agency currently uses health care and patient‐related information to make decisions

and how the HIE can enhance these functions.

Agencies will concentrate on how they can consolidate the collection of data from providers to

reduce repetitive data requests.

Agencies will also address what data they currently do not have access to and how that data

would improve policy and decision‐making with access.

Agencies will coordinate statewide HIE efforts with federally funded, state‐based programs that

have health IT implications under their purview.

Identify any other opportunities for cost‐savings or streamlining systems through OHIP.

Operationally, the SIC will address how the statewide HIE can help each agency do business better,

streamline data collection and improve customer service. The council will perform a complete analysis

of other IT systems containing information across all agencies that the HIE can facilitate. They will then

work with each agency to determine any potential for cost savings and reorganization once these

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systems are incorporated in the HIE. Since the SIC’s inception, the council has added representatives

from both Ohio’s Medical and Nursing Boards to coordinate efforts45. In addition, the council felt it was

best to divide into four teams based on the role of the state agency or board and their needs in relation

to the statewide HIE.

The focus of each team was defined by members as:

Data Exchange – Agency representatives discussed the need for an efficient and effective way to

exchange data between agencies. This effort would require no new data collection, but rather a way to

know what data each agency has and an easy way to share that data. Ultimately, it is the desire of

stakeholders for these agencies to streamline their data collection processes across agencies, which is a

service OHIP is well‐positioned to facilitate. It is projected that Ohio could save a significant amount in

costs currently spent to send same or similar data multiple times to multiple agencies in different


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formats. Long‐term, thousands of dollars could be saved in the enhanced ability to identify fraud and

abuse patterns.

Licensing – Representatives in this team found a significant overlap in managing the issuance or renewal

of licenses for healthcare professionals. They expressed the need to do this processing and record

keeping in the HIE to save time and money. OHIP and the licensing boards see a win‐win opportunity in

working together, since OHIP has a need to identify and validate individual providers who may use the

HIE. They are currently undergoing discussions about technology options to achieve this win‐win.

Claims – The agencies in this team all manage or administer benefit and claim adjudication processes.

They would like to explore opportunities to leverage use of the statewide HIE to streamline and simplify

their processes and provide more timely and accurate eligibility information.

EHR

Several agencies provide clinical care and would like to implement a certified EHR solution that could

also meet the specific requirements of state agencies. Most often, these agencies provide not only

medical care, but social and public health services. Their clients are frequently indigent homeless or

transient, receiving cross agency services and interfacing with the criminal justice system. Historically,

systems that support these agencies were either developed in‐house by each agency or supported

through niche vendors with limited scalability and interoperability. Since state government cannot

capitalize on IT investments, securing funds to purchase a robust EHR requires special legislative

approval, which is a challenge in tough budget times.

These agencies are excited to finally have a viable opportunity to identify and purchase a certified,

robust EHR that could be scaled to meet their needs and allow them to participate in the statewide HIE,

something they have wanted to do for a long time and have not been able to. With OHIP’s preferred

EHR vendor program, strong hospital stakeholder support and other relationships developed with

vendors for integration with the statewide HIE, this desire can become a reality. OHIP can also assist in

negotiating a fair price for a system usable across agencies, which can reduce the state’s current costs

for maintaining separate systems and ensure connectivity to the HIE. The latter will help these agencies

reduce their overall costs through avoidance of adverse drug events, duplicative tests or services and

identification of other treatment patterns difficult to discern without HIE.

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These four teams were in the process of developing tasks and deliverables to address their specific

needs; however, due to the recent gubernatorial and legislative transition, their work is currently on

hold. OHIP will continue to monitor developments so discussion regarding these efforts can resume as

soon as new leadership for these agencies are identified.

1.3.3 PUBLIC HEALTH

1.3.3.1 IMMUNIZATION AND DATA REGISTERIES

Ohio’s statewide Immunization Information System, ImpactSIIS, is a secure, web‐based information

system managed by the ODH. ImpactSIIS contains over 41 million recorded vaccinations for nearly 9

million Ohioans. Immunizations administered are both directly entered by participating providers via a

web portal and imported from other electronic sources (e.g., local immunization registries, electronic

health record systems, Medicaid claims data) using HL7 v2.5.1., ImpactSIIS has many beneficial features,

such as the ability to generate immunization reminder notices, forecasting immunizations that are due

and managing vaccine inventory.

1.3.3.2 REPORTABLE LAB AND SYNDROMIC SURVEILLANCE

REPORTABLE LAB

The Ohio Disease Reporting System (ODRS), Ohio’s information system for infectious disease

surveillance, was enhanced in 2007 to allow for electronic lab reports (ELR) for communicable diseases

to flow seamlessly from labs into ODRS. Although several other states are receiving ELR data from labs,

Ohio is one of only a handful of states that have automated this process.

Approximately 40,000 ELR reports were received and directed into ODRS in 2009, almost double from

2008. Roughly, 85 percent of these disease reports flowed directly into ODRS without manual

intervention – either creating a new person and disease report, a new disease report for a person

already in ODRS, or adding new information to an existing disease report already in ODRS.

At the end of 2009, participating ELR facilities included several regional labs (ARUP, LabCorp, and the

Mayo Clinic), several state agency affiliated labs (Corrections Medical Center and ODH), as well as many

labs within the Cleveland Clinic hospital system. ODH is in the process of working with Quest, another

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regional lab, as well as the hospital labs at Western Reserve Care and MetroHealth. These entities will

likely be certified to send disease reports via ELR, rather than paper, before the end of the year.

ARRA funding will allow extending ELR to several additional hospital labs in the coming year, including a

pilot project to accept electronic reporting of healthcare‐associated infections. The pilot project will

enable ODH to receive HL7 v.2.5.1 messages in addition to current HL7 v.2.3.1, and test the feasibility of

receiving this data in the clinical document architecture (CDA/continuity of care) format. The statewide

HIE will ultimately provide the primary interface for public health reporting, reducing the need to

connect with each individual laboratory and other provider.

SYNDROMIC SURVEILLANCE

ODH uses syndromic surveillance to detect and track health events such as pandemic influenza,

bioterrorism, outbreaks, seasonal illnesses, injuries and environmental exposures by monitoring and

analyzing the health behavior of Ohio’s population in real time. During a health event, syndromic

surveillance can provide answers to questions such as which zip codes have increased disease levels,

which facilities are treating patients, and whether the event is affecting males, females, or a specific age

group more than others are. This information, known as situational awareness, can be used to target

resources to the most affected areas and keep the public informed of important developments.

Currently, Ohio’s syndromic surveillance system, EpiCenter (Health Monitoring Systems, Pittsburgh),

collects information from approximately 150 facilities in real time. The majority of facilities submit data

in real time using HL‐7 (all versions accepted) over secure, virtual private network (VPN) connections. All

facilities submit the following data elements: time of visit, date of visit, patient chief complaint, age, sex,

and home zip code utilizing Health Level 7 (HL7) messaging. Some facilities are able to send additional

message types (e.g. A08, A01, etc.) to provide updates including discharge disposition and diagnosis

information.

A statewide HIE will make the transfer of syndromic surveillance data simpler and more efficient.

Instead of having a data feed from each healthcare provider, the HIE will allow for one data feed from

RHIOs and other exchanges, thus reducing the amount of technical work necessary to maintain the

connections. In addition, HIE will allow physician offices and outpatient clinics to submit syndromic

surveillance information to ODH, something that is currently limited to hospital emergency departments

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and urgent care centers. The additional data types will enhance Ohio’s situational awareness and event

detection capabilities.

1.3.3.3 PUBLIC HEALTH DATA

ODH collects additional public health data including disease reports through a web‐based system for a

variety of infectious diseases and outbreaks, with expanded testing, services and treatment data for

tuberculosis, sexually transmitted diseases, human immunodeficiency virus (HIV), cancer, stroke, lead

and other heavy metals, occupational conditions, birth defects and genetic disorders. Surveillance

reports come primarily from hospitals, laboratories, clinics, physician offices, emergency medical

services and local health departments. The ODH laboratory receives electronic submissions from

providers and submits results to both the providers and ODH surveillance systems. The ODH lab is

currently piloting the receipt of an HL7 v2.5.1 messages with integrated microbiology and demographic

information.

Dispensing of antiviral agents and antibiotics for influenza or potential bioterrorism agents are reported

by hospitals, clinics and physicians. A wide array of health services and procedures data primarily for

mothers, newborns and children is reported to ODH and includes metabolic, genetic, hearing and vision,

dental, family planning, nutrition, early intervention, breast and cervical cancer and other health

assessments and services from hospitals, clinics, schools, local health departments and physicians.

Long‐term care facilities report a variety of patient and facility information and hospitals report data for

registration. Hospital quality measure reports include 96 indicators of surgical and clinical infections,

deaths and other adverse outcomes, medical and surgical procedures and patient satisfaction survey

data.

The statewide HIE will dramatically increase the quantity and quality of information available to public

health, reducing the need for costly surveys and significantly improving the capacity to monitor priority

health measures such as obesity and tobacco use.

VITAL STATISTICS AND HIE

The Vital Statistics System in Ohio has transitioned from paper to electronic data collection. The birth

certificate is initiated at delivery within birth hospitals. Birth clerks compile demographic and medical

information onto facility and mother’s worksheets from medical records. Clerks then key this data into

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an electronic web‐based birth system (Integrated Perinatal Health Information System). Once the birth

record is completed at the hospital and saved, it becomes available for viewing at the local registrar and

state registrar levels. The local registrar checks the electronic record for specific items and then files the

record. At that point, the state registrar checks specific items and registers the record. The record is

available for public health use once saved at the hospital level. Out‐of‐state births and geo‐coded

residence information are added to the record, which various public health programs (e.g., birth defects

surveillance and services) utilize.

Death certificate processing is similar to that for births except that funeral directors initiate the death

record rather than hospitals. Funeral directors query informants and then enter decedent’s

demographic information into the electronic death reporting system (EDRS). Funeral directors then print

off a paper copy (drop to paper). They bring the paper copy to the certifying physician who enters the

medical information onto paper. Physicians cannot currently access the electronic death certificate

system. Once the physician has certified the death and entered the causes of death, the funeral director

delivers the completed death certificate to the local registrar. The registrar checks specific items, files

the record electronically and mails the paper copy to the state registrar. Once received in the central

state office, the state registrar keys in the paper only items and registers the death. The cause of death

statements are sent electronically to National Center for Health Statistics where International Statistical

Classification of Disease Codes 10th Revision (ICD‐10) codes are assigned to the death. Death certificate

information is available electronically once the funeral director has saved the record. This data is used

for various public health programs (e.g., child fatality review). The statewide HIE will greatly simplify

these interfaces and improve the efficiency of these processes.

1.3.3.4 OTHER PUBLIC HEALTH

MATERNAL AND CHILD HEALTH STATE SYSTEMS DEVELOPMENT INITIATIVE (SSDI) PROGRAMS

SSDI was launched in 1993 to complement the Title V Maternal and Child Health (MCH) Block Grant

Program and to combine the efforts of State MCH and Children with Special Health Care Needs (CSHCN)

Agencies. Administered by the Health Resources and Services Administration (HRSA), SSDI is intended to

assist state agency MCH and CSHCN programs in the building of state and community infrastructures

that result in comprehensive, community‐based systems of care for all children and their families.

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SSDI continues to focus grant resources on the Title V Block Grant Health Systems Capacity Indicator

(HSCI) #9(A): The ability of states to assure that the MCH program and Title V agency have access to

policy and program relevant information and data. States focus SSDI resources on establishing or

improving the data linkages between birth records and 1) infant death certificates, 2) Medicaid eligibility

or paid claims files, 3) Women Infants Children (WIC) eligibility files, and 4) newborn screening files.

States give first priority to these four data linkages, and then focus on establishing or improving access

to the following four. 1) Hospital discharge surveys; 2) a birth defects surveillance system; 3) a survey of

recent mothers at least every two years, similar to the Pregnancy Risk Assessment Monitoring System

(PRAMS); and 4) a survey of adolescent health and behaviors at least every two years, similar to the

Youth Risk Behavior Surveillance System (YRBS).

The statewide HIE will provide enhanced linkage capability using its MPI to significantly reduce the cost

and time for these activities. Furthermore, the HIE will reduce the need for risk knowledge and behavior

surveys by providing timely population‐based information on these critical health factors.

AWARDS/AIDS DRUG ASSISTANCE PROGRAM FORMULA AND SUPPLEMENTAL AWARDS (HRSA)

The Ryan White CARE program keeps electronic records of client program applications and is the

repository for medical information reported by healthcare providers for clients served through the

program. The program also pays Medicaid spend‐down to allow clients to have health cards, as well as

Medicare Part D wrap‐around services (e.g., premiums, co‐pays, deductibles, etc.) managed through a

third‐party administrator and pharmacy. ODH compares program data to Medicaid eligibility to assure

ODH is the payor of last resort.

STATE OFFICES OF RURAL HEALTH POLICY AND PRIMARY CARE (HRSA)

The Health Resources and Services Administration (HRSA) funds several programs at the state‐level

designed to increase access to healthcare services for underserved populations. In Ohio, the State Office

of Rural Health (SORH) and Primary Care Office (PCO) are co‐located under ODH. They work to assure

the availability of appropriately trained health professionals in primary care and other specialties

needed to deliver health services to underserved areas and populations. They also work to develop

community‐based systems of health care and assure access to high quality interdisciplinary, culturally

competent health services.

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The Ohio PCO focuses its activities on assessing the need for primary care providers by designating

Health Professional Shortage Areas (HPSAs) and on the recruitment and retention of needed providers

to work in these underserved communities. Funded through multiple state and federal provider loan

repayment and scholarship programs, much of the PCO effort is devoted to primary care workforce

development. The Ohio SORH focuses its efforts on mitigating the access disparity in rural communities

to healthcare services. Its core functions include the collection and dissemination of rural health

information; coordination of rural health resources and activities statewide; provision of technical

assistance to meet rural community health needs; and support for rural workforce development efforts.

HIT is a critical issue when addressing the health care access challenges faced by Ohio’s underserved

residents. The Primary Care and Rural Health Section (PCRHS) is actively engaged in this topic as it

relates to statewide healthcare workforce development planning efforts and in its work with the state’s

34 Critical Access Hospitals (CAHs). A statewide effort is underway to tackle many of the state’s

workforce issues, and four sub‐groups are in the process of being created.

The Unified Long Term Care System‐ Direct Service Workforce Development Subcommittee;

The Health Care Coverage and Quality Council – Primary Care Workforce Development

Subcommittee;

The Statewide Health Information Technology Workforce Development Team; and

The Interagency Team Focused on Coordination of All State Healthcare Workforce Initiatives.

The Primary Care and Rural Section Administrator and Primary Care Unit Administrator are represented

on the Interagency Team and will be working closely with the Primary Care Workforce Development

Subcommittee once formed. The PCRHS administrator collaborates closely with OHA and Ohio’s 34 CAHs

on HIT and related issues, with some funding being made available to CAHs for network

development/HIT activities.

As providers of primary care services, county health departments are also eligible for REC assistance

under the grant opportunity. ODH and OHIP are working together to explore alternatives for certified

EHR adoption in local health department settings. Ideas being explored include cost‐sharing options

through collaborating with other local healthcare providers or other health departments in the area or

region.

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NHIN DEMONSTRATION PROJECT WITH THE CDC

ODH was invited by the CDC to establish a direct connection to the NHIN. The CDC will cover all costs for

this project. Ohio would become one of only a few states to connect with NHIN and will facilitate the

exchange of public health information among Ohio, CDC, other participating states (currently Indiana,

Washington and New York) and other entities in a secure and standardized manner. This would assist

the statewide HIE in establishing NHIN protocols and provide a more immediate pathway for providers

in Ohio to meet meaningful use requirements for public health reporting.

1.3.4 BROADBAND INITIATIVES

Connect Ohio is a nonprofit, technology‐neutral partnership that works with telecommunications

providers, business and community leaders, information technology companies, researchers, public

agencies, libraries and universities in an effort to help extend affordable high‐speed broadband Internet

services to every household in Ohio.

Connect Ohio is a comprehensive initiative that will improve broadband Internet access and dramatically

increase the use of related technology. The program is the result of a partnership between the State of

Ohio and Connected Nation, a national non‐profit organization that specializes in increasing technology

access and literacy.

Connect Ohio works across all sectors of the state economy in partnership with telecommunications

providers, information technology companies, public agencies, business leaders, community leaders,

researchers and universities in an effort to meet specific goals, which include:

Affordable broadband availability for all of Ohio;

Dramatically improved use of computers and the Internet by all Ohioans;

Local technology planning teams that include every Ohio community;

A meaningful Internet presence in all Ohio communities, to improve citizen services and

promote economic development through e‐government, virtual education and e‐health

solutions; and

A policy and regulatory framework that encourages continued investment in communications

and information technologies year after year.

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In 2008, data provided by Connect Ohio was combined with information from healthcare resources to

produce maps overlaying broadband coverage with physician and hospital location information (see

Diagrams 4 and 5).

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Diagram 5 Broadband Coverage with Physicians by Zip Code

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Diagram 6 Broadband Coverage with Hospitals by Zip Code

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This information shows extensive broadband access in the majority of the state with the weakest points

appearing in the south‐central and southeastern portions, an area largely represented by OHIP’s RP, the

Ohio University Appalachian Health Information Exchange (OU). OU has been proactively participating in

state broadband initiatives for several years and is still actively engaged in discussions and solutions on

this issue.

In their 2010 assessment, Connect Ohio reported that only 2.1 percent of households in the state did

not have terrestrial fixed broadband access. This figure for rural households was 4.2 percent. Both

numbers reflect increases in broadband access statewide since 2008; however, the most common

barrier reported is not access itself, but the perception that broadband is not necessary or valuable. This

is followed by a lack of computers in both homes and businesses because of persistent economic

conditions.

In addition, ComNet, Inc., was recently awarded a $30 million grant with an additional $12.9 million

applicant‐provided match to construct almost 700 new miles of high‐capacity fiber to expand an existing

network throughout 28 western Ohio counties. ComNet estimates it will create over 300 jobs through

this project. Nearly 2 million people as well as 165,000 businesses and approximately 3,000 other

community institutions stand to benefit from this project. This project will help an area that has been

impacted by the automotive restructuring and by high unemployment rates.

These broadband initiatives will be valuable to OHIP as it moves forward with its message for HIT

adoption both at the statewide and community level. OHIP and its RPs can assist in raising awareness

about the availability of existing broadband access as they encourage HIT adoption through REC

assistance and education regarding the incentive payment program.

1.3.5 MEDICAID COORDINATION46

1.3.5.1 STATE MEDICAID HEALTH INFORMATION PLAN (SMHP)

In June 2010, Ohio Medicaid submitted their Planning Advanced Planning Document for HIT (PAPD)

outlining the steps necessary to complete the State Medicaid Health Information Plan (SMHP) and its

associated Implementation Advanced Planning Document (IAPD). These plans, in combination, will


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enable the implementation of Ohio’s Medicaid EHR Provider Incentive Payment Program (MPIP),

provide an assessment of Ohio’s current HIT landscape and the state’s Medicaid HIT vision and provide a

road map to accomplish the vision.

Since submission of the PAPD document, the following steps have occurred or are scheduled to occur:

CMS approved Ohio’s PAPD in July 2010

State Controlling Board approved release of funds to support MPIP program in

September 2010.

Ohio Medicaid has prepared the SMHP, which is currently being reviewed by

stakeholders and is targeted for submission to CMS before December 2, 1010

Following approval of the SMHP, Ohio Medicaid will submit the IAPD to CMS likely in

December 2010.

MPIP system build and related procurement activities will begin in January 2011.

Implement MPIP program in spring 2011

The SMHP requires Ohio Medicaid to look forward five years, anticipating technological innovations and

practice improvements. The plan is both a strategic and tactical plan, moving Medicaid participating

providers to improve both quality and efficiency, which is a goal common with OHIP’s vision. The plan

contains five sections, each with a comprehensive set of questions and answers required to obtain CMS

approval:

Documentation of Ohio Medicaid’s “As Is” state of EHR adoption, broadband availability and

electronic data exchange capacity.

Documentation of Ohio Medicaid’s “To Be” vision for HIT

Details about implementation of Ohio’s Provider Incentive Payment Program

Details about Ohio’s Strategy for Monitoring and Auditing the MPIP program

Ohio Medicaid’s HIT Roadmap, describing how Ohio Medicaid will achieve its five year vision

including annual benchmarks and indicators for each goal to measure progress

Strategies for execution of the SMHP and related coordination with OHIP include:

Resources for the MPIP project will be a combination of Ohio Medicaid staff, housed under

ODJFS and contractor staff. The cost of this phase of the project is estimated to be $1.4M and

qualifies for 90 percent enhanced federal funding. Medicaid staff denotes this amount is only to

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fund the staff necessary to implement and support the MPIP program as outlined in the SMHP.

Funds were not separately earmarked for other statewide efforts toward development of the

statewide HIE or EHR adoption (e.g., entity index development, etc.). This decision was made to

allow Medicaid staff to remain focused on high‐priority implementation initiatives such as MPIP

and MITS and the limited availability of match funds due to Ohio’s budget deficit.

Ohio Medicaid has engaged OHIP about leveraging its RP channels to communicate and educate

providers on the requirements and implementation of the MPIP. This includes exploring

additional targeted strategies for participation and related EHR adoption to support providers in

rural or economically challenged urban locations.

As the initial work of outreach with Ohio’s practitioners moves to the next phase of technical

support to establish adoption ,meaningful use of certified EHR and Ohio’s MPIP implementation,

ODI/OHIP and Ohio Medicaid will examine common business practices to support federal

Meaningful Use Quality Measures. Common goals between Medicaid and OHIP include using HIT

to gather and exchange clinical information for the purpose of health quality improvement,

using HIT to increase accountability through transparent and streamlined reporting on quality

measures, transforming data into meaningful information that can engage clinicians and

patients in informed decision‐making.

National meaningful use measures are well known. Ohio Medicaid’s quality focus is exemplified

by Ohio Medicaid has several value‐based activities already underway. These efforts include its

Emergency Department Diversion project, Medicaid payment reform, Best Evidence for

Advancing Childhealth in Ohio Now (BEACON) Council, and ePrescribing, as well as participating

in the HCCQC’s avoidable hospital readmission and multi‐payor enhanced primary care home

initiatives. These activities require an enhanced decision support system at Medicaid and the

exchange of relevant health information to promote value‐based decisions. They will influence

the type of information that Ohio Medicaid seeks through exchange and the partnerships and

strategies that Ohio Medicaid pursues to promote the adoption of EHRs and the exchange of

health information.

OHIP was the source of much of the information contained in the SMHP and will continue to

assist Ohio Medicaid in its efforts to obtain approval since implementation of the MPIP program

is of critical importance to OHIP’s stakeholders and a driver of EHR adoption in Ohio. Ohio

Medicaid is also a member of OHIP’s Communications Committee and is actively coordinating

with OHIP to communicate the status of the MPIP program to stakeholders through OHIP’s

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regional partner channels, media announcements, newsletters and OHIP‐sponsored

conferences.

1.3.5.2 MEDICAID INFORMATION TECHNOLOGY SYSTEM IMPLEMENTATION

As noted previously, Ohio Medicaid began planning efforts in 2004 to convert its existing claim

adjudication system [MMIS] to the new Medicaid Information Technology Architecture (MITA)47.

Following a formal procurement process, Ohio Medicaid selected a vendor (EDS, later HP) to assist in

making this transition.

Currently, key components of MITS are in place including front‐end support for managing the exchange

of HIPAA‐mandated48 administrative transactions between trading partners and an enterprise service

bus (ESB). Beginning First Quarter 2011, the new claim adjudication module of the MITS system will go‐

live for Phase I processing. Subsequent phases of implementation are also planned including integration

with sister state healthcare‐related agencies, ODJFS’ data warehouse and decision support system.

To fully support the transition of the MITS system from implementation to production and prepare for

certification, Ohio Medicaid does not intend to directly interface MPIP with the MITS system during the

first year of the MPIP. However, MITS’ portal and ESB middleware capabilities may be leveraged to

support the MPIP in a latter phase of the system lifecycle.

1.3.5.3 MEDICAID COORDINATION AND STAKEHOLDER ENGAGEMENT

To understand how OHIP is coordinating with Medicaid HIT initiatives, it is important to be aware of how

Medicaid is administratively structured in Ohio and how the leadership within this structure is engaged

in collaboration with OHIP.

OHIO’S MEDICAID STRUCTURE

As noted in a 2006 report to the state legislature conducted by the Ohio Medicaid Administrative Study

Council, ODJFS oversees Ohio’s Medicaid program along with seven other major state and federal

programs. Within ODJFS, Ohio Medicaid is administered at a “sub‐department” level and therefore must

47 See Appendix A, Reference # S13 48 See Appendix A, Reference # R14

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share leadership and support services with the other major programs administered by that agency as

noted below.

In addition, specific Medicaid program services are administered through delegated arrangements with

eight other state agencies. Of these agencies, the Department of Aging (ODA), Department of Alcohol

and Drug Addiction Services (ODADAS), Department of Mental Health (ODMH) and Department of

Developmental Disabilities (DODD) fund and/or deliver specialty population‐focused services to

hundreds of thousands of Medicaid and non‐Medicaid eligible Ohioans in addition to performing

Medicaid administrative functions. Four other state agencies also involved in Medicaid or health‐related

functions: Department of Health (ODH), Department of Education (ODE), Attorney General (AG) and

Auditor of State.

Although core Medicaid medical services have historically been administered using ODJFS’ MMIS, all of

the delegated agencies have purchased or developed independent systems over the years to manage

service delivery or administer payment within their respective scope of services. These systems are not

necessarily linked across all agencies, although some do feed into MMIS or related Medicaid reporting

databases. Plans for future MITS implementation phases include adding functionality or data to support

some of these delegated arrangements.

From a policy perspective, each agency can develop its own provider licensure, certification, major and

unusual incident, population reporting and other policies, although cross‐agency coordination is

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encouraged via interagency agreements. In 2007, the Executive Medicaid Management Administration

(EMMA) was created to serve as the central coordinating body to manage the Ohio Medicaid program

across all state agencies. EMMA has been active in facilitating coordination across similar policies (e.g.,

provider licensure) and plans for MITS implementation.

STAKEHOLDER ENGAGEMENT

As evidenced by Ohio’s Medicaid Administrative Structure, coordination with Medicaid programs is not

simply a matter of coordination with a single state agency or with a single benefits administration

system. Therefore, when Ohio’s State HIT Coordinator began discussions regarding the best mechanism

for coordinating with Medicaid, she first approached EMMA. The state agencies participating in

EMMA’s coordinating committee voted to establish a separate council, the State Interagency Council

(SIC) to coordinate health IT initiatives including MPIP. In total, Ohio Medicaid staff members from

ODJFS are represented on the following OHIP‐related stakeholder committees:

Committee Participating ODJFS Medicaid Staff

OHIP Board State Medicaid Director is not a board member, but an invited

guest who provides updates on MPIP, MITS and other related

HIT initiatives on a monthly basis

OHIP HIE Committee Chief, Health Services Research, Medicaid

OHIP Privacy Committee HIPAA Project Director, Medicaid

OHIP Regional Partner Committee Project Manager, Medicaid Communication and Outreach

State Interagency Council (SIC) Chief Strategy Officer; Program Manager, Public Program

Healthcare Coordination and Support; Chief, Health Services

Research

HCCQC State Medicaid Director; Chief, Policy and Health Plan services,

Medicaid

In addition to these committees, EMMA, Medicaid sub‐waiver agencies and/or State HIT Coordinator

staff are represented on the following OHIP‐related committees:

Committee Participating State Agency Staff

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Committee Participating State Agency Staff

OHIP Board State HIT Coordinator, Board Chair

OHIP HIE Committee Deputy Director, Center for Public Health Statistics and

Informatics (ODH)

OHIP HIE Vendor Scoring Team CIO (ODI)

OHIP Privacy Committee Legal Counsel (EMMA); Legal Counsel (ODMH)

OHIP ePrescribing Task Force State HIT Coordinator (ODI); Legislative Affairs Liaison (Ohio

Board of Pharmacy)

State Interagency Council (SIC) State HIT Coordinator (ODI), Chair; Strategic Planning and Data

Analysis Administrator (ODI), Facilitator

Behavioral Health REC Sub‐

Committee

Medicaid Policy Director (ODMH); CIO (ODADAS)

HCCQC All state health agencies are represented

1.3.5.4 BEST EVIDENCE FOR ADVANCING CHILD HEALTH IN OHIO NOW (BEACON)

BEACON is a statewide collaboration in Ohio among individuals and organizations that seek to

encourage and support initiatives that achieve measurable improvements in children’s health care and

outcomes through improvement science. The BEACON council is co‐chaired by Dr. Alvin Jackson,

Director of ODH and Dr. Mary Applegate, Medical Director for Ohio Medicaid. The focus on children’s

health quality, outcomes measurement and research, coupled with an existing data‐sharing

infrastructure presents a unique opportunity to improve quality and enhance innovation in the delivery

of healthcare for children. It may also be an excellent avenue for input/guidance related to Ohio’s

Medicaid Health IT Plan. This initiative could clearly benefit through leveraged use of the statewide HIE

to achieve and track improved outcomes.

1.3.5.4 CYBERACCESS

CyberAccess is a HIPAA‐compliant internet portal for Medicaid providers to access pharmacy

information regarding their patients. Prescribers can also use the tool to verify a drug’s prior

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authorization status and send ePrescriptions to pharmacies. Prescribers and/or their authorized staff

will have the ability to:

Review two years of pharmacy claims submitted by providers;

Identify potential care management concerns including adverse drug events, over or under

utilization and disease management best practices;

Electronically verify drug prior authorization status; and

Electronically send prescriptions to pharmacies.

Integration of this capability with the statewide HIE and direct integration with certified EHR vendors

would expand use and the related potential mitigation of prescription‐related adverse events.

1.3.6 MEDICARE COORDINATION

Medicare and OHIP efforts will intersect on the following levels:

Coordination of Medicare/Medicaid Incentive Payment Programs ‐ Eligible non‐hospital

providers must choose to pursue EHR incentive payments through either the federal Medicare

or a state Medicaid program. As noted under Medicaid Coordination efforts, Ohio Medicaid is in

the process of preparing the details of this coordination through the development of their state

Medicaid HIT Plan. Central to the process will be its integration with the National Level

Repository (NLR) being developed by CMS. The NLR will provide a single point of entry to

register providers for both incentive payment programs to:

- Prevent duplication of payments between Medicare and Medicaid and between states;

- Allows Medicare to meet its mandate for online posting requirements;

- Track EHR incentives nationally; and

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- Ensure accurate and timely payments.

The NLR will collect eligible providers’ name, NPI (Type 1), business contact information,

Taxpayer Identification Number (TIN) and desired incentive program selection. This data will bi‐

directionally interface with the MPIP as depicted in the Diagram 7 above.

Further details of the NLR interface are currently being vetted through CMS and State Medicaid

agencies. As this work develops, Ohio Medicaid representatives will continue to update OHIP on

important emerging issues to enhance communication to providers through OHIP’s stakeholder

committees, RP channels and OHIP’s website.

Medicare eligibility and coordination of benefits – Ohio Medicaid providers are required to bill

Medicare and other payors before seeking reimbursement through the Medicaid program.

Providers are required to report other coverage consumers may have, if the provider is aware of

the coverage, which is captured in the Ohio Medicaid MMIS/MITS. In addition, Ohio’s current

Medicare intermediaries, National Government Services (Part A) and Palmetto GBA (Part B)

support electronic eligibility inquiry and response transactions49. OHIP intends to leverage these

49 Neither of these entities won the current contract. CMS is currently in court over their appeal. These two entities will continue to process claims until the suit is settled.

Diagram 7 National Level Repository Narrative

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two sources of data to provide centralized eligibility information and ultimately the coordination

of benefits.

1.3.6.1 COORDINATION WITH BEHAVIORAL HEALTH PROGRAMS

OHIO PEDIATRIC/PSYCHIATRY DECISION SUPPORT NETWORK (OPPDSN)

The Ohio Pediatric/Psychiatry Decision Support Network (OPPDSN) is a grassroots, community‐driven

telehealth initiative launched by ODMH in May 2009 in response to growing concerns over timely access

to child psychiatric services and the detrimental impact those delays were creating for patients and the

state’s emergency care system. This highly‐endorsed program provides a technologically supported

system of consultation, communication, quality improvement and direct services designed to both

increase access to child psychiatry and triage for PCMHs, primary care, and community mental health

provider organizations and remove barriers to integrated care through system‐linking technology used

by a coordinated and competent decision support network.

The youth of Ohio are fortunate to be served by excellent children’s hospitals, in addition to an array of

pediatricians, internists, obstetrics/gynecology, family physicians and general psychiatrists who have

some experience treating children with mental illnesses. Together with primary care physicians,

advocates and others, the OPPDSN team is advancing a plan for providing a statewide network of expert

consultation by child/adolescent psychiatrists and other health professionals, including a state‐of‐the‐art

Web site focused on child and adolescent mental health, e‐visits, store‐and‐forward technology and

video/telemedicine services. A member of OHIP’s Board is an active participant in this telehealth

initiative that has received an overwhelming amount of support throughout the state’s healthcare

system since its inception.

TREATMENT EPISODE OUTCOMES SYSTEM (TEOS)

Pending award of a Data Infrastructure Grant (DIG) from the Substance Abuse and Mental Health

Service Administration (SAMHSA) in October 2010, ODMH plans to collect client level and sample data

to report the National Outcome Measures (NOMs). Each year of the grant, data will be sought from

approximately 170,000 consumers with Serious Mental Illness (SMI) and caregivers of children and

adolescents with Serious Emotional Disturbance (SED). Over the life of the grant, data will be sought

from approximately 500,000 consumers and caregivers.

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ODMH plans to develop reports and/or a database that will enable local mental health authorities and

service providers to use information from the proposed Treatment Episode Outcomes (TEO) system and

from survey sampling, with the overall goal of improving access, enhancing service quality and efficiently

meeting the requirements of funders and national accrediting bodies. To measure and report the NOMs

for housing, employment/school suspensions and criminal justice involvement, ODMH plans to develop

and implement a TEO system where service providers will collect and report on consumers with

SMI/SMD at either admission/discharge or annual update.

To measure and report the NOMs for client perception of care, social connectedness and functioning,

ODMH plans to draw a random sample from enrollment records in its outpatient billing system. Staff will

conduct an annual survey of 3,000 adult consumers using the SAMSHA’s Mental Health and Statistics

Improvement Program (MHSIP) and 3,000 caregivers of child and adolescent consumers using the Youth

Services Survey for Families (YSS‐F). Information collected through sampling 18,000 consumers and

caregivers over three years will permit the ODMH to report annual changes in perception of care, social

connectedness and functioning scores from 2011 through 2013.

1.3.7 PARTICIPATION WITH FEDERAL CARE DELIVERY ORGANIZATIONS

1.3.7.1 MILITARY AND VETERAN’S HEALTH SERVICES

There are five Veteran’s Affairs (VA) Medical Centers geographically dispersed in Ohio: Chillicothe VA

Medical Center, Cincinnati VA Medical Center, Louis Stokes VA Medical Center in Cleveland, Chalmers P.

Wylie Ambulatory Care Center in Columbus and the Dayton VA Medical Center. Ohio also has two VA

outpatient clinics and 28 VA community‐based outpatient clinics. There is one Department of Defense

(DOD) medical facility at Wright Patterson Air Force Base in Dayton, Ohio (the 88th Medical Group). The

state does not have any Indian Health Services (IHS) nor does it have any tribal health facilities.

Given OHIP’s REC structure, OHIP intends to engage military and veteran’s health organizations in health

IT adoption through its RPs, who have existing relationships within their communities with these care

delivery organizations and are better position to encourage HIE adoption at a local level. In addition,

OHIP is aligning its proposed HIE model and related committee structure with national standards

development such that NHIN or other protocols developed to connect federal care delivery

organizations with state HIEs will be used as they emerge.

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1.3.7.2 FEDERALLY QUALIFIED HEALTH CENTERS50

The Ohio Association of Community Health Centers (OACHC) represents all of the state’s 35 Federally

Qualified Health Centers (FQHC) and coordinates much of the primary care for Ohio’s at‐risk population.

In 2009, FQHCs provided care to over 475,000 Ohioans and recorded well over 1,900,000 patient visits.

With the ARRA funding granted to health centers in 2009, steady growth is expected to serve more than

550,000 patients in 2010 and over 1,000,000 patients by 2015.

OACHC estimates approximately 450‐500 providers practicing in their network have prescriptive

authority. Currently eight of Ohio’s 35 FQHCs have fully implemented, ONC certified EHRs with several

additional centers in the queue for completion by Spring 2010. Those remaining anticipate full EHR

implementation by 2013.

This successful rate of adoption is due to OACHC’s strategic approach through a healthcare controlled

network, Ohio Shared Information Services (OSIS) that provides centralized IT support on a common,

certified platform (NextGen) available to all Ohio FQHC locations. OACHC’s Executive Director is a

member of OHIP’s HIE Committee and the CIO for OSIS sits on OHIP’s Board. Both entities have been

actively engaged in HIT adoption at the statewide level for some time and are enthusiastic about its

potential for improved patient outcomes. Ohio’s FQHCs provide a model approach for other subsets of

healthcare providers with specific requirements to encourage adoption where IT solutions obtained

independently may have otherwise failed.

1.4 GOVERNANCE

1.4.1 COLLABORATIVE GOVERNANCE MODEL

1.4.1.1 STATE DESIGNATED ENTITY


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As the SDE for Ohio’s statewide HIE, OHIP is in a unique position to provide a cohesive approach to

delivering both HIE and REC services at a statewide level. To do this, OHIP must address the needs of its

stakeholders and promote a process that encourages transparency and communication.

1.4.2 GOVERNANCE STRUCTURE

1.4.2.1 BOARD EXECUTIVE COMMITTEE

During the creation of OHIP, five stakeholder groups came together to create the initial Board of

Directors for OHIP. In addition to serving as stewards within the healthcare community, these

stakeholders provided in‐kind funds to generate the start‐up capital required to establish the

organization and possess the funds necessary for the federal match requirement.

Currently identified as the Board Executive Committee, these five members have the authority to add,

change or remove board members from the larger Board of Directors.

The founding members are representatives from the following organizations:

BioOhio, a non‐profit organization designed to build and accelerate bioscience industry,

research, and education in Ohio

Ohio State Medical Association (OSMA)

Ohio Osteopathic Association (OOA)

Ohio Hospital Association (OHA)

State Government

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Following the submission of the State Health Information Exchange Cooperative Agreement Program

and the Regional Centers Cooperative Agreement Program grant applications, the Board Executive

Committee chose to expand the Board of Directors from five to fifteen members in February of 2010.

1.4.2.2 BOARD OF DIRECTORS

The Board of Directors is a 15‐member board that oversees the full breadth of OHIP’s operations. The

expansion of the board from the original five members was necessary to promote a broader stakeholder

base that would foster greater transparency within the organization. All OHIP board members have

voting, staff oversight, community stewardship and fiduciary responsibilities. The expanded board

members represent the following additional stakeholder groups:

Hospitals

Primary care MDs

Primary care DOs

Mental Health

FQHCs

Payors

Employers

Consumers

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Included in the group of expanded board members is one seat that is reserved as the “at‐large” seat.

This seat’s representation will rotate on an annual basis and be filled based on OHIP’s most active tasks.

Please refer to Table 2 for a list of OHIP’s current Board of Directors.

1.4.2.3 FINANCE AND AUDIT COMMITTEES

As required in ARRA, OHIP created committees for finance and auditing to ensure that OHIP is meeting

all federal fiduciary requirements regarding the use of ARRA grant money.

1.4.3 STAFFING STRUCTURE

OHIP’s planned leadership structure for supporting both the HIE and the REC is depicted in the diagram

below. Since the award announcements, OHIP has been actively working to recruit staff in these

positions. Further details regarding staffing under this leadership structure are included in OHIP’s HIE

budget and are further explained in the Staffing section of the Operational plan.

Table 2 OHIP Board of Directors

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While OHIP continues to recruit staff, Board Executive Committee members and their respective

organizations are supplying resources to assist with current operations. Several attempts have been

made to benchmark HIE staffing projections with other state efforts; however, due to the infancy of

field, it remains a challenge to know how much staff should be hired versus outsourced and there is a

limited pool of expertise available due to demand. ONC’s assistance regarding staffing projections would

be helpful to OHIP and other states as they progress with their efforts.

The Project Managers for both the HIE and REC will each serve as the facilitator to the committee

related to their scope of work. These committees will be responsible for performing a strategic advisory

role in the development of each of OHIP’s lines of business. Relevant, interested stakeholders compose

the majority of these committees and are led by members of OHIP’s board or staff. These committees

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represent a diverse range of stakeholders including hospital CIOs, M.D.s, D.O.s as well as behavioral

health, FQHC’s, state agencies and provider association representatives51.

Each committee will have the option of forming ad hoc work groups that address the specific needs for

their line of business. A few of those existing workgroups are noted in the diagram above (i.e., privacy

and policy52). For more information about alignment of OHIP’s committee structure with federal

committee structures, please refer to the Governance section of the operational plan (O‐7).

1.4.4 STAKEHOLDER INVOLVEMENT

As the SDE for Ohio, OHIP will rely on the SIC53 and the HCCQC to provide them with stakeholder

inquiries and concerns.

51 See Appendix E for a complete list of HIE and REC Committee Members 52 See Appendix P, Amendment #11


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As noted in the section on Federally Funded, State‐Based Programs of the strategic plan, the SIC includes

representatives from the state’s health oversight and coverage agencies as outlined in the diagram

above and serves as a forum for state agency input and coordination with HIE development efforts.

The HCCQC serves as a public‐private advisory group designed to improve the coverage, cost and quality

of Ohio’s health insurance and healthcare system. Established by the Ohio General Assembly in July

2009 following its initial creation by an Executive Order from Governor Ted Strickland, the HCCQC

consists of over 30 members from the provider, payor, consumer and policy communities. State

agencies responsible for health care and insurance delivery and oversight are represented, as is the Ohio

General Assembly. The Council encourages and provides regular opportunities for public comment.

Furthermore, the HCCQC has created an HIT taskforce that includes members of the council, interested

stakeholders and members of OHIP54. This taskforce is an effort to coordinate other state and federal

healthcare reform with the efforts of OHIP and the HITECH grants.

Lastly, OHIP received numerous letters of support from stakeholders during their federal grant

application process55.

1.4.5 STATE GOVERNMENT HIT COORDINATOR

In Ohio, the Enterprise Health IT Officer position is housed in ODI. This is a result of ODI’s designation by

Governor Strickland as the state agency responsible for managing funds and initiatives related to health

reform including oversight of the HCCQC and OHIP. Amy Andres, Chief of Staff for ODI, is currently filling

this position for the state. Amy’s unique background as a public sector CIO with a significant amount of

stakeholder leadership responsibility coupled with private sector experience in pharmaceutical data

exchange positions her well for the job. Amy led the state’s legislative task force on eligibility and claim

adjudication standardization. More importantly, Amy has the necessary skills and cross‐agency authority

to move both critical stakeholders and the state’s administration toward both short‐term and long‐term

health IT goals. It is her intent to leverage the state’s investment in OHIP by integrating the statewide

HIE’s resources into the state’s policy, operational and technology strategies.

As the State’s Enterprise Health IT Officer, Amy serves as OHIP’s Board Chair and a member of the Board

Executive Committee. As Board Chair, Amy provides the financial oversight for both state and federal

54 See Appendix F for a list of HCCQC HIT Task Force Members 55 See Appendix G for a list of stakeholders who submitted letters of support to OHIP

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funds allocated to OHIP, as well as ensures that all development and implementation strategies align

with OHIP’s efforts. She is also leading a workgroup composed of leaders from Ohio’s health‐related

agencies, the SIC. The task of this workgroup is to integrate OHIP’s efforts with state initiatives. This

group will be tasked with re‐evaluating their policy, operational and technology strategies to identify

ways to leverage the statewide HIE to improve their processes, take advantage of new information

available, and to integrate existing and proposed information systems with the HIE. Additionally, Amy is

a member of the core Medicaid team that will facilitate the provider incentive payments through the

implementation of the required meaningful use components.

1.4.6 ACCOUNTABILITY AND TRANSPARENCY

OHIP will act in a manner that provides stakeholders with succinct and timely communication necessary

to engage in health IT adoption efforts effectively. OHIP recognizes the importance of balancing the

stakeholders’ need for communication with fiscal responsibility for staff time such that OHIP does not

generate pointless communication tasks, unimpeded procurement efforts and prevent “information

overload.” To balance these goals, OHIP has adopted the following communication strategies:

Early on, OHIP established a formal Communication Committee comprised of the

Communication Directors for each of the initial board member organizations. Collectively, this

committee has a significant amount of experience in dealing with the media, public record

requests, web and print communications, lobbyists, vendors and other interested parties. This

committee vets all public announcements. The group has also been expanded to include a

communications representative from each regional partner. The committee communicates

regularly and will meet as needed to coordinate outreach efforts effectively.

In January 2010, OHIP created a website, www.ohiponline.org , where all news, procurement,

related links and other pertinent information is shared. In April 2010, OHIP contracted with a

vendor to provide a SharePoint platform to support both extranet and internet portals. The

extranet will be used to share documents, discussion, calendars and other important

information with committee members, regional partners and board members. This platform will

also provide with a portal to the federal CRM reporting tool.

Stakeholders and vendors may elect to be added to OHIP’s e‐mail list via the Contact OHIP

webpage on OHIP’s website. This mailing list is used for key announcements and procurement

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updates. Additionally, email addresses and related processes have been created to accept both

general public and procurement‐specific inquiries.

In May 2010, OHIP contracted with a Communication Director, who is responsible for managing

daily communications for all of OHIP’s initiatives. With extensive experience in health public

affairs and media communication, she will be responsible for all web and print materials and is

in the process of developing an OHIP Communications Plan and marketing materials for Regional

Partner use.

OHIP issues a weekly newsletter to the Board, all committee members and regional partners.

OHIP conducts separate weekly conference calls and/or webinars with members of the HIE

Committee, REC Committee and RPs. In addition, monthly face‐to‐face meetings are held with

the RPs and with members of the HIE or Communication Committees when necessary.

OHIP provides formal updates on HIE, REC and OHIP administrative tasks to OHIP Board

Members during their monthly meeting both face‐to‐face and via webinar for members who are

unable to travel.

OHIP staff members have been invited to serve on the REC Education and Outreach (E&O)

Advisory Group to help develop strategies and materials in support of the Community of

Practice (CoP).

1.5 FINANCE

The inherent juxtaposition of IT, especially in the healthcare industry, makes HIE sustainability difficult.

An HIE must be robust without the associated costs. OHIPs model is to offer a multitude of services that

noticeably improve efficiencies and offset infrastructure costs. The following two fundamentals are key

to the viability of an HIE and are in direct contention with each other:

That it is feasible for any healthcare provider, healthcare consumer or payor to electronically

share individually identifiable data to support efficiency and quality of care in a standards‐based

format; and

The costs and benefits of an HIE are aligned such that, once established, the HIE will be funded

through mechanisms that reflect the advantages and value created from participating in an HIE

rather than through extraordinary, one‐time sources.

To overcome these conflicting ideologies, non‐traditional revenue mechanisms will need to be

developed to provide sustainable services for those who cannot or will not afford them.

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1.5.1 SUSTAINABILITY56

OHIP’s sustainability strategy is based on three core objectives:

Leveraging the OHIP REC’s EHR adoption goals to assist the HIE with PIN target services;

- EPrescribing

- Exchange of structured lab results

- Sharing of patient care summaries across unaffiliated organizations

Offering HIE core and basic clinical data exchange services at significantly discounted prices or

for free; and

Developing additional value added, fee‐based services.

These three objectives will help create a sustainable HIE that will assist direct participants, such as

providers, payors, labs and pharmacies in achieving meaningful use, and also will create potential

revenue streams from current secondary data users, including government agencies, payors,

accreditation bodies and researchers.


HIE to encourage stakeholder participation. Concurrently, OHIP will use its REC program to expand

provider EHR adoption, directly increasing the possible user base of the HIE. As the HIE attains a critical

mass of users, additional, value‐added services will be phased in that can be purchased by current users

and secondary data users who may not require bi‐directional functionality.

To reduce costs for hospitals, providers, payors and patients, OHIP intends to sustain the HIE by

developing innovative solutions surrounding eligibility verification, coordination of benefits, real‐time

claims adjudication and real‐time payment. To provide value‐added services, OHIP sees significant

opportunities arising from the convergence of three historically separate provider processes: timely

identification of disease‐specific treatment protocols, clinical documentation workflows and

administrative workflows to secure payment. In the past, providers followed entirely separate electronic

or manual processes to perform these three functions, all of which were analyzed for errors

retroactively. Until recently, technology was not widespread enough to support a more sophisticated set


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of protocols using timely clinical and administrative data to ensure better outcomes for both the patient

and provider.

For example, through HIE technology, OHIP envisions the real‐time capability to validate clinical data

against treatment protocols, benefit coverage and payor edits to achieve a 99 percent propensity for a

provider to be paid on first pass. More importantly, the on‐demand merging of clinical and

administrative data flows allows patients to obtain point‐of‐service authorization and a clear

understanding of the cost of treatment. Deployed in an “open model” that supports all payors and

providers throughout the state, these future workflows also align with healthcare reform models such as

accountable care organizations or PCMHs. It is this future vision that has driven OHIP to select a

sustainability strategy that incorporates the clinical and administrative exchange services.

With the expansion of the clinical exchange creating an ever‐increasing provider base, the integration of

administrative functions will help improve healthcare quality and curtail costs through improving

operational efficiencies.

1.5.2 SUMMARY OF COSTS AND REVENUES

To maximize the amount of funding that OHIP would be able to acquire from the federal government, a

committed match from the State of Ohio for $2,106,801 was released by the state’s controlling board.

This match garnered a federal grant match of $14,872,199 ensuring adequate start‐up capital to

construct the core functions of the statewide HIE. OHIP’s business model includes generating

$11,625,000 in revenue through the initial four years of the HIE operations. Traditional sources of

revenue have been in the forms of subscription fees, transaction fees and sign‐up/sign‐on charges for

the exchange of clinical data. These traditional fee models discourage both initial participation and

lasting adoption. To encourage buy‐in, revenue structures must be, at worst, cost‐neutral for those who

will use the system. Ultimately, those on the service side will have to reassess what truly carries value in

the system. OHIP plans to continue stakeholder sustainability forums to monitor the services that OHIP’s

stakeholders will be willing to pay for.


HIE to encourage stakeholder participation. Concurrently, OHIP will utilize its REC to expand provider

EHR adoption, directly increasing the possible user base of the HIE. As the HIE attains a critical mass of

users, additional services will be phased‐in to offer value‐added, fee‐based services that can be

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purchased by current users and secondary data users who may not require bi‐directional functionality.

These fee‐based services will offer reductions in existing costs and allow the HIE to offer its core services

and clinical data exchange for little or no charge. OHIP has identified that sustainability is best achieved

through multiple revenue streams that do not simply rely on the exchange of clinical data. This multi‐

revenue stream model will leverage the buy‐in of all types of stakeholders, using a variety of services to

capture their individual desires for operational efficiency and cost reduction. Coordinating with national

standards and protocols, OHIP plans to generate sufficient revenue to assist Ohio’s entire, eligible

provider population with meeting each stage of meaningful use by 2015.

The budget is comprised of core infrastructure costs that include hardware and software costs that are

not unique to a specific function but are required to support the statewide HIE as a whole, such as the

cost of the core platform, Master Patient Index (MPI), Master Entity Index (MEI), etc. The budget also

includes the cost of human resources to implement and maintain the statewide HIE. The OHIP board

provides oversight to the budget, resolves any issues related to the budget and determines appropriate

financial risks. The total for the core infrastructure and Use Case costs is approximately $10.8 million for

the first and second years of operation, with an increase to around $17.3 million for the third and fourth

years. The revenue projections grow in year three and four with non‐grant revenues exceeding cost

projections in year five.

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Table 3 OHIP Projected HIE Revenues and Expenses

OHIP

REVENUES & EXPENSES

Total Total Total Total Total Federal Non‐Federal Grand

SUPPORT & REVENUE Year 1 Year 2 Year 3 Year 4 Year 5 Total Total Total

Support

Federal Grant ‐ HIE 5,765,566 3,142,235 3,004,316 2,960,082 0 14,872,199 0 14,872,199

State Grant ‐ HIE 878,593 516,425 372,500 339,283 0 0 2,106,801 2,106,801

TOTAL GRANTS 6,644,159 3,658,660 3,376,816 3,299,365 0 14,872,199 2,106,801 16,979,000

Revenue

HIE SERVICES 0 500,000 1,250,000 4,750,000 9,250,000 15,750,000 15,750,000

CLINICAL EXCHANGE 0 0 0 750,000 1,000,000 0 1,750,000 1,750,000

TOTAL REVENUE 0 500,000 1,250,000 5,500,000 10,250,000 0 17,500,000 17,500,000

TOTAL REVENUES 6,644,159 4,158,660 4,626,816 8,799,365 10,250,000 14,872,199 19,606,801 34,479,000

EXPENSES

HIE Overhead Expenses

Personnel Staff Costs 358,416 792,000 831,600 873,180 916,839 2,372,709 1,399,326 3,772,035

Fringe 129,030 285,120 299,376 314,345 330,062 854,175 503,758 1,357,933

Travel 50,000 50,000 75,000 75,000 78,750 200,000 128,750 328,750

Equipment 325,000 50,000 50,000 50,000 52,500 375,000 152,500 527,500

Supplies 115,000 115,000 115,000 115,000 120,750 400,000 180,750 580,750

Other 148,420 254,840 171,840 176,840 185,682 673,000 264,622 937,622

HIE Contractual

Legal 196,632 240,000 190,000 190,000 199,500 590,000 426,132 1,016,132

Audit/Acct 45,000 25,000 25,000 25,000 26,250 100,000 46,250 146,250

Financial 60,000 20,000 20,000 20,000 21,000 40,000 101,000 141,000

Accounting Ass't 6,000 0 0 0 0 6,000 0 6,000

Communications 75,000 75,000 50,000 50,000 52,500 250,000 52,500 302,500

OHIP IT Support 50,000 50,000 50,000 50,000 52,500 0 252,500 252,500

HIE Software & Suppt 3,766,801 800,000 2,020,000 5,800,000 6,090,000 5,750,000 12,726,801 18,476,801

HIE Edu & Outreach 218,860 200,000 50,000 50,000 52,500 300,000 271,360 571,360

HIE IT Devel & Custom 600,000 339,385 330,000 300,000 315,000 1,500,000 384,385 1,884,385

HIE Hosting 500,000 362,315 349,000 250,000 262,500 1,461,315 262,500 1,723,815

Total Contractual 5,518,293 2,111,700 3,084,000 6,735,000 7,071,750 9,997,315 14,523,428 24,520,743

TOTAL EXPENSES 6,644,159 3,658,660 4,626,816 8,339,365 8,756,333 14,872,199 17,153,134 29,349,000

SURPLUS/(DEFICIT) 0 500,000 0 460,000 1,493,667 0 2,453,667 2,453,667

1.5.2.1 REVENUE TIER METHODOLOGY

Noted in the Proposed HIE Business Model section of the strategic plan, OHIP will develop the statewide

HIE in phases. Similarly, revenue for the statewide HIE is projected to exponentially advance as the HIE

develops. Project revenue streams from HIE services will fall into one of three tiers as outlined below:

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Meaningful Use Revenue Tier – To assist providers as they adopt EHRs, this revenue tier will

apply to core support and basic clinical data exchange services required to meet meaningful use

objectives with HIE implications. Pricing for HIE services falling under this revenue level will be

kept minimal so that costs for related clinical data exchange is affordable and adoption is

encouraged. HIE services under this tier include discovery and location services, trust

enablement, integration with OHIP’s preferred EHR vendors, community‐based portals and

clinical data exchange services required to meet meaningful use objectives.

Administrative Revenue Tier – As HIE adoption increases, more cost‐effective and streamlined

administrative HIE services will be offered to providers. As the HIE incorporates these functions,

operational efficiencies and cost reductions will be realized for providers while providing

sustainable revenue for the HIE. There are immediate business benefits available to providers

and many health plans by having ubiquitous access, uniform across all payors, and real‐time and

batch response times to receive health plan benefit information with some providers already

able to submit claims to health plans without third‐party assistance. Providers are finding that

the electronic remittance advice and claim status transactions provide ways to reduce their

outstanding patient accounts and capture more revenue with less overhead. With a well‐

designed, standards‐based electronic network, all administrative data in health care will move

far more efficiently than it is today. HIE services under this tier include centralized insurance

eligibility verification, integration with Medicaid, centralized mailing address verification

services and centralized coordination of benefits, referral, pre‐authorization and certification

coordination.

Data Revenue Tier – As the data exchanged through the HIE becomes more comprehensive and

valuable to participants, services under this revenue tier will provide additional sustainable

revenue. These services include expanded integration with state agency systems to streamline

current reporting requirements, advanced data aggregation and reporting tools and other

payor/employer exchange services.

1.5.2.2 EXPLANATION OF MODEL ASSUMPTIONS

OHIP has identified that the funds needed to sustain the HIE are currently in the industry value chain

and the key is to offer initial services that will engage a large number of stakeholders early. The larger

the initial HIE user base is will result in a quicker delivery of additional benefits to those initial users and

others who may not have seen a benefit in being an early user. The pricing structure is designed to

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encourage stakeholders to use the HIE for a small fee and allow the statewide HIE to deliver value to its

participants very quickly adding Pay‐As‐You‐Grow functionality for core services. The pricing defined in

this proposal is preliminary and reflects the need to achieve a sustainable business model. HIE services

such as exchanging medical claims and administrative‐related data between providers and health plans

are subject to very significant efficiencies through the use of a statewide organization to move and

coordinate the interconnectivity of healthcare providers and health plans. If fees for moving the

transactions are assigned at a cost that meets the stakeholders budgetary needs, the overall cost savings

are economically advantageous to all users in Ohio. A tiered pricing model would be established to

provide attractive capped levels so that neither health plans nor healthcare providers have runaway

costs. Through continual input and feedback from the entire stakeholder community in Ohio, the OHIP

board will be required to approve all final pricing models.

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Table 4 OHIP Revenue Model Assumptions

Model Assumptions ‐ Subscription/ Month

Assessment Unit / Month Adoption Rates

Use Cases Per

Facility* Per

Physician Per

Payor** State

Agencies Year 1 Year 2 Year 3 Year 4 Year 5

Core Services $0.02 2 1000 1000 0% 30% 50% 90% 90%

Trust enablement & Authentication $0.02 2 1000 1000 0% 30% 50% 90% 90%

Privacy and Security $0.02 2 1000 1000 0% 30% 50% 90% 90%

National protocol dev and support $0.02 2 1000 1000 0% 30% 50% 90% 90%

Master Patient Locator Index $0.02 2 1000 1000 0% 30% 50% 90% 90%

Record Locator Services $0.02 2 1000 1000 0% 30% 50% 90% 90%

Master Entity Index $0.05 2 1000 1000 0% 0% 20% 50% 70%

Phased Services

Quality Reporting Requirements $0.03 2 0% 15% 30% 50% 70%

Expanded integration with Medicaid $0.03 2 1000 500 0% 15% 30% 50% 70%

Insurance Eligibility Verification $0.05 2 1000 1000 0% 0% 15% 50% 70%

Integration w/ state & other registries $0.05 2 1000 0% 0% 0% 5% 30%

Other Reporting Requirements $0.03 2 0% 15% 30% 50% 70%

Coordination of Benefits $0.05 2 1000 1000 0% 0% 0% 10% 30%

Preauthorization $0.03 2 0% 0% 30% 50% 70%

Remittance Advice, Claims & Claim Status $0.05 2 1000 1000 0% 0% 5% 15% 35%

Average Monthly Subscription $4,000 $28 $11,000 $9,500

Max Monthly Subscription $10,000 $28 $15,000 $10,000

Projected Revenue for Core Services $0 $500,000 $1,250,000 $4,750,000 $9,250,000

Clinical Data Exchange 0% 30% 70% 90% 90%

MU objectives – Stage 1 0% 30% 50% 70% 90%



Average Monthly Subscription – All Core Service $600 $25

Max Subscription for all Clinical Services $1,000 $25

Projected Revenue for Clinical Data Exchange $0 $0 $500,000 $750,000 $1,000,000

Other Services

Consumer PHR integration

Integration with OHIP’s preferred EHR vendors

Total Projected HIE Revenue $0 $500,000 $1,750,000 $5,500,000 $10,250,000

*Monthly Charge – Per Acute Care Facility is a Sliding Fee Scale based upon Annual Inpatient Discharges (Annual Inp Disch * $) / month

**Monthly Charge – Per Payor Organization could also implement a Sliding Fee Scale

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1.6 TECHNICAL INFRASTRUCTURE

Prior to the formation of OHIP, stakeholders were engaged in discussions regarding a desired technical

model to support a statewide HIE to support meaningful use and the state’s data exchange priorities.

During this period, representatives of the healthcare industry consulted with industry experts who

noted the immaturity of the HIE vendor market, a blending of traditional EHR vendors and HIE vendors

in this space and the need for a vendor who could support the range and capacity of a substantial

statewide HIE network. In August 2009, a vendor forum was held to share thoughts about strategic

direction and to elicit input from vendors active in the HIE market.

Given OHIP’s strategic direction, the infancy of the HIE vendor marketplace and the rapid evolution of

standards, OHIP stakeholders concurred that the technical model must be sustainable yet fluid and

easily adaptable to change. This will require a comprehensive, technically advanced infrastructure

designed for the future yet well‐grounded in privacy and security safeguards.

1.6.1 REQUEST FOR INFORMATION57

In January 2010, OHIP’s HIE Committee issued an HIE RFI58 to potential vendors. The purpose of the RFI

was to identify a pool of full service HIE vendors who have the “breadth, depth and width” to support a

statewide HIE to participate in an RFP process. OHIP was fortunate to receive several outstanding

responses to the RFI from a variety of vendors in the HIE market.

Each vendor’s response was evaluated on five core axes by a subset of the HIE Committee who have

extensive experience in the healthcare industry and HIT. These axes included technical, product/service,

financial and organizational viability, as well as the clarity, quality and completeness of the response.

Certain vendors were eliminated from further consideration after evaluation of their initial responses

and the remaining vendors were asked to provide additional information to clarify their initial

responses. The responses of the remaining vendors were then re‐evaluated, taking into consideration

the additional information provided by each vendor.

57 See Appendix P, Amendment #9 58 See Appendix H, OHIP HIE RFI

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The RFI was concluded in March 2010 and resulted in the identification of eight vendors who will be

invited to participate in an RFP process:

ACS Healthcare

CSC

GE Healthcare

HealthBridge

Medicity

MedPlus

Microsoft

Thomson Reuters

OHIP intended to be further along in its procurement process so it could inform its strategic and

operation plans; however, due to the plans’ tight deadlines, the HIE Committee decided to postpone

releasing the RFP until September 2010. The process of creating the RFP proved a challenging but

worthwhile effort for committee members. Unlike EHR procurements, there is little precedence in the

market place for this type of procurement, and many of the HIE RFI or RFP documents publicly available

preceded ARRA or further ONC clarifications about state‐designated service priorities and national

standards initiatives. The process, however, allowed committee members to focus on key emerging

drivers which may not have been apparent in earlier procurement efforts. There also was significant

legal counsel input and oversight to ensure consistency and compliance with all regulatory requirements

pertaining to statewide HIEs. OHIP is currently in the final stages of its RFP process and will recommend

a final vendor to OHIP’s board in January for implementation of core services beginning June 2011.

1.6.2 TECHNOLOGY DEVELOPMENT PRINCIPLES

1.6.2.1 INTEROPERABILITY

Due to the rapid, co‐occurring evolution of standards and

the recent adoption of the Standards and Certification Final

rule, OHIP recognizes that, while comprehensive

interoperability is the goal, the process to achieve this will

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require incremental steps. These steps will require working with providers and vendors to understand

requirements, how to achieve certification and to provide ongoing clarity around specific data exchange

uses in Ohio.

STANDARDS‐BASED, INCREMENTAL INTEROPERABILITY

Despite these challenges, OHIP is committed to a technical model that will support all federally

endorsed standards and integration protocols for each respective architectural layer (data vocabularies,

messaging, privacy and security protocols, NHIN transport protocols, etc.) and will allow providers to

incrementally progress from basic data exchange to full integration capability with their EHR. Where

standards are not final or fully adopted, OHIP will encourage the use of industry best practices or a

multi‐state collaborative approach while supporting exchange standards necessary for state or other

federal regulatory compliance. To assist providers, vendors and others in understanding the full scope of

regulatory, certification or best practice compliance in Ohio, OHIP has outlined these requirements in a

“living” document included in Appendix A.

DEVICE NEUTRAL, SINGLE ACCESS METHODOLOGY

To the extent possible, the technology model will support a device‐independent, singular approach to

access for HIE participants. Examples of this approach include single sign‐on integration with existing

HIEs, central web portal access and centralized patient insurance eligibility verification via desktop,

laptop, other mobile devices, EHR integration, fax, email messaging, etc.

PEER‐TO‐PEER CONNECTIVITY

Any entity that meets the criteria established would be able to connect to the statewide HIE. Entities

may include providers, community‐based HIEs, payors, consumers, pharmacies, state agencies,

registries, hospitals, long‐term care facilities, labs, and other ancillary providers who can serve as both a

provider and consumer of services.

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1.6.2.2 TECHNICAL APPROACH

As with interoperability, OHIP’s technical approach will have to be flexible to accommodate a rapidly

growing market that will continue to change and evolve. With the full scope of HIE capabilities still in

their infancy and simultaneous NHIN protocol development,

the technical approach has to be able to incorporate new

features, standards and abilities that may not have been

identified during the HIE’s creation. This will require a fluid and

scalable approach that restrains itself from an excess of

proprietary systems. The HIE must also be able to connect with

other exchanges on a level where trust agreements are applied and access issues are understood. In

addition, OHIP is pursuing a “full service” HIE vendor where a thin layer of management is retained

within OHIP, but the majority of service and support for the HIE infrastructure lies with the selected

vendor who has overarching responsibility and expertise in managing the infrastructure.

STRONG TECHNICAL SUPPORT FOR PROGRESSIVE TRUST AGREEMENT MODEL

The HIE will initially support primary uses for data exchange and progress to secondary use for

authorized and non‐competitive purposes only if the latter provides clear benefit to participants through

effective and efficient streamlining of data reporting. To the extent possible, the technical infrastructure

will support protocols necessary to authorize and authenticate appropriate use of progressive data

exchange through the statewide HIE based on OHIP’s data trust agreement model. OHIP intends to use

the NHIN DURSA as a framework for developing its trust agreements.

VENDOR NEUTRALITY

The technical model should provide standards‐based connectivity to the maximum number of certified

EHR systems as possible to leverage existing provider investments.

PRIORITY‐BASED SCALABILITY

The technical infrastructure must have the capacity to provide statewide support for OHIP’s highest

service priorities while allowing for feasible expansion of services and deployment to additional entities

in a scalable manner with consideration of the incremental technical, financial and operational

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implications. OHIP’s priorities will be consistent with the state’s healthcare quality objectives, federal

meaningful use requirements and requirements for financial sustainability.

FULL SERVICE SOLUTION WITH TRANSITION CAPABILITY

OHIP seeks to engage a single HIE service provider who has the capacity and ability to manage all

aspects of the statewide HIE operation including staffing, hosting, training, implementation, support,

software and all related sub‐components of the operation. The full service provider must disclose and

manage all sub‐sourcing arrangements and should have the ability to transition certain functions back to

OHIP over time as an effective means to control operational costs.

1.6.2.3 TECHNICAL ARCHITECTURE

Based on OHIP’s HIE RFI responses and materials from the

State Level Health Information Exchange (SLHIE) group,

OHIP identified specific features vital to an effective and

sustainable HIE. One such feature is the ability of the HIE to

adapt quickly to inevitable changes in the healthcare

environment. The landscape is an ever‐shifting field of

standards that the infrastructure must adapt to in order to remain a viable resource.

HIGHLY ADAPTABLE INFRASTRUCTURE

The technical model will provide for a flexible infrastructure that can quickly and easily support rapidly

changing data exchange standards, security and privacy protocols, financing, policy and regulatory

healthcare environment.

HYBRID MODEL, SERVICE ORIENTED ARCHITECTURE (SOA)

OHIP endorses a hybrid technical model that supports both distributed data and health record banks

(i.e., patient‐controlled personal health records) using location services for the purposes of identification

and retrieval of information. A distributed model ensures that data is held where it is created, therefore

avoiding negative perceptions and potential privacy and security consequences resulting from storing all

patient information in a large, central HIE repository. This model will support a service‐oriented

approach for connecting disparate technology.

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ENHANCED PROVIDER SERVICES

The technical solution will offer enhanced service capability to providers as an incentive for HIE

participation, especially for those providers who may not have extensive EHR capability. These services

may include clinical decision support, patient messaging, patient access to health information or other

value added services.

ADVANCED CONSUMER INTEGRATION

The technical infrastructure will support a sophisticated, secure and standards‐based consumer consent

model allowing for direct consumer access, authentication and authorization of health data exchange at

granular levels as well as a standard interface for personal health records (PHR).

ADVANCED DATA AGGREGATION CAPABILITIES

The technical model will use advanced solutions to extract, normalize, aggregate and de‐identify data

from various sources in a manner that significantly streamlines the current provider data reporting

requirements for population health purposes and minimizes duplication, error and potential for data

misuse. This includes integration of clinical data with large data sources such as MITS.

1.6.2.4 HIE FLOW CHART59

OHIP intends to follow emerging industry standards to support its core service model. This includes

deploying technology that supports a two‐tier authentication model, allowing for the authentication of

participating entities at the OHIP level and delegation of provisioning, identify proofing and

credentialing of end‐users at the entity level. Although core service interoperability standards are not

defined in the Standards and Certification Final Rule, it is OHIP’s desire to implement standards

consistent with NHIN, IHE and HITSP capabilities as well as emerging consumer preference protocols.

A schematic of OHIP’s authentication and patient query flow is provided on the next page. Further

details will be provided upon selection of an HIE vendor.


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1.7 BUSINESS AND TECHNICAL OPERATIONS

1.7.1 IMPLEMENTATION

As described under the Proposed HIE Model section (S‐34)of the strategic plan, OHIP intends to

implement the statewide HIE in phases. A “pre‐phase” is necessary to build the core components of the

statewide HIE. The first service phase will focus on Stage 1 meaningful use requirements and OHIP’s

sustainability model. The second phase will target expanded core services, Stage 2 meaningful use,

advanced reporting capabilities and national protocol development. The final phase will support Stage 3

meaningful use, expanded administrative transaction support, integration with Medicaid, other state

agencies, payors, employers and consumers. Table 5 describes the specific services in each phase.

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Table 5 Proposed Core Infrastructure Services Implementation Model

Core Service Description Implementation

Phase

Discovery/

Location Services

Provide discovery/location services of sufficient granularity to identify

where patient data exists among trusted exchange partners including

but not limited to:

Master Patient Index (MPI)

Master Entity Index (MEI) – To include licensed service providers

such as providers, hospitals, payors, pharmacies, labs, etc.

Record Locator Service (RLS)

Pre‐Phase Core

Support

Trust Enablement

Services

Provide services and mechanisms to garner trust among HIE

participants including:

Secure data exchange

Compliance with federal and state regulations

Ensuring appropriate data use

Reliable authentication of users and articulation

Adequate audit controls

Enforcement of consumer privacy preferences

Pre‐Phase Core

Support

Support for MU

objectives with

direct HIE

implications –

Stage 1

Provide support for Stage 1 meaningful use objectives with direct HIE

implications in a manner consistent with the interoperability standards

as mandated by ONC including:

Support of transmission of electronic prescriptions; Most EHR

vendors are supporting this functionality; however, see

“Integration with OHIP’s preferred EHR vendors, Service Phase I”

of this table for more information about OHIP’s proposed

strategy.

Exchange of clinical laboratory and pathology results

Provide summary care record for each transition of care or

referral (at a minimum, in human readable form)

Reporting of required ambulatory quality measures to CMS or

State Medicaid agencies

Transmission of data to immunization registries or to public

health agencies for electronic syndromic surveillance where

possible and accepted.

Service Phase I

Community‐based

web portal and

branding support

Provide support to build branded web portals to encourage HIE

adoption at the community level which would provide connectivity to

the statewide HIE. These portals could be used by trusted providers

who currently do not have EHRs or whose EHRs are not yet fully

interoperable to view permissible patient information.

Service Phase I

Insurance Eligibility

Verification

Offer a centralized, fully integrated service at the statewide level to

support insurance eligibility verification for patients covered under

Medicaid, Medicaid Managed Care Organizations, Medicare and other

third party payors. This integration service would support real‐time or

Service Phase I

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Phase

batch eligibility inquiry and response transactions meeting federally

endorsed standards and CAQH Committee on Operating Rules for

Information Exchange (CORE) Phase I requirements with the goal of

migration to Phase II requirements as recommended by Ohio’s

advisory committee on eligibility60

Integration with

OHIP’s preferred

EHR vendors

Integrate with OHIP’s preferred EHR vendor solutions using federally

endorsed standards for clinical and administrative data exchange.

Since these vendors must support electronic prescription capability

and meet Ohio’s Board of Pharmacy requirements, use of OHIP’s

preferred vendor solutions will encourage adoption and use of

ePrescription in Ohio.

Service Phase I

Centralized mailing

address verification

service

Providers currently pay a significant amount for services required to

resolve bad mailing address information. OHIP proposes to offer this

type of service at the statewide level to provide economies of scale to

reduce costs associated with these services

Service Phase I

Support for MU

objectives with HIE

Implications –

Stage 2

Expand support for the clinical exchange of data among HIE

participants in a manner consistent with the interoperability

standards as mandated by the ONC. These standards are yet to be

defined.

Service Phase II

Integration with

state level and

other registries

Integrate state level and other registries for additional public health

assessment, newborn screenings, vital statistics, cancer or other

priority disease, injury or adverse health conditions.

Service Phase II

Advanced data

aggregation and

reporting tools

Provide advanced data aggregation and reporting tools for the

purposes of significantly streamlining and reducing current provider

and other stakeholder reporting burden to government or other

oversight entities such that significant savings is realized by the

healthcare system in Ohio. Examples of reporting services include:

Other quality reporting requirements and quality gap

notifications not included in Stage 1 meaningful use objectives

Population health and related oversight reporting requirements

Service Phase II

National standards

and protocol

development

Support the development of emerging national protocols to provide

for the exchange of data across state borders, nationally and with

federal agencies. This includes participation and support for the

evolving umbrella of NHIN components such as NHIN exchange, NHIN

Direct, NHIN governance models and related open source software

support.

Service Phase II

Support for MU

objectives with HIE

implications –

Stage 3

Expand support for the clinical exchange of data among HIE

participants in a manner consistent with the interoperability standards

as mandated by the ONC. These standards are yet to be defined.

Service Phase III

60 See Appendix A, Reference # S5

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Phase

Other centralized

administrative

transaction

support

Offer a centralized, fully integrated service at the statewide level to

support real‐time and batch transactions for the purposes of

streamlining coordination of benefits, referrals, pre‐authorization,

certification, pharmacy benefits, claim adjudication, remittance advice,

and claim status verification processes in a manner consistent with the

standards mandated by ONC.

Service Phase III

Expanded

integration with

Medicaid and

other State

agencies

Integrate Medicaid and other state agency systems into the health

information exchange to streamline access to claims or other

information and to receive information in a more streamlined manner

from providers and other stakeholders.

Service Phase III

Additional

payor/employer

data exchange

services

Support for the exchange of additional information to/from payors and

employers such as:

Real‐time exchange of updated eligibility and benefits data

directly from employers to payors

Integration of employer‐sponsored health screening information

and other medical services provided by employers

Exchange of cost data to providers/patients at the point of

service so alternatives can be fully considered.

Phase III

Consumer PHR

integration

Expand support for direct patient or provider services such as personal

health record integration, patient messaging, patient access to health

information or other value added services.

Phase III

1.7.2 PROJECT MANAGEMENT

Inclusion of key stakeholders and careful coordination among the state’s Medicaid and other related

health agencies are viewed as essential components to OHIP’s project management strategy for

implementation of a statewide HIE. To this end, the project management approach will be to provide

linkage to three main entities: The OHIP governance board, the HCCQC and the SSIC as outlined in

Diagram 7.

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Diagram 8 Project Management Coordination

Currently, OHIP’s project management team is comprised of three project managers who are

accountable to the President/CEO and OHIP Board as noted in Diagram 8 below.

One project manager, with guidance from the President/CEO, will be responsible for the leadership of

the HIE project. Receiving recommendations from the OHIP Board, the project manager will identify key

performance indicators, steps and goals involved in completing the creation of the statewide HIE. To

track project progress, the project manager will utilize project management software to ensure proper

reporting and continuity of operations. While the project manager is required to track the progress of

the entire project, efforts to execute the technical infrastructure and business services implementation

will take top priority. The governance board will be required to focus on broader, non‐technical issues

surrounding finance, governance, legal and policy. They will then report to the project manager.

Based upon prescribed periods or the completion of key milestones, it is also the responsibility of the

HIE project manager to create and present progress reports for the board. The OHIP communications

team will then receive these reports and disseminate them to its respective constituents.

OHIP’s REC is led by a separate project manager; however, both the HIE and REC project managers will

closely align their efforts through their respective committees and the OHIP Board. A third project

manager will assist primarily with REC facilitation and communication efforts, but will also provide

linkage to HIE efforts.

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Diagram 9 Project Management Reporting Structure

Key roles and responsibilities for the dedicated project management team include:

Establish project scope, key milestones and related deadlines.

Create and manage the project work plan to meet required milestones and produce necessary

deliverables. Identify and report project risks and delays to OHIP leadership.

Create and/or refine project organizational structure. Coordinate leadership, schedules and

primary activities of the project stakeholder teams. Recommend adjustments of team members

to include the necessary content expertise to execute tasks defined in the plan.

Oversee HIE vendor procurement activities, such as establishing selection and evaluation

criteria, conducting vendor forums, developing requests for information/requests for proposals

templates and related documents.

Align HIE technical and business service implementation tasks with leadership direction

regarding RECs, finance, governance, legal and policy work.

Establish routine communication protocols with OHIP leadership, stakeholder teams and the

wider community regarding the status of the project and completion of major milestones. Use

of project management software and a collaboration portal will be central to the

communication approach among stakeholder participants.

Coordinate issue identification and resolution activities between OHIP leadership and

stakeholder teams.

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1.8 LEGAL/POLICY61

1.8.1 PRIVACY AND SECURITY

FOUNDATIONAL WORK COMPLETED BY HISPC

Ohio was one of 42 states that participated in the HISPC62. The project was active from June 2006

through July 2009. The HISPC project examined a myriad of issues related to privacy and security

challenges relative to the electronic exchange of health information. HISPC Phase I required assessment

of state law and business policies that affect HIE and proposal of practical solutions, taking into account

the requirements of state and federal law.

For Phases II and III of the project, Ohio chose to investigate the use of several legal policy options to

facilitate exchange across state lines. The work product from Ohio’s participation in HISPC, as

summarized below, has served as a starting point for further development of the privacy and security

framework for operating a statewide HIE in Ohio through OHIP.

HISPC Phase I required Ohio to identify variations in Ohio law as compared to federal law that affect HIE

as applied to the specific scenarios presented by HHS. Ohio’s final report outlines the variations

discovered and concludes, for the most part, that there are no legal barriers in the sense that covered

entities must apply both federal and state law, or whichever law is more stringent, in order to use or

disclose or exchange health information. The HISPC report does not address the merits of trying to

update state law to be more conducive to privacy, security or exchange concerns. The HISPC Legal Work

Group identified that Ohio has consent requirements for not only specially protected information such

as HIV/AIDS, mental health, and drug abuse and alcohol records, but also for treatment, payment and

healthcare operations as evidenced by Ohio case law interpreting the statutory physician/patient

privilege (ORC, 2317.02(B)). The HISPC Legal Work Group produced a two‐part model permission form

that complied with state and federal requirements for use, disclosure and exchange of information as of

December 2007.

OHIP will use the HISPC Phase I findings to determine whether to recommend changes to state law or to

recommend that the healthcare industry implement uniform consent processes and/or policies and



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procedures that comply with both Ohio and federal law as synthesized in the model permission form.

The HISPC Model Permission Consent Form63 reconciles state and federal law into a document with two

forms. One form applies to uses of protected health information (PHI) for purposes of treatment,

payment and healthcare operations [TPO]. This is a baseline form that demonstrates the baseline

consent needed by each person whose PHI is put into the HIE. The second form is a Health Information

Portability & Accountability Act (HIPAA64) compliant authorization for use and disclosure of PHI for non‐

TPO purposes. Both forms include all state and federal requirements for a legally effective permission to

use and disclose PHI.

OHIP PRIVACY AND POLICY COMMITTEE

The OHIP Privacy and Policy Committee held its kick off meeting on September 1, 2010 and has

continued to meet twice a month to address the privacy and policy deliverables identified in the OHIP

State Plan. The committee’s charter is to address the eight principles articulated in the HHS Privacy and

Security Framework for Electronic Exchange of Individually Identifiable Health Information65. These

principles are:

Individual access;

Correction;

Openness and transparency;

Individual choice;

Collection, use and disclosure limitation;

Data quality and integrity;

Safeguards; and

Accountability

The committee is comprised of Ohio stakeholders representing providers, practice managers, hospitals,

Medicaid, and osteopathic and allopathic associations66. It was determined after the first two meetings

that given the complexity of Ohio case and statutory law related to privacy and the background of the

committee’s membership that the best direction for the committee would be to focus its efforts on

63 See Appendix J, Ohio HISPC Model Permission Consent Form 64 See Appendix A, Reference #R12 65 See Appendix A, Reference #S15 66 See Appendix N, Privacy and Policy Committee Members

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privacy and policy aspects of HIE. The OHIP HIE Committee would then assume the role of providing

guidance on any technical security components needed for the HIE. The Privacy Committee reports to

the HIE Committee to ensure that the privacy and security policies are developed in tandem and the

work of both committees is then presented to the full OHIP Board on a monthly basis.

The Privacy and Policy Committee has committed to addressing the following issues:

Updating the legal citations and model consent forms as necessary. The Committee will also

assess whether the consent requirements can be reasonably adopted in electronic form or

whether a blanket consent process, such as opt‐in or opt‐out, is preferred or sufficient.

Ways to promote and implement the model permission forms as a standard document and

procedure for obtaining patient consent or authorization to exchange health information by all

types of entities.

Additional clarification from the Office for Civil Rights as to whether the use of the forms in

combination would be considered a compound authorization in violation of HIPAA.

Many healthcare entities may be operating on the assumption that consent for TPO is not an

Ohio requirement. If so, significant education is required to change practice patterns and update

processes (paper and electronic systems to obtain consent). The committee will suggest ways to

facilitate education of healthcare entities about State and federal consent requirements.

Reviewing the work accomplished by HISPC Phase II and II resulting in an assessment of four

policy options that could be used to facilitate interstate exchange: interstate compact, uniform

law, model act and choice of law. The HISPC Legal Work Group recommended use of the

interstate compact as the most viable of the four options to legally exchange information across

state lines. This HISPC basic research remains valid; however, in order to implement use of an

interstate compact, OHIP would need to develop an implementation plan and timeframe. The

Committee will continue to evaluate the appropriate and legal exchange of information across

state lines and whether the interstate compact is the most viable alternative. Reviewing the

DURSA to determine how, or if, it aligns with Ohio consent requirements. The Committee will

further determine how the DURSA might be used, as is or amended, to facilitate exchange and

enforce privacy standards until other legal enforcement mechanisms can be determined.

1.8.2 STATE LAWS

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The analysis of state laws is an ongoing process. The Privacy and Policy Committee has reviewed the

work already performed by the HISPC Legal Work Group and confirmed the various state law

requirements that influence privacy and security. The regulatory requirements contained in Appendix A

(Health IT Regulatory, Certification and Other Standards) have been updated accordingly.67

The Committee has also reviewed Ohio’s physician/patient privilege law and how it has been

interpreted by Ohio courts to require consent for any use of a person’s health information subject to a

few exceptions that are found within the physician/patient privilege statute or other statutes. This

information is driving the Committee’s recommendation as to how to obtain the required consent and

whether the HIE will be an opt‐in or opt‐out program. This Committee is also address out‐of‐state

disclosures and the consent requirements for out‐of‐state disclosures.

1.8.3 POLICIES AND PROCEDURES

The Privacy and Policy Committee will develop policies and procedures necessary to enable and

promote HIE within the state and with other states, including policies and procedures addressing:

Data governance and use among HIE participants including compliance with state regulations

and alignment with NHIN governance/DURSA;

Privacy and security processes including privacy policies, user authentication, user authorization

and network security methods. This would also include policy, technical and administrative

layers such as license management, accounting, billing or other management controls. Policies

will be consensus‐based and evaluated for appropriate use in the context of clinical or

administrative exchange and ePrescribing initiatives;

User support processes related to privacy and security including access management, education,

help desk, and others to assist users; and

Development to enable and promote information exchange within Ohio and between states.

The Privacy and Policy Committee adopted a four‐phase approach to develop the policies and

procedures for the statewide HIE related to privacy. The first phase included a review of the work of a

previous Ohio legal work group created to address privacy concerns as part of the national Health

Information Security and Privacy Collaboration (HISPC). As well as a review of Ohio law, consent models


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of other states, publications from the Office of Civil Rights and publications from the Department of

Health and Human Services’ (HHS) Office of the National Coordinator (ONC).

During the second phase the committee compiled all of this research and drafted the recommendations

for standardized consent policies and procedures found in this document. The third phase of the

committee’s work will include soliciting stakeholder feedback on the policies presented in this

document, making revisions as necessary and presenting the revised recommendations to the OHIP

board for final approval. During this stage, the committee will work to address any items that were not

included in the original recommendations. The final, fourth stage of the Committee’s work will include

the creation of a comprehensive policy and procedure manual that will include the required Participant

Agreements, Business Associate Agreements and Trust Agreements for the Statewide HIE.

The work conducted thus far and planned for the future is itemized in the following table. A more

detailed description of the research conducted for the first phase follows the chart.

Phase I 9/1/10‐ 10/20/10

Review HISPC work

Update model permission form created by HISPC Legal Work Group

Review ONC Privacy Directives

Review Ohio statutes and rules related to medical record privacy

Review Ohio Case Law

Research other State consent models

Phase II 10/20/10‐12/10/10

Draft summary of items reviewed in Phase I and recommendations for standardized consent policies and procedures

Review recommendations at December 1st Committee meeting

Present research and recommendations white paper to OHIP Board on Dec 10th

Phase III 12/10/10‐ 3/2/11

Solicit stakeholder feedback on recommended consent policies and procedures

Adjust the recommendations if needed and resubmit to OHIP board

Address items not included in original recommendations including sensitive health information and minors

Phase IV 3/2/11‐ 5/25/11

Final Policy and Procedures Manual approved by OHIP Board

Final Participant Agreements, Business Associate Agreements, and Technical Certificate Agreements approved by OHIP Board

1.8.4 TRUST AGREEMENT

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OHIP plans to develop and circulate a model agreement among stakeholders. This agreement will serve

as the trust agreement among the participants in OHIP, establishing common agreement on use of the

statewide HIE, such as:

Permitted and prohibited uses;

Cooperation among HIE users;

Limitations on future use of data received via the statewide HIE;

Minimum privacy and security protections that participants must have in place before using the

statewide HIE; and

Related issues (the OHIP Trust Agreement), which will be signed by OHIP and each individual

participant.

The model OHIP Trust Agreement is currently under development.

Rather than developing the OHIP Trust Agreement de novo, OHIP plans to model its Trust Agreement on

the DURSA, which is a comprehensive, multi‐party trust agreement establishing common rights and

responsibilities among signatories participating in an HIE. The DURSA will govern the exchange of health

information through the NHIN or other similar protocols recommended by ONC and will support the

secure, interoperable exchange of health data between and among the many HIEs nationwide. All HIEs,

public and private, wishing to participate in the NHIN will be required to sign the DURSA, including OHIP.

The DURSA requires that a similar trust agreement consistent with the DURSA must be signed by all

Ohio users of the statewide HIE, which will be the OHIP Trust Agreement. The DURSA requires that the

OHIP Trust Agreement address, at a minimum, compliance with applicable law, cooperation with other

HIEs, requirements to use the NHIN for only permitted purposes, limitations on future use of data

through the NHIN, and security measures regarding password protection. As indicated above, OHIP

plans to develop policies and procedures that are compatible and/ or consistent with the governance

and policy framework developed by NHIN or other similar protocols recommended by ONC and

documented within the DURSA. Entities wishing to participate in the statewide HIE may need to modify

policies and procedures for authorization, authentication, access, audits, and other issues to conform to

required standards to access the statewide HIE.

OHIP plans to have a draft model OHIP Trust Agreement ready for circulation among its stakeholders in

first quarter 2011. After the final model OHIP Trust Agreement is approved, OHIP may adapt the

agreement to accommodate the various desired connectivity levels of HIE participants (e.g., centralized

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versus federated publishers). These participant type‐specific versions will then be circulated for final

approval. OHIP plans to have participant‐type‐specific versions of its OHIP Trust Agreement approved

and ready for signing by OHIP and participants by the end of second quarter 2011.

1.8.5 OVERSIGHT OF INFORMATION EXCHANGE AND ENFORCEMENT

Oversight of the OHIP exchange of health information will be provided through a variety of channels.

Ohio has several laws that together comprise a comprehensive body of law that govern the use and

exchange of health information and privacy protections afforded to individuals in their health

information68. In addition, HIPAA establishes the federal floor for privacy and security protection of an

individual's PHI. The Ohio laws will be enforced by the Ohio Attorney General's office, which also has

authority under the new privacy updates to HIPAA in ARRA to file HIPAA enforcement actions on behalf

of the people of their state.

Day‐to‐day oversight of OHIP's HIE activities will be provided by OHIP’s leadership staff with guidance

from OHIP’s Executive Committee, which includes representatives of major stakeholders such as the

OHA, OSMA, OOA, the State of Ohio and BioOhio. Strategic guidance will be provided by OHIP’s Board

of Directors, as discussed in the Governance Section of the strategic plan.

OHIP staff will implement the policies and procedures identified in the forthcoming recommendations

from the Privacy and Policy Committee. With the assistance of OHIP’s legal counsel, the committee will

develop a Participation Agreement and Business Associate Agreement that will ensure all participants in

the statewide HIE agree to adhere to the policies and procedures. OHIP staff will coordinate the

execution and storage of all the required agreements and investigate any breaches, complaints and non‐

compliance with the published policies and procedures. System audit logs will be created and

maintained for all events within the HIE. Utilizing HITSP constructs SC109, T15, T16 and T17 the HIE will

preserve a consistent network time and record event data according to recognized standards.

The contractual language of the participant agreements will include periodic audits that will be

conducted by an outside vendor. The final version of these agreements and the Policy and Procedure

manual will be made available through the OHIP website and the OHIP help desk will answer questions

about the policies and procedures.

68 See Appendix A, all regulatory references

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1.8.6 CONSENT TOOLKIT AND EDUCATIONAL CAMPAIGN

In October, OHIP hired a Communications Director who has joined the Privacy and Policy Committee.

She will coordinate the efforts of communicating OHIP’s privacy strategy and plan to the provider

community. The committee will work with the new director to develop an educational toolkit and

campaign to share the policies, procedures and model forms with the provider community. The

Communications Director will act as the liaison between the Privacy and Policy Committee and OHIP’s

seven regional partners to develop and implement this campaign. The Physician Association’s Advisory

Council members will serve as a review for materials in development. The toolkit will be developed in

December and the kick off will be held in January. Communications vehicles will include newsletters,

email blasts, press releases, statewide media calls, a prominent presence on the OHIP website,

distribution of printed materials through the RECs, at health community and association events, and

during workshops planned for March 2011.

1.8.7 SECURING HEALTH DATA

OHIP’s HIE Committee is charged with ensuring the technical infrastructure supports the policies

developed by the Privacy and Policy Committee and complies with the security requirements mandated

by law in accordance with emerging industry standards. Transmission of data will be protected with

message layer security and transport layer security. The messages transported over the HIE will be

encrypted and sent using FIPS 140‐2 standards to ensure that even if a message fails to be sent securely,

the message will be secure.

USER AUTHENTICATION

A two factor authentication will be required for a user to gain access to the HIE.

USER AUTHORIZATION

The HIE architecture will be designed so that a hospital or physician’s office can assign a hierarchy to the

type of patient information that different business roles in their organization are allowed to view. Users

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will only be able to view patient information that corresponds with the business need of their roles in

the organization.

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2 OPERATIONAL PLAN

2.1 INTRODUCTION TO OPERATIONAL PLAN

OHIP’s Operational Plan provides supporting details on how the Strategic Plan will be carried forward

and executed to enable a statewide HIE. It includes specific action steps for development and

deployment of core HIE services including an extensive procurement process, projected budget

information as well as necessary stakeholder engagement work through OHIP’s committee structure to

reach consensus on operational issues.

Since OHIP’s procurement process is in progress, the final selection of an HIE vendor, projected during

Fall Quarter 2010, will be essential to informing further details of this plan.

2.1.1 PROJECT PLAN

OHIP’s HIE Project Plan69 outlines current and future key tasks for development of a statewide HIE and

related timeframes necessary to meet the requirements of OHIP’s federal grant in the following areas:

Administrative tasks (e.g., staffing)

Office of National Coordinator (ONC)/Grants Management Office Coordination

Stakeholder Engagement

Procurement Process

HIE Implementation Planning

HIE Phased Go‐Live Plans

2.1.2 RISKS AND MITIGATION STRATEGY

Workgroup issues will continue to evolve as development of the statewide HIE occurs; however, key

issues identified by Board and OHIP Committee Members to‐date are noted in Table 6:

69 See Appendix I, OHIP HIE Project Plan and Appendix P, Amendment #12

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Table 6 Projected Risks and Mitigation Strategies

Risk Mitigation Strategy

Staffing – Supporting a statewide HIE requires a

unique combination of extensive healthcare

industry knowledge, system implementation and

project management experience, detailed

interoperability and technical infrastructure

knowledge as well as excellent communication

skills. The pool of resources with this combination

of experience is limited and in high demand. In

addition, since statewide development is in its

infancy, there is a lack of projected staff

benchmarking statistics available and target dates

for HHS grants for workforce development exceed

HIE target dates.

‐Hiring additional qualified direct staff through stakeholder

references

‐Weighing outsourcing opportunities

‐Requested benchmarking of staffing estimates/roles from

ONC Technical Assistance (TA) Teams

‐Working with the REC Workforce Development Workgroup

to create health IT training programs that will lead to

internship opportunities in the short‐term and to 2 to 4 year

curriculum programs in the long‐term

Sustainability – Significant discussion has occurred

regarding a sustainable financing model for the

HIE. As frequently reported, most stakeholders

concur as to the overall benefit of HIE, but

translating this value to specific stakeholder

groups is more challenging.

‐Implementing an HIE business model that supports clinical

data exchange but is financed through improved

administrative data exchange

‐ Leveraging the potential for administrative efficiency

through improved exchange of data with state agencies such

as Medicaid, the Ohio Department of Health and other

oversight bodies or payors

‐ Monitoring NHIN development to determine where a state

HIE, serving as a “trusted agnostic” can provide value‐added

services complementary to, rather in competition with,

transfer protocol standardization

Provider Adoption – The value of the HIE is

dependent upon the level of provider adoption of

certified EHR solutions at an effective level of

integration

‐Requiring preferred EHR vendors to integrate with the

statewide HIE and to structure payment terms around

provider’s receipt of incentive payment funding

‐Executing a Health IT Loan Program with the State’s Treasury

Office to provide zero‐interest loans through banks to

providers for certified EHR adoption

‐ Leading a Behavioral Health Sub‐Committee to encourage

health IT adoption among that community. Also participating

in an ONC Community of Practice to further efforts for

behavioral health IT adoption given their specific barriers and

issues

Regional Variances – Although Ohio is a densely

populated state with an impressive list of top‐

ranked hospital systems, it is a state that

historically has been regionalized around distinct

metropolitan and rural communities with strong

stakeholder relationships and practice patterns.

There is a wide‐variety of adoption issues specific

‐Developing an HIE model which supports core infrastructure

services, clinical and administrative exchange but encourages

market outreach, education and adoption efforts at the

regional level

‐Leveraging OHIP’s existing regional partnership structure to

assist in adoption efforts

‐Working with future HIE vendor to branded web portals to

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Risk Mitigation Strategy

to each region including varying degrees of HIT

adoption, competitor issues, significant numbers

of small doctor offices, large pockets of

rural/health shortage areas, broadband and

funding issues.

the HIE to encourage HIE adoption at the local level

Co‐Occurring Medicaid Health IT Initiatives –

Although there is strong desire to integrate the

statewide HIE with the state’s future Medicaid

system (MITS), stakeholders acknowledge that the

implementation of MITS (Phase I: December 2010)

co‐occurs with HIE development and Medicaid

Incentive Payment program planning efforts.

‐Phase I of MITS primarily affects Medicaid’s claim

adjudication functions and not eligibility data; therefore,

Ohio’s Medicaid office has agreed to pursue integration of

eligibility and coordination of benefits information with the

statewide HIE as a first step

‐OHIP staff and Medicaid staff are working closely to align

planning efforts to support the Medicaid Incentive Payment

program

Patient Engagement/Trust Enablement – Patients

must have confidence that data is secure and

being shared appropriately. At the same time, the

potential for HIE to improve patient outcomes and

reduce costs is contingent upon patients’

willingness to share data when necessary.

‐The Privacy and Policy70 Committee will determine the

consumer opt‐in/opt‐out models required to comply with

Ohio law

‐The HIE vendor RFP will require extensive granularity and

advanced technical support for both models as well as

assurance that the vendor is compliant with all necessary

privacy and security requirements

ePrescription Adoption – Due to stringent

requirements for software certification in Ohio

and related clinical qualifications and workflows,

OHIP will need to facilitate methods for broader

adoption.

‐ OHIP has created an71 ePrescription Task Force to address

barriers to adoption that includes representatives from the

BOP, retail chain and independent pharmacies, hospitals,

physicians and the Ohio Pharmacists Association. This task

force is charged with improving the ease of ePrescription use,

aligning software certification requirements and

demonstrating quality improvements such as

avoidance/decrease of adverse drug events

‐ The BOP participated in OHIP’s EHR Preferred Vendor

Program Selection Committee to ensure that all selected

vendors complied with state certification requirements

Project Implementation Risk – Experience shows

that risk management is critical to project

management. Unmanaged or unmitigated risks

are among the primary causes of project failure.

With the complexity of a statewide HIE endeavors,

significant project execution risks will exist.

‐ The HIE vendor and OHIP will use proactive risk

management strategies

‐The HIE vendor and OHIP will identify risks and develop

mitigation strategies and contingency plans to minimize

impact

The HIE vendor and OHIP will monitor identified project risks

to trigger the implementation of risk mitigation strategies

and contingency plans



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2.2 COORDINATION WITH OTHER ARRA PROGRAMS

2.2.1 REGIONAL EXTENSION CENTER

Indicated in the strategic plan, OHIP is in a unique position to coordinate both HIE and REC services

closely, by virtue of having been awarded both grants. Administratively, this coordination will be

accomplished through the following strategies:

Leveraging regional partner relationships – HIE marketing and outreach efforts will be

coordinated through OHIP’s regional partners to encourage awareness and adoption and to

identify issues at the community level. These partnerships allow OHIP to distribute consistent

materials efficiently and receive direct feedback about barriers or concerns at a local level.

Leveraging EHR preferred vendor program – Certified EHR vendors selected as a part of OHIP’s

preferred vendor program have agreed to comply with standards for interoperability with the

statewide HIE in a manner that allows for direct integration both inbound and outbound. In

addition, vendors must demonstrate the ability to support the rapid evolution of standards

without additional customization or extraneous costs to providers.

Leveraging HIE vendor capabilities – The HIE vendor to be selected through OHIP’s procurement

process will be expected to offer automated, incremental, provider‐controlled flexibility to

exchange data consistently with the providers’ capabilities to accept data (e.g., direct interface

into EHR, via web portal, via fax, email or other form of clinical messaging). This will allow

providers at varying levels of IT sophistication to participate in HIE activities necessary to

achieve meaningful use.

2.2.1.1 COORDINATION WITH BEHAVIORAL HEALTH

In Ohio, there is significant stakeholder support to include behavioral health providers in HIE adoption

efforts. There is recognition across the state that supporting these providers is clearly critical to

achieving the state’s healthcare quality goals since the populations they serve currently experience high

rates of co‐morbidity, homelessness and incarceration. However, there is acknowledgement from the

healthcare community that this group of providers faces unique barriers to the adoption of HIT:

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Behavioral health providers in Ohio have experienced significant cuts in local, state and federal

funding over the past several years and their Medicaid payment rate ceilings have not increased

for a decade.

Non‐physician, behavioral health providers are currently not defined as eligible professionals

under Medicare and Medicaid stimulus incentive payments for EHR adoption and they are not

defined as PPCPs under the REC initiative.

Behavioral health providers often lack IT resources, use specialized software and lack integration

within the larger medical community.

Their IT adoption efforts are hampered by the wide variety of agencies they must report to and

the variance of reporting requirements, including criminal justice systems, local boards, federal

agencies (SAMHSA) and accreditation bodies.

OHIP’s strategies to encourage behavioral health provider participation in the statewide HIE include72:

Creation of Behavioral Health REC Subcommittee – In August 2010, OHIP created a

subcommittee of behavioral health representatives throughout the state to coordinate adoption

efforts among OHIP’s RPs, Board, REC Committee, state agencies and community partners73.

This workgroup is led by one of OHIP’s Board members who has significant experience in

primary care and behavioral health integration and is participating in a statewide telemedicine

initiative led by the ODMH to provide timely child psychiatry services to primary care providers

and family members. One of the workgroup’s first deliverables was a list of important tasks

necessary to achieve their vision.

Creation of Behavioral Health Outreach and Strategy Materials – In November 2010, the

Behavioral Health REC Subcommittee published an educational document outlining its vision,

goals, benefits, barriers and strategies to health IT adoption (see Appendix L). This document

has been shared with RPs, primary care physicians and the behavioral health community to help

raise awareness of the benefits of their inclusion, current barriers to adoption and strategies to

overcome those barriers.

EHR Vendor Analysis – OHIP’s subcommittee is working with the Ohio Council of Behavioral

Health and Family Services Providers to identify EHR vendors who offer solutions that support

Ohio‐specific behavioral health requirements. Using a survey tool distributed by OCBHP in

72 See Appendix P, Amendment #13 73 See Appendix L, Behavioral Health Sub‐Committee Information

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November, the subcommittee hopes to glean important information about these vendors, such

as their architecture model, types of providers they support, ONC certification status and other

indicators. The subcommittee is also in the process of evaluating use of the Welch Allyn provider

readiness assessment tool for behavioral health providers and the potential use of OHIP’s

preferred EHR vendors in integrated primary care and behavioral health settings.

Participation on ONC Community of Practice – OHIP was asked to participate in a federally led

CoP to address issues with HIT adoption within the behavioral health community, specifically,

efforts to further integration between primary care and behavioral health services.

HITECH Extension for Behavioral Health Services Act of 2010 (H.R. 5040) 74‐ On April 14,

Congressmen Patrick Kennedy (D‐RI) and Tim Murphy (R‐PA) introduced H.R. 5040 to address

the current deficiencies within ARRA about behavioral health. The bill recommends to:

- Amend the current law to make certain providers of addiction treatment and mental

health services eligible for HIT funds that are made available through the ARRA;

- Extend eligibility for Medicaid HIT implementation funds to these providers;

- Extend eligibility for Medicare HIT payment incentives to certain physicians, clinical

psychologists and clinical social workers; certain psychiatric hospitals would also be

included as hospitals eligible to receive Medicare HIT funds;

- Authorize a $15 million grant program, through ONC ; entities eligible to receive grant

funds would include: mental health and substance abuse treatment facilities and certain

psychiatric hospitals

OHIP is closely monitoring the status of this proposed bill, which was spearheaded in part by a vendor

who is active in the Ohio behavioral health market and has been instrumental in raising national

awareness for the need to include behavioral health in HIT initiatives.

2.2.2 COORDINATION WITH MEDICAID, MEDICARE AND FEDERALLY FUNDED, STATE‐BASED

PROGRAMS

As noted in Federally Funded State‐Based Programs section (S‐54) of the strategic plan, the SIC serves as

the primary forum for coordination of Medicaid, Medicare and other federally funded, state‐based

programs with HIT implications. All agencies overseeing health or health benefit programs for the State


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of Ohio are members of the SIC and are responsible for coordinating HIT initiatives under their purview

with statewide HIT adoption efforts.

In addition to the SIC, smaller, more focused workgroups have been formed to coordinate specific HIT

activity between OHIP, Ohio Medicaid and ODH, since the latter two state agencies comprise a

significant portion of current HIT activity that must be closely aligned with development of the

statewide HIE.

2.2.3 PARTICIPATION WITH FCDOS AND COORDINATION WITH OTHER STATES

OHIP has combined these two topics from an operational perspective because both efforts will be

related to further development and deployment of national standard frameworks such as NHIN.

In the case of federal care delivery organizations such as the Military Health Service of the Department

of Defense or the Veteran’s Health Administration, the exchange of data with the Virtual Lifetime

Electronic Record (VLER), Armed Forces Health Longitudinal Technology Application (AHLTA) or VistA

(Veterans Affairs Health Information Systems and Technology Architecture) applications will entail

national protocols such as the NHIN gateway or NHIN Direct. OHIP intends to leverage these exchanges

and other emerging national protocols for standardized communication with other state HIEs.

To continue to monitor national framework development, coordinate current and future state

involvement in NHIN activities and disburse educational materials as protocols develop, OHIP is

proposing to create an NHIN Workgroup under its HIE Committee. Their focus will be the application of

national standards frameworks for the purposes of federal care delivery and other state coordination as

they develop.

2.3 GOVERNANCE

A significant portion of OHIP’s governance structure is already in place as noted in the Governance

section of the strategic plan. Moving forward, OHIP’s three‐part strategy to align and engage

stakeholders in key tasks necessary to comply with the requirements of the HIE planning grant includes:

Synchronizing OHIP’s committees with federal and state efforts – Due to the numerous

committees and co‐occurring tasks, OHIP attempted to illustrate how federal, state and OHIP

committees align in Table 7 below. It will be important for OHIP committee members to stay

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tuned to their sister federal and state committee efforts as they proceed with tasks and

deliverables.

Table 7 Federal, State and OHIP Committee Alignment

Clarifying Responsibilities between OHIP Board/staff and committees – Although specific tasks

and deliverables are noted in the project plan, high‐level responsibilities between board, staff

and OHIP strategic advisory committees are clarified in Diagram 9 on the next page:

Diagram 10 Key Responsibilities of OHIP Board and Advisory Committees

Managing communications across OHIP’s governance structure ‐ The major challenge in terms of

governance is managing communications across the structure. The combination of significant a

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stakeholder interest, complex topics and rapid deployment deadlines call for timely, clear and

consistent communication. In a perfect world, a large communication staff would keep all

sectors of interest apprised of co‐occurring activities; however, current funding figures do not

allow for a large communications staff. OHIP will need to leverage its leadership and staff efforts

with existing communication channels such as provider associations, RPs, HIT professional

associations and state agency forums to ensure all committees and workgroups are aware of

concurrent efforts.

2.4 FINANCE

OHIP’s cost estimates to support the HIE over the four year grant period, staffing plans, financial

controls and reporting policies are described on the next page.

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2.5 COST ESTIMATES75

The cost estimates for the implementation and support of the statewide HIE are estimated in Table 8

below:

Table 8 OHIP HIE Budget

Federal Federal Non‐Fed

Personnel Expenses Year 1 Year 2 Year 3 Year 4 Total Match Total

Pres/CEO 100,000 105,000 110,250 315,250 315,250

COO/CTO 364,275 364,275

CFO 75,000 78,750 82,688 236,438 236,438

IT MGR 35,000 36,750 38,588 110,338 17,500 127,838

Acct/Budget Officer 35,000 36,750 38,588 110,338 15,000 125,338

Communications 16,664 50,000 52,500 55,125 174,289 174,289

Admin Ass't 10,000 17,000 17,850 18,743 63,593 31,525 95,118

Project Coordinator 43,750 75,000 78,750 82,688 280,188 280,188

HIE Project Mgr 100,000 105,000 110,250 315,250 63,000 378,250

HIE Implementation Mgr 35,000 70,000 73,500 77,175 255,675 255,675

HIE Implementation Mgr 35,000 70,000 73,500 77,175 255,675 255,675

HIE Coordinator 35,000 70,000 73,500 77,175 255,675 255,675

Admin Ass't 31,525 31,525

Total Personnel 175,414 697,000 731,850 768,445 2,372,709 522,825 2,895,534

Fringe Benefits 63,150 250,920 263,466 276,639 854,175 188,217 1,042,392

Other Operating Expenses

Travel 50,004 50,004 50,004 50,004 200,016 0 200,016

Equipment 300,000 25,000 25,000 25,000 375,000 50,000 425,000

Supplies 40,300 23,600 23,600 23,600 111,100 0 111,100

Contractual 5,087,051 2,013,491 1,828,176 1,731,176 10,659,894 1,149,899 11,809,793

Other 49,645 82,220 82,220 85,220 299,305 195,860 495,165

Total Other 5,527,000 2,194,315 2,009,000 1,915,000 11,645,315 1,395,759 13,041,074

Total Expenses 5,765,564 3,142,235 3,004,316 2,960,084 14,872,199 2,106,801 16,979,000

State Match 782,237 564,025 368,777 391,762 2,106,801


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It should be noted that during OHIP’s HIE RFI process, cost estimates were not asked of vendors since

any figures provided would likely be unreliable without further negotiation around scope, volume and

service. Other states who are further along in their procurement efforts indicate there is a wide range in

pricing among HIE vendors making it difficult to estimate costs at this time. However, OHIP has inserted

language in its RFP to more accurately assess the total cost of ownership from a number of perspectives,

including OHIP costs, HIE participant costs, specific service or data exchange costs, integration expenses

and a requirement to balance these numbers against projected revenue under OHIP’s proposed

sustainability model.

2.5.1 STAFFING PLANS

Although specific positions dedicated to HIE development are noted in OHIP’s budget, the reality is that

multiple resources supplement this staffing structure due to OHIP’s dual‐service capacity as both an HIE

and a REC, in‐kind services provided by OHIP’s Executive Committee through their respective

associations and close integration with state agency HIT efforts. This multi‐sourced strategy was a

common structure among states and SDEs during the HIE Leadership Summit held in May 2010.

Table 9 below is a complete list of current and planned staff, a brief job description/role, staffing status

(recruiting, hired, contracted or other) and the number of current and budgeted FTEs. Since OHIP is both

an HIE and REC recipient, the grant under which the position is budgeted is denoted as HIE (H) or REC

(R).

At this time, direct OHIP staff (D) comprises a total of 9 FTEs for HIE and REC support. Contracted, in‐

kind or state staff (O) currently comprise an additional 3.85 FTEs. Two roles, legal counsel and office IT

support, are not listed as they are currently outsourced and are to remain outsourced per OHIP’s

submitted HIE budget.

Despite these resources, staffing remains an important issue for OHIP since the deadlines associated

with the HIE and REC efforts are very tight, many initiatives are co‐occurring, the majority of resources

have other responsibilities and very little precedent exists for benchmarking around a successful staffing

model. Because several of these positions are funded through state or other match funds, not all

positions are counted as ARRA‐created jobs since the latter are limited to positions funded directly by

federal dollars.

O ‐ 12

Table 9 OHIP Staff (Current and Planned)

Position Responsible For Staffing Status

Current

FTEs

D | O

Budget

FTEs

H | R

Positions Supporting both HIE and REC

State HIT

Coordinator

Responsible for federal and state

grant coordination and oversight,

state fiscal oversight, state

interagency and Governor’s office

coordination.

Filled by Chief of

Staff, Ohio

Department of

Insurance

0 1 0 0

President/CEO

Executive level management of OHIP

including stakeholder engagement,

federal/state coordination, strategic

business development, fund‐raising

and sustainable model development,

general oversight of operations and

leadership of senior management

team.

Recruiting; Interim

position filled by

OHIP Executive

Committee

Member 0 1 .5 .5

COO/CTO

Overseeing day‐to‐day operations,

managing deadlines, working with

software vendors, contractors and

federal/state entities,

communication, outreach and

training.

Hired Sept 2010

1 0 .5 .5

IT Manager

Intranet, internet and extranet

SharePoint platform, survey tool and

general office IT support

management

Pending IT service

contract

negotiations 0 0 .5 .5

CFO

All fiscal oversight including

managing in‐kind, federal and state

funds, grant management

compliance, auditing, financial

reporting, payroll, budgeting and

purchasing.

Recruiting: Part‐

time contractor

with federal grant

experience is filling

role through Dec

2011

0 .75 .5 .5

Accounting

Assistant

Daily accounting operations related

to payroll and reporting

Recruiting: Part‐

time contractor is

filling role through

Aug 2010

0 .6 .5 .5

Communication

Director

All marketing, outreach, media and

web‐based communications,

planning and strategy.

Hired Oct 2010

1 0 .5 .5

Project Manager

Assists with coordination of REC and

HIE activities, preferred EHR vendor

program management and other

cross‐coordination services.

Hired July 2010

1 0 l75 .25

O ‐ 13


Current

FTEs

D | O

Budget

FTEs

H | R

Administrative

Assistant

Staff and meeting coordination,

managing schedules, travel,

communications, files, facilities and

other general support.

One hired April

2010 1 0 1 1

Positions Supporting HIE

Project Manager,

HIE Services

Project management of health

information exchange activities

including scheduling and

management of sub‐projects,

coordination of stakeholders,

vendors, contractors, federal and

state staff.

One FTE hired

September 2010

1 0 1 0

HIE

Implementation

Managers

Assisting PM for HIE Services with

tasks and deliverables, standards and

protocols management and related

integration services.

To be filled after

vendor selection 0 0 2 0

HIE Coordinator

Assisting HIE participants and

consumers with HIE adoption,

education and support.

Hired October 2010

1 0 1 0

Positions Supporting REC

PM REC Services

Responsible for the daily operation

of the REC including scheduling and

management of sub‐projects,

coordination of vendors and

contractors, gathering of data for and

creation of required reports, etc.

Hired May 2010

1 0 0 1

Implementation

Manager, REC

Services

Responsible for assisting with

oversight and coordination of REC

services. Duties include:

Acts as CRM lead for OHIP and

each of the REC regional

partners by providing

development of data, training

and acting as data administrator

for the CRM project.

Supports the REC Committee

Serves on the EHR RFP Review

Team

Serves in a supportive role on

the HIE Committee

Facilitates staff IT and website

support – both development and

Hired April 2010

1 0 0 1

O ‐ 14


Current

FTEs

D | O

Budget

FTEs

H | R

maintenance

Lead, Workforce

Development

Coordinating stakeholders,

community colleges, training

programs, universities, Board of

Regents and other state agencies in

efforts to advance health IT

workforce initiatives.

Role filled by Ohio

Department of

Insurance staff 0 .5 0 0

REC

Administrative

Assistant

Assisting providers with EHR

education and adoption.

Hired Oct 2010

1 0 0 1

Total 9 3.85 8.75 7.25

2.5.2 CONTROLS AND REPORTING

OHIP has established financial policies, procedures and controls to maintain compliance with Generally

Accepted Accounting Principles (GAAP) and all relevant federal Office of Management and Budget

(OMB) circulars. The Board approved a policy and procedure manual and distributed it to employees on

October 5, 2010. A copy of the administrative procedures section from the manual is in Appendix P. In

addition to the procedures outlined below and in the appendix, OHIP has met quarterly with an

independent auditing firm for a review of accounting and financial procedures and activities. OHIP is in

the process of releasing an RFP to contract with an independent accounting firm to provide ongoing

review and consultation about operations.

The Chart of Accounts was structured in accordance with GAAP and was reviewed by an independent

auditing company. The financial and reporting structure mirrors the financial plan and budget created

for OHIP, utilizing QuickBooks software for Non‐Profit Entities. OHIP operates and accounts for its

activities according to OMB Circular A‐122 and Circular A‐13376, which dictate that a CPA firm conducts

an audit and certifies that the appropriate financial policies, procedures and controls are maintained.

There are adequate accounting controls to track both the receipt and expenditure of ARRA funds in the

accounting system.

There is a separation of duties for making payments. Invoices are date stamped and initialed by the

office’s administrative assistant and given to the accounting specialist. The accounting specialist verifies


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that there has either been prior authorization as required by procedures approved by OHIP’s Board, or

ensures that invoices are approved and signed by appropriate staff. The Chief Executive Officer (CEO),

the Chief Operating Officer (COO) or the Chief Financial Officer (CFO) must authorize all payments.

Payments are made by check or entered into the accounting system for payment through on‐line

banking services. For disbursement of OHIP funds equal to or less than $5,000, one authorization is

required. For disbursements greater than $5,000 but equal to or less than $20,000, two authorizations

are required. For disbursements greater than $20,000, prior Board approval and two authorizations are

required. Disbursements shall not be intentionally divided into lower increments so as to avoid the

limitations set forth. Invoices that have been processed for payment are stamped as paid and dated.

Monthly bank statements are given to the COO unopened for review. Upon approval, the COO provides

the bank statement to the CFO. The CFO conducts monthly reconciliations by balancing bank statements

with transaction and balance reports from the accounting system.

Quarterly and semi‐annual reports are submitted to the federal government in accordance with the

requirements of the HIE grant award as follows:

ARRA reports: No later than 10 days after the end of the quarter

SF425 Financial Report: No later than 30 days after the end of the quarter

Program Progress Report: Semi‐Annually

SF 269 Financial Report: No later than October 30 of each year

An OHIP Board representative currently functions as the CEO to provide key expertise and ensure that

the financial aspects of the business plan are identified and addressed in order to create a sustainable

operation for the HIE.

2.6 TECHNICAL INFRASTRUCTURE

OHIP’s technical strategy including interoperability approach, relation to national protocol development,

architectural structure and deployment method are described below.

2.6.1 STANDARDS AND CERTIFICATION

As noted in the Strategic Plan, one of OHIP’s primary drivers is aligning with the ongoing development of

national interoperability standards. Although the Health IT Standards and Certification Criteria Final

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Rule77 is published and will be considered “the source of truth,” OHIP anticipates a need for the

statewide HIE to facilitate adoption of these standards both at the provider and vendor level through

the following strategies:

Building an HIE infrastructure that supports data management and integration services for the

next several years until complete compliance has penetrated the market and the direction of

NHIN and other national protocols are more fully realized. Within this context, OHIP recognizes

that it cannot reasonably support the wide variety of standards in use today, but can facilitate

transition to national standards such that widespread HIE adoption is achievable.

Supporting bi‐directional, structured integration with OHIP’s EHR preferred vendors using ONC‐

promulgated standards.

Remaining active in NHIN protocol development via Ohio stakeholders that are currently

involved with the NHIN exchange, our future HIE vendor and state/federal agency initiatives.

Develop a list of HIT regulatory, certification and other pertinent standards or references 78

applicable to OHIP’s statewide HIE. Due to the rapid rate of change in the regulatory, standards

and certification environment, OHIP decided to refer to each references “source of truth” rather

than repeat them in this plan. This “living” regulatory and standards reference document can

then be used by vendors and other interested parties as a comprehensive resource for

compliance requirements and will continue to be updated as OHIP progresses with its efforts

and as national standards evolve.

At this time, criteria have not been developed at the federal level to certify that HIE networks are

compliant with interoperability, privacy and security standards other than through pre‐ARRA voluntary

certification programs. If a national HIE certification program is adopted, OHIP will seek certification

accordingly.

2.6.1.1 NATIONAL HEALTH INFORMATION NETWORK (NHIN)

Listed as one of OHIP’s primary HIE drivers, there is no doubt that national exchange frameworks such

as NHIN will have a significant impact on OHIP’s technical development strategy. To put this framework

in context, it is important to stay focused on the rationale behind the NHIN and ONC’s call to “develop a

nationwide health information technology infrastructure that allows for the electronic use of exchange

77 See Appendix A, Reference # R11 78 See Appendix A, Health IT Regulatory, Certification or Other Standard References

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of information and that promotes a more effective marketplace, greater competition (and) increased

consumer choice” among other goals.

As acknowledged during the State HIE Leadership Summit in May 2010, there are varying levels of

understanding about the role NHIN and other national frameworks will play as states progress with their

HIE efforts.

OHIP’S ROLE IN RELATION TO NHIN

Per guidance from the SLHIE Forum and subject matter experts, OHIP sees its role as a complementary

one with NHIN development. Specifically, OHIP can provide the following support:

Providing trust and consent mechanisms to ensure data exchanged using NHIN protocols comply

with state privacy, security, consumer preference and trust agreements of HIE participants.

Facilitating exchange between parties using NHIN protocols by making statewide discovery and

location services available to them that will simplify the process of identifying where patient

data resides and/or where it should be appropriately sent.

Offering mechanisms to deliver data exchanged using NHIN protocols to providers in a manner

consistent with their current level of HIT adoption (e.g., fax, web portal or structured integration

with EHR).

Providing the “highway” for senders of data via NHIN protocols to channel data to multiple

sources at once rather than simply single point‐to‐point (ex., lab, pharmacy and hospital).

Facilitating the ability to aggregate data exchanged beyond state borders for the purpose of

population health management in a secure and de‐identified manner where appropriate.

STRATEGIES FOR NHIN PARTICIPATION AND DEVELOPMENT

OHIP will use a three‐prong strategy for NHIN participation and development:

Continued stakeholder participation in NHIN development – Ohio currently has four participants

in NHIN pilot or production efforts: HealthBridge, HealthLink, the Cleveland Clinic and ODH. The

first three participants have been engaged in NHIN demonstrations since 2008. HealthBridge

and HealthLink are current grantees of the Social Security Administration (SSA) medical evidence

gathering program that will exchange clinical data using NHIN protocols to accelerate the

process of authorization for SSA benefits. HealthBridge is also participating in CARE Health

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Information Exchange Project (C‐HIEP), which will contribute to the maturation of CMS’

technological and business processes associated with the receipt and management of clinical,

quality information. ODH is participating in an NHIN demonstration with the CDC and other

states.

Formation of OHIP NHIN Workgroup ‐ OHIP is forming a workgroup under the HIE Committee to

focus on NHIN protocol development, statewide tracking of participation in NHIN activities,

border state and federal care delivery exchange. This workgroup will work closely with the

Privacy and Security Committee to align trust agreement and governance efforts with NHIN

governance development. Prior to formation of the workgroup, OHIP has accelerated NHIN

education and outreach through members of the HIE Committee. All members have been

provided SLHIE, NHIN University and NHIN website materials and are routinely invited to

participate in open NHIN webinars.

HIE RFP NHIN Requirements – Vendors participating in OHIP’s HIE procurement process will be

required to demonstrate extensive knowledge of NHIN protocols, related development and

participation in NHIN pilot or limited production efforts.

2.6.2 TECHNICAL ARCHITECTURE

Using the technology development principles described in the Technology Infrastructure section (S‐95)

of the strategic plan, OHIP intends to develop a hybrid model architecture for the statewide HIE. This

structure will use a small set of critical infrastructure components and standards‐based protocols that

will facilitate trusted HIE participants in locating and accessing data at its source. Leaving patient data

where it currently resides in the HIE participants’ clinical systems and related databases provides for

appropriate patient data privacy safeguards and clear accountability for data ownership and

stewardship. Additionally, OHIP’s architecture will leverage national protocols, such as NHIN

specifications, to communicate between states and with federal care delivery organizations.

Although OHIP has narrowed the number of HIE vendors to participate in its RFP process, there is still a

wide range of technical models capable of supporting OHIP’s desired approach. Therefore, it is the HIE

Committee’s preference to be less prescriptive with respect to the technical approach so as not to stifle

alternative innovations and emerging technologies presented during the final stages of procurement.

However, OHIP has attempted to visually describe a desired business model in its Proposed HIE Model

Diagram found in the HIE Development and Adoption section (S‐34) of the strategic plan.

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2.6.3 TECHNICAL DEPLOYMENT

Given the rapid timeline with which deployment of HIE services must occur, OHIP intends to use the

following strategies to facilitate access to the statewide HIE once a vendor is selected and

implementation tasks are underway:

Integrate with OHIP’s preferred EHR vendors – Providing standards‐based integration with

OHIP’s preferred EHR vendors using structured data that feeds directly in/out of the EHR will

maximize the number of providers interested and capable of using the statewide HIE, especially

targeted PPCPs.

Provide community‐based access to the statewide HIE – For providers without a fully

implemented, certified EHR, OHIP intends to provide web access to the statewide HIE through a

community‐branded portal. Leveraging the RP structure, healthcare communities within these

regions can provide enhanced outreach services to their delivery systems to encourage use and

adoption of the statewide HIE.

Connect to Ohio’s existing HIE networks – There are several active regional, university‐based

and hospital‐based exchange networks in place today in Ohio. Connecting these networks to the

statewide HIE will allow for interconnectivity among the networks and ultimately across state

borders. It also maximizes the number of physicians with access the statewide HIE early in the

implementation cycle.

Sub‐source or link to experienced EDI vendors – There are several electronic data interchange

(EDI) vendors who efficiently support the exchange of administrative data (eligibility, claims,

etc.) today with whom OHIP can contract with to provide rapidly available services at affordable

price points. Some HIE vendors offer this service, others are advancing their ability to directly

integrate with EHRs, while others are partnering with HIE vendors.

2.7 BUSINESS AND TECHNICAL OPERATIONS

2.7.1 CURRENT HIE CAPACITIES

Historically, groups of exchanges within the state have arisen from the need to create regional and

community‐based environments where a high concentration of patients is shared between non‐

affiliated provider settings. In some cases, these regional or community exchanges have reached out to

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connect to national exchanges (namely, the NHIN) to extend their reach. At least one exchange that

resides on the border has reached out across a tri‐state area to create a regional exchange environment.

These exchanges arose from community partnerships, university affiliations or via large medical centers

within their respective communities with the goals of improving quality, reducing costs and providing

efficient uses of new technology.

2.7.1.1 REGIONAL AND NATIONAL EXCHANGES

Ohio is home to several regional exchanges. – The largest and most active HIE in the state is

HealthBridge. Formed in Cincinnati in 1997, HealthBridge serves a community of over 2,000,000

residents, twenty‐eight (28) hospitals, multiple ancillary centers, twenty (20) federally qualified health

centers (FQHCs) and 5,500 practitioners with their clinical messaging needs. This exchange is currently

sending over 36 million clinical messages per year to physicians in the region from over 95 percent of

the hospitals, three national laboratories and multiple imaging centers. The results and reports that are

exchanged include: laboratory, cardiology, microbiology, pathology, radiology, transcriptions,

registrations, discharge medications, discharge summaries, chart completions, PACS, fetal heart

monitoring results and registries. In addition, HealthBridge supports live connectivity with other HIEs, 20

FQHCs, 15 long‐term care facilities and 10 billing companies. It also successfully interfaced with

electronic health records (EHRs) from 26 vendors including 60 different versions. Furthermore,

HealthBridge exchanges real‐time results with the Indiana Health Information Exchange and HealthLINC,

which created the first multi‐region to exchange results in the nation. HealthBridge is also considered

one of the few HIEs in the country with a sustainable funding model.

Recognizing the sustainability of HealthBridge’s funding model, the Collaborating Communities Health

Information Exchange (CCHIE) chose to collaborate with HealthBridge from its inception. Formed in

2008, CCHIE is the second largest, operational HIE in the state. Currently reaching out to over 50 percent

of the physicians in the Springfield Ohio area, CCHIE is sending over 60,000 laboratory and radiology

results per month from multiple sources. They are also working with several clinics in the Springfield

area that are servicing the underserved as well as the local FQHC.

Another community‐based quality initiative funded in part by the Robert Wood Johnson Foundation is

Better Health Greater Cleveland (BHGC). They are an independent organization dedicated to improving

the health of people in Northeast Ohio living with chronic disease. This alliance is comprised of

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organizations such as Care Alliance, Cleveland Clinic, Kaiser‐Permanente Ohio, MetroHealth System,

Neighborhood Family Practice, Northeast Ohio Family Health Services, and University Hospitals that

total more than 400 primary care doctors in 45 partner practices. This organization collects quality

metrics electronically from its partners for patients that suffer from hypertension, heart failure and

diabetes with the goal to measure and improve overall outcomes for the region. In 2010, there were

over 90,000 hypertensive patients, 5,000 heart failure patients, and 26,000 diabetic patients tracked and

measured. The results of this effort are positive and continue to improve against national benchmarks.

This results from the focus of the alliance on quality goals, education on best practices, identification of

health disparities, managing transitions in care, and support of EHR adoption to improve care.

2.7.1.2 UNIVERSITY‐BASED HOSPITAL EXCHANGES

Focusing mainly on the underserved in the Dayton area, the HealthLink HIE at Wright State University

was developed in 2001 using federal (HRSA) funds to provide a central data repository for a shared

community health record. Administered through HealthLink, the HIEx™ system currently maintains over

75,000 patient records in the repository that can be accessed by either VPN or public portal across the

internet. The primary users of this system are outpatient physician practices, public school nurses,

county child welfare workers, home care geriatricians, the local public health department and

community health workers serving primarily uninsured and underinsured patients. Currently, HealthLink

is a member of the Nationwide Health Information Network Cooperative.

Another operational, university‐based HIE is the Appalachian Health Information Exchange (AHIE), based

in Southeastern Ohio. Funded through a grant awarded from the National Institutes of Health (NIH) and

supported by Ohio University, AHIE has been sending results to physicians through connecting hospitals

and clinics in rural areas since 2004. Striving to overcome the difficulties of limited resources and an

insufficient IT infrastructure, AHIE has diligently involved with Ohio’s broadband initiatives to connect its

rural communities to the Internet.

2.7.1.3 HOSPITAL‐BASED EXCHANGES

As noted in US News and World Report’s, America’s Best Hospitals (2009) and Reuter’s 100 Top

Hospitals, 2009, Ohio is fortunate to be home to several top‐ranked hospital systems. These lists include

the following hospitals: Cleveland Clinic, University Hospitals Health Systems, Catholic Health Partners,

The Ohio State University Medical Center, OhioHealth, The Health Alliance of Greater Cincinnati and

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Kettering Health Network. These hospitals, as well as others in the state, have taken the initiative to

improve the quality of care in their communities through the adoption of health information technology.

Several hospital systems have purchased EHRs for their employed physicians and non‐employed

physicians have the option to purchase them at a discounted rate. Some hospital‐owned EHRs are

interfaced via HL7 to receive hospital information directly, thus allowing the physician’s office to

become paperless. Some of these EHRs also have the capability to ePrescribe as well as provide some

quality reports that are required for Physician Quality Reporting. Many hospitals have the capability to

allow users to access hospital information such as laboratory, radiology and transcribed reports through

their portals.

Currently, 40 percent of hospitals in Ohio are sharing information among their respective organizations.

Many of these organizations have or will have met the meaningful use requirements for 2013 and

beyond. Another 40 percent of the hospitals in Ohio are in a position to begin implementation of an EHR

or initiate the steps to purchase one. These hospitals are committed to implementing steps to increase

efficiency and improve their level of quality care. They should be able to meet the meaningful use

requirements by 2013. The remaining 20 percent are either rural or small hospitals that are at risk of

failing to achieve HIT within their organizations, which is mainly due to the lack of capital funding. Those

organizations that are behind in the adoption of EHR technology will require both financial and technical

assistance in order to meet the meaningful use requirements for 2013 and 2015. The Ohio Hospital

Association (OHA) has been working directly with these rural hospitals to provide such assistance. The

steering committee for this group involves small and rural hospitals that are not part of larger hospital

systems that need technical and/or buying support for their IT purchase to achieve the requirements of

meaningful use.

2.7.1.4 SCOPE OF HIE SERVICES PROVIDED

In an attempt to analyze the levels of HIE services that are currently provided by these exchanges, OHIP

explored the following topics with representatives of the entities mentioned above:

Current use‐cases describing the nature of exchange within these organizations

A description of these organizations plans for expansion of exchange services until the statewide

HIE becomes available

From an existing HIE perspective, what key services would be needed from the statewide HIE

perspective?

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The outcome of these discussions is summarized in Table 10 below.

Table 10 Summary of HIE Services by Existing HIOs in Ohio

Service Provided Selectively Provided

Often Provided

Always Provided

Master Patient Index (within their exchange) X

Electronic Lab Ordering X

Electronic Lab Resulting X

Manual delivery of non‐electronic results (via fax or print) X

Discrete Lab Results integration with EHR X

ePrescribing X

Eligibility Verification X

Exchange of Clinical Patient Summaries X

Syndromic Surveillance X

Reportable Disease Routing X

Quality Reporting X

Personal Health Record (consumer access) X

Electronic Medical Record (lightweight version) X

Medical Evidence Transmittal (SSA data transmission via NHIN)

X

2.7.2 STATE LEVEL SHARED SERVICES AND REPOSITORIES

As described in the Proposed HIE Model (S‐35) and Business and Technical Operations/Implementation

(S‐100) sections of the strategic plan, OHIP intends to implement an HIE architecture that will provide

the following core support components:

Master Patient Index (MPI) – An accurate master patient index links patient activity across

organizations and across patient care settings with the minimum necessary data to identify

patients positively, using sophisticated technology.

Master Entity Index (MEI) – The MEI will be used to positively identify trusted HIE participants

who have agreed to the standard terms and conditions for use of the HIE in a manner that

protects patient rights and maximizes data security. The MEI may include information about

licensed providers, hospitals, payors, pharmacies, laboratories, etc., such that sending entities

have enough information about the receiving entity to make an appropriate determination for

data exchange.

Record Locator Service (RLS) ‐ The RLS provides authorized users of a RHIO with pointers to the

location of a patient’s PHI across network nodes (i.e., the clinical data sources).

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Trust Enablement Services – This includes a range of services and mechanisms to garner trust

among HIE participants to ensure data is exchanged appropriately and in a secure manner with

trusted exchange partners and according to consumer preferences and consent.

Based on RFI responses, technologies exist that would preclude the necessity for a full data repository to

aggregate data for purposes of population health management. Having the ability to streamline current

provider reporting burdens without replicating data at its source would improve data accuracy, mitigate

privacy and security issues, and provide an opportunity to bring significant administrative savings to

Ohio’s healthcare system.

In addition to the core components noted above and exchange support for meaningful use objectives,

OHIP will work to offer a centralized insurance eligibility verification service that includes Medicaid and

other third party coverage data with expansion plans to provide coordination of benefits, streamlined

pre‐authorization, certification, claim and payment adjudication workflows.

2.7.3 STANDARD OPERATING PROCEDURES FOR HIE

OHIP will develop standard operating policies and procedures to support the production of a statewide

HIE. The development of these policies and procedures will be guided by OHIP's mission that includes:

Support the adoption and meaningful use of EHRs by Ohio's healthcare providers

Promote timeliness and efficiency of data exchange

Ensure patient privacy

Advance safety, quality, accessibility, and availability of health care for the citizens of Ohio

These policies will follow prudent business practices and state/federal laws and regulations regarding

HIE's. These policies will address the following, but will not be limited to:

Governance ‐ Compliance with state regulations, rules for accountability/transparency, rules on

public notices/meetings, rules on documentation

Administration ‐ User licensing, accounting, billing, insurance and other day‐to‐day operations

Privacy/Security ‐ Includes privacy policies, patient consent models, user authentication, user

authorization, network security

User Support ‐ Training, help desk, installation, if needed

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Compatibility ‐ Consistency with the national standards framework(s) now and in the future,

CCHIT if needed, and other certifying bodies now and in the future.

2.8 LEGAL/POLICY

OHIP recognizes the need to assume a leadership role to develop the path for statewide HIE in Ohio. The

Strategic Plan will be implemented through this Operational Plan and outlines a corresponding and

comprehensive set of activities to achieve statewide HIE. Execution of the Operational Plan will provide

support and facilitate Ohio’s providers to achieve meaningful use of HIT to enhance delivery, quality,

and value of health care.

2.8.1 ESTABLISH REQUIREMENTS

The Privacy and Policy Committee79 will have primary responsibility for compliance of the OHIP HIE with

federal and state laws and policy requirements. The Privacy and Policy Committee will develop policies

and procedures to ensure legal compliance by OHIP HIE, including policies and procedures related to the

operation of the HIE and the monitoring of the HIE for compliance by participants. The chair of the

committee will report to the CEO of OHIP as well as to its Board of Directors.

2.8.2 PRIVACY AND SECURITY HARMONIZATION

The Privacy and Policy Committee will build upon the work performed by HISPC Legal Work Group.

Discussed in the Privacy and Security section of the strategic plan, this work will be used to identify and

review state and federal privacy and security laws, policies, and procedures for barriers to HIE. They will

also use this work to harmonize privacy and security laws, policies and requirements and coordinate

activities to establish consistency on a statewide basis, as set forth in the Strategic Plan.

2.8.3 FEDERAL REQUIREMENTS

Ohio has a number of federal health facilities serving its population. Specifically, Ohio has five VA

Medical Centers and 29 community‐based outpatient clinics serving the large veteran population in

Ohio. Additionally, 35 FQHCs and 11 rural health clinics provide a critical safety net of health care to

79 See Appendix P, Amendment # 11

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Ohio’s underserved counties. Ohio is also home to the Wright Patterson Air Force Base Medical Center,

serving Ohio’s active duty and reserve military personnel and their families.

OHIP is committed to collaborating with each of these federal health facilities in HIE. OHIP plans to

foster technical, organizational, and legal practices that will speed the exchange of health information

between federal health facilities and other healthcare systems and providers in Ohio.

1

3760974v5

# Name Brief Description Web Link Issued By Regulatory Reference Comments

REGULATORY

R1 A133 Audit Circular A‐133 sets forth the standards to be used by Federal agencies when auditing non‐Federal entities expending Federal awards. OHIP will be using Federal grant money to implement the health information exchange and pay HIE vendors. Thus, the Federal government will use Circular A‐133 as guidance when auditing OHIP’s expenditures of grant funding.

http://www.whitehouse.gov/omb/rcewrite/circulars/a133/a133.html

OMB Circular A‐133 is issued under the authority of sections 503, 1111, and 7501 et seq. of title 31, United States Code, and Executive Orders 8248 and 11541

R2 ARRA/ HITECH

The Health Information Technology for Economic and Clinical Health Act (HITECH) expands the HIPAA data privacy and security requirements to all “business associates” of health care covered entities. Since OHIP and HIE vendors will be transmitting identifiable health information on behalf of such covered entities, they may qualify as business associates and as such be subject to the requirements of HIPAA and HITECH. The HITECH Act also provides funding for health information technology expansion, including for the development of health information exchanges and Medicare and Medicaid incentives for the adoption and meaningful use of certified EHR technology (see additional rules below at *).

http://edocket.access.gpo.gov/2009/pdf/E9‐20169.pdf

HHS 74 FR 4273945 CFR Parts 160 and 164

R3 Electronic Prescriptions for Controlled Substances (DEA/NCPDP EHR Controlled Substance IFR)

Under this Interim Final Rule, practitioners are now allowed to write prescriptions for controlled substances electronically. OHIP and HIE vendors may be transmitting these electronic prescriptions through the health information exchange, thus they need to be aware of the applicable restrictions.

http://edocket.access.gpo.gov/2010/pdf/2010‐6687.pdf

DEA 21 CFR 1300, 1304, 1306, and 1311 75 FR 16235

R4 Electronic This Ohio rule establishes the standards for http://codes.oh ODH Ohio Rev. Code § 3701.75

Appendix A - Health IT Regulatory, Certification and Other Standard References

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Signatures in Health Records

when entries in an electronic health record may be authenticated by an electronic signature. OHIP and HIE vendors will be transmitting electronic health records, thus they should be aware of applicable restrictions for such records.

io.gov/orc/3701.75

R5 Identification of Backward Compatible Version of Adopted Standard for E‐Prescribing and the Medicare Prescription Drug Program (NCPDP SCRIPT 10.6)

This interim final rule permits the use of a newer standard for conducting electronic prescribing transactions in the Medicare Part D e‐prescribing program. The newer standard adopted under the rule, NCPDP SCRIPT 10.6, is a backward compatible version of the older NCPDP SCRIPT 8.1. Version 8.1 has been the official Part D e‐prescribing standard for communicating prescription‐related information between prescribers and dispensers since 2009. According to the interim final rule, NCPDP SCRIPT 10.6 retains the functionality of version 8.1, thus permitting the successful completion of e‐prescribing transaction with entities that continue to use NCPDP SCRIPT 8.1 for Part D.


CMS 75 FR 38026

R6 Integration of Physician Quality Reporting and EHR Reporting Proposed Rule

Section 3002(d) of PPACA requires CMS to move towards the integration of EHR measures with respect to the Physician Quality Reporting Initiative (PQRI) program. No later that January 1, 2012, the Secretary of HHS shall develop a plan to integrate reporting on the quality measures under PQRI with reporting requirements for meaningful use of EHRs. Since OHIP and HIE vendors will be providing EHR technology to health care providers, they need to understand the reporting requirements


CMS 75 FR 40201


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associated with meaningful use.

R7 *

Establishment of the Temporary Certification Program for Health Information Technology Final Rule

This Final Rule establishes a temporary certification program for purposes of testing and certifying health information technology to assure the availability of Certified EHR Technology. OHIP and HIE vendors will be implementing electronic health record technology, thus they need to be aware of the EHR certification process adopted under this rule for EHR systems to be deemed Certified EHRs.

http://www.ofr.gov/OFRUpload/OFRData/2010‐17210_PI.pdf

HHS‐ONC 45 CFR Part 170

R8 Gramm‐Leach‐Bliley Act: Obligations with respect to disclosures of financial information

The Gramm‐Leach‐Bliley Act sets forth obligations with respect to disclosures of financial information by non‐affiliated third parties that receive nonpublic financial information from financial institutions. OHIP and HIE vendors may need to be aware of these restrictions if they are transmitting financial information as part of claims processing.

http://www.ftc.gov/privacy/privacyinitiatives/financial_rule_lr.html

FTC 15 USC §§ 6801 ‐ 6809

R9 Health Breach Notification Rule (Federal Trade Commission)

The Health Breach Notification Rule requires individual notification following the discovery of a breach of identifiable health information contained in unsecured personal health records maintained by a vendor of such records or a related entity. This rule would be applicable to OHIP and HIE vendors only if they did not meet the definition of “business associate” under HIPAA.

http://ecfr.gpoaccess.gov/cgi/t/text/text‐idx?c=ecfr&tpl=/ecfrbrowse/Title16/16cfr318_main_02.tpl

FTC 16 CFR Part 318

R10 Health Breach Notification Rule (Health and Human Services)

This rule requires notification to individuals, HHS, and the media from HIPAA covered entities upon discovery of a breach of a members unsecured protected health information. This rule also requires business associates to notify covered entities following


HHS 45 CFR Parts 160 and Subparts A and D of Part 164


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the discovery of such breach. As outlined above, OHIP and HIE vendors may be business associates providing health information exchange services to health care providers.

R11 *

Health IT Standards & Certification Criteria Final Rule

This Interim Final Rule represents the first step in an incremental approach to adopting standards, implementation specifications, and certification criteria to enhance the interoperability, functionality, utility, and security of health IT and to support its meaningful use. OHIP and HIE vendors will be implementing electronic health record technology, thus they need to be aware of the certification criteria adopted under this rule that establish the capabilities and related standards that this technology must include.


HHS – ONC 45 CFR Part 170 75 FR 2013‐2047

R12 HIPAA Privacy Rule

The HIPAA privacy rule establishes national standards regarding health information privacy. As outlined above, OHIP and HIE vendors may be subject to HIPAA regulations as business associates providing health information exchange services to health care providers.

http://www.hhs.gov/ocr/privacy/hipaa/understanding/summary/index.html

HHS 45 CFR Part 160 and Subparts A and E of Part 164

R13 HIPAA Security Rule

The HIPAA security rule establishes standards for safeguarding and protecting health information. As outlined above, OHIP and HIE vendors may be subject to HIPAA regulations as business associates providing health information exchange services to health care providers.

http://www.hhs.gov/ocr/privacy/hipaa/understanding/srsummary.html

HHS 45 CFR Part 160 and Subparts A and C of 164

R14 HIPAA Transaction and Code Set Rule

HHS is adopting X12 Version 5010 and NCPDP Version D.0 for HIPAA administrative transactions effective January 2012. HIE vendors are required to comply with the

http://www.cms.gov/TransactionCodeSetsStands/02_Transacti

HHS 45 CFR Part 162 For eligibility, vendors must comply with CAQH CORE Phase I


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Phase I requirements. onsandCodeSetsRegulations.asp

requirements.

R15 Modifications to the HIPAA Privacy, Security, and Enforcement Rules under the HITECH Act Proposed Rule

This proposed rule contains modifications to

HIPAA, specifically it covers: business

associate liability, the sale of protected

health information (PHI), research issues, the

minimum necessary standard, restrictions to

uses and disclosures of PHI, access to PHI,

fundraising and notice of privacy practices. As

outlined above, OHIP and HIE vendors may

be subject to HIPAA regulations as business

associates providing health information

exchange services to health care providers.

http://www.ofr.gov/OFRUpload/OFRData/2010‐16718_PI.pdf

HHS 75 FR 40868

R16 HISPC – Legal Framework for Ohio

Ohio’s Health Information Security and Privacy Collaboration (HISPC) brought legal and security experts together to assess organization‐level business policies, practices and state laws that affect the health information exchange within Ohio. In implementing the health information exchange, OHIP and HIE vendors need to be apprised of the results of HISPC’s assessments.

https://hispc.pbworks.com Report: http://hispc.pbworks.com/f/Intrastate_Interstate_FinalReport_20090911.pdf

HPIO Multiple Ohio’s laws require a more prescriptive approach to achieve consent for data exchange than HIPAA.

R17 HITECH Extension for Behavioral Health Services Act of 2010

The proposed amendment extends eligibility for EHR incentive payment programs and REC services to behavioral health providers.

http://www.govtrack.us/congress/bill.xpd?bill=h107‐5040

HHS H.R. 5040

R18 *

Medicare and Medicaid Programs; Electronic Health Record Incentive

This final rule implements provisions of the HITECH Act which authorizes incentive payments to eligible professionals, eligible hospitals, and critical access hospitals that demonstrate meaningful use of electronic


CMS 75 FR 44314


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Program Final Rule

health record (EHR) technology. Since OHIP and HIE vendors will be providing such EHR technology to health care providers, they need to understand the requirements for achieving meaningful use.

R19 Ohio Board of Pharmacy – Electronic Prescription Transmission Systems

The Ohio Board of Pharmacy requires prior approval of all electronic prescription transmission systems intended to be used in Ohio. If the system used by OHIP and HIE vendors to transmit electronic health records also transmits electronic prescriptions, then the system will need to meet the qualifications set forth by the Ohio Board of Pharmacy and be approved prior to use.

http://pharmacy.ohio.gov/faq.htm

Ohio Board of Pharmacy

OAC 4729‐5‐21

R20 Ohio Medicaid Restrictions on Information regarding Public Assistance Recipients

This statute sets forth restrictions on the use or disclosure of any information regarding recipients of Ohio public assistance. Since OHIP and HIE vendors may be transmitting the electronic health records of such recipients of public assistance, they are subject to these restrictions.

http://codes.ohio.gov/orc/5101.27

ODJFS Ohio Rev. Code § 5101.27

R21 Other Standards applicable to Data Protection/ Privacy Outside Healthcare

This statute requires disclosure and notification of certain breaches of security of computerized personal information systems. OHIP and HIE vendors must report any unauthorized access to and acquisition of computerized data that causes, reasonably is believed to have caused, or reasonably believed will cause a material risk of identity theft or other fraud to individuals.


Ohio Rev. Code § 1349.19

R22 Patient Protection and Affordable Care Act (PPACA)

Section 3002 of PPACA requires the Secretary of HHS to integrate the respective reporting mechanisms for the Physician Quality Reporting Initiative and the electronic health record “meaningful use” incentives. Such

http://www.bricker.com/documents/resources/reform/healthreform1.pdf

HHS 42 USC 1395w‐4(k)(4) Revised by the Health Care and Education Reconciliation Act of 2010


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integration must consist of the selection measures, the reporting of which would demonstrate both meaningful use of EHR and quality of care furnished to an individual.

R23 Record Retention Requirements

Ohio and federal laws require health care providers to retain patient records for specified periods of time. While individual health care provider organizations and practitioners may interpret and apply these requirements differently, generally adult patient records must be retained for at least a period of 10 years after discharge and minor records must be retained for a period of 10 years after the patient reaches the age of majority (18); Numerous Ohio and federal laws require health care providers to retain other types of records, including records containing health information that may not be included in the patient record for specified periods of time. In addition, EHR systems have varying functional capabilities to purge records by type or otherwise operationalize record retention policies.

http://codes.ohio.gov/oac/3701 http://codes.ohio.gov/oac/5101

http://www.hhs

.gov/ocr/privac

y/hipaa/underst

anding/summar

y/index.html

ODH; ODJFS (Medicaid); HHS

OAC 3701.83‐11(E);OAC 3701‐84‐11(E); OAC 5101:3‐1‐17.2 45 CFR 164.530(j)

Regulatory references listed are for adult and minor patient records and federal HIPAA requirements; to the extent that the HIE vendor will be required to support other functions, additional record retention requirements may apply, such as for maintaining and reporting records required to comply with public health reporting., claims adjudication, etc.

R24 SAS 70 Audit Requirements

SAS No. 70 is the authoritative guidance that allows service organizations to disclose their control activities and processes to their customers and their customer’s auditors in a uniform reporting format. Since HIE vendors provide transaction processing, data hosting, and other data processing services to OHIP, they are service organizations and the SAS 70 guidance is applicable.

http://infotech.aicpa.org/Resources/Assurance+Services/Standards/SAS+No.+70+Service+Organizations.htm

AICPA Codification of Auditing Standards AU Section 324

R25 SSA Limitations This regulation sets forth the Social Security Administration’s application of the Privacy

http://www.ssa.gov/OP_Home/

SSA 20 CFR § 401.20


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Act rules to medical information maintained by Social Security programs. Since OHIP and HIE vendors may transmit electronic health records containing information regarding persons participating in such programs, they need to be aware of these rules.

cfr20/cfrdoc.htm

R26 Standards for De‐identified Data/ Research

The HIPAA Privacy Rule provides that de‐identified health information is not protected health information subject to HIPAA’s privacy and security requirements. De‐identified health information is health information that does not identify an individual and with respect to which there is no reasonable basis to believe that the information can be used to identify an individual. HIPAA requires that specified identifiers must be removed from health information for it to be deemed “de‐identified”. To the extent that OHIP and its HIE vendors may be involved in de‐identifying health information for certain purposes or transmitting information that has been determined to be de‐identified by others, they should be aware of HIPAA de‐identification requirements.

http://www.hhs.gov/ocr/privacy/hipaa/understanding/summary/index.html

HHS 45 CFR Part 160 and Subparts A and E of Part 164; 164.502(d); 45 CFR 164.514

R27 The Privacy Act of 1974

The Privacy Act governs the collection, maintenance, use, and dissemination of personally identifiable information about individuals that is maintained in systems of records by federal agencies. To the extent that OHIP and HIE vendors exchange information with the Federal government, they will need to understand this Act.

http://www.foia.cia.gov/txt/pa.pdf

HHS 5 USC § 552a; 45 CFR Part 5b

R28 The Freedom of Information Act

This act allows for the full or partial disclosure of previously unreleased information and documents controlled by the

http://www.foia.cia.gov/txt/foia.pdf

HHS 5 USC § 552; 45 CFR Part 5


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United States Government. The Act defines agency records subject to disclosure and outlines mandatory disclosure procedures. To the extent that OHIP and HIE vendors exchange information with the Federal government, they will need to understand this Act.

R29 Confidentiality of Substance Abuse Patient Records

This statute prohibits disclosures of substance abuse patient records and any information that identifies an individual as an alcohol or drug abuser without written consent of the individual. OHIP and HIE vendors may work with records covered by this statute, thus they need to be aware of its restrictions.

http://www.law.cornell.edu/uscode/html/uscode42/usc_sec_42_00000290‐‐dd002‐.html

SAMHSA 42 USC § 290dd‐2; 42 CFR Part 2

R30 Genetic Information Nondiscrimination Act of 2008 (GINA)

Generally, this Act prohibits discrimination by group health plans and employers on the basis of genetic information and protects genetic information.

http://www.gpo.gov/fdsys/pkg/PLAW‐110publ233/content‐detail.html

N/A Pub. L. No 110‐233

R31 Clinical Laboratory Improvement Amendments

This law regulates laboratories conducting testing on human specimens for medical purposes. Specifically, this law states that certified labs may disclose test results or reports only to authorized people. OHIP and HIE vendors may be involved in the exchange of laboratory testing results, thus they should be aware of these disclosure requirements.

http://wwwn.cdc.gov/clia/regs/toc.aspx

CMS 42 USC § 263a; 42 CFR Part 493

R32 Federal Food, Drug and Cosmetic Act

The Federal Food, Drug, and Cosmetic Actgives authority to the U.S. Food and Drug Administration (FDA) to oversee the safety of food, drugs, and cosmetics. Additionally, this law explains that investigators may not use human beings as subjects in research covered

http://www.law.cornell.edu/uscode/21/ch9.html

FDA


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by these regulations unless informed consent is given.

R33 Controlled Substances Act

This Act protects identifiable research information from forced or compelled disclosure and allows for refusal to disclose identifying information regarding research participants in civil, criminal, administrative, legislative or other proceedings.

http://www.fda.gov/regulatoryinformation/legislation/ucm148726.htm

N/A 21 USC § 801 et seq.

R34 Federal Policy for Protection of Human Subjects

This rule establishes procedures and protections for human subjects participating in research funded by Federal agencies. It specifies that the research must include adequate provisions protecting the privacy of subjects and maintaining the confidentiality of data.

http://www.hhs.gov/ohrp/humansubjects/guidance/45cfr46.htm

HHS 45 CFR 46.111 – 46.113

R35 Statutory Authority for Certificates of Confidentiality

This provision allows the Secretary of HHS to issue a certificate to protect information on research participants from forced or compelled disclosure.

http://www.law.cornell.edu/uscode/42/usc_sec_42_00000241‐‐‐‐000‐.html

HHS 42 USC § 241(d)

R36 AHRQ Confidentiality Provisions

This provision states that data collected by AHRQ cannot be used for any purpose other than the purpose for which it was supplied, unless the person or supplier of the data has consented to its use for such other purposes.

http://codes.lp.findlaw.com/uscode/42/6A/VII/D/299c‐3

HHS 42 USC § 299c‐3

R37 CDC Confidentiality Provisions

This provision requires the CDC to get consent before releasing identifiable information for any purpose other than the purpose for which it was supplied.

http://www.law.cornell.edu/uscode/html/uscode42/usc_sec_42_00000242‐‐‐m000‐.html

CDC 42 USC § 242m(d)

R38 Confidentiality Provisions for Data Collection and Security

Under this provision, identifiable mental health and substance abuse information obtained in the course of activities undertaken or supported by SAMHSA may

http://codes.lp.findlaw.com/uscode/42/6A/III‐A/A/290aa

SAMHSA 42 USC § 290aa(n)


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Information not be used for any purpose other than the purpose for which it was supplied unless consent of the person or establishment is obtained prior to the use or release.

R39 Patient Safety and Quality Improvement Act

This Act allows providers to voluntarily report information to Patient Safety Organizations on a privileged and confidential basis for aggregation and analysis of patient safety events.

http://frwebgate.access.gpo.gov/cgi‐bin/getdoc.cgi?dbname=109_cong_public_laws&docid=f:publ041.109

HHS 42 USC § 299b‐21 to 299b‐26

R40 Children’s Online Privacy Protection Act

This Act protects the privacy of children under the age of 13 by requesting parental consent for the collection or use of any personal information of the users.

http://www.law.cornell.edu/uscode/html/uscode15/usc_sup_01_15_10_91.html

FTC 15 USC §§ 6501‐6506

R41 Federal Information Security Management Act

This Act ensures that federal government information systems follow a mandatory set of IT system security processes. This Act applies to the federal government and to outside entities acting on behalf of the federal government, including government contractors. OHIP and HIE vendors need to be aware of these requirements when working with federal entities and contractors.

http://www.law.cornell.edu/uscode/44/3541.html

N/A 44 USC § 3541(a)(1)(A)

R42 Electronic Signatures in Global and National Commerce Act

Under this Act, electronic signatures and contracts are given the same legal validity as those executed by hand. This Act will apply to electronic signatures in electronic health records that OHIP and HIE vendors may work with.

http://www.law.cornell.edu/uscode/15/ch96schI.html

FTC 15 USC § 7001

R43 Stored Communications

This Act prohibits unauthorized access of electronic communications and provides civil

http://www.law.cornell.edu/usc



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Act and criminal remedies for violations. Additionally, this Act requires notice in the event of unauthorized access to a consumer’s electronic records. OHIP and HIE vendors will be storing electronic communications in the form of electronic health records, thus, they need to be aware of the restrictions under this Act.

ode/html/uscode18/usc_sec_18_00002701‐‐‐‐000‐.html

R44 Electronic Communications Privacy Act

These sections protect wire, oral and electronic communications while in transit and communications held in electronic storage. Since OHIP and HIE vendors will be transmitting and storing electronic communications they need to be aware of these requirements.

http://www.law.cornell.edu/uscode/html/uscode18/usc_sup_01_18.html

N/A 18 USC §§ 2510‐2522, 2701‐2711, and 3121‐3126

R45 Computer Fraud and Abuse Act

This Act protects computers used in Federal government, certain financial institutions or computers used in interstate and foreign commerce from unauthorized access and imposes fines and imprisonment for violations. OHIP and HIE vendors may be transmitting health information through computers covered under this Act.

http://www.law.cornell.edu/uscode/18/1030.html

N/A 18 USC § 1030

R46 Patriot Act This Act restricts, reduces or eliminates the following privacy law protections applicable to OHIP and HIE vendors: Electronic Communications Privacy Act and the Computer Fraud and Abuse Act .

http://frwebgate.access.gpo.gov/cgi‐bin/getdoc.cgi?dbname=107_cong_public_laws&docid=f:publ056.107

N/A P.L 107‐56

R47 Confidential Information Protection and Statistical

This Act protects the confidentiality of information supplied by individuals and organizations to all federal agencies under a pledge of confidentiality for statistical

http://www.law.cornell.edu/uscode/html/uscode44/usc_sup_0



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Efficiency Act purposes. This may apply to OHIP and HIE vendors if they supply such information to the federal government.

1_44_10_35_20_I.html

R48 Physician‐Patient Privilege

This statute sets forth the testimonial privilege for confidential communications between physicians and patients.


n/a Ohio Rev. Code § 2317.02

R49 Disciplinary Actions for Physicians

Under this statute, a physician may be disciplined by the State Medical Board for willfully betraying a professional confidence.


State Medical Board

Ohio Rev. Code § 4731.22

R50 Duty of Confidentiality

This case established an independent tort for the unauthorized, unprivileged disclosure by a physician or hospital to a third party of nonpublic medical information that physician or hospital has learned within a physician‐patient relationship.

http://www.supremecourt.ohio.gov/rod/docs/pdf/0/1999/1999‐Ohio‐115.pdf.

Supreme Court of Ohio

Biddle v. Warren General Hospital, 86 Ohio St. 3d 395, 1999‐Ohio‐115.

R51 Uniform Administrative Requirements for Awards and Subawards to Institutions of Higher Education, Hospitals, other Non‐Profit Organizations, and Commercial Organizations

This section establishes uniform pre‐award and post‐award administrative requirements governing HHS grants and agreements awarded to institutions of higher education, hospitals, other nonprofit organizations and subgrants or other subawards awarded by recipients of HHS grants and agreements to institutions of higher education, hospitals, other nonprofit organizations and commercial organizations. Since OHIP is participating in HHS HIE programs, they are required to comply with these administrative requirements.

http://ecfr.gpoaccess.gov/cgi/t/text/text‐idx?c=ecfr;sid=85fa827d5b4cde0a8286b0541125d28e;rgn=div5;view=text;node=45%3A1.0.1.1.35;idno=45;cc=ecfr

HHS 45 CFR 74

R52 Uniform Administrative Requirements for Grants and Cooperative

This part establishes uniform administrative rules for Federal grants and cooperative agreements and subawards to State, local and Indian tribal governments. Since OHIP is the state designated entity participating in

http://ecfr.gpoaccess.gov/cgi/t/text/text‐idx?c=ecfr&sid=61cd24225c7b0

HHS 45 CFR 92


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Agreements to State, Local and Tribal Governments

HHS HIE programs on behalf of the state, they are also required to comply with these administrative requirements.

7e01958f829f1b34f7c&rgn=div5&view=text&node=45:1.0.1.1.50&idno=45

R53 Cost Principles for State, Local, and Indian Tribal Governments

This part establishes principles and standards for determining costs for Federal awards carried out through grants, cost reimbursement contracts, and other agreements with State and local governments and federally‐recognized Indian tribal governments (governmental units). Since OHIP is operating under HHS grants on behalf of the state, they are required to comply with these cost principles.


OMB 2 CFR 225

R54 Cost Principles for Non‐Profit Organizations

This part establishes principles for determining costs of grants, contracts and other agreements with non‐profit organizations. Since OHIP is operating under HHS grants, they are required to comply with these cost principles.


OMB 2 CFR 230

R55 Confidentiality of Medical Records

Under this statute, a health care provider cannot release medical records without first receiving a written request signed by the patient, personal representative, or authorized person not more than one year from the date of the request,


ODH Ohio Rev. Code § 3701.74

R56 Confidentiality of Alcohol and Drug Abuse Patient Records

These regulations impose restrictions upon the disclosure and use of alcohol and drug abuse patient records which are maintained in connection with the performance of any federally assisted alcohol and drug abuse program.

http://ecfr.gpoaccess.gov/cgi/t/text/text‐idx?c=ecfr&rgn=div5&view=text&node=42:1.0.1.1.2&idno=42

HHS 42 CFR Part 2; Ohio Rev. Code § 3793.13; OAC 3793:2‐1‐06.


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R57 Medicare Conditions of Participation – Patients’ Rights

Under these Medicare conditions of participation, patients have the right to the confidentiality of their medical records.

http://ecfr.gpoaccess.gov/cgi/t/text/text‐idx?sid=a05c7cb359f6117045a8536124843a88&c=ecfr&tpl=/ecfrbrowse/Title42/42cfrv5_02.tpl#482

CMS 42 CFR 482.13 (Hospitals); 42 CFR 483.10 (Long Term Care Facilities); 42 CFR 484.10 (Home Health)

R58 Family Educational Rights and Privacy

This law protects the privacy of student education records.


US Dept. of Education

34 CFR Part 99

R59 Disclosures of HIV Test Results or Diagnosis

This law prevents health care providers from disclosing or compelling another to disclose the identity of any individual on whom an HIV test is performed, the results of an HIV test in a form that identifies the individual tested, or the identity of any individual diagnosed as having AIDS or an AIDS‐related condition.



R60 Confidentiality of Protected Health Information

This statute requires that protected health information reported to or obtained by the Ohio Department of Health, a board of health of a city or general health district be kept confidential and shall not be released without the individual’s consent.



R61 Disclosure of Mental Health Information

Under these sections, all mental health certificates, applications, records and reports that directly or indirectly identify a patient or former patient or person who has been hospitalized as mentally ill shall be kept


Department of Mental Health

Ohio Rev. Code § 5122.31; OAC 5122‐27‐08


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confidential and not disclosed by any person.

R62 HIV Testing of a Minor

This law allows a minor to consent to an HIV test. Under HIPAA, when state law permits an unemancipated minor to consent to treatment, the information regarding that treatment is given special privacy.


n/a Ohio Rev. Code § 3701.242; 45 CFR 164.502

R63 Minor may Give Consent for Diagnosis or Treatment of Venereal Disease

This statute allows a minor to consent to the diagnosis or treatment of any venereal disease by a licensed physician. Under HIPAA, when state law permits an unemancipated minor to consent to treatment, the information regarding that treatment is given special privacy.



R64 Minor may Give Consent to Diagnosis or Treatment of Condition Caused by Drug or Alcohol Abuse

This law states that a minor may give consent for the diagnosis or treatment by a physician licensed to practice in this state of any condition which it is reasonable to believe is caused by a drug of abuse, beer, or intoxicating liquor. Under HIPAA, when state law permits an unemancipated minor to consent to treatment, the information regarding that treatment is given special privacy.



R65 Confidential Outpatient Services for Minors

This statute allows a minor to consent to six sessions or thirty days of outpatient mental health services, whichever occurs sooner. The minor’s parent or guardian shall not be informed of the services without the minor’s consent unless the mental health professional treating the minor determines that there is a compelling need for disclosure based on a substantial probability of harm to the minor or other persons, and the minor is notified of the mental health professional’s intent to inform the parent or guardian.




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Under HIPAA, when state law permits an unemancipated minor to consent to treatment, the information regarding that treatment is given special privacy.

R66 Confidentiality of Artificial Insemination Records

Pursuant to this law, a physician who is associated with a non‐spousal artificial insemination must place certain records relating to the artificial insemination (i.e., the required written consent, information provided to the recipient and, if married, her husband as permitted by Ohio law, other information concerning the donor that the physician possesses, and other matters concerning the artificial insemination) in a file that shall bear the name of the recipient. This file shall be retained by the physician in the physician’s office separate from any regular medical chart of the recipient, and shall be confidential. The consent form and other information provided to the recipient woman (and her husband, if married) must be available for inspection by the recipient and her husband until the child reaches 21 years of age.



R67 Confidentiality of Family Planning Services

Pursuant to this law, any program receiving Title X funding for family planning and other related preventive health services such as patient education and counseling, breast and pelvic examinations, breast and cervical cancer screening, sexually transmitted disease and HIV prevention education, counseling, testing and referral, and pregnancy diagnosis and counseling must not disclose information related to individuals receiving any services funded, in full or in

http://law.justia.com/us/cfr/title42/42‐1.0.1.4.41.1.19.11.html

HHS 42 CFR 59.11


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part by Title X, without the individual’s documented authorization, except as necessary to provide services to the patient or as required by law.

CERTIFICATION/ACCREDITATION

C1 CCHIT EHR Certification

The Certification Commission for Health IT offers EHR certification tracks including Preliminary ARRA IFR Stage 1.

www.cchit.org CCHIT n/a

C2 EHNAC Certification

Electronic Healthcare Network Accreditation Commission (EHNAC) is a federally‐recognized standards development organization which currently offers an HIE accreditation program.

www.ehnac.org EHNAC n/a EHNAC is currently the only entity offering HIE accreditation

C3 Joint Commission Standards

The Joint Commission Standards require hospitals to protect the privacy of, maintain the security and integrity of, and effectively manage the collection of health information. OHIP and HIE vendors need to be aware of these information management standards because hospitals utilizing the health information exchange must comply with them for accreditation purposes.

http://www.jointcommission.org

Joint Comm‐ission

Standards IM 02.01.01; 02.01.03; 02.02.01

OTHER STANDARDS

S1 CAQH CORE Phase I Certification for Administrative Transaction Exchange

The Council for Affordable Quality Healthcare (CAQH) issues CORE operating rules built on existing standards to make electronic transactions more predictable and consistent, regardless of the technology.

http://www.caqh.org/CORE_phase2.php

CAQH 45 CFR Part 170 Health IT Standards & Certification Criteria IFR requires compliance with CAQH CORE Phase I

S2 Consumer Consent Options for Electronic Health Information

White paper prepared by the ONCHIT outlining the various consumer consent models deployed by state HIEs. OHIP and HIE vendors will be implementing the health information exchange.

http://healthit.hhs.gov/portal/server.pt/gateway/PTARGS_0_11673_911197_0

HHS‐ONC n/a


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Exchange: Policy Considerations and Analysis

_0_18/ChoiceModelFinal032610.pdf

S3 HIE Implications for Meaningful Use Stage 1 (pre final rule)

The Healthcare Information Management Systems Society (HIMSS) published a matrix outlining the HIE implications for each Stage 1 MU objective.

http://www.himss.org/content/files/MU_HIE_Matrix.pdf

HIMSS n/a

S4 Healthcare Information Technology Standards Panel (HITSP)

Although recently disbanded, HITSP was formed for the purpose of harmonizing and integrating standards that will meet clinical and business needs for sharing information among organizations and systems.

http:/hitsp.org HITSP n/a

S5 House Bill 125 Advisory Committee on Eligibility and Real‐Time Claim and Adjudication

The charge of the Advisory Committee was to study and recommend standards to enable providers and payers to communicate electronically and effectively with each other regarding patient eligibility for services.

http://www.insurance.ohio.gov/Legal/Documents/hb125‐finalreport.pdf

ODI Ohio HB 125 The Advisory Committee recommended implementation of CAQH CORE Phase II requirements for eligibility data exchange.

S6 Integrating for the Healthcare Enterprise (IHE) Profiles

IHE promotes the coordinated use of established standards such as DICOM and HL7 to address specific clinical domain and privacy/security needs in support of optimal patient care.

http://www.ihe.net/

IHE 45 CFR Part 170 Health IT Standards & Certification Criteria IFR proposes use of IHE’s cross‐enterprise authentication protocols.

S7 Nationwide Health Information Network (NHIN)

The NHIN is a set of standards, services and policies that enable secure health information exchange over the internet.

http://healthit.hhs.gov/portal/server.pt?open=512&mode=2&cached=true&objID=1142

HHS‐ONC n/a The National eHealth Collaborative offers free NHIN University courses through http://www.nationalehealth.org/NHIN‐U/

S8 National Information

NIEM is designed to develop, disseminate and support enterprise‐wide information

www.niem.gov DOJ and DHS

n/a This framework is being considered for


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Exchange Model (NIEM)

exchange standards and processes that can enable jurisdictions to effectively share critical information.

application to HIE.

S9 National Institute of Standards and Technology (NIST)

Founded in 1901, NIST is a non‐regulatory federal agency within the US Department of Commerce. NIST's mission is to promote U.S. innovation and industrial competitiveness by advancing measurement science, standards, and technology in ways that enhance economic security and improve our quality of life.

www.nist.gov DOC n/a ONC is seeking input from the NIST for development of testing tools and procedures necessary to certify EHRs

S10 Ohio Health Information Partnership (OHIP)

OHIP is the state‐designated entity for health information exchange development.

www.ohiponline.org

OHIP n/a

S11 Ohio Health Reform Initiatives

Refer to this website for a list of Ohio’s initiatives in response to the Patient Protection and Affordable Care Act (PPACA)

http://www.healthcarereform.ohio.gov/Pages/default.aspx

ODI Patient Protection and Affordable Care Act (PPACA) Public Law 111‐152

S12 Ohio Healthcare Coverage and Quality Council (HCCQC)

The HCCQC is a public‐private partnership designed to improve the coverage, cost, and quality of Ohio’s health insurance and health care system. Part of the council’s focus will require expertise in health information technology and exchange.

http://www.hccqc.ohio.gov/Pages/default.aspx

ODI Ohio Revised Code § 3923.90

S13 Ohio Medicaid Information Technology System (MITS)

Ohio’s Medicaid agency is implementing a new claims adjudication system that will allow Ohio’s Medicaid Program to be better aligned with the federal guidelines for the Medicaid Information Technology Architecture (MITA).

http://www.jfs.ohio.gov/mits/.

ODJFS Ohio Revised Code § 5111.091

S14 Health Information Technology Regional

This grant program establishes Health Information Technology Regional Extension Centers (Regional Extension Centers) that will offer technical assistance, guidance

http://healthit.hhs.gov/portal/server.pt?open=512&objID=14

HHS‐ONC OHIP was awarded this grant for 77 of the 88 counties in Ohio. HealthBridge


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Extension Center Program

and information on best practices to support and accelerate health care providers’ efforts to become meaningful users of Electronic Health Records (EHRs).

95&parentname=CommunityPage&parentid=58&mode=2&in_hi_userid=11113&cached=true

was awarded this grant for the other 11 counties in the Southwestern portion of the State, parts of Northern Kentucky and Southeastern Indiana.

S15 State Health Information Exchange Cooperative Agreement Program

This grant program will support states and/or State Designated Entities (SDEs) in establishing health information exchange (HIE) capacity among health care providers and hospitals in their jurisdictions.

http://healthit.hhs.gov/portal/server.pt?open=512&objID=1336&parentname=CommunityPage&parentid=10&mode=2&in_hi_userid=11113&cached=true

HHS‐ONC Section 13301 of the Health Information Technology for Economic and Clinical Health Act (HITECH) provisions of ARRA

OHIP was awarded this grant for the state of Ohio.

S16 Healthy Ohio Healthy Ohio is a program managed by the Ohio Department of Health (ODH) to improve the health of all Ohioans by creating a better quality of life, assuring a more productive workforce and equipping students for learning about their health, while increasing the efficiency and cost‐effectiveness of medical services.

http://healthyohioprogram.org/

ODH n/a

S17 State HIE Program Information Notice – July 2010

In July 2010, ONC issued a Program Information Notice (PIN) to recipients of the State Health Information exchange Cooperative Agreement containing additional guidance about the requirements and recommendations for statewide HIEs.

http://statehieresources.org/wp‐content/uploads/2010/07/Program‐Information‐Notice‐to‐

ONC


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States‐for‐HTML_7‐6_1028AM.htm


Revised 11/29/2010 A22

OHIP Environmental Scan V2OHIP Environmental Scan V2OHIP Environmental Scan V2OHIP Environmental Scan V2

Instructions for Completing the Survey

Step 1: Make certain you are the right person to answer the survey. The appropriate survey respondent is the practice manager or someone else

who has knowledge of both clinical operations and health information technology. If you do not think you are the right person to respond, then

please forward the survey link to the correct person and exit the survey. As you take the survey, keep in mind that you are answering the

questions on behalf of your practice/hospital.

Step 2: As you take the survey, you will see PREV and NEXT buttons at the bottom of each page. Press NEXT when you are ready to move to

the next question. If you need to go back and review or change a response, just click on the PREV button. You do not have to complete the

survey all at one time. You can answer some questions, exit the survey, and return to complete the survey at a later time. However, you must

complete the survey on the same computer. In fact, the computer you are using can be used to complete one survey only.

Step 3: When you are finished, click DONE at the end of the survey. Keep in mind that once you do this, you will not be able to re-enter the

survey.

QUESTIONS?

If at any time you have questions or need more definition of terms, please email [email protected].

1. Please identify what type of entity you are:

2. If you are a physician or responding for a medical practice, please indicate your

specialty:

3. Please identify the number of PHYSICIANS that are covered in your response to this

survey:

Instructions

Survey Respondant

6

6

Physician Office

nmlkj

Rural Hospital

nmlkj

Critical Access Hospital

nmlkj

Acute Care Hospital

nmlkj

Hospital Other (please indicate type below)

nmlkj

Behavioral Health Clinic

nmlkj

Federally Qualified Health Center

nmlkj

If Other, please identify

nmlkj

Appendix B - 2010 EHR/HIE Survey Tool

B1

OHIP Environmental Scan V2OHIP Environmental Scan V2OHIP Environmental Scan V2OHIP Environmental Scan V24. Please identify the number of NON-PHYSICIAN PROVIDERS (e.g., PA, NP, or NM) that

are covered in your response to this survey:

5. Please provide the following information about your entity:

6. Please specify your county:

7. Survey responder/survey contact (who is filling out the survey?):

8. Are any of the physicians in your practice/hospital anticipating on applying for

Medicare or Medicaid incentive payments for adopting health information technology?

EHR Section I: General Questions

DEFINITION OF AN EHR: An EHR is an electronic record of health-related information on an individual that conforms to nationally recognized

interoperability standards and that can be created, managed, and consulted by authorized clinicians and staff across more than one health

care organization.

6

Name/Organization

National Provider Identifier (either individual or Type 2

for groups)

Address

City

Zip Code

Business Affiliation w/ Another Organization

6

Best Method to Contact You

Name

Title

Email Address

Phone Number

Medicare and Medicaid Incentive Payments

Electronic Health Record (EHR) Questions

Yes - Medicare

nmlkj

Yes - Medicaid

nmlkj

Yes - But not sure whether applying for Medicare or Medicaid

nmlkj

No

nmlkj

Not Sure

nmlkj


B2

OHIP Environmental Scan V2OHIP Environmental Scan V2OHIP Environmental Scan V2OHIP Environmental Scan V29. Which statement best describes your entity's EHR system?

EHR Section 2: Please Identify Your EHR System

The drop-down list below contains a list of CCHIT certified EHR system. The list contains the some of the most prevalent systems across the

state, but does not contain all certified systems.

10. Please select your entity's EHR system from the drop-down list below:

EHR Section 3: CCHIT Certified EHRs

This page addresses CCHIT CERTIFIED EHRs.

11. What year did your entity COMPLETE installation of your current EHR system?

EHR Section 4: Non-CCHIT Certified EHRs


6



We do not have a practice management or EHR system

nmlkj

We are using a practice management system but no clinical EHR component

nmlkj

We have purchased/begun installation of an EHR but are not yet using the system

nmlkj

We have an EHR installed and in use for some of our clinical staff and providers

nmlkj

We have an EHR installed and in all (more than 90%) areas of our practice/clinic

nmlkj

We have used an EHR system in the past, but chose to discontinue its use

nmlkj

Name of CCHIT ceritified EHR not in list

2005 or earlier

nmlkj

2006

nmlkj

2007

nmlkj

2008

nmlkj

2009

nmlkj

2010

nmlkj

Installation in progress

nmlkj


B3

OHIP Environmental Scan V2OHIP Environmental Scan V2OHIP Environmental Scan V2OHIP Environmental Scan V2This page addresses EHR systems that are not certified by CCHIT and those not found in the drop-down list from the previous section.

12. What is the name of the main EHR system your entity uses?

13. What is the version of your entity's EHR system?

14. Does your EHR system have the ability to track and record...

EHR Section 5: EHR Use Information

DEFINITIONS

Clinical Staff: Any employee who performs medical duties including nurses, LPNs, physical therapists, etc.

Providers: Physicians, physician assistants, nurse midwives, and nurse practitioners

15. What is the estimated percentage of STAFF currently using your EHR system

routinely?

Yes No Not Sure

providers associated with a patient encounter? nmlkj nmlkj nmlkj

clinical documentation and notes (i.e., progress notes)? nmlkj nmlkj nmlkj

ordered and pending labs? nmlkj nmlkj nmlkj

ordered and pending diagnostic test results (e.g., mammography or other screening tests)? nmlkj nmlkj nmlkj

provider orders (including referrals)? nmlkj nmlkj nmlkj

external documents (e.g., advanced directives or history and physicals)? nmlkj nmlkj nmlkj


We use paper charts only

nmlkj

Less than 25% of all staff

nmlkj

25-50% of all staff

nmlkj

51-90% of all staff

nmlkj

Greater than 90% of all staff

nmlkj

Not Sure

nmlkj


B4

OHIP Environmental Scan V2OHIP Environmental Scan V2OHIP Environmental Scan V2OHIP Environmental Scan V216. What is the estimated percentage of PROVIDERS (physicians and other providers)

currently using your EHR sytem routinely?

17. Which phrase best describes your entity's use of paper charts for patient

information tracking?

HIE Section I: General Questions

18. Does your entity use a primary information exchange network to exchange clinical

data between your EHR and other providers, hospitals, payors, etc., such as a hospital-

based network, university-based network or regional health information organization

(RHIO) and what type of arrangement is it? (select all that apply)

Health Information Exchange (HIE) Questions

We use only paper charts

nmlkj

Less than 25% of all staff

nmlkj

25-50% of all staff

nmlkj

51-90% of all staff

nmlkj

Greater than 90% of all staff

nmlkj

Not Sure

nmlkj

We do not maintain paper charts - we are entirely paperless

nmlkj

We maintain paper charts, but the EHR is the most accurate and complete source of patient information

nmlkj

We document all patient data in both paper charts and the EHR system

nmlkj

We primarily use paper charts, but maintain electronic records for come clinical information

nmlkj

Not sure

nmlkj

Yes - We exchange clinical data using a hospital-based network

nmlkj

Yes - We exchange clinical data using a university-based network

nmlkj

Yes - We exchange clinical data through a regional Health Information Organization (e.g., HealthBridge, CCHIE, OneCommunity)

nmlkj

Yes - We use a third party vendor or clearinghouse exchange service (i.e., RxHub)

nmlkj

No - We DO NOT exchange clinical data

nmlkj

Not Sure

nmlkj

If Yes, please specify the name of the network or entity who operates the network


B5

OHIP Environmental Scan V2OHIP Environmental Scan V2OHIP Environmental Scan V2OHIP Environmental Scan V219. What are your largest challenges related to secure information exchange with

outside organizations? (select all that apply)

HIE Section 2: Electronic Prescribing (ePrescribing)

Definition

ePrescribing: Based upon the definition provided by HHS through ARRA/HITECH grants, ePrescribing includes drug-to-drug checking,

electronic routing of prescriptions to a Pharmacy, and the inclusion of formulary information for cost decisions.

20. Does your entity use ePrescribing for a majority of prescriptions?

HIE Section 2: Electronic Prescriptions [ePrescribing] (continued)

21. What EHR system or software does your entity use to ePrescribe?

22. Is this software certified by the Ohio Board of Pharmacy?



Unclear value on investment (VOI) or return on investment (ROI)

gfedc

Subscription rates for exchange services are too high

gfedc

Competing priorities

gfedc

Access to technical support or expertise

gfedc

Lack of integration with EHR

gfedc

Insufficient information on options available

gfedc

HIPAA, privacy or legal concerns

gfedc

Other (please specify)

gfedc

Yes

nmlkj

No

nmlkj

Not Sure

nmlkj

Yes

nmlkj

No

nmlkj

Not Sure

nmlkj


B6

OHIP Environmental Scan V2OHIP Environmental Scan V2OHIP Environmental Scan V2OHIP Environmental Scan V2

HIE Section 3: Electronic Lab Results

23. Do you electronically receive or send LAB RESULTS?

HIE Section 3: Electronic Lab Results (continued)

24. What exchange format is used to exchange LAB RESULTS?

HIE Section 4: Electronic Lab Orders

25. Do you electronically send LAB ORDERS?





Send

nmlkj

Receive

nmlkj

Both

nmlkj

Neither

nmlkj

Not Sure

nmlkj

If Yes, what health information network is used?

Direct integration w/ EHR system

nmlkj

Lab Vendor Web Portal

nmlkj

Health Information Exchange Web Portal

nmlkj

Email

nmlkj

Fax

nmlkj

Yes

nmlkj

No

nmlkj

Not Sure

nmlkj



B7

OHIP Environmental Scan V2OHIP Environmental Scan V2OHIP Environmental Scan V2OHIP Environmental Scan V2HIE Section 4: Electronic Lab Orders (continued)

26. What is used to exchange LAB ORDERS?

HIE Section 5: Eligibility and Claims Submission

27. Does your entity routinely check insurance ELIGIBILITY electronically?

HIE Section 5: Eligibility and Claims Submission (continued)

28. What is used to verify ELIGIBILITY INFORMATION?




nmlkj

Web Portal

nmlkj

Email

nmlkj

Fax

nmlkj

Yes - For 80% or more of patients

nmlkj

Yes - For fewer than 80% of patients

nmlkj

No - We do not have this function or it is turned off

nmlkj

Not Sure

nmlkj

If applicable, please identify the clearinghouse or billing service used.


nmlkj

Web Portal

nmlkj

Email

nmlkj

Fax

nmlkj


B8

OHIP Environmental Scan V2OHIP Environmental Scan V2OHIP Environmental Scan V2OHIP Environmental Scan V229. Does your entity routinely file CLAIMS electronically for patients?

HIE Section 6: Clinical Summary Records and Patient Reminders

30. Does your entity exchange CLINICAL SUMMARY RECORDS?

HIE Section 6: Clinical Summary Records and Patient Reminders (continued)

31. What exchange format is used to exchange CLINICAL SUMMARY RECORDS?

HIE Section 8: Immunization Data




Yes - For 80% or more of patients

nmlkj

Yes - For fewer than 80% of patients

nmlkj

No - We do not have this function or it is turned off

nmlkj

Not Sure

nmlkj

If applicable, please identify the clearinghouse, billing service or software used.

Yes

nmlkj

No

nmlkj

Not Sure

nmlkj



nmlkj

Unstructured textual document

nmlkj

Web Portal

nmlkj

Email

nmlkj

Fax

nmlkj


B9

OHIP Environmental Scan V2OHIP Environmental Scan V2OHIP Environmental Scan V2OHIP Environmental Scan V232. Does your entity transmit IMMUNIZATION DATA?

HIE Section 8: Immunization Data (continued)

33. What format is used to transmit IMMUNIZATION DATA?

HIE Section 9: Reportable Lab Results

34. For public health reporting, does your entity transmit REPORTABLE LAB RESULTS

electronically?

HIE Section 9: Reportable Lab Results (continued)




Yes

nmlkj

No

nmlkj

Not Sure

nmlkj



nmlkj

Web Portal

nmlkj

Email

nmlkj

Fax

nmlkj

Paper

nmlkj

Yes

nmlkj

No

nmlkj

Not Sure

nmlkj



B10

OHIP Environmental Scan V2OHIP Environmental Scan V2OHIP Environmental Scan V2OHIP Environmental Scan V235. What is used to transmit REPORTABLE LAB RESULTS?

36. Are there other services (not listed) that you either are doing in a health information

exchange or would like to do (e.g., electronic referrals, disease registry submissions,

etc.)? Please specify:

Thank you for taking the time to fill out this survey. Your assistance is appreciated!

End

55

66


nmlkj

Web Portal

nmlkj

Email

nmlkj

Fax

nmlkj


B11

Northeast Central Ohio Regional Extension Center (NECO REC) Marianne Lorini Akron Regional Hospital Association 3200 West Market St., Ste. 200 Akron, OH 44333 330-873-1500 [email protected]

Northeast Central Ohio Regional Extension Center (NECO REC) Kathy Dellinger Akron Regional Hospital Association 3200 West Market St., Ste. 200 Akron, OH 44333 330.873.1500 [email protected]

Case Western Reserve University (CWRU) Joseph Peter Case Western Reserve University 10900 Euclid Ave, BRB109 Cleveland, OH 44106-4961 216-368-5756 [email protected]

Case Western Reserve University (CWRU) Julie Rehm Case Western Reserve University 10900 Euclid Ave BRB 109 Cleveland, OH 44106-4961 216-368-6070 [email protected]

Central Ohio Health Information Exchange (COHIE) Matthew Esker COHIE 155 E. Broad St. 23rd Floor Columbus, OH 43215 614-358-2710 [email protected]

Central Ohio Health Information Exchange (COHIE) Michael Krouse OhioHealth 755 Thomas Ln Columbus, OH 43214 614-566-4484 [email protected]

Dayton West Central Ohio Regional Extension Center (DWCO REC) Bryan Beer Greater Dayton Area Hospital Association 2 Riverplace Dr Ste 400 Dayton, OH 45405 937-424-2361 [email protected]

Dayton West Central Ohio Regional Extension Center (DWCO REC) Marty Larson CCHIE 1150 E Home Rd Springfield, OH 45503-2726 937.271.2343 [email protected]

Northwest Ohio Regional Extension Center (NOREC) Jan Ruma Hospital Council of NWOhio 3231 Central Park West #200 Toledo, OH 43617 419-842-0800 [email protected]

Northwest Ohio Regional Extension Center (NOREC) W Scott Fry 419.842.0800 [email protected]

Northeast Ohio Health Connect (NEOHC) Gina Pastella NEOHF 141 Boardman-Canfield Rd Boardman, OH 44512 330-965-1787 x 7143 [email protected]

Northeast Ohio Health Connect (NEOHC) Mike Seiser Humility of Mary Health Partners 250 Federal Plaza E, 2nd Floor Youngstown, OH 44503 330-884-6616 [email protected]

Ohio University Appalachian Health Information Exchange (OU) Shane Gilkey Ohio University 105 Research & Technology Bldg Athens, OH 45701 740.593.0378

Ohio University Appalachian Health Information Exchange (OU) Brian Phillips Ohio University College of Osteopathic Medicine 383 Building 20 Athens, OH 45701 740-593-2170

Appendix C - OHIP Regional Partners

C1

Regional Extension Center: Request for Proposal For EHR Comprehensive Products

OHIP

4/16/2010

The Ohio Health Information Partnership (OHIP) is seeking responses regarding electronic health record (EHR) ambulatory systems that can be used in physician and other health care provider office settings.

Appendix D - EHR Request for Proposal (RFP)

D1

Table of Contents

I. Summary ............................................................................................................... 3 II. Dates and Schedule of Events .............................................................................. 3 III. RFP Instructions .................................................................................................... 3

a. Hyperlinks and Electronic Attachments .............................................................. 4 b. Questions ........................................................................................................ 4

IV. Background ........................................................................................................... 4 V. Reference Documents ........................................................................................... 5 VI. General Terms and Conditions .............................................................................. 5

Appendix A: Request for Proposal for HER Comprehensive Products .................. 7 I. Organizational Information .................................................................................... 7 II. Name and Version # of Product ............................................................................ 8 III. Ohio Installations ................................................................................................... 8 IV. Interfaces ............................................................................................................... 8 V. Financial Information ............................................................................................. 9 VI. Minimum Requirements ............................................................................................ 9 VII. Meaningful Use Criteria ....................................................................................... 10 VIII. Pricing ........................................................................................................... 13

a. Cost Estimate ................................................................................................... 14 IX. Financial Options ................................................................................................. 15 X. Client References ................................................................................................ 15

Appendix B: Contract Terms and Conditions .......................................................... 16 I. Products .............................................................................................................. 16 II. Fees .................................................................................................................... 16 III. Implementation .................................................................................................... 18 IV. Equipment ........................................................................................................... 20 V. Warranties ........................................................................................................... 20 VI. Third Party Products ............................................................................................ 22 VII. Support ................................................................................................................ 22 VIII. Confidentiality ............................................................................................... 24 IX. Term/Termination ................................................................................................ 24 X. General ................................................................................................................ 25

Appendix C: Preferred Vendor Agreement .............................................................. 28 1. Responsibilities and Warranties of Vendor .......................................................... 28 2. Role of OHIP ....................................................................................................... 30 3. Administrative Fee ............................................................................................... 31 4. Confidentiality ...................................................................................................... 31 5. Limitation of Liability, Insurance and Indemnification .......................................... 32 6. Term and Termination ......................................................................................... 33 7. General Provisions .............................................................................................. 33

Appendix D: Regional Partners and Geographic Distribution of Regions ............ 35 I. Regional Partners ................................................................................................ 35 II. Geographic Distribution Map by County .............................................................. 37


D2

I. Summary The Ohio Health Information Partnership (OHIP) is seeking responses regarding electronic health record (EHR) ambulatory systems that can be used in physician and other health care provider office settings. This Request for Proposal (RFP) addresses OHIP’s mission to advance the adoption, implementation and meaningful use of health IT among health care providers to improve the safety, quality, accessibility, availability and efficiency of health care for the citizens of Ohio. As the state-designated entity for Ohio’s statewide health information exchange, OHIP is seeking vendors whose products are capable of bringing providers to meaningful use in a cost efficient and effective manner. It is OHIP’s intent to contract with a number of vendors that can be designated as high quality and reasonable cost vendors to act as the front line for electronic health record adoption in Ohio. OHIP views the selection of these vendors as part of the overall process in Ohio to create an effective electronic health records system. That system will be accessible to both the individual and to his or her physician, hospital and other health care providers. To assist EHR vendors in providing IT support to their clients in this state, Ohio is moving ahead quickly to establish IT educational certification programs linked to recognized vendor products. The first IT support personnel certified by Ohio’s community colleges and universities should be available for hiring by early fall, 2010. It is the hope that such educational programs will allow the vendors, OHIP and OHIP’s regional partners to provide in-depth support for products selected as OHIP’s recognized vendor solutions. As a part of the qualifying process, respondents may be asked to provide a demonstration of their proposed solutions.

II. Dates and Schedule of Events Responses must be submitted electronically to OHIP on or before 5:00 PM ET, May 17, 2010.

Event Date OHIP releases RFP April 16, 2010 Vendor questions due by close of business April 23, 2010 Vendor RFP responses due by close of business May 17, 2010 Notification of RFP awards May 31, 2010

III. RFP Instructions Appendix A contains the general RFP information which must be submitted. Appendix B is a list of proposed terms and conditions to be included in the vendor/provider contracts for any preferred OHIP EHR vendors. Vendors are asked to review these terms and conditions and, if acceptable or acceptable with modification, reference them to the vendor’s current provider contract terms. Appendix C is a Preferred Vendor Agreement to be executed between vendor and OHIP. All three Appendices must be completed for a vendor to be considered in the RFP process. Appendix D is a list of OHIP’s regional partners and their geographic territories so vendors will be aware of what entities will be providing support for EHR assessment, installation and service.


D3

Please note the following when submitting your RFP response:

Responders must submit information in a Word document to [email protected] and are encouraged to review all reference documents before submission.

Responses are saved based on the e-mail address of the responder. If you need to collaborate with colleagues before submission, use Appendix A of this document to collect and organize responses in advance.

Responses and all related attachments should not exceed a total of 50 pages. Verification of receipt of your submitted RFP will be emailed to your RFP contact within two

business days of receipt.

a. Hyperlinks and Electronic Attachments If hyperlinks or other electronic documents are to be provided, please include the links and/or

name of the documents in the response under the question to which they pertain. To email electronic document attachments, please email them to [email protected] and

place “OHIP EHR RFP Response Attachment” in the subject line.

b. Questions If you have questions regarding the RFP, please email them to [email protected] and

place “OHIP EHR RFP Question” in the subject line. Answers to questions will be made available to all vendors through OHIP’s website at

http://ohiponline.org/ehr_rfp_faqs.aspx. Questions must be submitted by close of business on April 23, 2010. We ask that you keep your questions brief and specific to the RFP.

IV. Background OHIP is a newly formed non-profit organization whose initial board members include representatives from BioOhio, the State of Ohio, the Ohio State Medical Association, the Ohio Osteopathic Association and the Ohio Hospital Association. OHIP’s board has been expanded to include representation from the business community, consumers, payers, behavioral health providers, hospitals, physician providers and Federally Qualified Health Centers (FQHCs). In September 2009, OHIP was designated by the State of Ohio as the authorized non-profit entity to submit an application for the American Recovery and Reinvestment Act (ARRA) State Grant to Promote Health Information Technology Planning and Implementation. At that time, OHIP decided also to submit a bid for the development of a statewide regional extension center (REC) to support the provider adoption of EHR. In November 2009, OHIP submitted the application (FOA # EP-HIT-09-003) to serve as the statewide Regional Extension Center (REC) under the ARRA Health Information Technology Extension Program. On February 8, 2010, OHIP was notified of its award (Grant Award No. 90RC0012/01) as a statewide REC with overlapping responsibilities for the 11 Ohio counties also covered by HealthBridge in its REC award. OHIP’s model for providing REC services includes partnering with regional entities (“Regional Partners”) around the state to provide many of the services necessary for successfully implementing EHR in a meaningful way. The services that will be provided by both OHIP and the Regional Partners are listed in the REC Project Abstract and Narrative. On March 9, 2010, OHIP designated 7 such groups to be regional entities. These regional partners are listed in Appendix D along with a map of the regions.


D4

http://ohiponline.org/ehr_rfp_faqs.aspx

This RFP is being issued to enhance the role that OHIP and its regional partners can play in bringing physicians and other providers to meaningful use of electronic health records.

V. Reference Documents It is recommended that responders review the following documents or websites before submitting RFP responses:

Document Location OHIP REC Project Abstract and Narrative http://ohiponline.org/ohip.hierfi.rec.abstract.narrativ

e.pdf OHIP Regional REC Partners Appendix D OHIP Main Website (News) http://www.ohiponline.org/ Ohio Health Care Coverage and Quality Council Website

http://www.healthcarereform.ohio.gov

VI. General Terms and Conditions

1. This RFP process is solely for OHIP’s benefit and is only intended to provide information to OHIP. The issuance of this RFP does not imply an offer to do business with any respondent. The RFP is designed to provide respondents with the information necessary for the preparation of informative responses.

2. OHIP reserves the right not to review or otherwise to reject, in whole or in part and at any time, any or all responses received in response to this RFP. Issuance of the RFP in no way constitutes a commitment by OHIP to award any contract for the goods and services described in the RFP.

3. OHIP is subject to strict accountability and reporting requirements as a recipient of funds from public sources. Any response or other information submitted by a respondent to OHIP is subject to disclosure by OHIP as required by law, including but not limited to, the American Recovery and Reinvestment Act of 2009 (Public Law 111-5). OHIP makes no agreements or representations of any kind, and expressly disclaims any requirement to maintain the confidentiality of any information provided by respondent in response to this RFP. All material and information provided to OHIP in response to this RFP shall upon receipt become the property of OHIP and will not be returned.

4. By submitting a response, the respondent agrees that OHIP may copy the response for purposes of facilitating OHIP’s review or use of the information. The respondent represents that such copying will not violate any copyright, license or other agreement with respect to the materials submitted.

5. Ohio has laws which restrict the gifts which may be given or received by state employees and require certain individuals to disclose information concerning their activities with state government. By submission of a response, respondent certifies that respondent has not paid or agreed to pay to any employee, official or current contracting consultant of OHIP any fee, commission or any other thing of value that is in any way contingent upon OHIP contracting with respondent.

6. OHIP reserves the right to modify this RFP at any time. OHIP reserves the right to contact respondents after the submission of responses for the purpose of clarifying any response. Respondent understands that any and all information provided in response to the RFP is subject to validation. By submitting a response each respondent agrees that it will not bring any claim or have any cause of action against OHIP, or any agent of OHIP or the State of Ohio, based on any


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misunderstanding concerning the information provided in the RFP or concerning OHIP’s failure, negligent or otherwise, to provide the respondent with pertinent information as intended by this RFP.

7. OHIP is not responsible for any costs incurred by a respondent which are related to the preparation or delivery of the response or any other activities of respondent related to this RFP.

8. The laws of the State of Ohio and the United States of America shall apply to and govern the interpretation, validity and effect of this RFP. OHIP contractors and subcontractors may be subject to federal or state laws or regulations applicable to recipients of funds from public sources. Respondents are responsible for determining the applicability of these laws to their activities and for complying with applicable requirements.

9. OHIP will not be responding to phone or email inquiries about the selection process or identifying vendors still under consideration, or releasing information about the proposals or results until contracts for the EHR RFP have been awarded, and OHIP determines, in its sole discretion, that the release of such information will not unduly prejudice this or future RFP processes.


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Appendix A: Request for Proposal for EHR Comprehensive Products

I. Organizational Information

Company Information Company Name Address Phone Number Company Web Site Company Contacts Business Contact Name Title Phone Number eMail Address Technical Contact Name Title Phone Number eMail Address Structure of Business EHR employees (Total) Within Ohio: Outside of Ohio:

# of EHR employees in sales and marketing Within Ohio: Outside of Ohio: # of EHR employees in product development Within Ohio: Outside of Ohio: # of EHR employees in implementation/ training

Within Ohio: Outside of Ohio:

# of EHR employees in product support Within Ohio: Outside of Ohio: # of EHR employees in administrative roles Within Ohio: Outside of Ohio:

Installations # of new EHR installations over the last 3 years Within Ohio: Outside of Ohio: # of new EHR users over last three years Within Ohio: Outside of Ohio:

# EHR installations by practice size Small (1-4 physicians):

Medium (5-9 physicians)

Large (10+ physicians):

Total # of Ohio installations Small (1-4 physicians):



Total # of Ohio users Small (1-4 physicians):



Total # of EHR installations nationally Small (1-4 physicians):



Resource Availability # of state EHR installation initiatives (other than the Ohio REC) in which the vendor is participating or has submitted a proposal


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II. Name and Version # of Product The name and version number of the product that is the subject of this RFP. NOTE: Separate RFPs must be completed for each product requested for consideration.

Name of Product Version Number

III. Ohio Installations

Type of Organization List Two (2) Organizations in Each Category

Product and Modules Installed (EHR, CPOE, eRX, CDS, Other)

Tertiary Hospitals Community Health Centers Large Group Practices (10+ Physicians

Small/Solo Practices (< 10 Physicians)

Behavioral Health Facilities

IV. Interfaces List all EHR products (generally) or Health Information Exchanges (HIEs) specifically within Ohio to which this version of your product successfully interfaces:

EHR Product or HIE Location in Ohio with Established Interface


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V. Financial Information

Financial Information for FY 07, 08 and 09 Total Annual Revenue (by year):

Revenue from EHR products or services:

EHR Revenue per EHR employee: % of EHR Revenue spent on R&D:

Revenue from other products or services Cash: Net Income: Net Margin %: Total Assets: Total Liabilities:

CAGR - Compound Annual Growth Rate FTE Growth (annual, previous FY) Publicly traded: Yes / No Symbol: Private: Yes / No Investors: Ownership structure ( specify who is the owner and what is the % ownership)

Do you currently send aggregated de-identified data to anyone?

VI. Minimum Requirements In order to qualify to participate in the selection process, an EHR vendor must meet a minimum set of requirements. The following narrative describes the minimum set of vendor and system capabilities a potential vendor must possess to be considered. Specify if you meet the requirement and if you do not meet a specific requirement please indicate your plans and timetable to meet it.

1. CCHIT 2011 certification or at least:

a. Preliminary ARRA 2011 Certification (modular certification limited to security, privacy and interoperability)

b. If not CCHIT 2011 or Preliminary ARRA 2011 certified please specify your expected timeframe

c. CCHIT 2008 or 2009 outpatient certified

2. Must use the following EHR standards: ICD9/10, LOINC, CPT, HCPCS, SNOWMED-CT, and nationally available medication terminology

3. Interoperability with state of Ohio HIE, as developed by OHIP.

4. Generates as well as accepts HL7 Continuity of Care Documents as structured data (not images)

5. Compliance with meaningful use criteria, as specified below.

6. Compliance with HIPAA Privacy and Security Rules and other regulatory requirements [The Joint Commission (TJC), Center for Medicare and Medicaid Services (CMS), NHIN protocols, Ohio Board of Pharmacy e-prescribing and other applicable requirements and other state and local laws]


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7. Compliance with fair data sharing practices set forth in the Nationwide Privacy and Security Framework

8. Role-based access controls

9. Ability to flag or otherwise identify sensitive diagnosis by ICD-9, CPT-4 or other codes (give timeline for software upgrade for ICD-10 or plans for adoption).

10. Ability to track and report 2011 Meaningful Use quality metrics.

11. Ability to configure security features (such as password policy, lockouts, timeouts, etc.).

12. Must provide a complete solution covering all of the following system functions: EHR, Practice Management (including scheduling), Billing, Clinical Decision Support, Patient Portal, e-Prescribing, Laboratory Interfaces. Partnering with a vendor offering any of this functionality which may not be part of the core EHR is permissible.

13. System in-use by 300+ providers nationwide.

14. Local support office in Ohio or willingness to establish a local presence in Ohio to assist in the EHR implementation efforts of regional REC partners.

15. If selected as an OHIP vendor, must supply a formal training plan with estimated time table that supports timely implementation of EHR products.

16. Must guarantee Go-Live dates, and must agree to compensate providers for failure to meet such guarantee.

17. Vendor must agree to establish a reasonable price for ongoing support at a rate that will encourage continued use of an EHR system.

VII. Meaningful Use Criteria Although the definition of “meaningful use,” as specified in the rule proposed on January 13, 2010 by the Office of the National Coordinator (ONC) of the HHS, is subject to change in the final rule, the categories are spelled out. This RFP is designed to establish the ability of EHR systems to meet the 2011 provider objectives and the 2011 ambulatory measures in the meaningful use rule. If the proposed rule is modified before the RFP awards, vendors will be given the opportunity to comment on their ability to meet the updated definition.

Comment briefly on your system’s ability to meet the following criteria:

I. System Capabilities for Providers to Meet Stage 1 of Meaningful Use

a. Ability to support CPOE (requires computer-based entry by providers of orders (meds, lab, procedure, diagnostic imaging, immunization, referral) but electronic interfaces to receiving entities not required in 2011

b. Ability to support drug-drug, drug-allergy, drug-formulary checks

c. Ability to support maintenance of up-to-date problem list of current and active diagnoses based on ICD-9 or SNOMED

d. Ability to generate and transmit permissible prescriptions electronically (eRX)

e. Ability to support maintenance of active medication list

f. Ability to record demographics including: preferred language, insurance type, gender, race and ethnicity

g. Ability to record vital signs including: height, weight, BP

h. Ability to record smoking status


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i. Ability to calculate and display both adult and pediatric BMI

j. Ability to incorporate lab-test results into EHR as structured data

k. Ability to generate lists of patients by specific condition to use for quality improvement, reduction of disparities and outreach

l. Ability to report ambulatory quality measures to CMS

m. Ability to send reminders to patients per patient preference for preventive/follow up care

n. Support the implementation of five clinical decision support rules relevant to specialty or high clinical priority

o. Ability to check insurance eligibility electronically from public and private payers

p. Ability to submit claims electronically to public and private payers

q. Ability to provide patients with an electronic copy of their health information (including diagnostic test results, problem list, medication lists, allergies) upon request

r. Ability to provide clinical summaries for patients for each office visit

s. Ability to exchange key clinical information (e.g., problem list, medication list, allergies, diagnostic test results) among providers of care and patient authorized entities electronically (HIE capability and demonstrated exchange to be further specified by HIE WG of HIT Policy Committee)

t. Ability to perform medication reconciliation at relevant encounters and each transition of care

u. Ability to submit electronic data to immunization registries and actual submission where required and accepted

v. Ability to provide electronic syndromic surveillance data to public health agencies and actual transmission according to applicable law and practice

w. Ability to protect electronic health information created or maintained by the certified EHR technology through the implementation of appropriate technical capabilities

II. 2011 Measures

Report the following quality measures to an outside entity (electronic interfaces to receiving entities not required in 2011)

a. % diabetics with A1c under control

b. % of patients with LDL under control

c. % of patients screened for tobacco use

d. % of smokers who received advice to quit smoking

e. % of patients with a calculated BMI index

f. % of patients receiving asthma assessment

g. % of patients with recorded blood pressure

h. Use of high-risk medications (Re: Beers criteria) in the elderly

i. % of patients over 50 with annual colorectal cancer screening

j. % of females over 40 receiving mammogram within 24 months

k. % of females 18 – 64 years receiving PAP test for cervical cancer screening within 24 months


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l. % of patients at high-risk for cardiac events on aspirin prophylaxis

m. % of patients over 50 who received an influenza immunization during the flu season

n. % of children aged 3 months to 18 years with URI who were not prescribed or dispensed an antibiotic prescription within 3 days of initial visit

o. % of children aged 2 years to 18 years with a diagnosis of pharyngitis who were prescribed an antibiotic and received a strep test

p. % of patients with low back pain who received imaging studies within 28 days of onset

q. % of adults assessed for drug and alcohol dependence

r. % of orders (for medications, lab test, procedures, radiology and referrals) entered directly by physicians through CPOE

s. % of lab results incorporated into EHR in coded format

t. % of all medications entered into EHR as generic, options exist in the relevant drug class

u. % of orders for high cost imaging services with specific structured indications recorded

v. % claims submitted electronically to all payers

w. % patient encounters with insurance eligibility confirmed

x. % of all patients with access to personal health information electronically

y. % of all patients with access to patient-specific educational resources

z. % of encounters for which clinical summaries were provided

aa. % of encounters where medication reconciliation was performed

bb. % of transitions in care for which summary care record is shared (i.e., electronic, paper, e-Fax)

Stratify reports by gender, insurance type, primary language, race and ethnicity Implemented ability to exchange health information with external clinical entity (specifically labs, care summary and medication lists) Report up-to-date status for childhood immunizations Conduct or update a security risk assessment and implement security updates as necessary


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VIII. Pricing The estimated cost of the EHR solution will be an important factor in determining which vendors will participate in the program. Pricing should be comprehensive and include all hardware, software and services associated with a comprehensive EHR solution. Estimated costs should closely reflect the total implementation costs, including:

Server hardware / software. The vendor must supply or recommend/price a server (or ASP/SaaS) that is configured to support the practice’s patient population and proposed number of users. The server specification must include minimum and recommended hardware configurations, operating system software versions and appropriate tools or utility software to manage/maintain the server environment. The vendor must also provide the growth assumptions that would trigger the need to upgrade or replace the proposed server.

Network infrastructure. The vendor must supply or recommend/price the hardware and software necessary to establish the local area network over which the workstations will communicate with the server and necessary security infrastructure.

Client hardware /software. The vendor must supply hardware recommendations/pricing for physician and administrative staff workstations, including minimum and recommended hardware configurations, and operating system software and versions. In addition, the vendor must supply recommendations/pricing for other desktop devices (e.g., printers, scanners) required by the application and appropriate to offices of these sizes.

Telecommunications/Connectivity services. The vendor must identify and price the telecommunications or broadband connectivity services required to access any external services and support remote access to the EHR solution.

Application software. The vendor must identify and price the EHR software application including all of the modules and components necessary to achieve the EHR functionality described in other sections of the proposal.

Third party software. The vendor must identify and price any third party software, dictionaries, databases or services required to achieve the EHR functionality described in other sections of the proposal.

Implementation. The vendor must estimate the cost and number of days of consulting, project management, training and other professional services necessary to successfully install the EHR solution in the physician practice. The vendor must also specify the cost of additional professional services if requested by the practice.

Interfaces. The vendor must detail the price to develop and implement each of the required interfaces.

Product maintenance and support. The vendor must specify the price of the product maintenance and technical support services described in the proposal. If maintenance and support are priced separately, please make note of that.

Data conversion. The vendor should estimate the cost and number of days of assistance that will be required to convert key data from the practice’s paper charts. If the practice is converting from a different EHR system, the vendor should estimate the cost to convert data to the vendor’s system.

o Vendors must provide a complete cost estimate for the proposed EHR solution for each proposed practice size. Use the attached chart to list any costs related to installation. Theoretical practice sizes are listed below.


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Proposed Size Large Practice Medium Practice Small Practice

Physician Users 10 5 1

Physician Extenders 15 10 2

Exam Rooms 20 10 2

Patients 20,000 10,000 2,000

Workstations 45 (or 25, plus 10 mobile devices)

25 (or 15, plus 5 mobile devices)

5 (or 3, plus 1 mobile device)

a. Cost Estimate

Practice Size Large Practice Medium Practice Small Practice

Hardware (vendor provided or through 3rd party)

Core software

Optional software

3rd Party Software

Interfaces

Network

Basic services

Additional optional services

First year maintenance and support

Please describe the items included in each category (The table below includes some examples in each category. Complete the list of items included in each).

Hardware Core software

Optional software

3rd Party Software Interfaces Network Basic

services Additional services

First year maintenan

ce and support

Server EMR

License eRx

3rd party software license if

any

Lab Router EHR install

EHR training

Laptop PMS

License

Transcription

PMS install


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IX. Financial Options

The availability of reasonable financing options for providers is a key component to widespread EHR adoption. Please describe financing options that the vendor will make available to providers for either a client- server or SaaS model. Please comment in your response on the following options:

1. Vendor letter of credit with a financial institution for a physician loan guarantee program covering multiple installations. Such program is being established with the assistance of the state of Ohio.

2. Vendor guarantees of individual practice loans from financial institutions for installation of that vendor’s EHR product and related costs.

3. Other Vendor financing options that defer payment of equipment, license, service, support, annual, subscription and any other fees, until the provider achieves meaningful use and begins receiving Medicare or Medicaid incentive payments.

X. Client References Please supply a minimum of three (3) client references. If possible, the client list should encompass different market segments. Organization Name:

Contact Name & Title:

Contact Telephone:

Product(s) Installed:

Organization Name:


Contact Telephone:


Organization Name:


Contact Telephone:


Organization Name:


Contact Telephone:



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Appendix B: Contract Terms and Conditions As part of the process of selecting preferred EHR vendors (“Vendors”) for Ohio providers, OHIP is requesting Vendors to address selected contractual terms and conditions. Completion of this Attachment is required for consideration of the Vendor in the RFP process. Blank or negative responses may result in elimination of the Vendor from further consideration. The Vendor is required to attach a contract template modified to reflect the terminology the Vendor proposes in its response to this Appendix. The terms and conditions the Vendor proposes must be inserted word for word in the response to each of the questions in this Appendix, and cross-referenced to the Vendor’s contract template. OHIP will score the Vendor’s responses based on the wording the Vendor offers. OHIP will assign the highest score if the Vendor accepts OHIP’s provision without modification, no credit if the Vendor refuses to concede anything, and varying credit if the Vendor modifies the provision. Please respond to each question below by circling one of the following designations, and indicate where in the Vendor’s contract template this provision appears:

A = Accept with No material changes

M = Propose modifications in any manner; include proposed language

D = Decline to Accept

I. Products 1.1 Any equipment, software including any and all third party software and any interfaces (collectively “Software”), and other products and services, which are required to achieve effective system functionality and performance, shall be identified by Vendor in a product/cost spreadsheet to be attached to and incorporated in the agreement. Any additional equipment, software, products and services not so specified, but later deemed necessary by the Vendor, shall be provided by the Vendor to Provider at no charge.

_A_ _M_ _D_ 1.2 Unless specifically indicated in the product/cost spreadsheet, Software and other products shall not have a limit on the number of users or concurrent users. _A_ _M_ _D_ 1.,3 The Vendor agrees to provide Provider updated documentation to the equipment, Software and other products, as the same are updated. _A_ _M_ _D_

II. Fees 2.1 All fees shall be identified in the product/cost spreadsheet by line item for each item of equipment, Software, other product or service. _A_ _M_ _D_


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2.2 Payment terms must be tied to the achievement of milestones rather than to the passage of time or specific dates, assuming there is no delay caused by the Provider when it is in the reasonable control of the Provider. Payment terms for Software license and implementation fees will be as follows for each Software module: a. ____% down upon agreement execution; _A_ _M_ _D_ b. ____% upon installation of product on Provider hardware and completion of training and pre-Live Status acceptance testing, as defined in Section 3.13 of this Appendix C; _A_ _M_ _D_ c. ____% upon “Live Status” operations (e.g. systems integration and actual processing of live data); _A_ _M_ _D_ d. ___% upon Acceptance, which shall be defined as the system operating in accordance with the warranties set forth in the agreement and without material error for a period of at least forty-five (45) continuous days. Acceptance shall not occur prior to the first successful month-end reporting process. _A_ _M_ _D_ 2.3 Payment terms for remotely hosted products shall be fifty percent (50%) upon the Provider’s certification of achievement of meaningful use, and fifty percent (50%) due sixty (60) days thereafter. _A_ _M_ _D_ 2.4 Vendor agrees to offer Provider financing options to extend payment for equipment, Software and other products and services until the Provider achieves meaningful use, and to have payment tied to Provider’s receipt of Medicare or Medicaid EHR incentive payments. _A_ _M_ _D_ 2.5 Payment for support and maintenance services shall begin on Acceptance of product, and may be deferred until the Provider achieves meaningful use. _A_ _M_ _D_ 2.6 Any increases in fees, including without limitation license fees, annual fees, hosting fees, support fees, implementation fees and service fees, shall be limited on an annual basis to the lesser of 3% or the percentage change in the Consumer Price Index All Items/Urban Consumers (CPI) for the preceding twelve (12) month period. Vendor agrees there will be no increases in fees during the first 36 months after execution of the agreement. _A_ _M_ _D_ 2.7 “Additional Services” shall not include any implementation services required to install the system. Vendor shall identify any Additional Services in advance to Provider. Charges for Additional Services shall be agreed upon in advance and shall not be assessed without the Provider’s written approval. _A_ _M_ _D_


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2.8 The words “then current rates” or any equivalent terminology shall be deleted from the agreement and replaced with a schedule of the Vendor rates with annual increases capped by the lesser of 3% or CPI. _A_ _M_ _D_ 2.9 There will be no interface fees amongst the Vendor’s own products. The only interface fees that can be charged are the interface fees identified in the product/cost spreadsheet for interfaces to non-Vendor products. _A_ _M_ _D_ 2.10 Interest and late fees may not be imposed on overdue payments except in the case of undisputed charges, which are more than 45 days overdue. The interest rate may not exceed 10% per year. The Provider will not be responsible for the payment of the Vendor’s collection fees, including without limitation attorney’s fees. _A_ _M_ _D_ 2.11 Additional purchases of equipment, software and other products by Provider shall be at the same discounted percentage reflected in the prices on the product/cost spreadsheet. _A_ _M_ _D_ 2.12 The fees quoted will include all interfaces and Vendor services required for the Provider to achieve meaningful use in accordance with federal regulatory standards. _A_ _M_ _D_ 2.13 The fees for customizations shall be reasonable, fixed in amount, and set in advance by mutual agreement of the Provider and Vendor. _A_ _M_ _D_

III. Implementation 3.1 An Implementation Work Plan encompassing all products shall be attached to the agreement which shall identify: (i) detailed tasks; (ii) responsibilities of Provider and Vendor for each task; (iii) timeline/schedules for each task; and (iv) assumptions. _A_ _M_ _D_ 3.2 The implementation services shall address the migration and conversion of existing Provider data to the Vendor’s system, and shall clearly define what data or records will be converted, the cost for conversion, any additional equipment or software requirements needed for the conversion, and the timeline for conversion. _A_ _M_ _D_ 3.3 The implementation services shall include all necessary training to allow the Provider to use the system for the Provider electronic health record and other functions. _A_ _M_ _D_


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3.4 The implementation fees quoted shall be fixed and inclusive of all fees, charges and expenses (including without limitation travel and out-of-pocket expenses), provided that the Provider does not modify the Implementation Work Plan in a manner that increases Vendor’s costs. _A_ _M_ _D_ 3.5 Any changes in implementation services and fees must follow a written change order procedure. All additional services and the fees for additional services must be approved in writing in advance by Provider. _A_ _M_ _D_ 3.6 The Vendor will provide a guaranteed Live Status date for each Software module as part of the Implementation Plan, which shall not exceed eight (8) months after agreement execution. If delays in the Live Status date occur due to the Vendor’s fault or system error, Provider will receive a credit equal to 1% of total implementation fees for each day of delay. If the system has not been accepted as the result of Vendor delay or system error within ninety (90) days after the date scheduled for Live Status in the Implementation Work Plan, Provider may return all items of the system without further obligation to Vendor and shall receive a full refund of all amounts paid to Vendor. _A_ _M_ _D_ 3.7 Vendor shall provide qualified personnel in adequate numbers to maintain the scheduled timeline for each task, as designated in the Implementation Work Plan. _A_ _M_ _D_ 3.8 Provider shall have the right to review the qualifications and references of all implementation staff assigned to Provider’s installation. Provider may refuse the services of any personnel Provider deems to be of insufficient experience. _A_ _M_ _D_ 3.9 Vendor personnel assigned to the implementation shall remain with the project through Acceptance, unless Provider requests replacement or the assigned personnel leaves Vendor’s employment. _A_ _M_ _D_ 3.10 Vendor’s Project Manager shall have at least three (3) successful prior implementations of the proposed system/products as a Project Manager at customer sites comparable to Provider’s site. _A_ _M_ _D_ 3.11 Vendor’s implementation personnel assigned to install Ohio Providers shall work from Vendor offices located in Ohio. _A_ _M_ _D_ 3.12 Vendor will permit Provider to delay implementation of equipment, Software or other products for a period of up to 12 months, provided Provider gives Vendor 60 days advance written notice. _A_ _M_ _D_ 3.13 The parties shall agree upon Acceptance testing standards for each product and the system as a whole, and Vendor shall provide for both a pre-Live Status and post-Live Status product and system


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Acceptance testing periods of not less than 60 days each. Pre-Live Status Acceptance testing shall confirm that each item of equipment, Software and other products has been installed and is functioning in accordance with the warranties of the agreement and without material error. Post-Live Status Acceptance testing shall confirm that each item of equipment, Software and other products is functioning on an integrated basis with the system in accordance with the warranties of the agreement and without material error. _A_ _M_ _D_ 3.14 Vendor shall correct and resolve any and all demonstrated errors or malfunctions of the equipment, Software and other products as part of the implementation services. Acceptance of the system shall not occur until Vendor has resolved all material problems and defects. _A_ _M_ _D_

IV. Equipment 4.1 Hardware and other equipment purchased from or through Vendor shall be new, and not used or refurbished, unless Provider specifically consents to the purchase of used equipment. A reasonable price discount shall be allotted for used equipment. _A_ _M_ _D_ 4.2 Upon payment of the purchase price, Vendor shall deliver to Provider clean title to the equipment free and clear of liens and encumbrances. _A_ _M_ _D_ 4.3 The Provider shall be permitted to purchase any equipment meeting specifications of the Vendor from a third party supplier if the cost is less than that offered by the Vendor for the same equipment. If equipment is purchased from a third party supplier, all response time warranties will apply so long as Provider purchases the equipment recommended by Vendor. _A_ _M_ _D_ 4.4 The Provider shall be permitted to update equipment without incurring additional license, use or support fees. _A_ _M_ _D_

V. Warranties 5.1 The Vendor warrants that it has good title to and the right to license or sell each Software module, item of equipment and other product listed in the product/cost spreadsheet. _A_ _M_ _D_ 5.2 The Vendor warrants that each Software module, item of equipment, and other product shall be free from defect in design and workmanship and shall operate in accordance with the Vendor’s specifications and documentation, which were provided during Provider’s system selection process and attached to the agreement as an exhibit, and in accordance with the Vendor’s written responses to any Provider request for proposal.


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_A_ _M_ _D_ 5.3 The Vendor warrants system response time for 99% of transactions to be less than two (2) seconds for screen to screen and field to field transactions, and less than three (3) seconds for database queries, measured over a two (2) hour period and assuming no concurrent report writing functions. For each Software module, if response times fall below the guaranteed standards, the Vendor will purchase and install at no charge to the Provider the necessary equipment and software to achieve this performance level for the period commencing upon the date of agreement execution through twenty-four (24) months after Live Status. _A_ _M_ _D_ 5.4 The Vendor warrants that the system, Software and other products shall be available for Provider’s use a minimum of ninety-nine percent (99%) of the time as measured over a 24-hour period. In the event that system, Software or product availability falls below 99% due to a Vendor or system problem, Vendor shall provide Provider a credit in the amount of three percent (3%) of total monthly system support and maintenance fees for each failure to meet the system availability warranty. _A_ _M_ _D_ 5.5 The Vendor warrants that the Software, equipment and other products shall comply with, and permit Provider to comply with, all applicable local, state and federal laws and regulations including without limitation the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”) security and privacy rules and the Health Information Technology for Economic and Clinical Health Act (“HITECH”) meaningful use rules, the Ohio Board of Pharmacy rules, and with the standards of any applicable accreditation organization. _A_ _M_ _D_ 5.6 The Vendor warrants that any electronic health record Software will be certified as of August 1, 2010, and remain certified during the term of the agreement, as qualifying EHR technology, within the meaning of HITECH, by the certification agency designated by the United States Department of Health and Human Services. _A_ _M_ _D_ 5.7 The Vendor warrants that the Software and other products shall be free from all viruses and worms and shall not contain disabling devices, to disrupt Provider’s use of the system, disable Provider’s information systems, or compromise the integrity or availability of Provider data. _A_ _M_ _D_ 5.8 The Vendor warrants that all services shall be performed by competent personnel in a professional manner and in compliance with local, state and federal laws and regulations. _A_ _M_ _D_ 5.9 The Vendor warrants that the Software modules, equipment and other products will be compatible, and operate in an integrated manner, with other system components, including operating system and application Software, hardware and any existing Provider software to be interfaced with an existing Provider network hardware and software. _A_ _M_ _D_


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5.10 The Vendor warrants that all interfaces with third-party software shall be HL7 and TCP/IP compliant, and that Vendor has achieved interface in practices or facilities similar to Provider with the third party software in use or to be in use by Provider. _A_ _M_ _D_ 5.11 The Vendor warrants that any enhancements or upgrades to the Software and/or system will be compatible with the Provider’s version of the Software and/or system. _A_ _M_ _D_ 5.12 The Vendor of a remotely hosted system warrants the security of its system and of Provider data, which security shall include the following safeguards: (i) data encryption technologies for both transmission and storage; (ii) appropriate firewalls to block viruses; (iii) appropriate physical safeguards for the data center where the server is located; and (iv) twice daily backup of Provider’s data with offsite storage. _A_ _M_ _D_ 5.13 The Vendor warrants that it will not “sunset” support and enhancement for, or remove any functionality being used by Provider from, any of the Software or other products acquired pursuant to the agreement within seven (7) years from the date of agreement execution. _A_ _M_ _D_

VI. Third Party Products 6.1 The Vendor will attach to the agreement any third party terms and conditions applicable to Provider. The Vendor agrees that Provider will not be obligated to provide indemnity or to undertake any other financial obligation by such third party terms and conditions unless Provider specifically consents in writing to such obligation. _A_ _M_ _D_ 6.2 The Vendor shall act as first point of contact in resolving any disputes between Provider and any Third-Party Vendor at no charge to Provider. _A_ _M_ _D_

VII. Support 7.1 Vendor agrees to offer Software, equipment and other product support and maintenance to Provider for a minimum of seven (7) years, during which period Provider may terminate such support and maintenance after the expiration of the first year upon sixty (60) days notice to Vendor. _A_ _M_ _D_ 7.2 Vendor agrees that the system shall continue to meet the performance warranties and standards of the agreement during any period for which Provider purchases support and maintenance from Vendor. _A_ _M_ _D_


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7.3 Vendor agrees that support and maintenance services shall include without additional charge (i) all updates, releases, new versions and enhancements to the Software and other products; (ii) telephone consultation; (iii) telephonic or electronic response by qualified personnel to problems and issues reported by Provider within two (2) hours of receiving the Provider’s contact; (iv) resolution within 24 hours of Provider contact of critical errors causing the system or major functionality to be down or compromising the integrity or availability of Provider data; (v) resolution of major errors and malfunctions for which a workaround exists within two (2) business days of Provider contact; and (vi) correction of minor errors that do not impact system functionality within 30 days of Provider contact. _A_ _M_ _D_ 7.4 Vendor agrees to offer support and maintenance services for the system at rates that are reasonable and designed to encourage continued use by providers. _A_ _M_ _D_ 7.5 Vendor agrees to provide Provider a credit equivalent to one day’s fees for support and maintenance for the affected equipment, Software or other products for each day that an error continues beyond the times reflected in the resolution standards set forth above. _A_ _M_ _D_ 7.6 Vendor agrees that Provider shall not be responsible for the payment of travel and other out-of-pocket expense associated with the resolution of errors and failure of the equipment, Software or other products to operate as warranted. _A_ _M_ _D_ 7.7 Vendor agrees to update and otherwise modify the Software and other products as may be required to permit Provider to comply with applicable local, state and federal laws and regulations, including without limitation HIPAA privacy and security regulations, HITECH meaningful use regulations, and Ohio Board of Pharmacy rules. Such updates or modifications shall be provided in a timely manner to permit Provider to comply with the regulations’ time frames. Vendor agrees to provide such regulatory updates and modifications to Provider at no charge beyond the agreed upon support fees. _A_ _M_ _D_ 7.8 Any future releases of new software or other products replacing those being purchased by Provider in the agreement shall be made available to Provider at no charge, including license fees and installation fees, for seven (7) years after agreement execution. Annual support fees for such releases shall not exceed those of the existing product being replaced. _A_ _M_ _D_ 7.9 Vendor agrees to provide maintenance and support for each Software module or other product’s current version and one previous version. Vendor agrees to allow Provider a minimum of 12 months to install any updates or new releases. _A_ _M_ _D_ 7.10 In the event that Vendor makes any changes to its platform or infrastructure, whether in hardware, operating system or database, within three (3) years post Live Status for the entire system, all fees related to the new platform or infrastructure, including license, implementation, conversion and out-of-pocket expenses will be borne by Vendor. Any associated support fees will be provided to Provider at the level that existed prior to the changes.


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_A_ _M_ _D_ 7.11 The Vendor agrees that support personnel servicing Providers in Ohio shall be based at Vendor offices located within the State of Ohio. _A_ _M_ _D_

VIII. Confidentiality 8.1 The Vendor agrees that it will not, at any time during the term of the agreement or any time thereafter, use for any purpose other than performance of its obligations to Provider, or disclose to any person, firm, or corporation, any confidential or proprietary information of Provider without Provider’s prior written consent. Confidential and proprietary information shall include: (i) all patient and practitioner information and records; (ii) financial data; (iii) charges, rates and other billing information; (iv) clinical outcomes and quality information; and (v) employee and personnel information. _A_ _M_ _D_ 8.2 The Vendor will execute the Provider’s HIPAA Business Associate Agreement, which shall be attached to and incorporated into the agreement, prior to Vendor accessing any patient information. _A_ _M_ _D_ 8.3 The Vendor agrees to follow Provider’s information systems security policies including those governing remote access, firewalls, and security codes. _A_ _M_ _D_ 8.4 The Vendor agrees that the Provider owns the Provider’s records and data, and that Provider shall have the irrevocable right to access Provider’s data and records during the term and after the termination of this Agreement, without additional cost to Provider. Under no circumstance shall Vendor withhold Provider access to Provider records. _A_ _M_ _D_ 8.5 For remotely hosted systems, the Vendor agrees that (i) the Vendor’s data storage policies shall be consistent with the Provider’s record retention policies; and (ii) the Vendor shall provide the Provider upon request a HIPAA-compliant back-up log. _A_ _M_ _D_

IX. Term/Termination 9.1 The term for licensed Software shall be perpetual. _A_ _M_ _D_ 9.2 The Provider shall have the right to terminate any annual license and support obligation after the expiration of the first year upon sixty (60) days notice to Vendor. _A_ _M_ _D_


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9.3 The agreement may be terminated for breach. Failure by either party to comply with any material term or condition of the agreement shall constitute a breach. The non-breaching party shall be entitled to give written notice to the breaching party. If the breaching party does not cure the breach within 30 days after receipt of the notice, the non-breaching party may terminate the agreement by giving written notice. The right to terminate is in addition to any other rights and remedies provided under the agreement or otherwise under law. _A_ _M_ _D_ 9.4 The Provider may terminate the agreement immediately in the event of Vendor’s exclusion, suspension, debarment or other ineligibility to participate in federal health care programs as defined in 42 USC 1320a-7b(f). _A_ _M_ _D_ 9.5 Upon termination of the agreement, Vendor agrees to assist Provider in an orderly transition to another vendor or system, during which transition period Provider shall have access to Provider’s data and Vendor’s systems and services. _A_ _M_ _D_ 9.6 Upon termination of this Agreement, Vendor promptly shall make available to Provider in electronic copy and usable format, as reasonably requested by Provider, all Provider data and records in Vendor’s possession. _A_ _M_ _D_ 9.7 Vendor shall not impose a termination fee or other liquidated damages upon Provider as the result of termination of the agreement. _A_ _M_ _D_

X. General 10.1 The agreement shall be governed by the laws of the State of Ohio. Any disputes arising under the agreement shall be brought exclusively in the federal or state courts located within the Ohio County in which the Provider is located. The parties consent to the jurisdiction and venue of such courts and waive any objections thereto. _A_ _M_ _D_ 10.2 Any disputes between the parties that cannot be resolved within thirty (30) days shall be resolved by the use of an informal resolution/escalation process defined by the Provider and the Vendor in the agreement. _A_ _M_ _D_ 10.3 Any disputes between the Vendor and Provider that cannot be resolved within thirty (30) days by the process defined above, may be submitted by agreement of the parties to arbitration to be conducted by the American Health Lawyers Association pursuant to its Dispute Resolution Rules in the Ohio County in which the Provider is located. Arbitration shall not apply to disputes involving injunctive or class action relief. _A_ _M_ _D_


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10.4 Vendor shall escrow with an independent escrow agent the source code for all versions, releases, and updates of the Software together with appropriate updated documentation and installation instructions at no additional charge to Provider. _A_ _M_ _D_ 10.5 Vendor shall not require Provider to defend, hold harmless or indemnify the Vendor or any other person or entity. _A_ _M_ _D_ 10.6 Vendor shall defend, indemnify and hold harmless the Provider from and against all claims, liabilities, damages and expenses related to the infringement of third party rights by the Software, equipment and other products acquired from Vendor. In the event that Provider’s use of the Software, equipment or any other product is enjoined, Vendor shall arrange for Provider to use such Software, equipment or product, or provide comparable non-infringing Software, equipment or products, or refund to Provider all sums paid by Provider to Vendor for the acquisition and installation of the Software, equipment or product. _A_ _M_ _D_ 10.7 Neither party shall assign the agreement or any right or obligation under the agreement without the written consent of the other party, provided that consent shall not be required in the case of assignment to a successor in interest to substantially all of the party’s assets. Provider may outsource Provider’s data processing operations to a third party organization without incurring any additional license or other fees pursuant to the agreement. _A_ _M_ _D_ 10.8 Vendor agrees that documents will not be incorporated by reference into the agreement unless made available to and approved by the Provider prior to the agreement execution. The Provider shall not be bound by any terms and conditions not set forth in the agreement. _A_ _M_ _D_ 10.9 Vendor agrees that any limitations or disclaimers of liability shall be mutual, shall not be less in amount than twice the total amount paid by the Provider under the agreement, and shall not apply to limit or disclaim: (i) Vendor’s defense and indemnity obligations for infringement; (ii) damages resulting from the unauthorized use or disclosure of confidential information, including without limitation breach of the HIPAA Business Associates Agreement; (iii) damages resulting from either party’s knowing violation of federal or state laws or regulations; and (iv) personal injury or property damages resulting from either party’s gross negligence or reckless conduct. _A_ _M_ _D_ 10.10 Vendor agrees that to the extent Section 952 of the Omnibus Reconciliation Act of 1980 (Public Law 96-499) is found applicable to the agreement, until the expiration of four (4) years after the furnishing of services pursuant to the agreement, Vendor shall make available, upon written request by the Secretary of the United States Department of Health and Human Services, the Comptroller General of the United States, or to any of their duly authorized representatives, the agreement and the books, documents, and records of Vendor that are necessary to certify the extent of any costs of Provider arising from the agreement. Further, if Vendor carries out any of its duties arising from the agreement through a subcontract, the value or cost of which is Ten Thousand Dollars ($10,000.00) or more over a twelve (12) month period, with a related organization, such subcontract will contain a clause to the effect and until the expiration of the four (4) years after furnishing of such service pursuant to such subcontract, that the


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related organization will make available upon written request to the Secretary of the United States Department of Health and Human Services, the Comptroller General of the United States, or any of their duly authorized representatives, the subcontracts, books, documents, and records of such organization that are necessary to verify the nature and extent of such costs. _A_ _M_ _D_ 10.11 Vendor agrees to represent and warrant that there are no suits, claims, investigations, or other proceedings pending or threatened, which might adversely affect its ability to perform its responsibilities under the agreement. Vendor further agrees to warrant that neither Vendor nor any of its principals, owners, officers, or employees have been excluded, suspended, debarred, or otherwise rendered ineligible to perform services to providers in federal or state health care plans. Vendor agrees to acknowledge that Provider has made available to Vendor information about the federal false claims act and federal administrative remedies law for false claims and statements, and any related civil or criminal Ohio laws and the Provider's policies and procedures for detecting and preventing fraud. Vendor agrees to abide by such Provider's policies and procedures as to the items and services Vendor provides pursuant to this Agreement and to make such policies and procedures available to Vendor's employees involved in performing such services. _A_ _M_ _D_


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Appendix C: Preferred Vendor Agreement This Preferred Vendor Agreement (the “Agreement”) is made as of _________, 2010 (the “Effective Date”), by and between Ohio Health Information Partnership (“OHIP”), an Ohio non-profit corporation located at 1275 Kinnear Road, Columbus, Ohio 43212, and ___________________________, a ___________ corporation located at _______________________________ (“Vendor”). Vendor is engaged in the business of developing, licensing/providing, implementing and supporting electronic health records technology and products. OHIP has been designated by the State of Ohio as the authorized entity to lead the implementation and support of health information technology throughout Ohio. OHIP also has been awarded the Regional Extension Center (REC) grant for the State of Ohio (with 11 Ohio counties overlapping with the HealthBridge REC) under the American Recovery and Reinvestment Act of 2009 Health Information Technology Extension Program. (Award No. 90RC0012/01) In its role as a REC, OHIP and its regional partners will assist physicians and other health care providers in achieving meaningful use of electronic health records. The parties desire to enter into this Agreement to promote the meaningful use of electronic health records. NOW THEREFORE, the parties agree as follows.

1. Responsibilities and Warranties of Vendor

1.1 Vendor-Physician Contracts. Vendor agrees to deliver, implement and support the products and services (“Vendor System”) identified in Vendor’s responses to OHIP’s REC Request for Proposal for EHR Comprehensive Products (“RFP”) in accordance with the terms and conditions of this Agreement and Vendor’s responses to the RFP.

1.2 Vendor Warranties. Vendor will warrant:

1.2.1 good title to and the right to license or sell each module or item of the Vendor System;

1.2.2 each module or item of the Vendor System shall be free from defect in design

and workmanship and shall operate in accordance with the Vendor’s specifications and documentation, and in accordance with the Vendor’s written responses to any Provider request for proposal;

1.2.3 Vendor System response time for 99% of transactions will be less than two (2)

seconds for screen-to-screen and field-to-field transactions, and less than three (3) seconds for database queries, measured over a two (2) hour period and assuming no concurrent report writing functions. For each Software module, if response times fall below the guaranteed standards, the Vendor will purchase and install at no charge to the provider the necessary equipment and software to achieve this performance level for the period commencing upon the date of agreement execution through twenty-four (24) months after Live Status for the Vendor System;

1.2.4 the Vendor System shall be available for use a minimum of ninety-nine percent

(99%) of the time as measured over a 24-hour period. In the event that Vendor System availability falls below 99% due to a Vendor or Vendor System problem, Vendor shall provide the provider a credit in the amount of three percent (3%) of total monthly system support and maintenance fees for each failure to meet the system availability warranty;

1.2.5 the Vendor System shall comply with, and permit the provider to comply with, all

applicable local, state and federal laws and regulations including without limitation the Health


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Insurance Portability and Accountability Act of 1996 (“HIPAA”) security and privacy rules, the Health Information Technology for Economic and Clinical Health Act (“HITECH”) meaningful use rules, the Ohio Board of Pharmacy rules, and the standards of any applicable accreditation organization;

1.2.6 any electronic health record component(s) of the Vendor System will be certified

as of August 1, 2010, and remain certified during the term of the agreement, as qualifying EHR technology, within the meaning of HITECH, by the certification agency designated by the United States Department of Health and Human Services;

1.2.7 the Vendor System shall be free from all viruses and worms and shall not contain

disabling devices to disrupt the provider’s use of the system, disable provider’s information systems, or compromise the integrity or availability of provider data;

1.2.8 all services shall be performed by competent personnel in a professional manner

and in compliance with local, state and federal laws and regulations; 1.2.9 the Vendor System will be compatible, and operate in an integrated manner, with

other system components, including operating system and application software, hardware and any existing provider software to be interfaced with an existing provider network hardware and software;

1.2.10 all interfaces with third-party software shall be HL7 and TCP/IP compliant, and

Vendor has achieved interface in physician practices or facilities similar to Provider with the third party software in use or to be in use by the provider;

1.2.11 any enhancements or upgrades to the Vendor System and/or system will be

compatible with the provider’s version of the Vendor System; 1.2.12 for remotely hosted systems, Vendor will assure the security of the Vendor

System and of provider data, which security shall include the following safeguards: (i) data encryption technologies for both transmission and storage; (ii) appropriate firewalls to block viruses; (iii) appropriate physical safeguards for the data center where the server is located; and (iv) twice daily backup of the provider’s data with offsite storage;

1.2.13 Vendor will not “sunset” support and enhancement for, or remove any

functionality being used by the provider from, the Vendor System within seven (7) years from the date of agreement execution;

1.2.14 neither Vendor nor its officers, owners or employees performing services on

behalf of providers is or will be excluded, suspended, debarred or otherwise rendered ineligible to participate in federal health care plans, as defined in 42 USC 1320a-7b(f), or otherwise receive payment from funding under any federal grant or program.

1.3 Dedicated Installation Staff. Vendor agrees to dedicate qualified personnel in sufficient

numbers to guarantee that priority primary care physicians (“PPCPs”) go live on the Vendor System within no more than eight (8) months following execution of the applicable license or service agreement. “Priority primary care physicians” shall mean allopathic and osteopathic physicians who are family physicians, general internal medicine physicians, pediatricians or OB-GYNs, practicing in public or critical access hospitals, federal qualified health centers, rural health clinics, or other settings for predominantly uninsured, underinsured or medically underserved populations. Vendor will reimburse the PPCP for the amount of any meaningful use incentive payments which are lost as the result of Vendor’s failure to install the Vendor System in a timely manner.

1.4 Commitment to Ohio Employment. Vendor agrees that implementation and support

services for the Vendor System will be provided predominantly by personnel located in the State of Ohio.


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1.5 Vendor Pricing. Vendor agrees that quoted prices will include the price for a

comprehensive system including without limitation all interfaces and that payment terms with PPCPs shall be tied to the achievement of performance milestones, and shall permit PPCPs to defer payment until the PPCP’s certification of achievement of meaningful use. Vendor further agrees that price increases for ongoing services and support shall not exceed on an annual basis the lesser of three percent (3%) or the change in the CPI-U.

1.6 Vendor System Support. Vendor agrees to support the Vendor System installed for a

minimum of seven (7) years, and that support shall encompass all updates required to permit use of Vendor System in accordance with applicable federal and state laws and regulations, including without limitation the HIPAA, HITECH and Ohio Board of Pharmacy rules.

1.7 Financing Options. Vendor agrees to participate in PPCP financing options, including:

1.7.1 Vendor-issued letter of credit with a financial institution for a loan guarantee

program covering multiple Vendor installations, such program to be established with the assistance of the Ohio Treasury Department “linked deposit” program;

1.7.2 Vendor guarantee of individual PPCP loans with financial institutions; 1.7.3 Other Vendor financing options that defer payment of equipment, license,

service, support, subscription and other fees, until the provider achieves meaningful use and begins receiving Medicare or Medicaid incentive payments. 1.8. Infringement Indemnity. Vendor will defend and indemnity providers from and against

any and all damages, liabilities, costs or expenses (including without limitation reasonable attorneys’ fees) arising from any claims of infringement in relation to the Vendor System. 1.9 Source Code Escrow. Vendor will escrow with an independent escrow agent the source code for all versions, releases and updates of the software of the Vendor System.

2. Role of OHIP

2.1 Vendor Promotion. OHIP will identify Vendor to PPCPs in Ohio as a preferred vendor of the OHIP REC program and promote Vendor’s EHR System among providers in Ohio. If requested by Vendor, OHIP or OHIP’s regional partners in the OHIP REC program will provide commercially reasonable efforts to assist Vendor in finalizing the execution of provider contracts with PPCPs.

2.2 PPCP Identification. OHIP and OHIP’s regional partners shall identify PPCPs as

potential customers of Vendor System by providing Vendor contact information. 2.3 First Line of Support. OHIP’s regional partners shall serve as a first line of support for

PPCPs with regard to mutually agreed-to non-critical support issues, as identified by Vendor and the regional partner.

2.4 State Law Changes. OHIP and OHIP’s regional partners will assist Vendor in identifying new Ohio laws and regulations, or changes to Ohio laws and regulations, applicable to the Vendor System and providers’ use of the Vendor System.


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3. Administrative Fee In consideration for the marketing and support services provided by OHIP and its regional partners, Vendor agrees to pay OHIP an administrative fee in the amount of three percent (3%) of the fees collected by Vendor for the Vendor System, including without limitation all Vendor’s products and services provided to PPCPs in Ohio during the first five (5) years following the execution of each PPCP contract. Administrative fees shall be paid on a monthly basis within thirty (30) days of Vendor’s receipt of payment from or on behalf of the PPCP or any institution financing payment for the PPCP. Vendor agrees to allow OHIP or its designee reasonable access to Vendor’s business records to confirm the calculation and payment of administrative fees. This provision shall survive the termination of this Agreement.

4. Confidentiality

4.1 Definition. Each party acknowledges that in the course of performing under this Agreement, it may learn confidential, trade secret, or proprietary information concerning the other party or third parties to whom the other party has an obligation of confidentiality (“Confidential Information”). Without limiting the foregoing, Vendor’s Confidential Information shall include non-public information about Vendor’s business, products or customers; reports generated by or for Vendor; databases and methods of database creation; software tools for report creation; distribution and retrieval; and associated algorithms, tools, programs, software architecture, and technology. Without limiting the foregoing, OHIP’s Confidential Information shall include non-public information regarding OHIP’s services, products, contracts, finances, business and customers, and pricing; reports generated by or for OHIP; databases and methods of database creation; health data reporting, analysis, and profiling methods and formats; systems for report creation, distribution and retrieval; and associated algorithms, tools, programs, software, and technology.

4.2 Confidentiality Obligations. Each party agrees that (a) it will use such information only as may be necessary in the course of performing duties, receiving services or exercising rights under this Agreement, (b) it will treat such information as confidential and proprietary, (c) it will not disclose such information orally or in writing to any third party without the prior written consent of the other party, (d) it will take all reasonable precautions to protect the Confidential Information, and (e) it will not otherwise appropriate such information to its own use or to the use of any other person or entity. Without limiting the foregoing, each party agrees to take at least such precautions to protect the other party’s confidential and proprietary information as it takes to protect its own confidential and proprietary information. Each party is solely responsible for all use of confidential information by anyone who gains access to the Confidential Information of the other party under such party’s authorization. Upon termination or expiration (without renewal) of this Agreement, each party will return to the other party or certify as destroyed all tangible items containing any of the other party’s proprietary or confidential information which are held by that party or its employees or contractors. Each party agrees to notify the other party if it becomes aware of any unauthorized use or disclosure of the other party’s Confidential Information. Without limiting the foregoing, Vendor and OHIP shall not use the other party’s trademarks for any purpose without express written permission from the other party.

4.3 Disclosure to Governmental Body. If either party believes it is required by law or by a subpoena or court order to disclose any of the other party’s confidential or proprietary information, it shall promptly notify the other party prior to any disclosure and shall make all reasonable efforts to allow the other party an opportunity to seek a protective order or other judicial relief.

4.4 Exceptions. Nothing in this Agreement shall be construed to restrict disclosure or use of information that (a) was in the possession of or rightfully known by the recipient, without an obligation to maintain its confidentiality, prior to receipt from the other party; (b) is or becomes generally known to the


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public without violation of this Agreement; (c) is obtained by the recipient in good faith from a third party having the right to disclose it without an obligation of confidentiality; or (d) is independently developed by the receiving party without the participation of individuals who have had access to the other party’s confidential or proprietary information.

4.5 Patient Information. Each party agrees not to disclose or utilize individual patient or medical claim information in any way that would violate any physician-patient confidence or any state or federal laws or regulations. Each party agrees not to access or use patient information without entering into a HIPAA compliant business associate agreement with the applicable covered entity.

5. Limitation of Liability, Insurance and Indemnification

5.1 Limitation of Damages. Each party’s liability to the other party for direct damages arising out of this Agreement shall not exceed the greater of $1,000,000.00 or the amount of administrative fees paid or to be paid by Vendor to OHIP under this Agreement. Under no circumstances will either party be responsible under this Agreement for any indirect, incidental, special or consequential damages resulting from either party’s performance or failure to perform under this Agreement. The limitations and disclaimers of this Section shall not apply to (i) Vendor’s defense and indemnity obligations pursuant to Section 5.3, (ii) damages resulting from breaches of Article 4, or (iii) personal injury or property damages caused by the gross negligence or reckless conduct of either party or its employees.

5.2 Insurance. For the periods covered by this Agreement, Vendor shall maintain the following types of insurance and shall identify OHIP as an additional insured under each such policy:

5.2.1 Commercial General Liability with minimum limits of liability of $1,000,000.00 per occurrence/$3,000,000.00 aggregate.

5.2.2 Professional Errors & Omissions with minimum limits of liability of $1,000,000.00

per occurrence/$3,000,000.00 aggregate. 5.2.3 Products Liability with minimum limits of liability of $1,000,000.00 per

occurrence/$3,000,000.00 aggregate. 5.2.4 Privacy and Security Liability with minimum limits of liability of $1,000,000.00 per

occurrence/$3,000,000.00 aggregate. In the event that any of the above policies are maintained as claims made coverage and the coverage is cancelled, suspended or otherwise interrupted for any reason, Vendor shall secure an extended reporting endorsement or tail coverage to provide for continuous coverage with limits of liability as set forth above. Vendor shall provide at least thirty (30) days written notice to OHIP if any of the above-mentioned insurance coverage is limited, cancelled, suspended, interrupted or materially altered in any way. Upon request, Vendor shall provide OHIP with certificates evidencing the above-referenced coverage.

5.3 Indemnification. Vendor agrees to defend, hold harmless and indemnify OHIP and OHIP’s regional partners, and their respective officers, directors and employees against and from all third party claims, damages and liabilities arising from Vendor’s products, services, and other acts and omissions of Vendor; provided that OHIP gives Vendor prompt, written notice of any such claim, sole control of the defense and settlement of such claim, and all reasonable assistance to defend such claim. Vendor shall not agree to settle the claim without OHIP’s written consent, provided that such consent is not unreasonably withheld, conditioned or delayed. Vendor shall have no obligations under this paragraph if such claims, damages and liabilities result from OHIP’s breach of this Agreement. This indemnification provision shall survive the termination of this Agreement


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6. Term and Termination

6.1 Term. This Agreement commences as of the Effective Date and, unless earlier terminated as provided in this Agreement, continues for any period during which Vendor continues to provide products and/or services to any PPCP who contracted with Vendor during the REC Program. All sections of this Agreement relating to administrative payments (during the designated five year period), confidentiality, indemnification, insurance, limitations of liability, and governing law/venue shall survive termination or expiration of this Agreement. Upon termination or expiration of this Agreement, each party shall return to the other party all copies of the other party’s products and documentation, within thirty (30) days after termination.

6.2 Breach. If one party breaches any material provision of this Agreement, the non-breaching party may begin the process to terminate this Agreement by giving written notice of termination to the breaching party. If the breach is capable of being cured and is reasonably cured within thirty (30) days after receipt of the notice, the termination shall not become effective. If the breach is not capable of being cured or is not reasonably cured within 30 days after receipt of the notice, the non-breaching party may terminate this Agreement by delivering a second notice to the breaching party, specifying a termination date not later than thirty (30) days after the expiration of the cure period.

6.3 Termination without Cause. OHIP may terminate this Agreement at any time for any

reason upon ninety (90) days prior written notice to the other party.

7. General Provisions

7.1 Entire Agreement. This Agreement constitutes the entire understanding between the parties and supersedes all proposals, communications and agreements between the parties relating to its subject matter. No amendment, change, or waiver of any provision of this Agreement will be binding unless in writing and signed by both parties. In the event one or more of the provisions of this Agreement are found to be invalid, illegal or unenforceable by a court with jurisdiction, the remaining provisions shall continue in full force and effect.

7.2 Compliance. Vendor represents and warrants that there are no suits, claims, investigations, or other proceedings pending or threatened, which might adversely affect its ability to perform its responsibilities under this Agreement. Vendor further warrants that in performing its obligations under this Agreement, Vendor will comply with all applicable laws and regulations.

7.3 Independent Contractors. The parties’ relationship to each other is that of independent contractors. Neither party shall be deemed to be, or hold itself out as, a partner, sales agent, employee or joint venture partner of the other party.

7.4 Limitation on Assignments. Neither party may assign or transfer this Agreement or any of the rights or licenses granted under it, without the prior, written consent of the other party, which shall not be unreasonably withheld, provided, however, that no such consent will be required in connection with either party’s merger, reorganization or consolidation, or sale of all or substantially all of its assets. Except as provided herein, any attempted assignment without such consent shall be void.

7.5 Notices. Any notices of termination relating to this Agreement shall be in writing and will be sent by certified United States mail, postage prepaid, return receipt requested, or by facsimile transmission or overnight courier service, addressed to the party as set forth above, or at a different address as a party has notified the other party in writing.


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7.6 Force Majeure. The obligations of the parties under this Agreement shall be suspended to the extent a party is hindered or prevented from complying therewith because of labor disturbances (including strikes or lockouts), war, acts of God, fires, storms, accidents, governmental regulations, or any other cause whatsoever beyond a party’s control.

7.7 Non-Exclusivity. This Agreement is not an exclusive arrangement between Vendor and OHIP. OHIP in its discretion may contract with other vendors of electronic health records to serve as preferred vendors in OHIP’s REC program.

7.8 Governing Law. Any claim, dispute, or controversy arising out of or relating to this

Agreement shall be governed by and construed under the laws of the State of Ohio. Exclusive venue for any action or legal proceeding arising out of or related to this Agreement shall be in the state and federal courts of Franklin County, Ohio.

7.9 General Representations. Each party represents and warrants that: (i) it is a corporation

or limited liability company organized, existing, and in good standing under the laws of the State of Ohio; (ii) the execution of this Agreement and the performance of its duties and responsibilities hereunder will not violate its articles of organization or operating agreement or any other written agreement to which it is a party, or require the consent or approval of any third person or entity; (iii) to its knowledge, after due inquiry, neither it nor any manager, officer, or member of it has been convicted of any act or omission constituting a felony under the laws of the State of Ohio or constituting Medicare or Medicaid fraud or any other offense or violation under Titles XVIII, XIX, or XX of the Social Security Act, 349 Stat. 620 (1935), as amended, or has been excluded, suspended, debarred or rendered ineligible to participate in federal health care programs as defined in 42 USC 1320a-7b(f); and (iv) the execution and delivery of this Agreement and the performance and satisfaction by it of its duties and responsibilities hereunder will have been duly and validly authorized by all necessary action on the part of it, and this Agreement will constitute a valid and legally binding obligation of it enforceable against it in accordance with its terms.

IN WITNESS WHEREOF, the parties have executed this Agreement as of the date set forth

above. [Vendor] OHIP BY: BY: TITLE:

TITLE:


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Appendix D: Regional Partners and Geographic Distribution of Regions

I. Regional Partners

Name of Regional Lead Partner

Other Partners in the Region Region Adjusted PPCP

Akron Regional Hospital Association

(ARHA)

Austen Bioinnovation Institute, NEOUCOM,

University of Akron, Kent State University, Stark

State Technical College, ITT Institute, Public Health

Departments, Heartland Behavioral Healthcare,

Med Central—Mansfield, Med Central—Shelby,

Samaritan Regional Health System, Lodi Community College, 20+ hospitals,

including Summa, Boardman, and Aultman, Summa Physicians Inc., other Physican Groups

Ashland, Carroll, Harrison,

Holmes, Medina, Portage,

Richland Stark, Summit, Tuscarawas, Wayne

1628 PCP -326 EHR 1302 PCP

873 PPCP

(67%)

Case Western Reserve University (CWRU)

University Hospitals, Cleveland Clinic,

MetroHealth, Sisters of Charity, SW General,

Parma Hospital, Kaiser, VA Medical Center,

Academy of Medicine of Cleveland & Northern Ohio, Better Health

Greater Cleveland, One Community, Care Source, Medical Mutual, Boards of

Health, Dept. of Public Health, Community

Colleges, OSMA, OHA, CVS, Neighborhood

Health Services, ADAMSHS Board, Health Collaborative, Ohio KePro,

MSS Consultants

Ashtabula, Cuyahoga,

Geauga, Lake, Lorain

3291 PCP -658 EHR 2633 PCP

1765 PPCP

(67%)


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Central Ohio Health Information Exchange

(COHIE)

Central Ohio Hospital Council, Access Health Columbus, Central Ohio

Trauma System, Columbus Medical

Association, OSU Medical, Center, OSU Health Plan, OhioHealth, Mt. Carmel

Health System, Nationwide Children’s Hospital,

Central Ohio Primary Care Physicians, OSU

Physicians, Compete Columbus, Medical Group

of Ohio, Columbus Chamber of Commerce

Coshocton, Crawford, Delaware, Fayette,

Franklin, Hardin, Knox, Licking, Logan, Madison,

Marion, Morrow, Pickaway, Union

2522 PCP -504 EHR 2018 PCP

1352 PPCP

(67%)

Greater Dayton Area Health Information Network (GDAHA)

CCHIE, 20+ Hospitals, ADAMHA Boards, Public Health Agencies, Sinclair

Community College Wright State University

Montgomery County Medical Society

Allen, Auglaize, Darke, Mercer,

Miami, Montgomery, Preble, Shelby

1200 PCP -240 EHR 960 PCP

644 PPCP

(67%)

Hospital Council of Northwest Ohio

(HCNWO)

Academy of Medicine of Toledo and Lucas County, 20+ Hospitals, Arrowhead

Behavioral Health, Hospice of Northwest

Ohio, Ohio Academy of Family Physicians

Defiance, Erie, Fulton, Hancock, Henry, Huron, Lucas, Ottawa, Paulding,

Putnam, Sandusky, Seneca,

Van Wert, Williams, Wood, Wyandot

1190 PCP -238 EHR 952 PCP

639 PPCP

(67%)

NEO HealthForce (NEOHF)

4 Hospitals, Forum Health, Community Action Agency

of Columbiana County, Dandridge’s Burgundi Manor, Salem Visiting

Nurse Association, The Inner Office, Burdman Group, Inc., Children’s Center for Science and

Technology, Columbiana County Career and Technical Center,

Columbiana County JFS, East Ohio AHEC, 7

Technical Schools and Community Colleges, Kent

State University, Youngstown State

University, Trumbull County JFS, Youngstown-Warren Regional Chamber

of Commerce

Columbiana, Jefferson,

Mahoning, Trumbull

601PCP -120 EHR 481 PCP

323 PPCP

(67%)


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Ohio University (OU)

7 Hospitals, Coolville Healthcare Clinic, Fairfield Medical Center, Genesis

Healthcare System, Holzer Health Systems, Marietta Healthcare Physicians,

Muskingum Valley Health Centers, Physicians

Business Office, Southern Ohio Medical Center,

University medical Associates

Endocrine/Diabetes Center, Ironton-Lawrence

Community Action

Athens, Belmont, Fairfield, Gallia, Guernsey, Hocking,

Jackson, Lawrence, Meigs, Monroe, Morgan,

Muskingum, Noble, Perry, Pike, Ross, Scioto, Vinton,

Washington

752 PCP -150 EHR 602 PCP

404 PPCP

(67%)

II. Geographic Distribution Map by County

http://ohiponline.org/RECbycounty.pdf


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http://ohiponline.org/RECbycounty.pdf

Ohio Health Information Partnership Health Information Exchange Committee

Organization Name Title

Center for Family Medicine, Akron General Medical Center

Brian Bachelder, MD

Clinical Associate and OHIP Board Member

Cleveland Clinic Joe Turk Director, Information Systems Family Physicians of Urbana John Crankshaw, MD Practicing Physician Galion Community Hospital Andrew Daniels Director of Information Services Holzer Clinic Mark Harvey Chief Information Officer Ohio Department of Health Bob Campbell, PhD Deputy Director,

Center for Public Health Statistics and Informatics

Ohio Department of Insurance Adam Rossbach Policy Analyst Ohio Department of Insurance Margaret Eichner Project Manager (non‐voting

member) Ohio Department of Job and Family Services

Jon Barley, PhD Chief, Bureau of Managed Care

Ohio Health Information Partnership

Andrea Perry Project Manager

Ohio Health Information Partnership

Cathy Sonnhalter REC Implementation Manager

Ohio Hospital Association Dan Paoletti VP, Data Services, OHIP Board Member and HIE Committee Chair

Ohio State University Medical Center

Phyllis Teater Chief Information Officer

OSIS (representing FQHCs) Jeff Lowrance Chief Information Officer and OHIP Board Member

Premier Health Partners Mikki Clancy Chief Information Officer United HealthCare Richard Gajdowski, MD OHIP Board Member Academy Of Medicine Cleveland and Northern Ohio (AMCNO)

Lawrence Kent, MD Practicing Physician

Appendix E - HIE and REC Committee Members

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OHIP REC Committee Roster As of May 3, 2010

Gregg Alexander, DO Madison Pediatrics Inc

Amy Andres Chief of Staff/ODI Board Chair/OHIP

Mary Alice Annecharico CIO University Hospitals

Anthony Bacevice, MD EMH Womens Healthcare Brian Bachelder, MD Akron General Medical Center Bryan Beer Sr. Director, Health Information Technololgy Greater Dayton Area Hospital Association

Elayne R Biddlestone EVP/CEO Academy of Medicine of Cleveland & Northern Ohio

Phil Cass, PhD CEO Columbus Medical Association Mikki Clancy CIO Premier Health Partners

Cathy Costello, JD VP, REC Services OHIP Aly DeAngelo Strategic Planning and Data Analysis Administrator ODI

Rebecca Dunaway Practice Administrator Joint Implant Surgeons

C. Martin Harris, MD CIO Cleveland Clinic

Greg Kall CIO Summa Health System

Bill Kose, MD, JD Blanchard Valley Hospital

Michael Krouse CIO OhioHealth Marianne Lorini President & CEO Akron Regional Hospital Association Jeff Lowrance CEO OSIS Information Systems


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Amanda Lucas Director of Operations Nationwide Childrens Hospital

Brent Mulgrew CEO/Executive Director OSMA Paul Muneio VP, Future Technology ProMedica Health System

Melinda Nugent AHIE Board, Vice Chair, Administrator Marietta Healthcare Physicians Inc Dan Paoletti VP, Data Services OHA Joe Peter Director, Regional Extension Center Strategic Initiatives Case Western Reserve University Julie Rehm, PhD Sr Associate Dean & Associate VP Case Western Reserve University Jan Ruma VP Hospital Council of NW Ohio Ron Savrin, MD Medical Director Ohio KePro Mrunal Shah, MD, ABFM VP, Physician Technology Services, OhioHealth Information Systems Riverside Family Practice Center

Janis Shriver Executive Director North Coast Professional Co Nav Singh, MD Seven Hills Women Health Center

Rob Strohl Director of Health Informatics Central Ohio Primary Care Physicians Jon Wills Executive Director OOA Cathy Sonnhalter REC Implementation Manager OHIP Amy James Admin Asst/Staff Liaison OHIP

Andrea Perry Project Manager OHIP


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Ohio’s Health Care Coverage and Quality Council Health Information Technology Task Force Members

Organization Member Academy of Medicine, Cleveland and Northern Ohio

Elayne Biddlestone

Anthem Barry Malinowski CareSource Bob Gladden Cleveland Clinic Oliver Henkel Collaborating Communities Health Information Exchange (CCHIE)

Marty Larson

Health Policy Institute of Ohio (Former President) Bill Hayes, Chair Isthmus, Ltd. Bill Mitchin KeyPro Ron Savrin National Alliance on Mental Illness Paul Quinn Northeast Ohio Universities College of Medicine Brian Keaton Ohio Department of Health Bob Campbell Ohio Department of Insurance Aly DeAngelo, Staff Ohio Legislative Representative Dave Burke Ohio Medicaid Tracy Plouck Ohio Pharmacists Association Ernie Boyd Ohio State University Medical Center Jerry Friedman Ohio University Brian Phillips OSIS Information Services Jeffrey Lowrance University of Toledo Godfrey Ovwigho

Appendix F - HCCQC Health IT Task Force

F1

Ohio Health Information Partnership Stakeholders Who Submitted Letters of Support

Ohio Hospitals • Adams County Regional Medical Center • Aultman Health Foundation • Barnesville Hospital • Berger Health System • Bucyrus Community Hospital • Catholic Health Partners • Cleveland Clinic • Dunlap Community Hospital • Fairfield Medical • Fulton County Health Center • Genesis Healthcare System • Health Alliance of Greater Cincinnati • Humility of Mary Health Partners (CHP) • Kettering Health Network • Madison County Hospital • Marietta Memorial Hospital • Mary Rutan Hospital • MedCentral Health System • Mercer County Health System • O’Bleness Memorial Hospital • OhioHealth • Ohio State University Medical Center • Pomerene Hospital • Promedica Health System • Salem Community Hospital • Southeastern Medical • St Rita's Hospital (CHP) • Summa Health System • University Hospitals • Wood County Hospital • Wooster Community Hospital

Other Supporting Organizations

• Academy of Medicine of Toledo and Lucas County

• Aetna • American Academy of Medicine of Cleveland

and Northern Ohio • American College of Obstetricians and

Gynecologists • Americare Community Care • Anthem Blue Cross and Blue Shield • Appalachian Health Information Exchange • Board of Regents • Butler County Medical Society • CareSource • CCHIE • Center for Healthy Communities • Columbus Medical Association • HealthBridge • Medical Mutual of Ohio • NEO HealthForce • Ohio Academy of Family Physicians • Ohio Association of Community Health Centers • Ohio Chapter of American College of Pediatrics • Ohio Council of Behavioral Health and Family

Providers • Ohio Hematology Oncology Society • Ohio Hospital Association • Ohio KePRO • Ohio Ophthalmological Society • Ohio Osteopathic Association • Ohio State Medical Association • One Community • Scioto County Medical Society • State of Ohio • Unison Health Plan • United Healthcare

Appendix G - Stakeholders Who Submitted Letters of Support

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Health Information Exchange

Request for Information

Version 1.11 Prepared for OHIP Board Released January 21, 2010 Document Status Final

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Appendix H - HIE Request For Information (RFI)

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SUMMARY:

The Ohio Health Information Partnership (OHIP) is seeking responses regarding the implementation of an interoperable health information exchange (HIE) framework for the State of Ohio. This Request for Information (RFI) addresses OHIP’s mission to advance the adoption, implementation and meaningful use of health IT among health care providers by facilitating and developing a statewide HIE to improve the safety , quality, accessibility, availability and efficiency of health care for citizens of Ohio. As the state-designated entity for Ohio’s statewide health information exchange, OHIP is seeking a full service HIE solution that best fits its goals, objectives, strategies and vision as supported by Ohio Health Care Coverage and Quality Council (OHCCQC) and outlined in the reference documents included in this request. Responses to this RFI will be carefully reviewed and a more detailed Request for Proposal (RFP) will be prepared based on the feedback received. The RFP will be sent to selected, qualified respondents. As a part of the qualifying process, respondents may be asked to provide a demonstration of their proposed solutions. DATES: Responses must be submitted to OHIP on or before 5:00 PM ET, February 11, 2010. SCHEDULE OF EVENTS: Event Date OHIP releases RFI January 21, 2010 Vendor questions due by close of business February 4, 2010 Vendor RFI responses due by close of business February 11, 20101

Notification of acceptance for RFP phase By April 2, 2010 RFI INSTRUCTIONS: Please see Appendix A for a list of the RFI information, which must be submitted. Please note the following when submitting your RFI response:

• Responders must use the OHIP HIE RFI Survey Tool 2to submit information and are encouraged to review all reference documents before submission.

1 OHIP’s RFI response deadline was subsequently extended to March 1, 2010 to provide additional time for vendors to respond.

2 OHIP removed the survey tool link used to gather RFI responses after the RFI respond deadline to prevent vendors from inserting information at a later time.


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http://www.surveymonkey.com/s/OHIP_hie_rfi

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• Responses are saved in the OHIP HIE RFI Survey Tool based on the IP address of the responder. If you need to collaborate with colleagues before submission, use Appendix A of this document to collect and organize responses in advance. However, responses will not be accepted via the Word document.

• Responses and all related attachments should not exceed a total of 50 pages. • A copy of the submitted RFI will be emailed to your RFI contact following verification

of the submission within two business days of receipt. HYPERLINKS AND ELECTRONIC ATTACHMENTS:

• If hyperlinks or other electronic documents are to be provided, please include the links and/or name of the documents in the response under the question to which they pertain.

• To email electronic document attachments, please email them to [email protected] and place “OHIP HIE RFI Response Attachment” in the subject line.

QUESTIONS:

• If you have questions regarding the RFI, please email them to [email protected] and place “OHIP HIE RFI Question” in the subject line.

• Answers to questions will be made available to all vendors through OHIP’s HIE RFI website (http://ohiponline.org/ohip.hierfi.faqs.pdf). Questions must be submitted by close of business on February 4, 2010.

BACKGROUND: In September 2009, OHIP was designated by the State of Ohio as the authorized non-profit entity to submit an application for the American Recovery and Reinvestment Act (ARRA) State Grant to Promote Health Information Technology Planning and Implementation. OHIP is a newly formed non-profit whose initial board members include representatives from BioOhio, the State of Ohio, The Ohio State Medical Association, The Ohio Osteopathic Association and the Ohio Hospital Association. OHIP’s board is being expanded to include representation from the business community, consumers, payers, behavioral health providers, hospitals, physician providers and Federally Qualified Health Centers (FQHCs). In October and November 2009, OHIP completed submission of the above mentioned grant as well as a second grant application to serve as the statewide Regional Extension Center (REC) under the ARRA Health Information Technology Extension Program. Both applications contain project abstracts and narratives which provide a comprehensive description of Ohio’s current state of health IT and proposed statewide strategy for HIE and REC development (see reference documents for more information). It is important for responders to note that OHIP’s strategy for HIE development will be to initially maintain a thin layer of management within OHIP while outsourcing the majority of the HIE operation to a single, full-service solution provider responsible for managing all aspects of the HIE operation. Long-term, OHIP intends to consider options to return management of


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mailto:[email protected]

mailto:[email protected]

http://ohiponline.org/ohip.hierfi.faqs.pdf

4

certain functions to OHIP as necessary to effectively manage costs. This strategy and other core principles should be thoroughly reviewed by responders as outlined in OHIP’s Technology Development Principles referenced in this document. REFERENCE DOCUMENTS3: It is recommended that responders review the following documents or websites before submitting RFI responses:

Document Location OHIP Technology Development Principles http://ohiponline.org/ohip.hierfi.tech.principles

.pdf OHIP HIE Project Abstract and Narrative http://ohiponline.org/ohip.hierfi.hie.abstract.n

arrative.pdf OHIP REC Project Abstract and Narrative http://ohiponline.org/ohip.hierfi.rec.abstract.n

arrative.pdf OHIP Main Website (News) http://www.ohiponline.org/ Ohio Health Care Coverage and Quality Council Website

http://www.healthcarereform.ohio.gov

TERMS AND CONDITIONS:

1. This RFI and RFI process is solely for OHIP’s benefit and is only intended to provide information to OHIP. The RFI is designed to provide respondents with the information necessary for the preparation of informative responses. The RFI is not intended to be comprehensive, and each respondent is responsible for determining all the factors necessary for submission of a response. The RFI response will not be subject to an RFP type evaluation but only to a review of the information respondent provides. 2. OHIP reserves the right not to review or otherwise to reject, in whole or in part and at any time, any or all responses received in response to this RFI. An RFI response may be rejected outright and not reviewed for any or no reason. Issuance of the RFI in no way constitutes a commitment by OHIP to award any contract or any request for proposal (RFP) for the goods and services described in the RFI. 3. OHIP is subject to strict accountability and reporting requirements as a recipient of funds from public sources. Any response or other information submitted by a respondent to OHIP is subject to disclosure by OHIP as required by law, including but not limited to, the American Recovery and Reinvestment Act of 2009 (Public Law 111-5). OHIP makes no agreements or representations of any kind, and expressly disclaims any requirement to

3 OHIP’s website and detailed links have changed since the RFI was issued. The main website is still www.ohiponline.org


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http://ohiponline.org/ohip.hierfi.tech.principles.pdf


http://ohiponline.org/ohip.hierfi.hie.abstract.narrative.pdf

http://ohiponline.org/ohip.hierfi.hie.abstract.narrative.pdf

http://ohiponline.org/ohip.hierfi.rec.abstract.narrative.pdf

http://ohiponline.org/ohip.hierfi.rec.abstract.narrative.pdf

http://www.ohiponline.org/

http://www.healthcarereform.ohio.gov/


5

maintain the confidentiality of any information provided by respondent in response to this RFI. All material and information provided to OHIP in response to this RFI shall upon receipt become the property of OHIP and will not be returned. 4. By submitting a response, the respondent agrees that OHIP may copy the response for purposes of facilitating OHIP’s review or use of the information. OHIP will have the right to use ideas or adaptations of ideas that are presented in the response. The respondent represents that such copying will not violate any copyrights, licenses or other agreement with respect to the materials submitted. 5. Ohio law contains laws which restrict gifts which may be given or received by state employees and requires certain individuals to disclose information concerning their activities with state government. By submission of a response, respondent certifies that respondent has not paid or agreed to pay to any employee, official or current contracting consultant of OHIP any fee, commission or any other thing of value that is in any way contingent upon OHIP contracting with respondent. 6. OHIP reserves the right to modify this RFI at any time. OHIP reserves the right to contact respondents after the submission of responses for the purpose of clarifying any response. Respondent understands that any and all information provided in response to the RFI is subject to validation during any RFP process. By submitting a response each respondent agrees that it will not bring any claim or have any cause of action against OHIP, or any agent of OHIP or the State of Ohio, based on any misunderstanding concerning the information provided in the RFI or concerning OHIP’s failure, negligent or otherwise, to provide the respondent with pertinent information as intended by this RFI. 7. OHIP is not responsible for any costs incurred by a respondent which are related to the preparation or delivery of the response or any other activities of respondent related to this RFI. 8. The laws of the State of Ohio and the United States of America shall apply to and govern the interpretation, validity and effect of this RFI. OHIP contractors and subcontractors may be subject to federal or state laws or regulations applicable to recipients of funds from public sources. Respondents are responsible for determining the applicability of these laws to their activities and for complying with applicable requirements.


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APPENDIX A

Ohio Health Information Partnership Request for Information (RFI)

I. Organization Information Please provide the following information about your organization:

1. Contact information for the individual to whom RFI questions should be directed:

‐ Organization Name: ‐ RFI Contact: ‐ Title: ‐ eMail Address: ‐ Primary Phone Number: ‐ Secondary Phone Number: ‐ Mailing Address: ‐ City: ‐ State: ‐ Zip Code:

2. A brief history of how your organization began offering HIE services including an explanation of how your product(s) evolved from other products/services or were independently developed.

3. A list of where your data centers and staff are located including any critical sub-sourced locations or sites being considered for expansion.

4. Provide a recent white paper/case study prepared by your organization which provides a good explanation of your functional and technical model, strategy and lessons learned (e.g., hyperlink or e-document).

II. Financial Information Please provide the following financial information.

1. Please denote financial information from HIE services for the past three years. Describe the revenue source(s) for each year.

a. Annual revenue by calendar year (in dollars; CY-2009, CY-2008, CY-2007)

• This may include revenue from software license, subscription/participation fees, service/maintenance, public/grant and other


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b. Revenue source by calendar year (500 character maximum; CY-2009, CY-2008, CY-2007)

c. Research and development expenditures for HIE services (in dollars: CY-2008, CY-2008, CY-2007)

d. Provide additional explanation as necessary (free text)

2. Please identify which type of licensing fee your organization uses:

‐ Concurrent ‐ Named user ‐ Unlimited ‐ Role-based ‐ Other (please specify) ‐ N/A

3. Give an overview of your product pricing model beyond licensing fees including the

following: Maintenance fees; Hardware/storage fees; Transaction fees; Training fees; Implementation fees; Unbundled additional costs (third party products/support, etc); any other business models used to maintain financial viability (i.e., advertising placement, sponsorship, etc).

4. If your organization uses a participation fee model (ex., transaction or subscription

fees), describe the model, including which stakeholders pay and how fees are assessed. Please include if your model allows for potential revenue sharing between stakeholders.

5. Denote if you are a public or private entity and/or a for-profit or not-for-profit

organization.

6. Please describe if your organization has any type of minority business designation.

III. Product Offering Please provide the following information about your proposed HIE solution:

1. A brief executive summary including the name of the product(s) and version/release you are proposing for use.

2. A brief explanation of concerns you may have about your solution’s ability to meet any

of OHIP’s Technology Development Principles.


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3. A list of all certified EHR vendors with which you currently exchange clinical data using the proposed HIE solution including the information noted below. You will be provided an opportunity to provide additional comments as well.

EHR Vendor Product/Version Standard/Format Used

Bi-Directional or Uni-Directional

IV. Range and Type of Health Information Organizations Supported

1. List the health information organizations to which you provide services by type including the number of active users and start date.

Type Name of

Organization # of Active Users Mo/Year of

Go-Live State Designated HIO, Regional HIO, Health System HIO or University-Based HIO

2. Indicate the types of stakeholders who use your HIE services:

Stakeholders Use

(Yes/No) Hospitals Primary Care Physicians Specialty Care Physicians Ambulatory Care/Outpatient Clinics Nursing Homes Rehabilitation or Other Chronic Care Facilities Behavioral Health Providers or Facilities Laboratories Radiology Centers Pharmacies Pharmacy Benefit Managers (PBMs) Federally Qualified Health Centers (FQHCs) Other Community and/or Public Health Clinics Veterans Administration or Dept of Defense Hospitals/Medical Facilities Medicare or Medicaid Organizations

8


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Stakeholders Use (Yes/No)

Private Payer/Health Plans Other Local, State or Federal Governmental Agencies or Entities Employers or Healthcare Purchasers Quality Improvement Organizations Patient or Consumer Groups Other (please specify)

3. Describe your organization’s efforts to participate in the following:

a. Certification Commission for Health Information Technology (CCHIT); Examples: certified vendor, vendor seeking certification, a member of

the CCHIT Commission or an advisory task force) b. Office of the National Coordinator for Health Information Technology

(ONCHIT) Examples: Member of Policy, Standards and Meaningful Use Committees

c. National Health Information Network (NHIN) d. Other HIE Communities, Councils, Task Forces, Commissions, etc

V. Technical Architecture

1. What type of HIE architecture does your organization currently support?

HIE Architecture Type Supported

(Yes/No) Federated Centralized Hybrid Other (please specify)

2. Which of the following architectural elements do you support?

Architectural Element Supported (Yes/No)

Central registry of participating entities Central registry of users (centralized user authentication and authorization) Central patient index/Master patient index (central patient identity resolution)

Record locator service Clinical data repository (clinical data on patients stored centrally) Transaction logs (logs of who requested data and what data was provided) Portal for authorized viewing of data Document registry (locator of documents in federated systems)


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3. Is service-oriented architecture (SOA) used? (Yes/No) 4. Provide a high-level technical architecture diagram (hyperlink or e-document). 5. Describe all software and service components including subcontracted services used to

support your architecture and whether your organization or another entity is responsible for managing those components. Please specify open source components.

6. Describe the software, hardware or communication requirements that HIE

participants/providers must purchase/use in order to interface successfully with your HIE? VI. Data Exchange Information

Please provide the following data exchange information. If you support multiple HIOs, provide metrics for your three largest clients.

1. List below the type of data exchange your organization supports and the average number of daily transactions. Indicate “n/a” if not supported.

Data Exchanged Average Number of Daily

Transactions Comment (500 character max per text box)

Continuity of Care Document (CCD)

Continuity of Care Record (CCR)

Other clinical summaries Can include ER summary, discharge summary, referral summary, history and physical, etc

Clinical patient notes

Consultations and Referrals

Dictation Notes

Lab

Radiology

Cardiology

Other ancillary results

Digital chart information In comments, please describe the type of digital information supported (radiology


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Data Exchanged Average Number of Daily Transactions

Comment (500 character max per text box)

images, EKG readings, fetal monitoring results, etc)

e-Rx

Medication history

PBM/formulary integration

Patient messaging/alerts

PHR integration

Home-based monitoring integration

Reporting/receiving immunization data

Provider alerts to and from public health

Other population health reporting/exchange

Disease management reporting/exchange

Quality measure reporting

Eligibility inquiry/response

Referrals and Prior Authorization

Professional Claims

Institutional Claims

Dental Claims

Claim Attachments

Claim Status

Payment Advice

Patient appointment scheduling

2. List below the transaction standard used by your organization for each type of data exchange

you support (ex., HL7 2.5.1, HITSP C32, X12 835, custom/proprietary, PDF).

Data Exchanged Standard Used



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Other clinical summaries



Dictation Notes

Lab

Radiology

Cardiology


Digital chart information

e-Rx

Medication history

PBM/formulary integration


PHR integration









Professional Claims


Dental Claims

Claim Attachments


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Claim Status

Payment Advice


3. List if the data exchange is occurring in a production or pilot environment and among which types of HIE participants. You will be provided an opportunity to provide additional comments as well.

Data Exchanged Prod

Or

Pilot

Hosp

IP

Hosp

OP

Phys

Office

FQHCs/

Public

Health

Facility

Ancillary

Service

Public/

Private

Payer

State

Gov’t

Registry



Other clinical summaries



Dictation Notes

Lab

Radiology

Cardiology


Digital chart information

e-Rx

Medication history

PBM/formulary


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Data Exchanged Prod

Or

Pilot

Hosp

IP

Hosp

OP

Phys

Office

FQHCs/

Public

Health

Facility

Ancillary

Service

Public/

Private

Payer

State

Gov’t

Registry

integration


PHR integration









Professional Claims


Dental Claims

Claim Attachments

Claim Status

Payment Advice



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4. Which messaging standards and versions are supported: Messaging Standard Supported (Yes/No) Versions

HL7 DICOM NCPDP X12 CDA/CCR Other (please specify)

5. Which of the following data management strategies are supported by your service:

Data Management Strategy Supported (Yes/No)

Normalization and encoding Language normalization Export and registration of data objects/data staging Communication and display Correctness – data correction Data filtering Privileged data Data translation/file conversion (ex. proprietary to standard format or vice versa)


6. Which data vocabularies (i.e., reference terminologies) do you support?

Data Vocabulary Supported (Yes/No)

SnoMed LOINC NDC ICD-9 ICD-10 CPT-4 HCPCS RxNorm Other (please specify)


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VII. Additional Provider Services

1. Please denote the additional provider services you support:

Additional Provider Service Supported (Yes/No)

Full ASP-model EHR support (certified) e-Rx Document scanning Practice management solution Appointment scheduling solution PHR (specify type) Provider access to health research/educational information Patient access to health research/educational information Other (please specify)

VIII. Security and Privacy 1. Indicate which of the following security strategies are supported by your architecture:

Security Strategy Supported (Yes/No)

HIPAA Compliance (including ARRA requirements) FTC “Red Flag” rules for identity theft Access Role-based Encryption Entity/Individual Authentication/Trust Model Auditing/Logs/Review HISPC standards Other (please specify)

2. Does your HIE permit patient opt in/opt out? If yes, please indicate the type of opt in/opt out supported:

Type Opt-In, Opt-

Out or Both Supported (Yes/No)

By provider By facility


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By data type (specify behavioral health, infectious disease, etc.)

Other

IX. Staffing and Implementation Please provide the following information about your staff and implementation process:

1. A summary of your staffing history including the following:

a. Total number of full-time employees dedicated to your software solution broken down by sales, implementation, support and development (CY-2009, CY-2008, CY-2007)

b. Briefly describe any significant reorganizations or changes to your software lines of business in the past three years or planned in the next three years.

c. Briefly describe any significant changes in your executive leadership during the past three years and the impact on your software lines of business.

2. A sample work plan of the tasks and date ranges necessary to bring your proposed

solution live if implementation were to begin in May 2010 (hyperlink or e-document). 3. An example of the type of training materials you offer to HIE participants and the

mechanisms used (e.g., webcast, online training, e-document, on-site, etc; hyperlink or e-document).

X. Other At the end of the OHIP HIE RFI survey tool, you will be asked to provide the name and email address of the individual who completed the survey tool for your organization and to accept the terms and conditions of this RFI.


H17

ID Task Name Resource Names

1 OHIP Administrative Efforts

2 Expand Board Membership Exec Comm

3 Staffing

4 Hire President/CEO Exec Comm

5 Hire COO/CIO Exec Comm

6 Hire CFO Exec Comm

7 Hire Full-Time Communications Director Exec Comm

8 Hire Additional HIE Support Staff Exec Comm

9 OHIP Contract Resources

10 Contract with part-time financial expert Exec Comm

11 Contract with part-time communications expert Exec Comm

12 Contract with legal counsel Exec Comm

13 ONC PMO/GMO Coordination

14 HIE PMO Planning

15 Identify State HIT Coordinator Gov Office

16 ONC announces HIE awards ONC

17 Submit plan to complete strategic plan OHIP staff

18 Attend State HIE Leadership Summit OHIP

19 Complete HIE State Plan HIE Comm

20 Ongoing Webinars/Calls

21 Bi-weekly PMO calls OHIP staff

22 Bi-weekly CMS/HITECH calls OHIP staff

23 Weekly SLHIE webinars/calls OHIP staff

24 Routine NHIN webinars/calls OHIP staff

25 HIE Financial/Status Reporting

26 Establish reporting process

27 Register at FederalReporting.Gov (notify ONC) OHIP staff

28 Complete 199A DD form to PMS OHIP staff

2/26/10

9/30/10

10/1/10

12/31/10

11/1/10

10/31/10

3/1/10

5/1/10

3/27/10

1/1/10

2/12/10

3/15/10

5/12/10

7/26/10

2/1/11

9/27/10

2/1/11

2/1/11

4/29/104/29/10

3/2/10

3/2/10

Qtr 4 Qtr 1 Qtr 2 Qtr 3 Qtr 4 Qtr 1 Qtr 2 Qtr 3 Qtr 4 Qtr 1 Qtr 2 Qtr 3 Qtr 4 Qtr 1 Qtr 2 Qtr 3 Qtr 4 Qtr 1 Qtr 2 Qtr 3 Qtr 42009 2010 2011 2012 2013 2014

Task

Milestone

Summary

Rolled Up Task

Rolled Up Milestone

Rolled Up Progress

Split

External Tasks

Project Summary

Group By Summary

Inactive Task

Inactive Milestone

Inactive Summary

Manual Task

Duration-only

Manual Summary Rollup

Manual Summary

Start-only

Finish-only

Progress

Deadline

Incomplete tasks

Completed tasks

Completed Milestone

Ohio Health Information PartnershipHIE Technical Implementation Plan

Page 1

Project: ohip.hie.state.planDate: Tue 11/30/10

Appendix I

Revised 11/29/10 I1


29 Establish quarterly financial reporting process (FSR)

OHIP staff

30 Establish quarterly ARRA 1512 process OHIP staff

31 Determine HIE metrics

32 Document HIE metric reporting requirements ONC

33 Determine how HIE metrics will be gathered OHIP staff

34 Determine HIE metrics to be gathered by RPs OHIP staff

35 Update Sharepoint portal/CRM tool to support metrics

OHIP staff

36 Maintain reporting process

37 Submit Quarterly ARRA Reports OHIP staff

38 Submit Quarterly Financial Status Reports OHIP staff

39 Submit Semi-Annual ONC Program Process Reports

OHIP staff

40 Begin reporting HIE metrics OHIP staff

41 Stakeholder Engagement

42 HIE Committee

43 Form HIE Committee Exec Comm

44 Contribute to/oversight RFI process HIE Comm

45 Contribute to HIE State Plan HIE Comm

46 Contribute/oversight RFP process HIE Comm

47 Contribute/oversight HIE implementation process HIE Comm

48 Develop HIE communication strategy HIE Comm

49 Privacy and Security Workgroup

50 Finalize workgroup members and charter Exec Comm

51 Update pertinent legal citations P&S Comm

52 Recommend changes to state law if applicable P&S Comm

4/10/10

4/29/10

12/31/10

1/31/11

2/28/11

3/31/11

2/7/14

2/7/14

2/7/14

2/10/11

1/1/10

3/31/10

7/1/10

9/15/10

6/1/11

5/31/11

8/31/10

12/31/10

12/31/10


Task

Milestone

Summary

Rolled Up Task

Rolled Up Milestone

Rolled Up Progress

Split

External Tasks

Project Summary

Group By Summary

Inactive Task

Inactive Milestone

Inactive Summary

Manual Task

Duration-only


Manual Summary

Start-only

Finish-only

Progress

Deadline

Incomplete tasks

Completed tasks

Completed Milestone


Page 2


Appendix I

Revised 11/29/10 I2


53 Recommend consumer consent model P&S Comm

54 Develop trust agreement and related policies P&S Comm

55 Address cross-state exchange policies P&S Comm

56 Develop privacy and security workflows and policies

P&S Comm

57 Develop privacy and security education materials P&S Comm

58 Promote model permission form and policy/procedures

P&S Comm

59 Determine limits on Medicaid eligiblity data P&S Comm

60 Recommend technical security model P&S Comm,HIE Comm

61 Eligibility Workgroup


63 Determine PPACA (1561) impact on HIE efforts Elig Comm

64 Determine scope of eligibility services Elig Comm

65 Determine timeline for Medicaid integration Elig Comm

66 Pursue Medicaid eligiblity process changes Elig Comm

67 NHIN Workgroup


69 Monitor national protocol development NHIN Comm

70 Create/distribute national protocol education materials

NHIN Comm

71 Plan interstate/federal agency exchange efforts NHIN Comm

72 Conduct interstate outreach efforts NHIN Comm

73 REC Committee

74 Coordinate HIE requirements for preferred vendors

REC Comm

75 Coordinate REC BH Workgroup adoption efforts REC Comm

12/31/10

12/31/10

12/31/10

12/31/10

3/1/11

6/1/11

3/1/11

3/1/11

8/31/10

12/31/10

12/31/10

12/31/10

12/31/10

1/31/11

9/1/11

9/1/11

12/30/11

12/30/11

6/1/11

6/1/11


Task

Milestone

Summary

Rolled Up Task

Rolled Up Milestone

Rolled Up Progress

Split

External Tasks

Project Summary

Group By Summary

Inactive Task

Inactive Milestone

Inactive Summary

Manual Task

Duration-only


Manual Summary

Start-only

Finish-only

Progress

Deadline

Incomplete tasks

Completed tasks

Completed Milestone


Page 3


Appendix I

Revised 11/29/10 I3


76 Coordinate e-Prescription Workgroup efforts REC Comm

77 REC Regional Partners Committee

78 Coordinate HIE adoption efforts with RPs REC Comm

79 Communication Committee

80 Publish weekly OHIP newsletter Comm Comm

81 Update OHIP HIE internet portal Comm Comm

82 Create Sharepoint collaboration portal Comm Comm

83 Develop HIE materials for preferred vendors Comm Comm

84 Develop HIE outreach materials for RPs Comm Comm

85 Develop HIE education materials for RPs Comm Comm

86 Create method for gathering positive patient outcomes

Comm Comm

87 OHIP Board

88 Provide monthly status reports OHIP staff

89 Provide monthly HIE presentation updates OHIP staff

90 State Interagency Council

91 Form State Interagency Council State HIT

92 Contribute to HIE State Plan SIC

93 ODH: NHIN testing/development with CDC SIC

94 ODH: Immunization, surveillance and reportable lab

SIC

95 ODI: Coordinate health reform IT SIC

96 ODJFS: Coordinate incentive program requirements

SIC

97 ODJFS: Coordinate Medicaid eligibility data efforts

SIC

98 ODMH/ODADAS: BH health IT adoption efforts SIC,BH Comm

99 HCCQC HIT Task Force

100 Form HCCQC HIT Task Force Gov Office

6/1/11

6/1/11

2/7/14

7/1/10

8/31/10

5/31/11

5/31/11

5/31/11

12/30/11

1/31/14

1/31/14

4/1/10

7/8/10

12/31/10

2/7/14

2/7/14

2/7/14

2/7/14

7/25/12

4/1/10


Task

Milestone

Summary

Rolled Up Task

Rolled Up Milestone

Rolled Up Progress

Split

External Tasks

Project Summary

Group By Summary

Inactive Task

Inactive Milestone

Inactive Summary

Manual Task

Duration-only


Manual Summary

Start-only

Finish-only

Progress

Deadline

Incomplete tasks

Completed tasks

Completed Milestone


Page 4


Appendix I

Revised 11/29/10 I4


101 Provide monthly HIE status updates State HIT

102 Contribute to HIE State Plan State HIT

103 Procurement Process

104 RFI Process

105 Develop RFI HIE Comm

106 Issue RFI HIE Comm

107 Respond to vendor questions HIE Comm

108 Close RFI HIE Comm

109 Review Responses HIE Comm

110 Select vendors to participate in RFP (8) HIE Comm

111 RFP Process

112 Prepare RFP documents

113 Develop RFP Draft HIE Comm

114 Finalize requirements HIE Comm

115 Finalize use cases OHIP staff

116 Finalize scoring criteria HIE Scoring Team

117 Finalize contractual terms Exec Comm,Legal

118 Finalize selection committee(s) Exec Comm

119 Finalize dates HIE Comm

120 Issue RFP

121 Notify vendors OHIP staff

122 Hold bidders webinar OHIP staff,Legal

123 Respond to vendor questions Legal,OHIP staff

124 Close RFP OHIP staff

125 Evaluate responses and client references HIE Scoring Team

126 Select first round HIE Scoring Team

127 Conduct use cases/demos HIE Scoring Team

128 Select second round HIE Scoring Team

129 Conduct site/client visits OHIP staff

12/30/11

7/8/10

1/1/10

1/21/10

2/19/10

3/1/10

3/31/10

3/31/10

5/14/10

8/20/10

8/20/10

8/20/10

8/20/10

8/20/10

8/20/10

9/16/10

9/17/10

10/1/10

10/22/10

11/8/10

11/8/10

11/23/10

12/3/10

12/10/10


Task

Milestone

Summary

Rolled Up Task

Rolled Up Milestone

Rolled Up Progress

Split

External Tasks

Project Summary

Group By Summary

Inactive Task

Inactive Milestone

Inactive Summary

Manual Task

Duration-only


Manual Summary

Start-only

Finish-only

Progress

Deadline

Incomplete tasks

Completed tasks

Completed Milestone


Page 5


Appendix I

Revised 11/29/10 I5


130 Recommend final vendor HIE Scoring Team

131 Select final vendor OHIP Board

132 Select Vendor

133 Negotiate terms OHIP staff,Legal

134 Notify ONC/GMO OHIP staff,Legal

135 Finalize contract OHIP Board

136 HIE Implementation

137 Pre-Planning

138 Finalize core/phase deployment model Vendor,Exec Comm

139 Finalize key deliverables and dates Vendor,Exec Comm

140 Determine HIE staffing impact Vendor,Exec Comm

141 Create implementation workplan Vendor,OHIP Project Team

142 Select HIE Implementation Committee (s) Exec Comm

143 Hold Kick-Off Meeting Vendor,OHIP Project Team

144 Develop communication plan Vendor,OHIP Project Team

145 Requirements Planning

146 Technical system/network design Vendor

147 Trust model design P&S Comm

148 Functional component design core support Vendor,OHIP Project Team

149 Functional component design clinical services Vendor,OHIP Project Team

150 Functional component design administrative Vendor,OHIP Project Team

151 EHR integration strategy physicians Vendor,OHIP Project Team

152 EHR integration strategy hospitals and HIOs Vendor,OHIP Project Team

153 Provider on-boarding requirements Vendor,OHIP Project Team

154 NHIN protocol use Vendor,OHIP Project Team

155 Conversion/pre-load requirements Vendor,OHIP Project Team

156 Customization requirements Vendor,OHIP Project Team

157 Review conversion/pre-load requirements Vendor,OHIP Project Team

158 Review customization requirements Vendor,OHIP Project Team

1/21/11

1/21/11

1/21/11

1/24/11

1/31/11

2/15/11

2/15/11

2/15/11

2/15/11

2/15/11

3/1/11

2/28/11

4/1/11

3/31/11

3/31/11

3/31/11

3/31/11

3/31/11

3/31/11

3/31/11

3/31/11

3/31/11

3/31/11

3/31/11

3/31/11


Task

Milestone

Summary

Rolled Up Task

Rolled Up Milestone

Rolled Up Progress

Split

External Tasks

Project Summary

Group By Summary

Inactive Task

Inactive Milestone

Inactive Summary

Manual Task

Duration-only


Manual Summary

Start-only

Finish-only

Progress

Deadline

Incomplete tasks

Completed tasks

Completed Milestone


Page 6


Appendix I

Revised 11/29/10 I6


159 Sign-off on requirements Exec Comm

160 System Development

161 Build system environments (test, prod, etc) Vendor

162 Build DR environment Vendor

163 Master Entity Index Development

164 Determine source extent/source of data Exec Comm

165 Developing on-boarding model Vendor,OHIP Project Team

166 Test on-boarding process Vendor,OHIP Project Team

167 Develop issue resolution process OHIP Proj Team

168 Disaster Recovery Planning

169 Review/refine vendor disaster recovery plan Vendor,OHIP Project Team

170 Develop required audit documentation Vendor,OHIP Project Team

171 Document DR staff and contact information Vendor,OHIP Project Team

172 System Testing

173 Develop system test plans Vendor,OHIP Project Team

174 Conduct functional/use case tests Vendor,OHIP Project Team

175 Conduct performance/load tests Vendor,OHIP Project Team

176 Conduct integration testing Vendor,OHIP Project Team

177 Conduct DR test Vendor,OHIP Project Team

178 Refine test plans and design Vendor,OHIP Project Team

179 Policies and Procedures

180 Document operating policies and procedures OHIP Proj Team

181 Document help desk policies and procedures OHIP Proj Team

182 Document help desk materials (FAQs, tools) OHIP Proj Team

183 Document provider on-boarding policies and procedures

OHIP Proj Team

184 Training Materials

4/1/11

4/29/11

4/29/11

4/15/11

5/30/11

4/29/11

4/29/11

4/15/11

4/29/11

5/16/11

4/15/11

4/29/11

5/2/11

5/2/11

5/2/11

5/18/11

4/29/11

4/29/11

4/29/11

5/15/11


Task

Milestone

Summary

Rolled Up Task

Rolled Up Milestone

Rolled Up Progress

Split

External Tasks

Project Summary

Group By Summary

Inactive Task

Inactive Milestone

Inactive Summary

Manual Task

Duration-only


Manual Summary

Start-only

Finish-only

Progress

Deadline

Incomplete tasks

Completed tasks

Completed Milestone


Page 7


Appendix I

Revised 11/29/10 I7


185 Determine training approach/methodology Vendor,OHIP Project Team

186 Document/update entity training materials OHIP Proj Team

187 Document/update HIE staff training materials OHIP Proj Team

188 Document training schedule OHIP Proj Team

189 Marketing and Outreach Materials

190 Prepare final HIE marketing/outreach materials Vendor,OHIP Project Team

191 Review with regional partners/vendors REC Comm

192 Update OHIP HIE website OHIP staff

193 Core Support Go-Live

194 Finalize implementation plan Vendor,OHIP Project Team

195 Train implemementation staff Vendor,OHIP Project Team

196 Train users Vendor,OHIP Project Team

197 Conduct communication tasks in prep for go-live Vendor,OHIP Project Team

198 Resolve go/no-go issues Vendor,OHIP Project Team

199 Infrastructure Go-Live Vendor,OHIP Project Team

200 Phase I HIE Service Go-Live






206 Phase I Go-Live Vendor,OHIP Project Team

207 Phase II HIE Service Go-Live



210 Traini users Vendor,OHIP Project Team

4/29/11

4/29/11

4/29/11

4/29/11

5/31/11

5/31/11

5/31/11

6/30/11

6/30/11

6/30/11

6/30/11

6/30/11

7/1/11

7/29/11

7/29/11

7/29/11

7/29/11

7/29/11

8/1/11

11/11/11

11/11/11

11/11/11


Task

Milestone

Summary

Rolled Up Task

Rolled Up Milestone

Rolled Up Progress

Split

External Tasks

Project Summary

Group By Summary

Inactive Task

Inactive Milestone

Inactive Summary

Manual Task

Duration-only


Manual Summary

Start-only

Finish-only

Progress

Deadline

Incomplete tasks

Completed tasks

Completed Milestone


Page 8


Appendix I

Revised 11/29/10 I8




213 Phase II Go-Live Vendor,OHIP Project Team

214 Phase III HIE Service Go-Live






220 Phase III Go-Live Vendor,OHIP Project Team

11/11/11

11/11/11

12/1/11

5/31/12

5/31/12

5/31/12

5/31/12

5/31/12

6/1/12


Task

Milestone

Summary

Rolled Up Task

Rolled Up Milestone

Rolled Up Progress

Split

External Tasks

Project Summary

Group By Summary

Inactive Task

Inactive Milestone

Inactive Summary

Manual Task

Duration-only


Manual Summary

Start-only

Finish-only

Progress

Deadline

Incomplete tasks

Completed tasks

Completed Milestone


Page 9


Appendix I

Revised 11/29/10 I9

Permission to Use and Disclose Health Information for Treatment, Payment and Operations This form provides the permission needed to use and share your healthcare information in Ohio for medical care, payment for medical care and general operations of your healthcare providers and payers. This permission allows your health care provider to share information to assist in your care, and to provide information to your insurance company or other payer to obtain payment for care. Your information may also be disclosed when required by law. Read more about these required disclosures in our Notice of Privacy Practices. By signing this form, you are not giving your informed consent for medical treatment. The laws listed below may also apply to the release of your information. These definitions apply to the Permission Form. Mental health Stricter confidentiality rules protect your information if laws related to mental health cover any part of your records. See Ohio Revised Code (ORC) Section 5122.31. These laws prohibit anyone who receives your information from making any further disclosures without your specific written permission. A general permission for release of such information is not sufficient for this purpose. Mental health information released with your permission does not include psychotherapy notes. Also, state law may allow your provider to refuse to disclose mental health records to you if the provider thinks that releasing the information is not in your best interest. HIV/AIDS information Stricter confidentiality rules protect your information if laws related to HIV/AIDS cover any part of your records. See Ohio Revised Code (ORC) Section 3701.243. A general permission for release of such information is not sufficient for this purpose. Drug and alcohol treatment records Stricter confidentiality rules protect your information if drug and alcohol treatment laws (42 CFR Part 2) cover any part of your records. Federal law prohibits anyone who receives your information from making any further disclosures without your specific written permission. A general authorization for the release of medical or other information is not sufficient for this purpose. Federal law prohibits use of this information to criminally investigate or prosecute anyone having alcohol or drug abuse treatment records. Medicaid and public assistance programs If Ohio Medicaid or public assistance programs cover any part of your records, the Ohio Department of Job and Family Services (ODJFS) or a county equivalent may only release your records if you complete this form and meet all applicable conditions listed therein. These entities may only release your Ohio Medicaid (Chapter 5111 of the ORC) or public assistance information (found in Chapters 5101 and 5115) if both of the following apply:

A. The release of information is for purposes directly connected to administering the Medicaid and/or public assistance programs as defined in either federal or state law, whichever is directly applicable;

B. The information is released to persons or government entities that are subject to the standards of confidentiality and safeguarding of information substantially comparable to those established for the public assistance and/or Medicaid programs.

If this information is to be released for an insurance claim or tort action (lawsuit), Ohio law grants ODJFS rights of recovery against the liability of a third party for the cost of medical services paid by or billed to the agency. (See ORC Section 5101.58 and Ohio Administrative Code (OAC) Rule 5101:3-1-08.) When you or someone on your behalf requests a financial statement (a claim) from a Medicaid provider for services paid by or to be billed to ODJFS, the provider must immediately notify the agency when it receives your request (OAC 5010:3-1-08(L)). In addition, the provider must forward a copy of the request to the ODJFS Bureau of Plan Operations’ Benefit and Recovery Section. The provider must also stamp or type the following on each page of the financial statement: “Subject to right of recovery pursuant to Section 5101.58 of the Ohio Revised Code. Failure to comply may result in personal liability.” Workers Compensation If release of information is for use in administering an Ohio workers’ compensation claim, it is limited to medical, psychological and/or psychiatric data (excluding psychotherapy notes) causally or historically related to physical or mental injuries pertaining to that claim.

Appendix J - HISPC Model Permission Form

J1

Permission to Use and Disclose Health Information Treatment, Payment and Operations

[Insert name & Address of Provider or health plan/insurer]

Name: Date of birth (mm/dd/yyyy): Address: Telephone numbers: (home) (work) (cell) Email address: ________________________________________________________ Workers’ compensation claim number, if applicable: Social Security number (last four digits) Other identifier:

General Medical Use or Release

I give permission to [insert provider name or insurer/health plan] to use or release relevant personal health information, whether created by [insert provider name or insurer/health plan] or obtained from others, to any healthcare provider, facility, insurer or health plan so that I may receive treatment, pay for treatment or allow [insert provider or insurer/health plan] to conduct business necessary to treat or provide me with health care services. The person or entity will use or disclose only the minimum amount of information necessary. For treatment purposes, I understand that the minimum amount of information necessary may include all of my information. This permission includes records relating to (write your initials next to the records to be included and strike through lines that do not apply):

__ Diagnoses and/or treatment for alcohol and/or drug abuse or dependency; __ AIDS/AIDS-related complex (ARC) or HIV status diagnoses and/or treatment; __ Mental health records.

If this is a workers' compensation claim, I give permission for information relevant to my claim, either causally or historically, to be released to the Ohio Bureau of Workers’ Compensation (BWC), the Industrial Commission of Ohio (IC) and the following individuals or entities who are parties to my claim: the employer of record and/or any authorized representative(s), the employer of record’s managed care organization (MCO) or qualified health plan (QHP), and my authorized representative(s). This permission to release information in connection with my workers’ compensation claim will remain in effect for as long as my claim remains open under Ohio law. I request the following restrictions on the general release of my health information. I understand that my healthcare provider must agree with these restrictions:


J2

Signature

I have a right to inspect or copy my protected health information. You may charge me a reasonable fee for copies of my information. See instructions for the charges that apply. This permission continues unless I revoke it. If this permission applies to mental health records covered by ORC Section 5122.31, this permission expires 180 days from the date below unless I specify an earlier or longer date or a specific condition or event: ___________________________________

Patient: Date: OR: Personal/legal representative: I, (please print your name) ________________________, represent that I am the (circle one): legal healthcare agent/guardian/surrogate/parent of the patient named above. Signature: Date:


J3

Permission to Release Health Information This form combines all permissions needed to disclose your healthcare information in Ohio for specific reasons, other than for treatment, payment or operations. For example, this permission is necessary to allow access to your healthcare information in connection with legal medical claims, lawsuits, or other matters. Your information may also be disclosed when required by law. Notice of medical record copying charges Entities that charge individuals for copies of protected health information should insert fees and payment policy here. The laws listed below may also apply to the release of your information. These definitions apply to the Permission Form. Mental health Stricter confidentiality rules protect your information if laws related to mental health cover any part of your records. See Ohio Revised Code (ORC) Section 5122.31. These laws prohibit anyone who receives your information from making any further disclosures without your specific written permission. A general permission for release of such information is not sufficient for this purpose. Mental health information released with your permission does not include psychotherapy notes. Also, state law may allow your provider to refuse to disclose mental health records to you if the provider thinks that releasing the information is not in your best interest. HIV/AIDS information Stricter confidentiality rules protect your information if laws related to HIV/AIDS cover any part of your records. See Ohio Revised Code (ORC) Section 3701.243. A general permission for release of such information is not sufficient for this purpose. Drug and alcohol treatment records Stricter confidentiality rules protect your information if drug and alcohol treatment laws (42 CFR Part 2) cover any part of your records. Federal law prohibits anyone who receives your information from making any further disclosures without your specific written permission. A general authorization for the release of medical or other information is not sufficient for this purpose. Federal law prohibits use of this information to criminally investigate or prosecute anyone having alcohol or drug abuse treatment records. Medicaid and public assistance programs If Ohio Medicaid or public assistance programs cover any part of your records, the Ohio Department of Job and Family Services (ODJFS) or a county equivalent may only release your records if you complete this form and meet all applicable conditions listed therein. These entities may only release your Ohio Medicaid (Chapter 5111 of the ORC) or public assistance information (found in Chapters 5101 and 5115) if both of the following apply:

A. The release of information is for purposes directly connected to administering the Medicaid and/or public assistance programs as defined in either federal or state law, whichever is directly applicable;

B. The information is released to persons or government entities that are subject to the standards of confidentiality and safeguarding of information substantially comparable to those established for the public assistance and/or Medicaid programs.

If this information is to be released for an insurance claim or tort action (lawsuit), Ohio law grants ODJFS rights of recovery against the liability of a third party for the cost of medical services paid by or billed to the agency. (See ORC Section 5101.58 and Ohio Administrative Code (OAC) Rule 5101:3-1-08.) When you or someone on your behalf requests a financial statement (a claim) from a Medicaid provider for services paid by or to be billed to ODJFS, the provider must immediately notify the agency when it receives your request (OAC 5010:3-1-08(L)). In addition, the provider must forward a copy of the request to the ODJFS Bureau of Plan Operations’ Benefit and Recovery Section. The provider must also stamp or type the following on each page of the financial statement: “Subject to right of recovery pursuant to Section 5101.58 of the Ohio Revised Code. Failure to comply may result in personal liability.” Workers’ Compensation If release of this information is for use in administering an Ohio workers’ compensation claim, it is limited to medical, psychological and/or psychiatric data (excluding psychotherapy notes) causally or historically related to physical or mental injuries pertaining to that claim.


J4

Permission to Release Health Information For purposes other than treatment, payment or healthcare operations

[Insert name & address of Provider or Health Plan/Insurer]

Name: Date of birth (mm/dd/yyyy): Address: Telephone numbers: (home) (work) (cell) Email address: ________________________________________________________ Workers’ compensation claim number, if applicable: Social Security number (last four digits) Other identifier:

I authorize [insert provider name or insurer/health plan] to disclose (write your initials next to the records to be included and strike through lines that do not apply):

All records (whether originally created or obtained from others) ___

OR (choose from below)

__ Hospital/Emergency department records ___ Physician/Clinic records __ Skilled nursing facility/long term care records

__ Dental records ___ Physical/Occupational/Speech Therapy records ___ Treatment facility records ___Other: ________________________

This permission includes records relating to (check if applicable):

__ Diagnoses and/or treatment for alcohol and/or drug abuse or dependency; __ AIDS/AIDS-related complex (ARC) or HIV status diagnoses and/or treatment; __ Mental health records.

Send this information by (circle one) U.S. mail or electronically to: Name Email Address City, State, ZIP code Telephone Fax

If this is a workers' compensation claim, information will be released to the Ohio Bureau of Workers’ Compensation (BWC), the Industrial Commission of Ohio (IC) and the following individuals or entities previously identified who are parties to my claim: the employer of record and/or any authorized representative(s), the employer of record’s managed care organization (MCO) or qualified health plan (QHP), and my authorized representative(s). Purpose of disclosure: __ At my request __ Workers’ compensation; for use in administering my Ohio workers’ compensation claim identified above __ Other – Describe why you are disclosing information:


J5

By signing below, I understand that: I have the right to revoke this permission at any time by giving written notice to (insert name and address). This revocation must be in writing except in the case of drug and alcohol treatment records [insert provider name] will honor my revocation after [insert provider name] receives it, but I understand that my revocation will have no impact on uses or disclosures made while this permission was in effect. This permission will remain in effect for one year or until I revoke it, whichever comes first. If this permission applies to mental health records covered by ORC Section 5122.31, then this permission expires 180 days from the date below or an earlier or longer date or a specific condition or event that I specify: ___________________________________ Except as noted in the instructions, any information used or disclosed by this specific permission may be re-disclosed by the person or entity receiving the information and may no longer be protected by federal or state law. I have a right to inspect or copy my protected health information. You may charge me a reasonable fee for copies of my information. See instructions for the charges that apply. If by law you cannot send the protected health information to the entity listed above, I will initial the following space to have you send a copy of the information directly to me:__________. I am not required to sign this permission. If I refuse to sign this form, it will not affect my treatment, payment for treatment or eligibility for healthcare benefits to which I may be entitled. However, if I request a release of information, you cannot release it unless I sign this form. I have a right to receive a copy of this signed form.

Signature Patient: Date: OR: Personal/legal representative: I, (please print your name) ________________________, represent that I am the (circle one): legal healthcare agent/guardian/surrogate/parent of the patient named above. Signature: Date:


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Ohio’s Road to Health Information Exchange

What is OHIP’s

Strategy and How

can we help you? Executive Brief

2010

www.ohiponline.org 3455 Mill Run, Hilliard, OH 43026

Appendix K - HIE White Paper

Submitted 11/29/10 K1

2

TABLE OF CONTENTS

Executive Summary of OHIP’s Health Information Exchange (HIE) State Plan ................................................................... 4

What is a Health Information Exchange (HIE)? ................................................................................................................... 4

What is driving OHIP’s HIE Strategy? .................................................................................................................................. 5

Meaningful Use ................................................................................................................................................................ 5

Balancing Core Services with Regional Flexibility ............................................................................................................ 6

Sustainability .................................................................................................................................................................... 7

National Standards Development.................................................................................................................................... 7

Who Can Participate? .......................................................................................................................................................... 8

What Can OHIP Do for Ohio? .............................................................................................................................................. 8

Services to allow you to easily find patient information from trusted sources .............................................................. 8

Services to achieve meaningful use ............................................................................................................................... 10

Integration with Health Information Technology Vendors ........................................................................................... 11

Services to achieve administrative efficiency ................................................................................................................ 12

Is the technology ready? ................................................................................................................................................... 12

Can privacy and security be achieved? ............................................................................................................................. 13

Who Pays for it? ................................................................................................................................................................ 14

OHIP’s Sustainability Objectives .................................................................................................................................... 15

OHIP’s Sustainability Strategy ........................................................................................................................................ 15

Timeline ............................................................................................................................................................................. 16

Who Will Lead the Project? What is the Governance Model? ......................................................................................... 17

OHIP Leadership Staff .................................................................................................................................................... 17

OHIP Stakeholder Engagement...................................................................................................................................... 18

State Government Collaboration ................................................................................................................................... 19



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OHIP Was Created to Help Ohio .................................................................................................................................... 19

Appendix a- HIE phases ......................................................................................................................................................... 20

TABLE OF FIGURES

Figure 1 OHIP Revenue Chart ................................................................................................................................................ 16

Figure 2 OHIP Committees .................................................................................................................................................... 18

TABLE OF TABLES

Table 1 OHIP HIE ................................................................................................................................................................... 16

OHIP is funded through the Office of the National Coordinator, Department of Health and Human Services, grant number 90HT0024/01



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EXECUTIVE SUMMARY OF OHIP’S HEALTH INFORMATION EXCHANGE (HIE) STATE PLAN

On July 26, 2010, the Ohio Health Information Partnership (OHIP) formally submitted their HIE State Plan to the Office of the National Coordinator (ONC) as required under the State Grant to Promote Health Information Technology Planning and Implementation to obtain additional funding for HIE development. Developed collaboratively with OHIP’s board, staff, HIE Committee Members and privacy and security experts, the plan contains critical information regarding OHIP’s strategic and operational efforts for Ohio’s statewide HIE. The document will be made publicly available upon approval by ONC, which is expected in early 2011.

WHAT IS A HEALTH INFORMATION EXCHANGE (HIE)?

An HIE moves patient information electronically among physician offices, hospitals and other parties directly involved in a patient’s care. If you were to think of patient health information as mail and OHIP as the post office, the network of zip codes and designated mail routes is the HIE . Also like a post office, OHIP will use minimal, demographic information to ensure that patient data is sent to the correct, authorized recipients.

OHIP will concentrate on offering services that are most logical to be provided at a state level. Listed below are the services that will enable providers and other stakeholders to achieve efficiencies and cost savings and, most importantly, meaningful use.

Services to allow the discovery of patient information from trusted sources easily – Pre Phase Core Support


Master Provider/Entity Index

Record Locator Services

Trust Enablement

OHIP’s state HIE will allow clinical data to travel among health care systems that would otherwise not be connected. The OHIP HIE will allow all providers’ and stakeholders’ efficiency and cost savings through their core services and begin implementation with healthcare providers in the summer of 2011.

This paper outlines key points contained in OHIP’s HIE State Plan and is intended to address the fundamental questions succinctly:

o What is OHIP’s HIE strategy? o How can it help Ohio?



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Services to achieve Meaningful Use – Phase 1

e-Prescription

Structured lab results

Patient care summaries

Quality measures, Registry and surveillance data

Integration with OHIP’s preferred EHR vendors

Services to achieve administrative efficiencies – Phase II

Advanced insurance eligibility verification and connectivity

Coordination of benefits(COB) including Rx

Pre-authorization and referral routing

Advanced claim status and remittance coordination

Payor/Employer treatment cost and screening information Services to achieve enhanced integration – Phase III

Advanced data aggregation and reporting

National Health Information Network connectivity

Consumer integration and support

Community web portals

Address verification eligibility

WHAT IS DRIVING OHIP ’S HIE STRATEGY?

MEANINGFUL USE

Providers and hospitals are both incentivized and dis-incentivized to achieve meaningful use. There are over 11 objectives contained in the Electronic Health Record (EHR) Incentive Program Final Rule requiring providers to exchange health data electronically to receive incentive funding.

As the state-designated entity, OHIP is required to offer HIE services that support meaningful use objectives to every provider in Ohio, including hospitals, physicians, specialists, labs, pharmacies, health plans, nursing homes and other care providers. ONC requires that every state HIE focus on three specific priorities in Stage 1 of Meaningful Use. These three priorities are e-Prescription, the exchange of lab results using structured integration with EHRs and patient care summary exchange across unaffiliated organizations.

A detailed overview of the services and a timeline for service delivery is found in Appendix A



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OHIP can efficiently and cost effectively assist providers in attesting HIE capabilities as required to achieve Stage 1 Meaningful Use to apply for Medicare and Medicaid incentive payments. For more information about meaningful use, see www.ohiponline.org/Pages/MU.aspx.

BALANCING CORE SERVICES WITH REGIONAL FLEXIBILITY

While the delivery of healthcare is local, the data needed to deliver quality care can be located locally, regionally and nationally. As a result, it is important to provide a core infrastructure that facilitates a broad exchange, as well as engage stakeholders at a local level to cultivate community exchange.

This principle tenet of OHIP’s state HIE strategy is exemplified through OHIP’s Regional Extension Center (REC) program and approach to provider outreach. OHIP’s REC program consists of seven regional RECs that are a collaboration of local entities that work together to assist providers with the adoption of EHRs. Each REC is comprised of hospital systems, physician groups, quality improvement organizations, universities, and community colleges, professional associations, consultants and operational HIEs.

The primary focus of OHIP’s REC program is to provide educational and technical EHR support to providers, in both urban and rural areas. The relationships that the regional RECs will cultivate with the local hospitals and physicians through the REC program, will situate these RECs be in a unique position to coordinate health IT adoption efforts through close alignment of EHR and HIE adoption strategies.

The map below shows how each REC is divided within Ohio. The area in grey is serviced by the regional health information organization (RHIO), HealthBridge.

Central Ohio Health Information Exchange

Northwest Ohio Regional Extension Center

Dayton West Central Ohio Regional Extension Center

Case Western Reserve University Regional Extension Center

NorthEast Central Ohio Regional Extension Center

NEO Health Connect

Ohio University/Appalachian Health information Exchange

Many of you are exchanging data regionally or within your hospital networks. OHIP does not intend to replace your existing exchange service providers or capabilities, but rather connect them, creating a more robust network that will support meaningful use across the state and among a larger range of providers.

Figure 1- OHIP

Regional Partners



http://www.ohiponline.org/Pages/MU.aspx

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OHIP marketing and outreach efforts will be coordinated through RECs and will be used to encourage awareness and adoption of the state HIE, as well as identify issues at the community level. As the state designated entity, OHIP can deploy HIE outreach education across the state in an organized, efficient manner leveraging the expertise, communication channels, market knowledge and stakeholder relationships of the RECs. These partnerships will allow OHIP to receive direct feedback regarding adoption barriers and local concerns.

SUSTAINABILITY

HIEs across the country have had to deal with the inherent dilemma between the party that pays for the service and whether or not they are paying enough to sustain it.

OHIP’s financial strategy is discussed in more detail on p.11

NATIONAL STANDARDS DEVELOPMENT

National Health Information Network (NHIN). NHIN Exchange. NHIN Direct. National Information Exchange Model.

These terms refer to efforts at the national level to harmonize standards used to exchange data to allow for easier adoption of standards among providers, payors, labs, pharmacies and others on a local, statewide and national level. This is a worthy cause, but a technology team knows this is no easy task. IT experts refer to the seven layers of interconnectivity and national efforts address only a portion of those layers.

As the state-designated entity for Ohio, OHIP intends to facilitate exchange across state borders by supporting the service layers necessary to exchange data using NHIN protocols. One example is the development of statewide discovery and location services to help providers find information from trusted sources that are interested in data exchange using the NHIN framework. Our plans include establishing an NHIN Workgroup under our HIE Committee to facilitate this development and address cross-border issues.

OHIP will also provide support for regional HIE programs and communities that do not have established HIEs. These programs will provide a virtual exchange that may be branded for that region and supported by the state HIE. These virtual exchanges will also be able to leverage all the services that the state HIE offers.

OHIP’s strategy addresses this dilemma through plans to offer additional services beyond those required to support meaningful use and leverage Ohio’s economies of scale to offer significant opportunities for cost reduction. Ultimately providers and other stakeholders only pay for those services they determine add value and in which they participate.



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WHO CAN PARTICIPATE?

Unlike the limitations on eligibility for Medicare and Medicaid incentive payments, all primary care providers, specialty providers and hospitals will be eligible to participate in OHIP’s state HIE. In addition, OHIP plans to connect existing RHIOs, labs, pharmacies, long-term care organizations, health plans and other important organizations involved in a patient’s continuity of care. The state HIE will also interact with the state Medicaid program, Ohio Department of Health and other state and federal agencies to create additional efficiencies. Most important, OHIP intends to provide future integration options for consumers.

WHAT CAN OHIP DO FOR OHIO?

SERVICES TO ALLOW YOU TO EASILY FIND PATIENT INFORMATION FROM TRUSTED SOURCES


The MPI is the foundation that all HIE services will be based upon. The MPI must be capable of pulling the data from

multiple entities into one longitudinal record. The primary function of the MPI will be to utilize demographic data to

identify patients accurately. As the state HIE collects updated demographic data through subsequent medical

encounters, the MPI validates information to maintain a current profile.

Ohio has over 11 million residents. Many integrated delivery networks pull patients from Ohio’s bordering states.

Additionally, Ohio providers and other stakeholders offer virtual services that obtain patients from not all over the

United States, but the world. Ohio is a diverse state with many different ethnicities and OHIP’s MPI must accommodate

the idiosyncrasies and other name variations (i.e., maiden names, aliases, etc.). Due to the high volume of patients from

other states, OHIP’s MPI must be able to accommodate three to four times the number of patients, exceeding the

number of residents of Ohio.

Consistent with meaningful use, providers are advised to implement or upgrade to HHS-certified EHR applications to ensure robust integration with OHIP’s HIE. The OHIP REC program can provide the assistance necessary to achieve certification.

A high volume MPI tool is expensive. OHIP brings the ability to offer this tool at a much lower price point than an organization would be able to purchase individually. Facilities that want to consolidate disparate clinical data will be able to leverage the OHIP MPI for internal use to improve services for their patients.



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Master Entity Index

The primary function of the master entity index will be to store relevant information about providers, hospitals, labs and

any other entities necessary to facilitate exchange with trusted sources. Organization information related to these

entities changes frequently, thus difficult to keep up to date and organized. The master entity index will allow any entity

within the exchange to discover and locate other providers who may have information about their patients. The

effective use and maintenance of this index will ensure that contributors to the state HIE as well as the consumers of

this information are more efficient.

Record Locator Service (RLS)

The MPI contains algorithms that assign a unique identifier for each patient. The unique identifier is then used by the

Record Locator Service (RLS) to identify the location of multiple records that match that patient's unique identifier. The

RLS can indicate all of the different locations where medical information resides for the specified patient. The RLS only

stores information identifying the type of record and its location, not the actual record with the patient’s medical

information.

Trust Enablement

Trust enablement consists of the technology solutions necessary to validate and support privacy policies required by

state and federal law. The weakest link to security involves manual processes. Ensuring that manual processes are used

to collect the proper authorization from the patient is the important part of the trust enablement. The technology just

indicates if the manual processes have been properly executed.

It is extremely important that all members of the HIE use the same processes and documents for trust authorization. Consistent process and execution ensure that medical data on a patient is only released when the patient authorizes the release of the data. Extending the HIPAA privacy rules from the administrative data to the clinical data will require everyone involved to ensure that the desires of the patient are maintained.

One specific example of this inability to maintain proper entity information is the limitations of health plans to perform electronic funds transfers because they are not able to collect and maintain accurate banking information for low claim volume providers. A centralized index would allow health plans to subscribe to this service to obtain complete and accurate information.

When an HIE allows medical information to be held locally with the creator (provider or lab) or remotely by a third party data center, the HIE model is called a “Hybrid” model.



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SERVICES TO ACHIEVE MEANINGFUL USE

ePrescribing

The ability for a physician to send an accurate, error free and understandable prescription to a pharmacy is integral to

optimum patient care. In Ohio, the Ohio Board of Pharmacy must certify ePrescribing components before they can be

used. OHIP will create an ePrescribing Task Force to address this and other barriers to adoption and will include

representatives from the Board of Pharmacy, retail chain and independent pharmacies, hospitals, physicians and the

Ohio Pharmacists Association. The charge of this task force will be to improve the ease of e-Prescription use, align

software certification requirements with those on a national level and demonstrate quality improvements such as

avoidance/decrease of adverse drug events.

OHIP’s preferred EHR vendors must support ePrescribing and meet the requirements of the Ohio Board of Pharmacy.

The use of these preferred EHR vendor solutions will make the transition to ePrescribing that much easier for providers.


When sharing information between clinical laboratories and EHR system, standardized formatting and coding of the

information must take place to provide a common language for the patients’ health information. If the systems

between a lab and provider are interoperable, the need to manually enter the data or scan reports is eliminated. Timely

access, along with the ability to analyze the data effectively and the opportunity to use intelligent design to trigger

treatment protocols is also achievable. This functionality will help office staff maximize their time by automating what is

frequently a tedious process.


Sharing patient care summaries across EHRs is a service that will ultimately lead to better patient outcomes. Stage 1

Meaningful Use only requires that these summaries be exchanged, in human readable format (i.e., PDF). OHIP intends

to offer clinical summaries in both human readable and structured formats so the information contained in the

summaries can integrate with an EHR. Much of the data that needs to be shared exists today; however, it is not

necessarily in a consistent data vocabulary or accessible format. OHIP sees opportunities in offering the initial exchange

of human readable information and data management services that could normalize and aggregate the data until

widespread adoption of interoperability standards among providers is achieved.

Quality Measures, Registry and Other Surveillance Data

The OHIP state HIE will provide the primary interface for public health reporting, reducing the need for separate

interfaces to individually connect reporting agencies. The HIE will allow for state level integration of registries for public

health assessment, newborn screenings, vital statistics, cancer and other priority disease, injury or adverse health



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conditions. This will help streamline processes that can be highly labor intensive and dramatically increase the quantity

and quality of public health information available.

Cancer Surveillance is one example of a process that would be drastically improved with the implementation of a state

HIE. In order to assess the prevalence of cancer in Ohio, state law requires the reporting of all new cancer cases

diagnosed among Ohio residents to Ohio’s Cancer Incident Surveillance System (OCISS). Any practitioner that diagnoses

and/or treats cancer is required to report the incident within six months to OCISS. As OHIP combines state HIE services

with the ability to transmit cancer data, providers will be able to simplify their reporting processes.

OHIP’s state HIE can also streamline the process of surveillance to detect and track health events such as pandemic

influenza, bioterrorism, outbreaks, seasonal illnesses, injuries and environmental exposures by monitoring and analyzing

the health behavior of Ohio’s population in real-time. Instead of having a data feed from each health care provider to

the Ohio Department of Health, the HIE will allow for one data feed from RHIOs and other exchanges, reducing the

amount of technical work necessary to maintain the connections. It will also allow physician offices and outpatient

clinics to submit syndromic surveillance information to the Ohio Department of Health, something that is currently

limited to hospital emergency departments and urgent care centers. The additional data types will enhance Ohio’s

situational awareness and event detection capabilities.

INTEGRATION WITH HEALTH INFORMATION TECHNOLOGY VENDORS

OHIP preferred vendors

EHR vendors selected as part of OHIP’s preferred vendor program, have agreed to

become certified to ensure interoperability with the state HIE. The Board of

Pharmacy has approved each of the preferred vendors to perform ePrescribing. The

OHIP HIE can capitalize on the RECs work with the preferred vendors. The RECs will

be able to communicate the benefits of linking to the HIE via the preferred vendors to

their clients.

Market Leaders in Ohio

OHIP’s strategy is to not compete with the work already being done in Ohio, but capitalize on that work. As with the

OHIP Preferred Vendor program the concept is to bring other key players to the table and work with them to maximize

investments already made by providers in Ohio. This would include the important market leaders in the hospital and

ambulatory health information technology space, the e-prescription networks and lab companies. Creating strategic

partnerships with these entities will allow the OHIP HIE to connect rapidly to the majority of Ohio providers.

OHIP Preferred Vendors

dorendors Sage

NextGen eClinicalWorks

AllScripts eMDs



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SERVICES TO ACHIEVE ADMINISTRATIVE EFFICIENCY

Eligibility & Address Verification

OHIP will provide a centralized service for providers to verify patient insurance eligibility. The eligibility service will meet

HIPAA’s requirements for version 5010 and the operational rules established by the Patient Protection and Affordable

Care Act (PPACA). This centralized system will conversely provide payors a single place to provide services to the entire

healthcare community in Ohio.

Since OHIP’s MPI requires validated demographic data for patients, the burden of validating the data is lifted from the

entities utilizing the HIE.

Claims

In addition to the regulations for Meaningful Use, there are additional changes in the PPACA. This requires health plans

to publish their validation rules. In addition to eligibility verified claims, claims can be validated for administrative rules

as defined in HIPAA through the WEDI SNIP 1-7 rules as well as the clinical coding rules. Applying these three rules

consistently across the state would increase the payment propensity of a physician’s claim from 95% to 99%.

Performing these rules on a consistent basis across the state, would improve the quality of the data that payors receive.

Payors would be able to increase automation with a data verified quality claim. A high quality claim would allow payors

to provide adjudicated claim information quickly to the provider and drastically reduce provider relation interfacing.

Coordination of Benefits (COB)

Coordination of Benefits (COB) was very prevalent in the 90s with as high as 15% of patients having more than one

source of coverage. At the time, secondary and tertiary coverage was common, but over the past 10 years secondary

coverage has dropped as low as 5%. Now, with the advent of HSAs that are affecting coverage levels and lower

contributions, there is an increase in the dual coverage concept again.

The application of these rules to COB processing has caused numerous problems for providers to file claims properly.

The MPI systems have capabilities to store multiple ids that allow for the tracking of multiple coverage information. The

provider can inquire to the MPI to find multiple sources of coverage for a patient. This discovery process will allow

providers to bill payors properly, as well as collect all unclaimed funds.

IS THE TECHNOLOGY READY?

The industry of clinical data exchange has drastically improved over the last two years. The basic information for lab

results has been established along with basic information for a discharge summary or office visit. Some of the more

complicated data conditions still need to be improved. The standards for the data are in good working condition, but

there is still a lot of information in clinical conditions that are not codified well in messages exchanged.



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The issue that the industry still has to deal with is what clinical information is relevant? One example that illustrates this

issue today is that of a diabetic. Would a physician really want the last 10 A1C results or would the last three be enough

for a care decision? As the industry implements the technology to find and assimilate a medical record for a patient,

OHIP will be able to organize, filter and present the data to providers in a manner useful for making care decisions.

The industry has come a long way in the past 10 years with respect to EHRs clinical exchange; however, there is still

more to learn and implement. This industry will only move forward and improve if every stakeholder is networked

together.

CAN PRIVACY AND SECURITY BE ACHIEVED?

Individually, this issue is being address through avenues of legal, technical and operational expertise. There is a

common understanding of the complex nature of this challenge and the additional barrier of a more restrictive set of

state laws then those of HIPAA. Where stakeholders tend to differ is their interpretation of these laws and their

execution.

To address this important issue, OHIP has comprised a highly experienced team of legal experts to clarify, harmonize and

execute legal actions necessary to facilitate statewide and cross-border exchange. Many of these experts participated in

the Health Information Privacy and Security Collaboration (HISPC) effort concluded in July 2009 and identified barriers

and opportunities for facilitating exchange in Ohio. They concur that action will be needed on multiple levels from

education and awareness to provider policy, HIE policy and technical infrastructure. The OHIP Privacy and Security

Committee will keep the following principles in mind as they work through issues regarding consent, trust agreements

and general policies and procedures for the HIE.

Privacy and Security standards should protect patient rights while encouraging high participation in the HIE

Policies created should be technically achievable and actionable

Policies created should be operationally achievable and actionable

Policies created will be in compliance of Ohio and federal law

One major privacy issue the committee will work through is what type of consent is needed for a patient’s information

to be entered into the HIE. Every state is different and has different state law regarding the consent that must be given

before medical information is shared in any fashion, whether it is phone, fax or an electronic method. The OHIP Privacy

and Security Committee will provide clear direction for HIE participants regarding what consent is required to transfer

patient information through an HIE consistent with Ohio law.

OHIP provides a unique opportunity for all stakeholders to agree to a common understanding and

interpretation of privacy and security requirements in Ohio necessary to exchange data to achieve

consistency and confidence among Ohio’s consumers.



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The ultimate success of the HIE will depend on consumer confidence in its privacy and security. OHIP will follow the

framework outlined on the next page that is endorsed by the National Health Information Policy Committee for Privacy

and Security and adopted by the Department of Health and Human Services Office of the National Coordinator as the

HIE is developed.

WHO PAYS FOR IT?

The notion of how to sustain a statewide HIE beyond core ARRA funding has been the single most vetted topic through

the OHIP stakeholder engagement process. The good news is OHIP and its stakeholders wholeheartedly concur that the

statewide HIE’s ability to add value to the existing HIE environment in Ohio is a critical consideration in establishing the

priorities of OHIP. Below outlines OHIP’s strategies for sustaining the HIE over time.

Privacy and Security for the HIE

Individual Access – Individuals should be provided with a simple and timely means to access and obtain their individually identifiable health information in a readable form and format.

Correction – Individuals should be provided with a timely means to dispute the accuracy or integrity of their individually identifiable health information, and to have erroneous information corrected or to have a dispute documented if their requests are denied.

Openness and Transparency – There should be openness and transparency about policies, procedures and technologies that directly affect individuals and/or their individually identifiable health information.

Individual Choice – Individuals should be provided a reasonable opportunity and capability to make informed decisions about the collection, use and disclosure of their individually identifiable health information.

Collection, Use and Disclosure Limitation – Individually identifiable health information should be collected, used, and/or disclosed only to the extent necessary to accomplish a specified purpose(s) and never to discriminate inappropriately.

Data Quality and Integrity – Persons and entities should take reasonable steps to ensure that individually identifiable health information is complete, accurate, and up-to-date to the extent necessary for the person’s or entity’s intended purposes and has not been altered or destroyed in an unauthorized manner.

Safeguards – Individually identifiable health information should be protected with reasonable administrative, technical and physical safeguards to ensure its confidentiality, integrity and availability and to prevent unauthorized or inappropriate access, use or disclosure.

Accountability – These principles should be implemented, and adherence assured, through appropriate monitoring and other means and methods should be in place to report and mitigate non-adherence and breaches.

SOURCE: http://healthit.hhs.gov/portal/server.pt/gateway/PTARGS_0_10731_848088_0_0_18/NationwidePS_Framework-5.pdf



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OHIP’S SUSTAINABILITY OBJECTIVES

OHIP’s sustainability strategy is based on three core objectives:

These three objectives will help create a sustainable HIE that will assist direct participants (e.g., providers, payors, labs

and pharmacies) in achieving meaningful use while providing potential revenue streams from current secondary data

users (e.g., government agencies, payors, accreditation bodies and researchers). As EHR adoption wanes with a

growing number of PPCPs attaining meaningful use, the data value of the HIE will increase. This enhances the

capabilities for revenue to be generated from participation in the HIE services provided by OHIP. Through the

progressive development of an effective and comprehensive HIE, greater value for providers, researchers, payors and

others will be realized, encouraging further stakeholder buy-in and more opportunities for non-traditional revenue

streams. With the expansion of the clinical exchange creating an ever-increasing provider base, the integration of

administrative functions will help improve health care quality and curtail costs through improving operational

efficiencies.

OHIP’S SUSTAINABILITY STRATEGY

OHIP will leverage federal grant money to offset the initial build-out and core services of the statewide HIE to encourage

stakeholder participation. Concurrently, OHIP will utilize its REC to expand provider EHR adoption, directly increasing

the possible user base of the HIE. As the HIE attains a critical mass of users, additional services will be phased-in to offer

value-added, services that can be purchased by current users and secondary data users who may not require bi-

directional functionality.

OHIP has identified that sustainability is best achieved through multiple revenue streams that do not simply rely on the

exchange of clinical data. This multi-revenue stream model will leverage the buy-in of all types of stakeholders, using a

variety of services to capture their individual desires for operational efficiency and cost reduction. Similar to OHIP’s

phased implementation approach, revenue from HIE services is projected to fall into one of three tiers.

Leverage OHIP REC’s EHR adoption goals to assist the HIE with first year services; o e-Prescribing o Exchange of structured lab results o Sharing of patient care summaries across unaffiliated organizations

Offer HIE core and basic clinical data exchange services at competitive prices Developing additional value added services



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Figure 1 OHIP Revenue Chart

TIMELINE

OHIP began an extensive procurement effort in January 2010 by issuing a Request for Information (RFI) to identify full

service HIE vendors with the “breadth, depth and width’ to support a substantially-sized statewide HIE. Following

review of responses, OHIP selected eight vendors to participate in a Request for Proposal (RFP) issued in September

2010 following completion of OHIP’s HIE State Plan in July 2010.

The remaining timeline for selection and implementation of HIE services is noted in Table 1.

Table 1 OHIP HIE

Month/Year Key Action

September 2010 Request for Proposal (RFP) issued to 8 vendors selected to participate in RFP process

October 2010 Vendors submit proposals to OHIP

October-December 2010 OHIP conducts five-stage vendor evaluation process

January 2011 OHIP finalizes negotiations with HIE vendor and awards contract

January- June 2011 OHIP works with Ohio stakeholders to prepare for HIE launch



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o During this time the implementation plan is created with the vendor, the system is designed, developed and tested.

June 2011 OHIP’s core support services begin o See next page for detailed plan for a phased implementation

August 2011 HIE service phase I begins (meaningful use)

December 2011 HIE service phase II begins (administrative efficiency)

June 2012 HIE service phase III begins (enhanced administrative efficiency and integration)

WHO WILL LEAD THE PROJECT? WHAT IS THE GOVERNANCE MODEL?

OHIP was created in 2009 with the help of key healthcare stakeholders. These stakeholders represent statewide

interests and structured OHIP in a manner that would ensure continued alignment with stakeholder priorities.

At the highest level, OHIP’s fifteen-member board provides strategic, staff, fiduciary and community direction.

Comprised of industry leaders representing hospital, physician, payor, state agency, consumer and behavioral health

organizations located throughout the State, the Board provides active and valuable insight into Ohio’s dynamic

healthcare system.

OHIP LEADERSHIP STAFF

The Executive Committee is a subset of the Board and oversees the staff and daily operation. OHIP is a flat organization

with few layers of management to best facilitate teamwork and collaboration between the HIE staff and Regional

Extension Center (REC) staff under the oversight of the Executive Board. REC staff works to assist providers in

converting their record management to electronic systems with additional federal funding OHIP has secured. This REC

staff provides trusted unbiased support to providers making this often challenging transition and will help to assist the

same providers if they choose to join the HIE.

OHIP’s leadership team is comprised of seasoned health technology experts from Ohio who

have extensive new organization development, legal, government and health IT experience.

They understand the value of HIE and are passionately committed to delivering services which

will add value and efficiency to Ohio’s healthcare system. To view staff bios, see

www.ohiponline.org/Pages/Staff.aspx

To learn more about OHIP’s Board, go to www.ohiponline.org/Pages/Leadership.aspx.



http://www.ohiponline.org/Pages/Staff.aspx

http://www.ohiponline.org/Pages/Leadership.aspx

18

OHIP STAKEHOLDER ENGAGEMENT

OHIP is fortunate to have many interested and active stakeholders engaged in committee work. As a lean organization,

OHIP engages stakeholders through two primary committees that serve in a strategic advisory role: the HIE and REC

Committee. Underneath these committees, ad hoc workgroups are regularly formed to address specific issues or

provide defined deliverables as noted in Figure 2.

Figure 2 OHIP Committees

The Executive Committee reviews the recommendations made by the committees. Once the recommendations by the

committees are approved, the staff of OHIP will put the recommendations into action.

To keep the process manageable, only a few workgroups are active at the same time, which does limit the number of

positions for participation; however, that does not mean OHIP is not interested in future engagement with individuals

who express interest.

As new OHIP workgroups are formed, stakeholders are considered for participation based on

their interest, availability and expertise. To indicate interest in participation, please see

ohiponline.org/Pages/CommitteeInterestForm.aspx to share information about your expertise

that will help us in selecting future committee or workgroup members.



http://ohiponline.org/Pages/CommitteeInterestForm.aspx

19

STATE GOVERNMENT COLLABORATION

OHIP’s Board Chair, Amy Andres, is the federally designated State Health IT Coordinator as well as Chief of Staff the Ohio

Department of Insurance, the state agency with primary authority for health reform initiatives. Amy’s unique

experience and cross-agency authority positions her well to move critical stakeholders and the state’s administration to

achieve the necessary legislative and agency collaboration for OHIP to be successful.

OHIP also closely aligns its strategic direction with the Governor’s Health Care Coverage and Quality Council (HCCQC)

and the State Interagency Council (SIC). The HCCQC represents a broad range of stakeholders from nursing homes to

dentistry and is focused on improving the coverage, cost and quality of Ohio’s health insurance and health care system

through payment reform, medical home concepts, consumer engagement and health IT.

OHIP WAS CREATED TO HELP OHIO

As the state-designated entity for HIE in Ohio, OHIP is well positioned to effect change at the

state and federal level necessary to achieve true integration and administrative efficiency.

For more information about OHIP please visit www.ohiponline.org



http://www.hccqc.ohio.gov/Pages/default.aspx


20

APPENDIX A- HIE PHASES

HIE Service Benefits Phase

Services to allow you to easily find patient information from trusted sources


Master Provider/Entity Index

Record Locator Services

Trust Enablement

Eliminate interfaces you currently support to connect disparate MPIs

OHIP will validate the data so end users do not have to

OHIP can validate the source is trusted and has agreed to exchange terms even if across state borders

One consistent interpretation of HIPAA and Ohio Law

Pre-Phase Core Support

June 2011 (Target)

Services to achieve meaningful use

e-Prescription



Quality measures

Registry and surveillance data

Integration with OHIP preferred EHR vendors

OHIP maintains interfaces with EHR vendor so end users do not have to

Exchange data with public health, labs, pharmacies, nursing homes and others without adding more interfaces

Eliminate Board of Pharmacy approval process by using pre-approved preferred vendors

Service Phase I August 2011 (Target)

Services to achieve administrative efficiency

Advanced insurance eligibility verification and connectivity

Coordination of benefits including Rx

Pre-authorization and referral routing

Advance claim status and remittance coordination

payor /Employer treatment cost and screening information

Maintain one interface to payor information instead of several

Achieve consensus among payors on the quality and consistency of data exchanged

Integrate with employers to improve accuracy of benefit coverage

Replace slow and paper-based pre-authorization and referral processes with automation

Use claim/payor data to project reimbursement under ICD-10

Deliver to physicians the estimated cost of treatment at the point of service

Service Phase II and III Dec 2011 and June

2012 (Target)

Enhanced Integration

Advance data aggregation and reporting

NHIN connectivity

Consumer integration and support

Scalable services to meet providers capability (web , secure email, structured integration)

Significantly reduce population reporting requirements through streamlined integration with state agencies

Service Phase III June 2012 (Target)



21

Community web portals

Address verification capability

Exchange data across state borders using NHIN protocols without having to maintain them (OHIP will)

Access consumer preferences and deliver information without having to maintain individual interfaces to PHRs or data banks

Mine de-identified data to monitor clinical trends



Appendix L

Ohio Health Information Partnership Regional Extension Center

Behavioral Health Sub‐Committee

Regional Partner or Other

Representation Title/Organization Name

Akron Regional Hospital Association (ARHA)

CEO Community Health Center Ziegler, Ted

Case Western Reserve University (CWRU) CEO, Crossroads Lindstrom, Wayne

Central Ohio Health Information Exchange (COHIE)

CEO, Southeast, Inc Lee, Bill

Dayton‐West Central Ohio Regional extension Center (DWCO REC)

President/CEO, Samaritan Behavioral Health

McGatha, Sue

HealthBridge Director/Reimbursement Systems, Talbert House

Ripley, Maury

Northeast Ohio Health Connect (NEOHC) Executive Director, Burdman Group

Caruso, Joseph

Northwest Ohio Regional Extension Center (NW Ohio REC)

Vice President, Firelands Counseling and Recovery Services

Mruk, Marsha

Ohio Association of County Behavioral Health Authorities (OACBHA)

Director of Legal Affairs, ADAMHS Board of Cuyahoga County

Fini, Rose

Ohio Association of County Behavioral Health Authorities (OACBHA)

CIO, OACBHA Kiesel, Kurtis

Ohio Council of Behavioral Health and Family Service Providers

Consultant, Steve Duff, LLC Duff, Steve

Ohio Department of Alcohol and Drug Addiction Services (ODADAS)

CIO, ODADAS Rodriquez, Rudy

Ohio Department of Mental Health (ODMH)

Chief, Medicaid Policy Bergefurd, Angie

Ohio Health Information Partnership (OHIP)

Vice President, REC Services, Ohio Health Information Partnership

Costello, Cathy

Ohio Health Information Partnership (OHIP), Administrative Support

Administrative Assistant James, Amy

Ohio Health Information Partnership (OHIP); Outside Counsel

AttorneyBricker and Eckler

Smith, Karen

Ohio Health Information Partnership, Sub‐Committee Chair

Administrator, Behavioral HealthNationwide Children's Hospital

Lucas, Amanda

Ohio University, Appalachian Health Information Exchange (OU)

CIO, Ohio University Appalachian Health Information Exchange

Phillips, Brian

Ohio University, Appalachian Health Information Exchange (OU)

CEO Tri‐County Mental Health and Counseling Services

Weigly, George

Submitted 11/29/10 L1

November 2010 FOR YOUR FEEDBACK

www.OHIPonline.org 3455 Mill Run Drive, Suite 315 Hilliard, Ohio 43026 614-664-2600

Goals and Objectives

Encouraging adoption of certified electronic health record (EHR) and health information exchange (HIE) technology among non-hospital behavioral health providers to allow them to achieve meaningful use

Facilitating electronic access to and retrieval of clinical data to provide better, more timely, efficient, patient-centered care across health care settings and provider types

Actively engaging Ohio’s community behavioral health care system in healthcare reform by leveraging collaboration and related initiatives through a single voice

Identifying financial and human resources necessary to support health IT adoption

Promoting collaboration between behavioral health and priority primary care providers (PPCPs) across Ohio

Behavioral Health Subcommittee

Vision

Behavioral Health Care Providers will successfully adopt electronic health record solutions and have the

capacity to fully participate in the electronic exchange of health care information.

Strategies: Electronic Health Records*/Health Information Exchange

I. Governance

Ohio Health Information Partnership (OHIP)

Designated by Governor Strickland, OHIP is a public/private partnership which serves as the lead entity in the implementation and support of health information technology throughout Ohio.

OHIP Behavioral Health Subcommittee

The focus of this subcommittee is specifically on how to achieve meaningful use at the behavioral health provider level which will ultimately assure these providers participate in Ohio’s Health Information Exchange.

Stakeholders and Regional Partners

Collaborate with key partners in the Regional Extension Center Regions.

Communication

** For purposes of this subcommittee, the definition of an electronic health record encompasses a complete solu-tion covering all of the following system functions necessary to achieve meaningful use: EHR, Practice Management (including scheduling), Billing, Clinical Decision Support, Patient Portal, e-Prescribing, Laboratory and related Inter-faces.

Continued...


FOR YOUR FEEDBACK

www.OHIPonline.org 3455 Mill Run Drive, Suite 315 Hilliard, Ohio 43026 614-664-2600

Behavioral Health Subcommittee

Strategies: EHR/HIE

II. Adoption & Financing

Federal efforts (e.g., SAMHSA) Health IT Loan Program Preferred Vendor Software Discounts supported through the Regional Extension Center Program Development of provider-based consortia and volume purchasing across providers Stark Exemptions and partnership with other health care systems Behavioral health-specific vendor certification Development of business opportunities/administrative service organization capacity at the provider level

III. Policy & Regulatory

Health Reform

Position Ohio’s community behavioral health care system to fully engage in health care reform initiatives.

Take advantage of options within the health care reform legislation which will enable behavioral health care providers to integrate into the larger health care community.

State Initiatives

Reduce administrative burden at the provider level by:

Identifying and, if possible, eliminating requirements that are barriers to behavioral health care providers when considering IT solutions that are effective options for other health care provider types.

Utilizing Ohio’s HIE to more efficiently and effectively collect data for reporting, research and other purposes at all levels — local, state and federal.

Next Steps

Educate behavioral health providers on what questions to ask vendors, types of certifications to expect from vendors, and details to consider in contract terms.

Identify core elements of EMR that would be universal for behavioral health providers in Ohio. Continue advocacy efforts for H.R. 5040 and adoption of behavioral health providers for meaningful use

incentive payments, including expansion of provider definition to include social workers and counselors.

** For purposes of this subcommittee, the definition of an electronic health record encompasses a complete solu-tion covering all of the following system functions necessary to achieve meaningful use: EHR, Practice Management (including scheduling), Billing, Clinical Decision Support, Patient Portal, e-Prescribing, Laboratory and related Inter-faces.


Appendix L

Ohio Health Information Partnership ‐ Behavioral Health Sub‐Committee Workplan

# Task / Deliverable / Phase Target Start

Date

Target

Completion

Date

Owner

S O N D J F M A M J J A S O N D J F M A M J J A S O N D

1 Sub‐Committee Planning

1.1 Sub‐Committee Planning

1.1.1 Return COI Forms 8/25/10 10/24/10 OHIP d

1.1.2 Schedule ongoing meetings/webinars 8/25/10 10/24/10 Lucas d

1.1.3 Distribute final list of members 8/25/10 10/24/10 OHIP d

1.1.4 Coordinate with HCCQC PC/BH Workgroup 8/25/10 10/24/10 Lucas d

2 Collaboration

2.1 Sub‐Committee Portal/Communication

2.1.1 Make HIE State Plan available 8/25/10 10/24/10 OHIP d

2.1.2 Make REC documents available 8/25/10 10/24/10 OHIP d

2.2 OHIP BH WebPage

2.2.1 Create BH‐specific webpage 1/1/11 1/31/11 OHIP

2.2.2 Define content/links for webpage 1/1/11 1/31/11 OHIP

2.3 Coordinate with Regional Partners

2.3.1 Contact/introduction 1/1/11 1/31/11 Committee

2.3.2 Defining role/relationship/participation 1/1/11 1/31/11 Committee

3 Education/Awareness

3.1 Materials

3.1.1 Finalize BH Strategy Document 8/25/10 10/24/10 Lucas d d

3.1.2 Brand document (OHIP) 11/1/10 11/30/10 OHIP d d

3.2 Education

3.2.1 Prepare for OHIP MU BH Breakout 1/1/11 3/31/11 OHIP

4 Electronic Health Record Adoption

4.1 Software Analysis for BH Use

4.1.1 Welch Allyn 1/1/11 1/31/11 Committee

4.1.2 Preferred EHR Vendors 1/1/11 3/31/11 Committee

4.1.3 Identify required BH customization req in Ohio 1/1/11 1/31/11 Lucas/Duff

4.1.4 Identify EHR Vendors Who Support BH in Ohio 11/20/10 12/31/10 Duff d

4.1 EHR Adoption Strategies

4.2.1 Determine specific strategies to assist in adoption 8/25/10 10/24/10 Lucas d d

5 Privacy and Security

5.1 HIE Privacy and Security

5.1.2 Identify issues requiring resolution 3/1/11 4/30/11 Committee

6 Medicaid Incentive Payment Program

6.1 Coordination with ODJFS

6.1.1 Clarify eligibility and requirements 8/25/10 4/30/11 Bergefurd

6.1.2 Clarify process for psychiatrists and NPs 8/25/10 4/30/11 Bergefurd

2011 2012

11/30/2010 1Submitted 11/29/10 L4

Appendix M

Ohio Health Information Partnership E‐Prescribing Task Force Members


AARP, Ohio Chapter Joanne Limbach President

Berger Hospital Tiffin Barthelmas, MBA, RN Clinical Systems Analyst

Central Ohio Primary Care Rob Strohl CIO

Children’s Hospital of Dayton Doug Wurtzbacher, Pharm D, PhD

Clinical information Pharmacist

CVS Ed Chessar, RPh Pharmacy Supervisor

Firelands Regional Medical Center

James Spicer, Pharm D, CACP Director, Pharmacy Services


Steve Ayres Assistant Director, Information Systems

Memorial Hospital Cindy Gu, Pharm D Clinical Technology Pharmacist

Mercy Health Partners Mike Hibbard, RN, MBA, PMP CIO

Mercy Health Partners Wayne Bohenek, Pharm D, MS, FASHP

VP, Patient Safety and Pharmacy Excellence

Ohio Board of Pharmacy Mark Keeley Legislative Affairs Administrator

Ohio Osteopathic Association Martha Simpson, DO, MBA, FACOFP

General Practice Physician

Ohio Pharmacists Association Ernie Boyd, RPh, CAE Executive Director

Ohio State Medical Association Lisa Eidelberg Senior Account Manager

OHIP Cathy Costello, JD REC Project Manager

Summa Health System Pam Banchy, RN, PMP System Director, Clinical Information Systems

Toledo Clinic Ian Scott Elliot, MD Internal Medicine Physician

TriHealth, Inc Sue McBeth, RPh, MBA Director of Pharmacy

University Hospitals Dan Georges, MS Clinical Application Specialist

University of Findlay Patrick Malone, Pharm.D.,FASHP Associate Dean and Professor of Pharmacy

Submitted 11/29/10 M1

Appendix N

Ohio Health Information Partnership Privacy Work Group Members


Bricker and Eckler Karen Smith Legal Counsel

Bricker and Eckler Claire Turcotte Legal Counsel

Executive Medicaid Management Agency (EMMA)

Brad Singer Legal Counsel

Galion Community Hospital Andy Daniels Director of IS

Kegler, Brown, Hill and Ritter Jeff Porter Legal Counsel

Medicaid Rob Bergin HIPAA Project Director

Ohio Chapter AARP and OHIP Board Member

JoAnne Limbach President

Ohio Department of Mental Health

Janice Franke Legal Counsel

Marion Technical College Marge White Director of Health Information Technologies

Ohio Hospital Association Dan Paoletti OHIP Interim CEO

Ohio Hospital Association Rick Sites Legal Counsel

Ohio Osteopathic Association Martha Simpson Physician

Ohio State Medical Association Nancy Gillette Chief Legal Counsel

OHIP Andrea Perry Project Manager

The Ohio State University Medical Center

Jenny Barnes Assistant General Counsel

Providence Medical Group Yvonne Tudor Operations Manager

Walter and Haverfield Amy Leopard Legal Counsel

Submitted 11/29/10 N1

Appendix O - OHIP Financial Policies and Procedures

Submitted 11/29/10 O1

Appendix P HIE State Plan Amendments Approved January 25, 2011

#/Page(s) SectionReference

Amendment

1 Executive Summary

S‐5 1.1.3 An Executive Summary was added to provide an overall context for OHIP’s strategy for HIE development.

2 Meaningful Use Attainment

S‐27 1.2.5.6 Further explanation of Ohio’s current adoption environment and strategies to achieve top meaningful use exchange priorities (i.e., e‐Prescription, structured lab results and patient care summaries) was provided.

O‐3 2.1.2 Project risks and mitigation strategies were updated to reflect the formation of OHIP’s e‐Prescription Task Force.

M1 Appendix M A list of OHIP’s e‐Prescribing Task Force membership was provided.

3 HIE Deployment Strategy

S‐39 1.2.6.6 A description of goals and specific strategies for HIE deployment was added. This description includes current estimated adoption rates as well as targeted estimates for physicians, hospitals, labs, payers or other adopters per strategy.

4 Preferred EHR Vendor Strategy

S‐38 1.2.6.5 OHIP’s preferred EHR vendors were selected on September 28, 2010. S‐51 1.3.1.3

5 Federally Funded, State‐Based Program Coordination

S‐54 1.3.2.1 Strategies for engagement of members of the State Interagency Council (SIC), the committee responsible for coordination of federally funded, state based programs, were clarified.

S‐83 1.4.4 In the diagram of State of Ohio stakeholder committees, the State Interagency Council (SIC) was updated to reflect the addition of the Medical and Nursing Boards.

6 Medicaid Coordination

S‐67 1.3.5 An updated status of Ohio’s State Medicaid Health Information Plan (SMHP) was provided along with further explanation of Ohio’s Medicaid administrative structure and related OHIP coordination strategy.

S‐3 1.1.2 Bullet #4

The Ohio Department of Job and Family Services (ODJFS) which administers Medicaid in Ohio adjusted their target go‐live date for MITS to First Quarter 2011. S‐36 1.2.6.2

Bullet #3

7 Federally Qualified Health Center Update

S‐78 1.3.7.2 Current statistics regarding FQHC EHR adoption rates and practicing providers were noted.

S‐17 1.2.5.1 Table 1 FQHC statistics were updated.

P1


Amendment

8 Sustainability Strategy

S‐87 1.5.1 Further explanation of OHIP’s sustainability strategy was provided.

9 HIE Vendor Procurement Status

S‐94 1.6.1 An update about OHIP’s HIE vendor procurement process was provided.

10 HIE Flow Chart

S‐99 1.6.2.4 An explanation and schematic of OHIP’s authentication and patient query flow was provided (Diagram 3).

S‐35 1.2.6 A business model diagram was removed.

11 Privacy and Security Updates

S‐106 1.8.1‐1.8.6 Several updates were provided by OHIP’s Privacy and Policy Committee.

S‐82 1.4.3 The diagram of OHIP’s committee structure was updated to reflect the Privacy and Policy Committee’s new name.

O‐3 2.1.2 Project risks and mitigation strategies were updated to reflect the Privacy and Policy Committee’s new name.

O‐25 2.8.1‐2.8.2 These sections were updated to reflect the Privacy and Policy Committee’s new name.

N1 Appendix N This Appendix contains a list of OHIP’s Privacy and Policy Committee members.

12 Updated HIE Project Plan

O‐1 2.1.1 OHIP’s HIE Implementation Plan was updated to reflect completed tasks, interdependencies and role assignments. To allow for explanation, OHIP’s deployment strategy was documented separately in Section 1.2.6.6 (See Amendment #3).

I1 Appendix I OHIP’s HIE Implementation Project Plan was updated.

13 Formation of Behavioral Health REC Sub‐Committee

O‐5 2.2.1.1 In August 2010, OHIP formed a Behavioral Health REC Sub‐Committee that is assisting with EHR and HIE adoption.

L1 Appendix L This Appendix includes the Behavioral Health Sub‐Committee Strategy Document, a sub‐committee membership list and a list of important sub‐committee tasks.

14 Cost Estimate Updates

O‐10 2.5 OHIP’s HIE Budget (Table 8) was updated to reflect budget figures currently filed with the Grants Management Office (GMO).

O‐13 2.5.1 OHIP’s staffing plans were updated to reflect current status.

O‐14 2.5.2 Current status and explanation of OHIP’s financial policies and procedures were provided.

O1 Appendix O This Appendix includes OHIP’s financial policies and procedures.

15 Health IT Regulatory, Certification and Other Standards References Updated

A1 Appendix A Appendix A was designed to be a “living” document. Since the plan’s original submission, OHIP’s Privacy Committee has added several regulatory references pertinent to consumer consent and related privacy policies.

P2


Amendment

16 HIE White Paper

K1 Appendix K On September 30, 2010, OHIP released a white paper to explain core concepts included in the HIE State Plan to stakeholders interested in HIE development.

17 HIE Implementation Model

Q1 Appendix Q This document identifies the potential HIE gaps in Ohio and core strategies for supporting Stage 1 meaningful within a Direct Project framework.

P3

1

AMENDMENT 17 – HIE IMPLEMENTATION MODEL

This document describes the phases of the Ohio Health Information Partnership (OHIP)’s planned HIE

Implementation Model with special focus on the initial stage of implementation. The focus of this

amendment is on the initial phase of implementation to assist providers with their ability to achieve

Stage 1 of meaningful use. The approaches outlined are consistent with OHIP’s HIE State Plan, but are

structured to specifically respond to the outstanding questions requiring additional explanation as

requested in the January 3, 2010 email, “ONC Feedback on Updated OHIP State Plan.” This

amendment:

‐ Highlights from our environmental landscape that are of particular relevance to our Phase 1 strategy;

‐ Identifies gaps in our current capabilities for supporting Stage 1 Meaningful Use; ‐ Discusses our strategy for addressing those gaps; and ‐ Provides context for Phase 1 approach by outlining future phases.

Additional footnote cross‐references to OHIP’s HIE State Plan are also provided.

1 LANDSCAPE SUMMARY AND GAP ANALYSIS

1.1 PROVIDER READINESS FOR EXCHANGE

1.1.1 LANDSCAPE1

The results of OHIP’s environmental scan conducted in June 2010 reflect the environmental factors

driving OHIP’s strategy. For example, Ohio is experiencing significant activity in electronic health record

(EHR) implementation. Prior to stimulus funding, close to half of the providers who responded to the

survey were entirely paper‐based or using a practice management system only. OHIP estimates that

actual EHR adoption rates (~ 25%) are lower than reported in the survey due to the variance in

respondent roles and the potential for the respondent’s confusion between practice management

applications and a true EHR system.

1 Section 1.2.5 (Environmental Scan), S‐16 and Appendix B (EHR/HIE Survey Tool)

Appendix Q - HIE Implementation Model

Q1

2

In the current environment, there are large rural/Appalachian sections of geography that have no

current or planned resources to facilitate secure messaging. OHIP will invest federal dollars to focus on

helping providers in those areas to meet Stage 1 meaningful use. This is evidenced in the policy used to

identify priority settings for OHIP’s implementation of the Regional Extension Center (REC) Cooperative

Agreement Program approved by ONC on August 17, 2010. OHIP’s policy targets settings that

predominantly serve uninsured, underinsured and medically underserved populations. This policy is

included as Attachment A.

OHIP’s REC services2 are currently assisting Priority Primary Care Providers (PPCPs) to meet meaningful

use in these focus areas highlighted in orange in Figure 1. Additionally, the remaining geography of the

state is mostly urban/metropolitan and has the resources to facilitate secure messaging between their

organizations, but need a neutral convening body to facilitate secure messaging between disparate

organizations. There is only one small section of the state in the Cincinnati area (part of the

HealthBridge Tri‐State Health Information Exchange) that is currently utilizing Direct protocols to send

data between disparate organizations and providers. As a result, the majority of Ohio is looking to OHIP

to help facilitate secure messaging through the Direct Project for them to send data between

organizations in a meaningful way.

2 Section 1.3.1 (Regional Extension Center Services), S‐48


Q2

3

Figure 1: Map Identifying OHIP’s High‐Priority, Underserved Areas

This environment has created a highly motivated group of stakeholders that have already spent millions

of dollars of in‐kind expenses working towards the success of OHIP’s mission and goals for both the HIE

and REC programs. Because we (OHIP) were awarded grants for both the HIE and REC programs,

coordination between the two programs is seamless. Stakeholders for both programs have come

together in a shared governance model directing OHIP towards success in all aspects of their work. This

collaboration filters down to hundreds of participants on different committees and organizations

volunteering their time and resources3.

3 Section 1.4 ( Governance), S‐78 and Appendix E (HIE and REC Committees), Appendix M (ePrescribing Task Force),

Appendix N (Privacy and Policy Committee)


Q3

4

Figure 2: OHIP’s High‐Level Governance Structure

The OHIP structure, as depicted in Figure 2 above, has made it efficient and streamlined for us to

coordinate the dollars received between the HIE and REC programs and ensure that efforts are not

duplicated. This has been critical with the early success of OHIP and is reflected in the fact that OHIP’s

REC leads the nation with over 2700 PPCPs as of 1/7/11 who have already signed contracts committing

to the purchase and adoption of EHRs. Defying conventional wisdom that larger practices or those in

urban areas would be the first to respond to incentives, the regional partners with the highest

recruitment numbers are in Ohio’s gap/rural areas.


Q4

5

Figure 3 ‐ OHIP's REC Regional Partners

OHIP’s REC program consists of seven regional partners that are a collaboration of local entities that

work together to assist providers with the adoption of EHRs. Each REC is comprised of hospital systems,

physician groups, quality improvement organizations, universities, and community colleges, professional

associations, consultants and operational HIEs. The primary focus of OHIP’s REC program is to provide

educational and technical EHR support to providers, in both urban and rural areas. The relationships

that the regional RECs will cultivate with the local hospitals and physicians through the REC program, will

situate these RECs be in a unique position to coordinate health IT adoption efforts through close

alignment of EHR and HIE adoption strategies. Figure 3 above shows how each REC is divided within

Ohio. The area in grey is serviced by the regional health information organization (RHIO), HealthBridge.


Q5

6

In Figure 4 below, the blue line indicates the actual signed PPCP contracts recruited through OHIP’s

regional partners as reported in the ONC CRM system. The dashed red line is the projected number of

contracts we anticipate will be signed based upon our estimates of the s pipeline. The OHIP REC has

been actively working with our stakeholders to focus on the PPCPs per the ONC approved policy, while

addressing all PPCPs in OHIPs 77 county focus. OHIP has the highest number of signed PPCP contracts in

the country. The PPCP contracted services will create the installed EHR base necessary to build a robust

statewide HIE service delivery system.

Figure 4: OHIP’s REC Milestone 1 Contracted PPCPs

1.1.2 ANALYSIS

In response to a request under OHIP’s REC program, ONC approved OHIP’s prioritization strategy on

August 17, 2010. In this strategy, OHIP identified 57 of Ohio’s 88 counties as formally designated rural,

Appalachian or underserved areas of the state. This area represents 3.2 million Ohioans and

approximately 28.5% of the total health care provided in Ohio. These geographic regions have been

identified as the areas of Ohio that, without the support of the federal and state funding allocated to

facilitate secure messaging and future HIE development, will probably not meet Stage 1 and later stages

of meaningful use.


Q6

7

Figure 5: Number of PPCPs in OHIP’s High‐Priority, Underserved Areas

The gap area also represents 2,402 PPCPs as displayed in Figure 5 that will be a priority of OHIP’s efforts

to assist them in meeting Stage 1 meaningful use. In these 57 counties, 30% of the lab results are

provided by the Critical Access or Small and Rural Hospital affiliated labs, which will be a priority in

moving to structured lab results and facilitating the movement of those data as discussed below.

1.2 EPRESCRIBING4

1.2.1 LANDSCAPE

4 Section 1.2.5.6 (Specific HIE Service Issues, ePrescription), S‐27


Q7

8

In Ohio, 98.7% of pharmacies are activated for ePrescribing. As in many other states, there are very few

independent pharmacies, with the vast majority of prescription being filled by pharmacy chains capable

of accepting electronic prescriptions. The majority of the 1.3% gap appears to fall within the individual

or small pharmacy chains.

Figure 6: Concentration of Pharmacies by Zip Code

Figure 6 above shows the distribution of the pharmacies in Ohio, all of which are capable of receiving

prescriptions electronically. These ePrescribing‐enabled pharmacies are found in every county,

providing Ohioans the ability to access an e‐Rx‐ready pharmacy within 30 minutes of home.

On the physician side, adoption rates for ePrescribing remain relatively low (18%) compared to other HIT

activities in Ohio and compared to other states with similar sized markets. Ohio is the only state in the

country that requires Board of Pharmacy (BOP) approval for software to ePrescribe. The BOP has taken a

very strict approach to ensuring physicians provide dual authentication when signing every prescription

they send. EHR systems are not designed for dual authentication and vendors have resisted modifying


Q8

9

their systems for one state. Over time, the Ohio State Medical Association (OSMA) created a preferred

vendor program and worked with EHR vendors and the BOP to find an alternate solution. To date, the

BOP has approved approximately 75 ePrescribing systems for hospitals and office settings in Ohio. New

adopters tend to ePrescribe, but many of the original EHR adopters did not implement the ePrescription

module due to BOP requirements.

In the fall of 2010, the Drug Enforcement Agency (DEA) announced that it was adopting an approach

very similar to the BOP’s requirements. As a result of the collaboration between OHIP and the BOP, the

BOP approved an Ohio rule to adopt the DEA standard for certifying ePrescribing systems in Ohio. This

rule went into effect January 1, 2011.

1.2.2 ANALYSIS

ePrescribing Gap 1: Less than 2% of pharmacies cannot accept electronic prescriptions.

As nearly 99% of all retail pharmacies in Ohio are capable of receiving prescriptions electronically, there

is no gap in pharmacy adoption. The few independent pharmacies that have not yet adopted

ePrescribing do not restrict eligible providers (EPs) from achieving stage 1 meaningful use in 2011.

ePrescribing Gap 2: Physicians either do not have e‐prescribing technology, or they have the capability

to ePrescribe but have not enabled the module.

With less than 25% adoption of ePrescribing among prescribers, this represents the true gap in ePrescribing.

1.3 LABORATORIES5

1.3.1 LANDSCAPE

Statewide adoption of structured lab results delivery in Ohio is estimated to be less than 10%. Reported

top barriers to adoption are the lack of integration between EHR vendors and HIE networks, insufficient

information on HIE options coupled with privacy and security concerns.

5 Section 1.2.5.6 (Specific HIE Service Issues, Electronically Delivered Lab Results), S‐30


Q9

10

As noted in the HIE State Plan, LabCorp, Quest and MedPlan are the three major lab market leaders in

Ohio and comprise 70% of the current lab services offered today. The other 30% of lab work is being

done by hospital‐based laboratories inside Critical Access Hospitals (CAHs) or other rural or underserved

community hospitals that are not in areas being supported by HIE networks today and therefore, are not

exchanging information electronically (see Figure 7 below).

Figure 7: Lab Distribution in OHIP’s High Priority, Underserved Area

Note that, in contrast to other states, small community labs that are not physician or hospital‐based no

longer exist in Ohio. For historical context, in the late 1980s the Health Maintenance Organizations

(HMOs) and Preferred Provider Organizations (PPOs) began contracting with national laboratories for

the delivery of clinical lab services. As these managed care plans increased in the early 1990s, the

hospital lab business drastically declined. This required hospitals in Ohio to negotiate lab services with

these managed care organizations and helped to bring business back to the hospitals. Because of the

hospitals and national labs, the regional labs were either purchased or went out of business.


Q10

11

Consequently, the lab services in Ohio are currently delivered by two national laboratories (LabCorp and

Quest), one statewide lab provider (MedPlan) and the hospitals. As the use of EHRs has grown,

physicians have begun ordering lab services through their EHRs, rather than the more manual process

that is required when dealing with hospitals. This has created a need in rural hospitals to create the

ability for the delivery and creation of lab results to retain business. Hospital laboratories are also

motivated by the meaningful use incentives to electronically manage their internal lab results delivery.

1.3.2 ANALYSIS

Laboratory Gap 1: Hospital laboratories in rural or underserved areas have few affordable and

manageable options to deliver results to physicians involved in a patient’s care in a

secure manner

Thirty percent of lab work is being done by hospital‐based laboratories inside Critical Access Hospitals

(CAHs) or other rural or underserved community hospitals who are not in areas being supported by HIO

networks today and therefore are not exchanging information electronically.

Laboratory Gap 2: Few hospital laboratories in rural or underserved areas have the means to exchange

laboratory data in a structured or encoded form.

The majority of hospitals located in rural or underserved areas can generate lab results in unstructured

or semi‐structured forms, but do not have the resources to upgrade to fully structured formats using

federally endorsed interoperability standards.

Laboratory Gap 3: The Ohio Department of Health (ODH) would like to increase the number of hospitals

providing reportable lab results through its Ohio Disease Reporting System (ODRS)

Due to gaps 1 and 2, ODH is unable to gather reportable laboratory information from these rural and

underserved areas.

Laboratory Gap 4: The three lab providers offering statewide services can generate electronic lab

results, but they are not able to reach each provider in the state electronically.

The three major laboratories business model in the current point‐to‐point model can only justify

working with the EHR market leaders to move lab results to physician practices that produce significant


Q11

12

volume. Any physician practice below this level will either need to pay for the service or not receive lab

results electronically through its EHR.

1.4 PATIENT CARE SUMMARY EXCHANGE6

1.4.1 LANDSCAPE

While hospital organizations and large physician practices may be able to send these records within

their closed environments, there is almost no exchange that occurs between disparate offices or

organizations. The exception to this is HealthBridge, which is exchanging care summaries in the Greater

Cincinnati area between unaffiliated organizations.

1.4.2 ANALYSIS

Patient Care Summary Gap 1: There is little to no care summary exchange in Ohio that occurs between

disparate offices or organizations.

1.5 LEGAL AND PRIVACY7

1.5.1 LANDSCAPE

The privacy rights of patients in Ohio are protected by a combination of Ohio statute, statutory

interpretation of the American Medical Association (AMA) physician code of ethics, Ohio case law and

the HIPAA. These regulations reflect a strong desire to ensure that patients are protected from

unauthorized uses of personal health information. Ohio law puts significant restrictions on transferring

records in any form, electronic or otherwise, that preempt the HIPAA requirements. While Ohio statute

does not explicitly require written patient consent for medical record disclosure when used for

treatment purposes, there is an Ohio statute that contains an express requirement for written patient

consent when a health provider discloses medical records to a patient, the patient’s authorized

representative or to a third party.

6 Section 1.2.5.6 (Specific HIE Service Issues, Patient Care Summaries), S‐31 7 Section 1.8 (Legal/Policy), S‐106 and Appendix A (Health IT Regulatory, Certifications and Other References), Appendix J (HISPC Model Permission Form)


Q12

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Ohio case law that interprets physician/patient privilege and the recognition of the tort for unauthorized

disclosure of nonpublic medical information shows a strong support in Ohio law for a patient’s right to

confidentiality of their medical records, absent disclosures required by law or disclosures necessary to

protect a countervailing interest that outweighs the patient’s interest in confidentiality. Furthermore,

under Ohio statute a physician may be sanctioned for violating any provision of a code of ethics of the

AMA that includes the opinion that transferring physician records to another treating physician requires

“proper authorization for the use of records must be granted by the patient.”

1.5.2 ANALYSIS

Privacy Gap 1: While Ohio statute does not explicitly require written patient consent for medical record

disclosure when used for treatment purposes, there is an Ohio statute that contains an

express requirement for written patient consent when a health provider discloses

medical records to a patient, the patient’s authorized representative or to a third party.

In Ohio and across the country, HIEs are struggling to operationally define what constitutes adequate

and meaningful patient consent in the new era of electronic exchange of health information. All HIEs

must balance what is required legally, what is appropriate for risk management purposes, what

constitutes good public policy, what will hold up in an evolving market of commercialization of health

information and what is feasible from an implementation perspective. This is especially the case in Ohio

where a patchwork of statute and case law interpretations provides no clear guidance on what level or

type of consent is required to access a patient’s health record. In order for a provider to protect

themselves from litigation, the most prudent way to handle the disclosure of health information is with

a formal consent process.

Privacy Gap 2: Providers are confused about what constitutes meaningful patient consent. The different requirements under HIPAA and Ohio law have created confusion among health providers

and patients with regard to consent requirements. Many physicians in Ohio and across the country may

be under the false assumption that HIPAA supersedes state law and are not aware of the additional

privacy protections required when practicing in Ohio.


Q13

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As a result, there are conflicting views in Ohio as to whether explicit consent is required for disclosures

of health records when released for treatment. Ohio health care providers have adopted patient

consent policies and procedures that differ throughout the state.

1.6 ADDITIONAL HIE ASSETS

1.6.1 LANDSCAPE8

OHIP has had several communications with multiple licensing boards in Ohio. The Medical and Nursing

licensing boards were looking for OHIP to assist in the collection of quality provider data for the purpose

of developing a statewide provider directory. Data quality continues to plague their current process and

the boards began to negotiate with OHIP to assist in the development of a new licensing system. The

process was placed on hold when the current administration was replaced. Once the new

administration has been properly briefed on the current situation, OHIP plans that the administration

will see the benefit of this public/private partnership and encourage its continuation.

OHIP sought different provider repositories for use with the REC program. As each alternative was

reviewed, the quality of the data was found to be inadequate. OHIP identified that the data necessary

to populate an authoritative Master Provider directory was not available in the data that is currently

collected by the licensing boards, association member lists and Medicare/Medicaid billing information.

1.6.2 ANALYSIS

HIE Assets Gap 1: The state of Ohio has no validated repositories to utilize in the development of a

Master Provider Directory.

Although separate provider data sources exist, none of the sources currently available to OHIP are

considered comprehensive and reliable at this point in time.

8 Section 1.3.2.1 (Role of State Inter‐Agency Council, Licensing), S‐56


Q14

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2 GAP FILLING STRATEGY

The core strategies identified below will be used to assist providers with achieving the HIE PIN

requirements necessary to meet Stage 1 Meaningful Use.

2.1 CORE STRATEGIES

We are in the final stages of our Request for Proposal (RFP) process, through an appointed committee of

stakeholders, as defined by the OHIP Board. OHIP and the committee are currently performing due

diligence and work plan development. The final strategies below will be dependent upon negotiations

with our technical service provider.

Core Strategy 1: Facilitate Exchange Leveraging Direct Protocols

The Phase 1 level of physician‐oriented development will enable baseline services for “gap” providers to

facilitate point‐to‐point exchange (Direct Project) of clinical information necessary to achieve Stage 1

meaningful use. This would include the unsolicited exchange (push) of clinical care summaries, lab

results or medication history information. The Phase One development strategy would include options

for “gap” providers to rapidly and affordably connect to the HIE, identify and interface with other

providers using the Direct framework and select the level and range of sophistication consistent with

their capabilities (unstructured, semi‐structured or structured data).

Core Strategy 2: Establish Open Provider Directory

OHIP can leverage the information obtained through physician REC recruitment to create a

comprehensive provider directory necessary to support the Direct framework for point‐to‐point

exchange. This directory will include provider health domain addresses as issued. As the new state

administration takes hold, OHIP will resume discussions with licensure boards to leverage existing data

along with association member contacts. OHIP intends to reach out to all providers in the state to

ensure that the directory will be authoritative. OHIP will work with ONC and other states to leverage

the work of ONC’s HIT Standards Committee to establish the standards and protocols for offering

provider directory services to facilitate health information exchange using the Direct framework.


Q15

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Core Strategy 3: Provide HISP Services

Through a structured procurement process, OHIP will contract with a Health Information Service

Provider (HISP) to support the sending and receiving of secured messages for clinical information using

Direct Project protocols. The HISP will provision health domain addresses that will allow physicians to

be reached by other physicians.

OHIP’s contracted (HISP) will be accessible to any provider that needs one. The OHIP HISP will work with

existing HISPs and encourage other HISPs to provide their services in Ohio to ensure that every provider

has their choice of service offerings. This includes a commitment to facilitate exchange using Direct

protocols with the State’s designated Beacon community supported by the regional HIE network,

HealthBridge. OHIP only requires that if another HISP wishes to provide their services in Ohio, they must

be willing to exchange with any other HISP that operates in Ohio. Through this strategy, OHIP will not

constrain the market and will ensure through contractual authority that all HISPs operating in Ohio will

allow secure messages to pass between them. OHIP will offer two options to enable the Direct Project to

support any Ohio provider and lab who desires to meet Stage 1 Meaningful Use.

Option 1 (Physician Baseline HISP Services)

For those providers who do not require OHIP’s assistance in managing the coordination of patient

consent, OHIP will make freely available a complete Master Provider Directory and a list of HISPs that

offer services in Ohio. For providers who have chosen to handle consent for themselves, OHIP will not

allow the secure message to travel through its HISP. This prohibition is due to the liability incurred on

the part of OHIP if either party, sending or receiving, has not fulfilled the requirements under Ohio law

surrounding patient consent.

Option 2 (Physician HISP Services with Trust Management)

If providers decide that they would rather have OHIP assist with the collection and storage of patient

consent, OHIP will provide the services listed in Option 1 and include the patient consent coordination

layer through OHIP’s HISP. This option will require a minimal subscription fee, but the added step of

ensuring all parties have received consent is handled by OHIP. It will also require that the receiving

physician is located on OHIP’s HISP.


Q16

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Option 3 (Laboratory HISP Services)

For those labs that wish to send lab results for free, OHIP will provide their Master Provider Directory, a

list of HISPs and certificate authorities that operate in Ohio, and a their own basic certificate authority

for free.

Option 4 (Laboratory Data Management Services)

If labs require translation to LOINC, a data repository or assistance to create structured lab results, OHIP

will provide the services above, as well as the additional services they require. OHIP’s data repository

services are planned primarily for rollout in Phase 2. OHIP will, however, offer data repository services

to support hospital laboratories as described in Section 2.2.1.2 (Laboratories) on page 24.

Core Strategy 4: Offer Bundled Core Services at No Cost to Support Secure, Point‐to‐Point Messaging

OHIP will offer the Master Provider Directory, a list of HISPs and certificate authorities operating in Ohio,

and its own basic certificate authority at no charge. These free tools will be located on the OHIP website

and will be available for download on demand.

Core Strategy 5: Offer Trust and Consent Management Services for Nominal Fee

OHIP’s chosen technical service provider will also assist OHIP in creating a consent management

operational process that all providers will be able to use for a nominal fee. The first phase of this

development will include the following deliverables:

Public Education on Ohio and Federal Privacy Law

This step includes the publication of the Research and Recommendations for HIE Patient Consent

Policies white paper for a 60‐day public comment period (see Attachment B). An educational toolkit

regarding consent policy is also being developed for deployment through OHIP’s regional partners, the

media and other healthcare forums.

Creation of HIE Participant Trust Agreements

This statewide‐applicable model trust agreement is currently being developed and will align with Ohio

and federal law, clearly articulate sending and receiving provider responsibilities and speak to consumer


Q17

18

consent requirements. Adaptions of this agreement may be necessary depending on the type of HIE

participant (e.g., data receiver, centralized publisher, federated publisher).

Creation of Business Associate Agreements (BAA)

Since an HIE is considered a “business associate” under HIPAA, the necessary BAA agreement must be

developed to facilitate use of the HIE among providers.

Implementation of a Technical Trust Model

This step will align with policies put forth by OHIP’s Privacy and Policy Committee, the HIE Committee

and will be endorsed through the stakeholder comment period. It would include tasks that address

provider provisioning, identity proofing, digital certificate management and related issues of on‐

boarding, access rights, preferences and relationships.

Core Strategy 6: Provide Education and Outreach to Providers and Vendors on Leveraging Direct

Protocols to Facilitate Secure Messaging

OHIP’s REC structure can be leveraged to deploy education about the Direct Project and develop

outreach programs for physicians to raise awareness of Direct and other options available to them in

their region. OHIP will provide affordable opportunities to leverage the Direct Project and assist with

the creation of secure, point‐to‐point exchange. OHIP will also spread awareness of vendors who

support Direct protocols and strategies for connecting with hospitals.

Education and outreach materials and programs will be developed to help providers understand what is

required to conduct secure messaging using Direct protocols and which EHR vendors support these

protocols.

Core Strategy 7: Leverage OHIP REC Provider Services

OHIP would leverage its existing REC partner model to rapidly deploy the Direct framework throughout

Ohio focusing on “gap” providers first.

Preferred Vendor Program


Q18

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OHIP will work with the EHR vendors in their preferred EHR program9 to develop support for the Direct

framework. Four of the five vendors in the EHR preferred vendor program currently participate in the

Direct Project with the fifth anticipated to join in 2011.

WelchAllyn

OHIP can use the valuable and affordable EHR selection tools available through its REC program to assist

physicians with Phase One adoption. The WelchAllyn readiness assessment tool assesses where a

physician is in the process to move to an EHR, what steps still need to be completed to ensure the

smoothest transition possible and to create the RFP for the EHR solution that best suits their office.

Loan Program10

OHIP worked with three banks based in Ohio and one national bank to develop a program for physicians

desiring to implement an EHR. The program, created by OHIP, offers a simple process with lower

interest rates to assist physicians in supplementing their implementation costs. This easy process is

another component to make the process of transition simple and painless to move physicians toward

achieving Stage 1 meaningful use.

Core Strategy 8: OHIP Will Serve as a Convener of Interested HIT Stakeholders

OHIP will convene Ohio’s hospital system market leaders11 to encourage development of Direct

protocols within their ambulatory solutions, so that physicians using EHRs deployed under Stark

arrangements can communicate with physicians outside their existing hospital‐centric HIE platforms.

The REC programs for OHIP and HealthBridge have been working together to propagate PPCP contracts

for each organization. The two organizations have been sharing contracts with organizations that cross

the boundaries of their respective territories. The Loan Program that OHIP developed has also been

made available to providers that are located within HealthBridge’s 11 county area.

2.2 PHASING, TIMELINE AND MILESTONES12

9 Section 1.2.6.6 (HIE Deployment Strategy, Strategy #2‐ OHIP EHR Preferred Vendor Program), S‐42, Section 1.3.1.3 (EHR Preferred Vendor Program), S‐51, Appendix D (EHR RFP), S‐51 10 Section 2.1.2 (Risks and Mitigation Strategy, Provider Adoption), O‐2

11 Section 1.2.6.6 (HIE Deployment Strategy, Strategy #3 – Ohio Hospital EHR Market Leaders), S‐43


Q19

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OHIP will employ a phased approach to support the Direct Project in Ohio that focuses first on

addressing our gaps for supporting Stage 1 meaningful use. This will ensure that those providers who do

not have the tools necessary to share information in a secure way are guaranteed access to the

resources offered by OHIP. These resources will help them meet Stage 1 meaningful use and offer them

the ability to participate in future exchange options that may be more robust than secure, point‐to‐point

messaging.

A more phased approach that targets Ohio’s gaps will give providers the tools to share information in

the short run, increasing their motivation and readiness to participate in more robust exchange options

in the long run. OHIP has identified this phased approach as the HIE Implementation Model. This model

was designed to be consistent with the anticipated continuum of HIT adoption and is broken down into

three (3) phases:

‐ Phase 1: Initialization (Leverage the Direct Project to achieve Stage 1 Meaningful Use in 2011) o Plan Approval: January 2011 o Vendor Selection: January 2011 o Contract Finalized: February 2011 o Privacy Whitepaper Public Comment: February 2011 o Launch of HIE Education and Awareness Campaign: March 2011 o Privacy Whitepaper Comment Period Ends: April 2011 o Initial Consent Model Finalized and Education Campaign Started: April 2011 o Development of goals in coordination with stakeholders: May 2011

Goals will measure progress and success against the three PIN objectives required to meet Stage 1 Meaningful Use.

Agreed upon measurable goals will be benchmarked and tracked. o Completion of EHR Vendor Commitments to HIE: April 2011 o Phase 1 Core Services Go‐Live: June 2011

‐ Phase 2: Development (Longitudinal Patient Record) o Development of goals in coordination with stakeholders: May 2011

Goals will measure progress and success against future Meaningful Use requirements.

Agreed upon measurable goals will be benchmarked and tracked o Phase 2 Core Services Go‐Live: June 2012

Phase 2 services include:

Master Patient Index

Master Entity Index

Record Locator Service

12 Section 1.2.6 (Proposed HIE Model), S‐35, Section 1.2.6.6 (HIE Deployment Strategy), S‐39, Section 1.7.1 (Implementation), S‐100, Section 2.1.1 (Project Plan), O‐1 and Appendix I (HIE Project Plan)


Q20

21

Consent Tracking and Management

Community Data Repository Services

‐ Phase 3: Optimization (Sustainability) o With stakeholder involvement and in collaboration with ONC, we will develop a set of

services to integrate clinical and administrative data to streamline the efficiencies of payment processes.

The overall goal of the HIE Implementation Model is to ensure that all providers in Ohio are on equal

footing as OHIP progresses towards true HIE optimization. Figure 8 provides a visual representation of

OHIP’s timeline.

Figure 8: OHIP’s Implementation Timeline

Per the July 6, 2010, Program Information Notice (PIN) from ONC, recipients of HIE federal grants are

required to track and set goals for HIE adoption rates among stakeholder groups. OHIP will track rates

consistent with final ONC guidance and will set targets in collaboration with our REC and stakeholders.

This strategy allows for benchmarking and encourages healthy competition towards adoption of services

necessary to achieve meaningful use. It has been a successful, proven approach for motivating the REC

toward PPCP recruitment and aligns with strategies for leveraging the REC structure for education and


Q21

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outreach. For success, it is important to garner regional partner buy‐in when setting the measures and

targets and to develop a continuous improvement plan to ensure success moving forward.

2.2.1 PHASE ONE: MEETING STAGE 1 MEANINGFUL USE

This stage recognizes the service development steps necessary to enable Stage 1 meaningful use with a

focus on “gap” providers. Leveraging Direct provides the foundation to support transaction‐based,

secure messaging to replace current paper‐based processes in areas of the state where providers have

little to no options today (e.g., sending patient information electronically from one provider to another).

2.2.1.1 EPRESCRIBING

ePrescribing Gap 1: Less than 2% (30/2,157) of pharmacies cannot accept electronic prescriptions.

ePrescribing Strategy 1: OHIP will personally contact the 30 pharmacies that are not SureScripts

activated pharmacies.

OHIP will identify the reason they are not currently accepting electronic prescriptions and work with

them to resolve their issues and track the ongoing success of their adoption.

ePrescribing Strategy 2: Provide focused education to these small chains through OHIP’s Regional

Partners and ePrescribing Task Force members.

This task force includes physicians, hospitals, pharmacists, BOP and small and large pharmacy chains.

This group’s task is to do what is necessary to address the issues preventing ePrescribing and

widespread adoption.

ePrescribing Gap 2: Physicians have e‐prescribing technology, but do not have it enabled or are not using it.

The OHIP HIE will collaborate with its REC to ensure that providers with ePrescribing capabilities have

the functionality enabled and are actually able to use it to e‐prescribe.

ePrescribing Strategy 3: Ensure EHR software is not only ONC certified, but Ohio Board of Pharmacy

Approved.


Q22

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After the DEA rules were announced, OHIP worked with the Board of Pharmacy for a commitment that

the Board would now go with the national standard to approving EHRs, rather than an Ohio‐specific

approach. The Board agreed and approved an Ohio rule which went into effect January 1, 2011. OHIP

also included the Board on our Preferred EHR Vendor Selection Committee (part of our REC program) to

ensure the Preferred Vendors were in good standing with the Board. In the fall of 2010, OHIP created an

ePrescribing Task Force with members from:

Mercy Health Partners/CHP


TriHealth, Inc.

Summa Health System

Mercy Health Partners/CHP

University Hospital, Cleveland

OHIP

Memorial Hospital

Toledo Clinic

Ohio Board of Pharmacy

Ohio University College of Medicine

Berger Hospital

Ohio Pharmacy Association

University of Findlay

Children's Dayton

COPC, Columbus

CVS

The Task Force is charged with removing barriers to widespread e‐prescribing in Ohio. The HIE and REC

divisions of OHIP are represented on the Task Force and will leverage that team to ensure collaboration

between EHR vendors, HISP vendors and the BOP.

ePrescribing Strategy 4: Ensure physicians have e‐prescribing technology.

Work with the REC and Regional Partners to ensure physicians select EHRs that are ONC certified and

BOP approved. Each of OHIP’s five preferred EHR vendors were required to offer an ePrescription

module that was certified by the BOP prior to selection into the program. Each preferred vendor has

agreed to connect to the statewide HIE using federally‐endorsed interoperability standards without

additional cost to users. As a bridge strategy, through the RFP process OHIP required the offering of an

ePrescribing capability as a cloud service. Once an HIE vendor is selected, OHIP will fast‐track

certification of these services, if not already certified, through its e‐Prescribing Task Force, which

includes BOP representatives. This modular functionality will be offered to any eligible provider in the

State who desires to use the service to meet meaningful use requirements.

2.2.1.2 LABORATORIES


Q23

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Laboratory Gap 1: Hospital laboratories in rural or underserved areas have few affordable and

manageable options to deliver results to physicians involved in a patient’s care in a

secure manner.

Laboratory Strategy 1: Through OHIP’s RFP process, OHIP will offer HISP services in a Direct Project

framework so that any laboratory will be able to push results to the ordering

physician.

Any ordering physician that receives laboratory results will be able to push those results to other

providers involved in a patient’s care in either a structured or unstructured format. OHIP will provide a

free, Master Provider Directory so that information may be exchanged using OHIP’s HISP or any other

HISP service available in the State to securely deliver the results.

Laboratory Gap 2: Few hospital laboratories in rural or underserved areas have the means to exchange

laboratory data in a structured or encoded form.

Laboratory Strategy 2: OHIP’s strategy will target all of the 69 hospital labs located in the

underserved, priority settings to identify sites to serve as early integration

points for HIE deployment.

This process will involve assessing the hospital’s current laboratory systems and interoperability

capabilities, IT staff capacity, upgrade requirements and other key factors for structured laboratory

deployment. Leveraging the REC CAH supplemental grant program, OHIP will address issues identified

during the assessment, establish implementation teams and begin integration steps to connect these

hospitals and their referring physicians.

This strategy will address anticipated issues as follows:

Inability to support HL‐7 v2.5.1 or LOINC codes – OHIP will provide data management services to

allow for the necessary translation of formats (e.g., prior versions of HL‐7) or codes (e.g. SNOMED to

LOINC) efficiently and accurately.

Variances in narrative versus discrete laboratory data results ‐ OHIP’s data translation services will

identify and appropriately handle or route laboratory results based on result type.


Q24

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Inability to persist structured data ‐ For those hospital labs that do not have the technical

infrastructure to support a data management strategy, a data “canister” in the OHIP HIE

environment that will be made available for those providers to store and manage that data in a

structured way.

By implementing these strategies, physicians located in these underserved areas will gain access to

laboratory results they are currently unable to obtain electronically.

Laboratory Gap 3: The Ohio Department of Health (ODH) would like to increase the number of hospitals

providing reportable lab results through its Ohio Disease Reporting System (ODRS).

Laboratory Strategy 3: Through laboratory gap strategies 1 and 2, OHIP will not only increase the

degree of structured laboratory data exchange between hospitals and

providers, but it will also assist public health efforts by expanding the sources

of information available to ODRS in an efficient manner.

OHIP is currently coordinating efforts with ODH through the investigation of other grant funding sources

and providing education to align with LOINC laboratory coding best practices. OHIP will also work with

ODH to facilitate the education and communication to laboratory directors regarding itsunderstanding

of CLIA/CAP requirements for validating clinical laboratory results exchanged electronically.

Laboratory Gap 4: The three lab providers offering statewide services can generate electronic lab

results, but they are not able to reach each provider in the state electronically.

Laboratory Gap Strategy 4: Similar to Laboratory Gap Strategy 1, OHIP will offer HISP services in a

Direct Project framework so that any laboratory provider will be able to

push results to the ordering or other physicians.

OHIP will provide a free, Master Provider Directory so that information may be exchanged using OHIP’s

HISP or any other HISP service available in the State to securely deliver the results.

2.2.1.3 PATIENT CARE SUMMARY EXCHANGE


Q25

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Patient Care Summary Gap 1: There is little to no care summary exchange in Ohio that occurs between disparate offices or organizations. Patient Care Summary Strategy 1: To help raise the level of exchange of CCDs and structured lab

results, OHIP will leverage the core strategies that have been

outlined in Phase 1 of their HIE Implementation Strategy.

OHIP will encourage the use of the Direct Project protocols for providers to send secure messages to

each other. OHIP will offer the tools for free, but will charge a minimal subscription fee if providers

choose to have OHIP handle patient consent.

OHIP is using the Direct Project because there are currently no available assets on a state scale that can

be leveraged to achieve the same outcomes as Direct. Using the Master Provider Directory, any

physician desiring to share information with other providers involved in a patient’s care can do so

electronically by obtaining their health domain address through the transparent Provider Directory and

pushing the information through the secure HISP service. If the receiving provider chooses to use a

different secure HISP service, OHIP will still facilitate exchange across HISPs using Direct protocols;

however, consent must be managed by the receiving provider.

This type of basic transactional exchange can be used to exchange any type of clinical care summary

document (discharge summary, CCD or other) as well as fact sheets, referral documents or other

unstructured records, which may be of interest to other providers. Expediting this process from paper

to electronic could make a significant difference in a patient’s care and/or their ability to secure

insurance coverage for treatment that requires referral documentation and approval.

In addition, all of OHIP’s preferred EHR vendors support CCDs in both structured and unstructured

formats.

2.2.1.4 LEGAL AND PRIVACY

Privacy Gap 1: While Ohio statute does not explicitly require written patient consent for medical record

disclosure when used for treatment purposes, there is an Ohio statute that contains an

express requirement for written patient consent when a health provider discloses

medical records to a patient, the patient’s authorized representative or to a third party.


Q26

27

Privacy Strategy 1: OHIP will create a statewide‐applicable model trust agreement and business

associate agreement (BAA) which addresses privacy and related consent

requirements in a virtual environment.

Privacy Gap 2: Providers are confused about what constitutes meaningful patient consent.

Privacy Strategy 2: OHIP will publish a Privacy White Paper for public comment and follow‐up with a

privacy‐focused education campaign and toolkit.

2.2.1.5 ADDITIONAL HIE ASSETS

HIE Assets Gap 1: The state of Ohio has no validated repositories to utilize in the development of a

Master Provider Directory.

HIE Assets Strategy 1: OHIP will leverage information obtained through multiple database including

those from the REC recruitment, associations and licensing boards.

While OHIP has identified discrepancies in their data, there are portions of their data that will be helpful

to create the base for a reliable Master Provider Directory. OHIP will explore importing those accurate

elements of current data sets to add value to the directory while continually validating and scrubbing for

inaccuracies and discrepancies. This directory will be the authoritative Provider Directory for Ohio and

will be accessible to any provider that needs it, at no charge.

2.2.2 CORE STRATEGIES: PHASE TWO13

OHIP will work with ONC to chronicle lessons learned as Phase 1 services are rolled out to assess

penetration and overall project success. OHIP plans to build on the framework provided in Phase 1 to

move towards the creation of a longitudinal record and recognizes the service development steps

necessary to expand connectivity to support providers with this effort in Phase 2. Longitudinal patient

records provide an aggregated view of health‐related information on an individual, gathered

cumulatively across more than one health care organization involved in the patient’s care. A powerful

13 Section 1.2.6 (Proposed HIE Model), S‐34, Section 1.7.1 (Implementation), S‐100


Q27

28

example of the potential for these services is the ability of an emergency responder (EMT) to

immediately access patient information from several providers at the point of emergency response.

OHIP’s strategy is to use the NHIN Exchange to provide a framework for how to connect existing

networks together.

In Phase 2, if physicians do not adopt Direct in a meaningful way, OHIP will accelerate the build out of

Phase 2 with the core infrastructure built in Phase 1.

2.2.3 CORE STRATEGIES: PHASE 314

By 2013, OHIP’s anticipates a significant convergence of clinical and administrative exchange processes

based on the following drivers:

‐ In 2010, Medicare established pay‐for‐performance standards for end‐stage renal disease (ESRD)

facilities. The ESRD Quality Incentive Program (QIP) is based on a set of quality measures including

specific lab results. Medicare uses the clinical information to rate providers’ quality of dialysis care

and establishes a sliding scale for payment adjustments based on the facility’s performance. This is

the first of many administrative payments processes that will be based upon clinical circumstances.

The commercial payors will soon follow Medicare with payment being based upon documented

outcomes.

‐ In 2013 the industry will transition from the International Coding of Diseases (ICD 9) to ICD‐10. The

specificity for ICD‐10 coding will change the way payments are processed. The coding will allow

payors to make payments based upon intensity and complications of the procedure. This new

payment process will require additional clinical documentation to justify the additional payment.

The healthcare industry as a whole will need a fluid method to move the additional clinical data.

The industry will utilize the attachment transaction to convey clinical data to payors.

‐ The current trend in primary care is the concept of a patient centered medical home (PCMH). The

PCMH management process cannot be accomplished without interfacing with medical record

information.

14 Section 1.5.1 (Sustainability), S‐87


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29

‐ The industry is showing the trend in payment management that will require the merger of clinical

data with payment data to justify the expected payment amount. The HIE will need to build services

that will feed clinical data into the administrative payment processing.

To convene the stakeholders around these drivers, the OHIP Board has approved the formation of a new

committee. The committee has been given the objective of finding a process that combines

administrative and clinical data to improve the cost of data management. The second objective of the

committee is to look at the effect of ICD‐10 on payment process and work through how to ensure the

issues will not affect current payment functions. The committee will begin work on the objectives in

February 2011. The timing of the implementations of the recommendations will depend upon the

findings of the committee.

3 SUMMARY

In this addendum we provide a thorough analysis of factors that affect the current HIT landscape and

their influence on the success of optimization of our state plan. This includes a discussion of the

comprehensive and measured approach taken in prioritizing the population we seek to assist in

exchanging health data. We also identify the potential gaps in our current capabilities for supporting

Stage 1 Meaningful Use and present our strategic approach for how to address them. These strategies

include:

Core Strategy 1: Facilitate Exchange Leveraging Direct Protocols Core Strategy 2: Establish Open Provider Directory Core Strategy 3: Provide HISP Services Core Strategy 4: Offer Bundled Core Services at No Cost to Support Secure, Point‐to‐

Point Messaging Core Strategy 5: Offer Trust and Consent Management Services for Nominal Fee Core Strategy 6: Provide Education and Outreach to Providers and Vendors on

Leveraging Direct Protocols to Facilitate Secure Messaging Core Strategy 7: Leverage OHIP REC Provider Services Core Strategy 8: OHIP Will Serve as a Convener of Interested HIT Stakeholders

Finally, we identify Phases 2 and 3 of our implementation. All of the strategies for these future Phases

are contingent on maintaining our large stakeholder commitment. We recognize that this stakeholder

commitment is imperative to ensure that OHIP continues to be successful in the development of the

HIE, just as it has been on our REC side and is evidenced in the fact that Ohio is currently leading the


Q29

30

country in REC PPCP sign ups. We look forward to your response to this amendment and are anxious to

capitalize on the REC momentum and move forward with our stakeholders on Phase 1 of our plan.

Highlights of this amendment include:

‐ Inherent flexibility of our phased approach – will be able to leverage all capabilities of the core

services implemented in phase 1

‐ We can use our contracting and preferred vendor influence to ensure that we can leverage

Direct effectively. (everyone adopting is adopting Direct‐ready systems)

‐ Great stakeholder commitment – demonstrated by active participation and in‐kind donations –

helps ensure that we will be successful.

‐ REC/HIE combination maximizes our ability to coordinate and rapidly implement and adapt.

‐ Three priority areas

o ePrescribing – Pharmacy adoption is not the problem, so we’re focusing on prescriber

adoption

o Lab – Focusing on hospital labs by providing a robust set of services to enable electronic

delivery of lab results; statewide lab services providers will be supported through

provider directory services.

o Care Summary Exchange – No existing exchange capabilities of significance that occurs

between disparate offices or organizations. OHIP will leverage the Direct Project.

4 ATTACHMENTS

‐ Attachment A – Regional Extension Center PIN # ONC‐REC‐IP‐002 and # ONC‐REC‐IP‐001, August

24, 2010

‐ Attachment B – Privacy White Paper


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Attachment A

3968264v1

Ohio Health Information Partnership’s Policy for Defining Priority Settings – Program Information Notice # ONC‐REC‐IP‐002 and Program Information Notice # ONC‐REC‐IP‐001 Per the August 17, 2010 Office of the National Coordinator (“ONC”) Program Information Notice No. ONC‐REC‐IP‐002, entitled “Internal Process – Other Underserved Setting Policy”, and Program Information Notice No. ONC‐REC‐IP‐001, entitled “Internal Process – ‘Practice Consortium’ Policy” (the “PINs”), the Ohio Health Information Partnership (“OHIP”) has developed the following policy for defining the priority settings for OHIP’s implementation of the Regional Extension Center Cooperative Agreement Program. To the extent OHIP encounters practice situations not addressed above but which also predominantly serve uninsured, underinsured and medically underserved populations, OHIP will request approval for a modification of this policy.

Eligible professionals who are directly or indirectly employed by or otherwise practicing primarily in the following settings will be counted and entered into the CRM tool as follows:

1. Individual and small group practices of ten or fewer professionals per primary practice site

2. Public or not‐for‐profit hospitals (per HITECH Act Section 3012(c)(4) and as cited in both PINs and including providers and practices wholly‐owned or controlled by hospitals)

3. Critical access hospitals

4. Community health centers and federally qualified health centers (“FQHCs”)

5. Rural health clinics

Other Underserved Settings

For the sixth priority setting, “settings that predominantly serve uninsured, underinsured and medically underserved populations,” OHIP will apply the following guidelines consistently across the practices with which OHIP is working to those practices that do not otherwise fit within one of the other five priority settings but meet any one of the following definitions:

1. Practices located in a “Rural” county (defined as a county that is not considered as a “metropolitan” county by the Office of Management and Budget) or a county that is within the “Appalachian region” (as defined by Section 403 of the Appalachian Regional Development Act of 1965).


Q31

Mat Kendall Page 2 August 24, 2010

3968264v1

2. Practices located in and serving an area that has been identified as being in “situational distress” as defined by the Ohio Department of Development (see Ohio Revised Code Chapter 122), or those located in an “economically depressed” county, defined as a county where the poverty level is higher than the national average poverty level based on data from the most recent U.S. Census Bureau’s American Community Survey.

3. Practices located in and serving an area that has been identified as a Health Professional Shortage Area, as that term is defined at 42 U.S.C. 254e and 42 C.F.R. § 5.2.

4. Practices that have (a) at least twenty percent (20%) of their revenues derived from Medicaid beneficiaries, Medicare beneficiaries and uninsured patients; or (b) at least twenty percent (20%) of their patient visits are attributed to Medicaid beneficiaries, Medicare beneficiaries and uninsured patients; or (c) at least twenty percent (20%) of the practice’s active patients (defined as having been seen by a practice physician at any time within the past three years) are or were at the time of their treatment Medicaid beneficiaries, Medicare beneficiaries or uninsured.

5. Clinics that offer free or discounted services for patients who meet guidelines established by the clinic for receiving such free and discounted services and at least twenty percent (20%) of the patients served by such clinic qualify for free or discounted services.

6. Practices in remote areas with more than 10 primary care providers with prescriptive privileges.

Practice Consortium Definition

Practice “consortiums” defined as a group practice with more than 10 primary care providers all operating under a single tax identification number at more than one location but where each such location has either (a) historically operated independently in terms of physician‐patient encounters; or (b) functions independently in terms of physician‐patient encounters but consolidates billing and other administrative functions. Practice consortiums may target and enroll up to 10 primary care providers per primary practice location.


Q32

Attachment B

Research and Recommendations for HIE Patient Consent Policies for

Health Information Exchange in Ohio

Prepared for Stakeholder Review

December 2010

Ohio Health Information Partnership Privacy and

Policy Committee


Q33

Research and Recommendations for HIE Patient Consent Policy and Procedures Page | 2

CONTENTS

Contents ........................................................................................................................................................................ 2

1. Introduction and Background .................................................................................................................................... 4

2. OHIP Organizational Structure ................................................................................................................................... 4

3. Scope of OHIP’s HIE ................................................................................................................................................... 5

3.1 Technical Infrastructure for Statewide HIE ...................................................................................................... 6

4. Policy Development Process ...................................................................................................................................... 7

4.1 Phased Approach to Recommendations ......................................................................................................... 8

4.2 Review of Previous work Conducted by HISPC ................................................................................................ 9

4.3 Model Permission Form ................................................................................................................................... 9

4.4Review of ONC Directives ................................................................................................................................. 9

4.5 Consent Environment Under Ohio Law ......................................................................................................... 10

4.6 Review of Other States Consent Models ....................................................................................................... 11

4.7 Consent Environment Under HIPAA .............................................................................................................. 11

5. Current Consent Environment ................................................................................................................................. 12

6. Recommended Policy and Processes for OHIP HIE .................................................................................................. 13

6.1 Scope of Governed Activities ............................................................................................................................. 13

6.1.2 Uses of Health Information ......................................................................................................................... 14

6.1.3 Policies as the Floor for Interstate Exchange .............................................................................................. 15

6.2 HIE Participant Requirements ............................................................................................................................ 15

6.2.1 Business Associate and TEchnical Certificate ............................................................................................. 15

6.2.2 Population of the Master Patient Index ..................................................................................................... 16

6.2.3 Movement of A Patient Health Record Across the Statewide HIE ............................................................. 17

6.3 Patient Engagement .......................................................................................................................................... 18

6.4 Consent .............................................................................................................................................................. 18

6.4.1 Application of Consent ............................................................................................................................... 19


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6.4.2 Information about Participating Entities .................................................................................................... 19

6.4.3 Exceptions to Consent ................................................................................................................................ 19

6.4.4 Improvement and evaluation of Statewide HIE .......................................................................................... 20

6.4.5 Treatment and Coverage not Conditioned on Consent .............................................................................. 20

6.4.6 Consent Form ............................................................................................................................................. 20

6.4.7 Durability and Revocability ......................................................................................................................... 21

6.4.8 Audits and Enforcement ............................................................................................................................. 21

7. Next Steps ................................................................................................................................................................ 22

8. Terms and Definitions ......................................................................................................................................... 22


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1. INTRODUCTION AND BACKGROUND

This document sets forth research and recommendations surrounding the collection, use, access and disclosure of

health records in an electronic Health Information Exchange (HIE). The information collected in this document was

compiled by a committee of legal, provider and patient representatives convened by the Ohio Health Information

Partnership (OHIP). This document will be used to solicit feedback and guide the development of the final policies

and procedures used for OHIP’s statewide HIE.

The OHIP statewide HIE will permit the exchange of health information across diverse patient care delivery settings

throughout Ohio. Participants in the HIE will include:

Hospitals (Including Critical Access and Federally Qualified Hospitals)

County and State Health Departments

Physician Offices

Community Health Centers

Large Academic Medical Centers

Nursing Homes

Ambulatory Surgery Centers

Labs

Pharmacies

Other Government Health Agencies

These participants will be in geographic locations ranging from rural Appalachia to large metropolitan areas. The

statewide HIE is essential to realizing the expected value of health information technology to support patient care

improvements. Without it, the health information of Ohio residents will remain in isolated information systems

hampering continuity of care and the adoption of health IT tools.

It is necessary for health systems to work together in order to compile the complete experience of a patient’s care

and ensure accessibility of that information to clinicians as the

patient moves through various health care settings. The

statewide HIE will support clinicians in making cost‐effective,

fact‐based decisions that will reduce medical errors, decrease

redundant tests and improve care coordination with the help of

timely and standardized data aggregation.

One of the most important elements in creating an

interoperable HIE for the State of Ohio is patient consent. It is

important to emphasize that consent policies must be

accompanied by privacy and security protections relating to

authentication, authorization, access controls and auditing to

earn patient trust. The consent must also satisfy all federal and Ohio laws and regulations. The research and

recommendations included in this document are a starting point for the comprehensive privacy and security

policies and procedures that will be published by OHIP in the second quarter of 2011.

2. OHIP ORGANIZATIONAL STRUCTURE

OHIP is a nonprofit entity founded by health care industry stakeholders who have a vested interest in the use of

EHRs and the creation of a true statewide HIE infrastructure. The founders of OHIP include top leadership from the

Ohio State Medical Association, the Ohio Osteopathic Association, the Ohio Hospital Association, BioOhio and the

State of Ohio. The five founding members of this nonprofit organization serve as the executive board on the 15‐

“The statewide HIE is essential to realizing

the expected value of health information

technology to support patient care

improvements. Without an HIE, the health

information of Ohio resident’s will remain

in isolated information systems hampering

continuity of care and the adoption of

health IT tools.”


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DRAFT: Research and Recommendations for HIE Patient Consent Policy and Procedures Page | 5

member OHIP Board of Directors, made up of IT, medical, hospital, behavioral health and health insurance leaders.

OHIP is one of six state‐designated entities that also is a Regional Extension Center (REC) awardee and involves

experts who have a local, grass‐roots interest in the integration of EHRs into an HIE infrastructure.

The board’s diverse membership gives clear representation of the medical and health care communities across

Ohio and these leaders have the clout to create and implement an HIE that their organizations will use. For

instance, the board includes a member from each of the Cleveland Clinic, United HealthCare and a member of

AARP, each representing different perspectives and issues. Two committees – the Regional Extension Center

Committee and the Health Information Exchange Committee – form the umbrella for various subcommittees and

workgroups. One of these workgroups is the Privacy and Policy Committee that performed the research and

recommendations related to patient consent presented in this document.

3. SCOPE OF OHIP’S HIE

The vision for the statewide HIE is to make the exchange of health records sustainable, secure, and allow

physicians and other health care professionals to have patient authorized access to health information. The four

drivers for OHIP’s HIE development strategy include:

Helping physicians achieve meaningful use within the timeframe developed by the Department of Health

and Human Services (HHS) Office of the National Coordinator (ONC);

The use of national standards to ensure health system coordination;

Balancing the core HIE services with regional differences; and

Ensuring that the HIE is sustainable.

Core services will include a patient look up, a physician, lab, or participant registry, and patient health record

locator. A patient’s consent will be required to exchange the patient’s records electronically and only authorized

users will be able to access those records. Subsequent sections of this document give recommendations for how

and when this consent should be collected.

OHIP’s initial deployment strategy for the statewide HIE is to

reach out to 200 key technology partners and health care entities

so that roughly 80 percent of Ohio’s population potentially could

be reached by the end of 2011. This strategy will help physicians

achieve the meaningful use criteria with HIE implications within

the timeframe established by the Department of Health and

Human Service’s Office of the National Coordinator (ONC). This

resulting assistance will help physicians take advantage of the

Medicare/Medicaid financial incentives made available by HHS.

These 200 “touchpoints” will become both participants and users

of the HIE.

In addition to the work performed to ensure patient privacy, OHIP has developed an integration strategy that will

assist providers and vendors with their connection to the HIE. OHIP will define a technical model, clarify

“Participants will be able to connect to the

HIE in three different ways depending on

the maturity of their Electronic Health

Record (EHR) system: web portal access

through the provider’s browser; access to a

shared repository to facilitate data

exchange; and the ability to access records

on demand though the data remains at the

original source.”


Q37


integration standards necessary to connect to the statewide HIE, and offer tiered connectivity options for

providers to participate at a level compatible with their existing technology. Participants will be able to connect to

the HIE in three different ways depending on the maturity of their Electronic Health Record (EHR) system: web

portal access through the provider’s browser; access to a shared repository to facilitate data exchange; and the

ability to access records on demand through the data remains at the original source.

3.1 TECHNICAL INFRASTRUCTURE FOR STATEWIDE HIE

OHIP will create a trusted HIE platform that ultimately allows for the secure, electronic exchange of patient

information in real time. The HIE will not be a centralized repository or huge database; but will be a hybrid model

enabling federated access to data that remains stored at the original source of creation whenever possible.

Ohio is very fortunate to have many knowledgeable and

actively engaged stakeholders interested in OHIP’s technical

development strategy and they have been very clear and

consistent in their message to OHIP regarding their desires for

infrastructure design. These messages have been the

foundation of OHIP’s technology principles and development

strategy and are detailed below:

A sustainable, technical infrastructure that connects and leverages existing HIE activity as well as links providers, health plans, labs, pharmacies and other healthcare stakeholders currently not connected;

Desire for a hybrid model that only stores data within the HIE Master Patient Index necessary to facilitate exchange;

Desire for discovery and location services that streamline the identification of trusted sources both inside the state and across state borders;

Clear and consistent use of federally endorsed interoperability standards where defined and, where not defined, OHIP will set the standards;

Assurance that the privacy and security of patient data is consistent with Ohio and federal laws;

Recognition of the rapidly evolving standards environment and the need to select an innovative and easily adaptable technical platform;

Recognition of the incremental interoperability among stakeholders (i.e., the varying degree of technical capability of stakeholders);

Recognition that the historically separate administrative and clinical data flows are blending and will have significant impact on the future cash flow of providers; and

The strong desire for execution, action and deliverables.

These messages have formed the following action steps for OHIP toward the development of a statewide HIE

infrastructure:

Release of Request for Information (RFI) to potential HIE vendors in First Quarter 2010

Selection of 8 HIE vendors to participate in RFP process in April 2010

Completion of HIE State Plan in July 2010

“The HIE will not be a centralized repository

or huge database; but will be a hybrid

model that enables access to data that

remains stored at the original source of

creation whenever possible.”


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Release of HIE vendor Request for Proposals (RFP) in September 2010

Selection of HIE vendor in January 2011

Implementation of core services in June 2011

The core attributes of the HIE are identified in Table 1: Core Attributes of OHIP HIE.

TABLE 1: CORE ATTRIBUTES OF OHIP STATEWIDE HIE

Core Attribute Characteristics of the OHIP statewide HIE

Nature of Participants Involves multiple stakeholders across the patient care setting including hospitals, physician offices, community health centers, large academic medical centers, nursing homes, ambulatory surgery centers, county and state health departments, other government health agencies, labs and pharmacies

All patients receiving treatment in Ohio can participate in the HIE regardless of health status and insurance

Governance Structure State designated nonprofit entity

Strong leadership from founding members including representatives from: Ohio Hospital Association, Ohio Osteopathic Association, Ohio State Medical Association, State of Ohio and BioOhio

Purpose of exchange/mission Improve quality, safety, accessibility, availability and efficiency of health care for the citizens of Ohio

Type of information exchanges

Clinical data, prescriptions, lab results, patient care summaries, registry and surveillance data

How information is exchanged

The HIE will not be a centralized repository or huge database; but will be a hybrid model that enables access to data that remains stored at the original source of creation whenever possible.

Scope of services Privacy

Security (Authorization, Authentication, Access Controls and Auditing)

Consent Policy Development

HIE Sustainability

Enforcement of Policies and Procedures

4. POLICY DEVELOPMENT PROCESS

As previously mentioned, the OHIP Executive Board creates workgroups to address specific needs for the

development of the statewide HIE. Originally, a Committee was formed to address all of the Privacy and Security

issues surrounding HIE. This Committee held a kick‐off meeting on September 1, 2010 to devise a strategy to meet

the privacy and security objectives established by the OHIP Board in its State Plan. The Committee is comprised of

stakeholders throughout Ohio with representation from providers, practice managers, hospitals, Medicaid, and

Osteopathic and Allopathic associations. After the first two meetings, the Committee determined that given the

complexity of Ohio case law related to privacy and the background of their membership the best direction would

be to focus entirely on the privacy and policy aspects of HIE, and the Committee became the OHIP Privacy and

Policy Committee. The HIE Committee will assume the role of providing guidance on the technical security

components needed for the HIE, as this Committee’s membership has a technical background. The Privacy and

Policy Committee reports to the HIE Committee on a monthly basis to ensure that the privacy policies are

developed in tandem with security policies. The work of both Committees is presented to the full OHIP Board on

an as needed basis.


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4.1 PHASED APPROACH TO RECOMMENDATIONS

The Privacy and Policy Committee adopted a four‐phase approach to develop the policies and procedures for the

statewide HIE related to privacy. The first phase included a review of the work of a previous Ohio legal work group

created to address privacy concerns as part of the national Health Information Security and Privacy Collaboration

(HISPC) as well as a review of Ohio law, consent models of other states, publications from the Office of Civil Rights

and publications from ONC.

During Phase II, the Committee compiled their research and drafted the recommendations for the standardized

consent policies and procedures found in this document. Phase III of the Committee’s work will include soliciting

stakeholder feedback surrounding the policies presented in this document, making revisions as necessary and

presenting the revised recommendations to the OHIP board for final approval. During this phase, the Committee

will work to address any items that were not included in the original recommendations, such as administrative

services and sensitive information. The final phase, Phase IV, of the Committee’s work will include the creation of

a comprehensive policy and procedure manual that will include the required Participant Agreements, Business

Associate Agreements and Trust Agreements for the statewide HIE.

The work conducted thus far and planned for in the future is itemized in Table 2: Privacy and Policy Committee

Work Phases.

TABLE 2: PRIVACY AND POLICY COMMITTEE WORK PHASES

Phase I 9/1/10‐ 10/20/10

Review work of HISPC Legal Work Group

Update model permission form created by HISPC Legal Work Group

Review ONC Tiger Team Privacy Directives

Review Ohio statutes and rules related to medical record privacy

Review Ohio Case Law

Research other State consent models

Phase II 10/20/10‐12/10/10

Draft summary of items reviewed in Phase I and recommendations for standardized consent policies and procedures

Review Research and Recommendations at December 1st Committee meeting

Present Research and Recommendations to OHIP Board on Dec 10th

Phase III 12/10/10‐ 3/2/11

90 day period to solicit stakeholder feedback on recommended consent policies and procedures

The document will be posted on the OHIP webpage, sent to provider associations, RECs and a summary of the document will be prepared for consumer associations

The recommendations will be adjusted if needed and resubmitted to OHIP board

Items not included in original recommendations will be addressed including sensitive health information, privacy rights of minors, research and the transfer of administrative data

During this period of public comment, the Privacy and Policy Committee will draft Business Associate Agreements, Participant Agreements and a formal Policy and Procedures Manual

Phase IV 3/2/11‐ 5/25/11

Final Policy and Procedures Manual approved by OHIP Board

Final Participant Agreements, Business Associate Agreements, and Technical Certificate Agreements approved by OHIP Board

The Privacy and Policy Committee will address the consent required for administrative transactions in this


Q40


time period which will then undergo a public review process similar to that performed for consent for treatment

4.2 REVIEW OF PREVIOUS WORK CONDUCTED BY HISPC

The OHIP Privacy and Policy Committee is continuing the work conducted by the HISPC Legal Work Group that was

active from June 2006 to July 2009. Ohio was one of 42 states that participated in the HISPC project. HISPC was a

nationwide effort lead by RTI International. The goal of the HISPC project was to identify the state and federal

laws that create barriers to information exchange within and between states, and to recommend solutions to

overcome those barriers. This group examined a myriad of issues related to privacy and security challenges

relative to the electronic exchange of health information.

HISPC Phase I required an assessment of state law and business policies that affect HIE and proposal of practical

solutions, taking into account the requirements of state and federal law. Ohio identified variations in Ohio law as

compared to federal law that affect HIE in the specific scenarios presented by HHS. Ohio’s final report outlined the

variations discovered and concludes, for the most part, that there are no legal barriers in the sense that covered

entities must apply both federal and state law, or whichever law is more stringent, in order to use or disclose or

exchange health information. The HISPC report does not address the merits of trying to update state law to be

more conducive to privacy, security or exchange concerns. The HISPC Legal Work Group identified that Ohio has

consent requirements for not only specially protected information such as HIV/AIDS, mental health, and drug

abuse and alcohol records, but also for treatment, payment and health care operations as evidenced by Ohio

statute (ORC Section 3701.74), Ohio case law interpreting the statutory physician/patient privilege (ORC Section

2317.02(B)) and Ohio case law interpreting the physician duty of confidentiality and recognizing the tort for

unauthorized, unprivileged disclosure to a third party of nonpublic medical information learned from a

physician/patient relationship.

4.3 MODEL PERMISSION FORM

The HISPC Legal Work Group produced a two‐part model permission form, hereafter referred to as the Ohio Law

Consent form, which complies with state and federal requirements for use, disclosure and exchange of information

as of December 2007. The Ohio Law Consent form is a model permission form that reconciles state and federal law

into two documents, one for the use of treatment, payment and operations (TPO) and one for non‐TPO purposes.

The TPO form demonstrates the baseline consent needed for a physician to treat a patient and release information

for treatment and payment purposes. The second form is a Health Information Portability & Accountability Act

(HIPAA) compliant authorization for use and disclosure of health records for non‐TPO purposes. The OHIP Privacy

and Policy Committee updated the legal citations and forms as necessary. They are found in Appendices A and B.

4.4 REVIEW OF ONC DIRECTIVES

The Privacy and Policy Committee reviewed information disseminated by ONC and is following the work of their

Tiger Team that is currently addressing and receiving public comment on the issue of consent.

The Tiger Team identified a set of principles constituting good data stewardship to build a foundation of public

trust in the collection, access, use and disclosure of a health record. These principles were reviewed by and guided

the work of the OHIP Privacy and Policy Committee. They are listed in Table 3: ONC Tiger Team Principles.


Q41


TABLE 3: ONC TIGER TEAM PRINCIPLES

4.5 CONSENT ENVIRONMENT UNDER OHIO LAW

The Privacy and Policy Committee started its analysis of the Ohio law that applies to consent to use health records

with the work already performed by the HISPC Legal Work Group, discussed further above. The Committee

reviewed

the HISPC report;

Ohio law pertaining to the statutory provision for a patient or authorized representative’s access to

records;

Ohio’s physician/patient privilege law;

and Ohio’s tort of unauthorized, unprivileged disclosure of medical information.

While no specific Ohio statute exits that requires written patient consent for medical record disclosure when used

for treatment purposes, there is an Ohio statute that contains an express requirement for written patient consent

when a health provider discloses medical records to the patient, the patient’s authorized representative or to a

third party. In addition, Ohio case law interpreting physician/patient privilege and the recognition of the tort for

unauthorized disclosure of nonpublic medical information show a strong support in Ohio law for the patient’s right

to confidentiality of medical records absent disclosures required by law or disclosures necessary to protect a

countervailing interest that outweighs the patient’s interest in confidentiality. Thus there is no one place where

one can go and find Ohio’s stance on whether patient consent is required for medical record disclosure for

treatment purposes. As a result, there are differing views around the state as to whether explicit written

Individual Access – Individuals should be provided with a simple and timely means to access and obtain their individually identifiable health information in a readable form and format.

Correction – Individuals should be provided with a timely means to dispute the accuracy or integrity of their individually identifiable health information, and to have erroneous information corrected or to have a dispute documented if their requests are denied.

Openness and Transparency – There should be openness and transparency about policies, procedures and technologies that directly affect individuals and/or their individually identifiable health information.

Individual Choice – Individuals should be provided a reasonable opportunity and capability to make informed decisions about the collection, use and disclosure of their individually identifiable health information.

Collection, Use and Disclosure Limitation – Individually identifiable health information should be collected, used, and/or disclosed only to the extent necessary to accomplish a specified purpose(s) and never to discriminate inappropriately.

Data Quality and Integrity – Persons and entities should take reasonable steps to ensure that individually identifiable health information is complete, accurate, and up‐to‐date to the extent necessary for the person’s or entity’s intended purposes and has not been altered or destroyed in an unauthorized manner.

Safeguards – Individually identifiable health information should be protected with reasonable administrative, technical and physical safeguards to ensure its confidentiality, integrity and availability and to prevent unauthorized or inappropriate access, use or disclosure.

Accountability – These principles should be implemented, and adherence assured, through appropriate monitoring and other means and methods should be in place to report and mitigate non‐adherence and breaches.

SOURCE: http://healthit.hhs.gov/portal/server.pt/gateway/PTARGS_0_10731_848088_0_0_18/NationwidePS_Framework‐5.pdf


Q42


consent is required for disclosures of health records when disclosed for treatment. Due to this complexity, Ohio

health care providers have adopted patient consent policies and procedures that differ throughout the state.

Accordingly, after reviewing Ohio law and considering the principles of openness and transparency (identified by

the ONC Tiger Team), the Committee is recommending that the HIE provide patients with a choice to opt‐in to

allow the HIE to access their health records. The Committee is also recommending that the HIE require

participants, such as hospitals and physician practices, to use a standardized consent form to permit them to

access a patient’s record through the HIE which will reassure patients that all HIE participants are meeting

applicable consent requirements for exchange of their health records. A summary of the analysis of Ohio law

related to patient consent is included in Appendices C and D.

4.6 REVIEW OF OTHER STATES CONSENT MODELS

The Committee conducted a thorough examination of the policies and procedures of other states that are in the

process or have created an HIE. Performing additional due diligence, a number of Committee members contacted

several state privacy staff experts and discussed their adoption process and the steps they took to develop consent

models in their states. The information learned on these calls informed the work of the Committee. This

additional research revealed that the optimal solution to the issue of consent would be specific federal legislation

regarding the consent required for electronic exchange of health information or state legislation that clearly

directs Ohio practitioners to follow the current federal guidance. The Committee created a table to capture the

summary of the models and enabling legislation of other state consent models and it is included in Appendix E.

4.7 CONSENT ENVIRONMENT UNDER HIPAA

In addition to the Ohio consent law discussed above, the federal Health Insurance Portability and Accountability

Act (HIPAA) affects how health care providers may access, use and disclose a patient’s records. Unlike Ohio law,

HIPAA does not require a patient’s consent for a health care provider to use or disclose a patient’s record for

purposes of the patient’s own treatment, or payment for their treatment. The differing requirements under

HIPAA and Ohio law have created some confusion among health care providers and patients about consent

requirements. However, HIPAA defers to state law where state law offers more privacy protection or stronger

individual’s rights relative to patient health information. As a result, the Committee concluded that although

HIPAA does not require patient consent to use the patient’s health record for treatment and payment, the HIE

must obtain consent from the patient to “opt‐in” to allow a health care provider to obtain the record using the HIE

(HIE Consent) because of the stricter Ohio law consent requirements discussed above. To eliminate the need for

the HIE Consent and to align Ohio law with HIPAA would require Ohio to change its statutes to permit health

record exchange using an HIE without patient consent.

In addition, the Committee contacted the federal Office of Civil

Rights (which interprets and enforces HIPAA) to confirm that

HIPAA permits an HIE to create an index of the patient’s whose

information is accessible through the HIE (the Master Patient

Index) by asking participating health care providers to give the

HIE limited information about the patients who have records

stored on their systems. The Committee was able to confirm

that the Office of Civil Rights views an HIE as a “business

“the Committee concluded that although

HIPAA does not require patient consent to

use the patient’s health record for

treatment and payment, the HIE must

obtain consent from the patient to “opt‐in”

to allow a health care provider to obtain

the record using the HIE (HIE Consent)

because of the stricter Ohio law consent


Q43


associate” under HIPAA. Under HIPAA, a “business associate” is an organization that assists a health care provider

in performing certain health‐related or administrative functions, and receives, creates or maintains health record

information in connection with these activities. HIPAA allows health care providers to give health records to

“business associates” for these permitted purposes, including for purposes of an HIE. Health care providers that

participate in the HIE will treat the HIE as their “business associate.” Most health care provider participants will

use the HIE only as a conduit to ask for and receive health records that are stored at another health care provider.

A small number of health care provider participants in the HIE may store their health records on systems operated

by the HIE, if for example, they do not have appropriate storage systems. In either case, participating health care

providers will upload applicable health record information to the HIE under the terms of a Business Associate

Agreement that meets all HIPAA requirements. However, when a patient’s participating health care provider

wants to access a patient’s record using the HIE (such as a treating the provider seeking and want to find the

patient’s records located on another health care provider’s system), the health care provider will need to obtain an

HIE Consent to permit them to get the patient’s record using the HIE.

5. CURRENT CONSENT ENVIRONMENT

Health information exchanges across the country are struggling to define what constitutes adequate and

meaningful patient consent in this new era of electronic exchange of health information. Opinions are varied

among stakeholders as to what is required legally, what is appropriate for risk management purposes, what

constitutes the best public policy, what will hold up in an evolving market of commercialization of health

information and what is feasible from an implementation perspective. The introduction of a statewide HIE

represents a paradigm shift in the way information is shared among health care providers. In today’s largely

paper‐based world, the patient generally manages the exchange his or her health information between providers.

In order for Provider A to obtain health information from Provider B, the patient must tell Provider A that he or she

is receiving care from Provider B, would like their health information to be shared and sign a form confirming this

request. In the paper‐based world, the patient is the gatekeeper of the records and, in many instances, the courier

of the records.

The HIE will remove many of the current burdens placed on

patients surrounding the exchange of their health records.

Instead of the patient facilitating the exchange through direct

dialogue between previous and current providers, the patient is

now only required to provide consent to the current provider.

This enables current providers to reach out to large networks of

clinicians that have administered care to the patient and obtain

a more accurate and complete record of the patient’s previous

care. The HIE will eliminate the burden of gathering and

transporting paper records, help prevent duplicate tests and

procedures and ensure that providers have the best information

available to make coordinated medical decisions.

“The HIE will remove many of the current

burdens placed on patients surrounding

the exchange of their health records.

Instead of the patient facilitating the

exchange through direct dialogue between

previous and current providers, the patient

is now only required to provide consent to

the current provider.”


Q44


6. RECOMMENDED POLICY AND PROCESSES FOR OHIP HIE

After reviewing the work conducted by the HISPC workgroup, the consent policies of other states, Ohio law and

Ohio case law, and ONC privacy directives, the Committee crafted recommendations on the consent process for

the statewide HIE. These recommendations balance the need to protect patient privacy rights with the goal of

enabling a highly interoperable HIE. The recommendations are summarized in Table 4: Recommended Policy and

Processes for OHIP HIE, and a more through explanation of each recommendation follows.

TABLE 4: RECOMMENDED POLICY AND PROCESSES FOR OHIP HIE

6.1 SCOPE OF GOVERNED ACTIVITIES

All entities participating in the statewide HIE will be required to follow the policies and procedures established by

OHIP. Participants in the HIE will include:

Hospitals (Including Critical Access and Federally Qualified Hospitals)

County and State Health Departments

Physician Offices

Community Health Centers

Large Academic Medical Centers

Nursing Homes

Ambulatory Surgery Centers

Labs

Pharmacies

Other Government Health Agencies

1. Scope of Governed Activities of Statewide HIEThe policies for consent apply to all entities in the state that wish to share information on the statewide HIE. The initial scope of information exchange is for treatment purposes only, which includes uses that are likely to be expected by a patient and bring the patient direct medical benefit.

2. HIE Participant Requirements In order for an entity to participate in the Statewide HIE, the participant will be required to sign a Business Associate Agreement (BAA) and a Participant Agreement. These agreements will require participants to comply with current laws, policies and procedures pertaining to patient consent, and adopt the consent policies developed by OHIP to access a patient’s health record using the HIE.

Population of the OHIP Master Patient Index (MPI) OHIP will populate a Master Patient Index (MPI) with basic demographic information. The information within the HIE will not be available to participant entities until affirmative patient consent for the Participant to access the HIE is obtained.

3. Patient Engagement OHIP will implement a patient outreach plan to educate the public about the statewide HIE and the consent policies that govern health records. 4. Consent Every entity participating in the statewide HIE must obtain a signed HIE Consent form from the patient prior to viewing the patient’s medical records. The consent for accessing data on the statewide HIE has a time limit of one year. The OHIP statewide HIE will have policies and procedures in place to ensure the occurrence of audits and transparency of operations. Consent standards will be enforced contractually and by OHIP staff.


Q45

Attachment B

To become a successful HIE the term “liquidity” is often used. A liquid exchange is one where almost all consent

based queries succeed in finding information about a patient to inform medical decisions. An exchange would be

perceived as illiquid (i.e., unsuccessful) if a large number of queries result in failures. OHIP aspires to create a

liquid exchange and the key to this is stakeholder support.

6.1.2 USES OF HEALTH INFORMATION

The HIE Consent form will be for uses expected by a patient and benefit the patient directly. These uses currently

include:

Information exchange for the purposes of treatment;

Quality improvement; and

Care management.

Treatment is defined as the provision, coordination, or management of health care and related services among

health care providers or by a health care provider, and may include providers sharing information with a third

party. Consultation between health care providers regarding a patient and the referral of a patient from one

health care provider to another also are included within the definition of treatment. All participating entities must

follow these policies and procedures. The following elements or uses are from the first phase of implementation of

the HIE:

De‐identified data and

Sensitive health information

Health records of minors

Administrative Transactions

6.1.2.1 DE‐IDENTIFIED DATA

While the disclosure of de‐identified data may be extremely useful to advance important healthcare research and

public health goals, it is not the intent of OHIP to address the use of this data at this time. Once the statewide HIE

is operational, and OHIP has engaged the public regarding this topic, the concept of using de‐identified data will be

addressed.

6.1.2.2 SENSITIVE HEALTH INFORMATION

The Code of Federal Regulations (42 CFR Part 2) sets forth limitations on the release of alcohol and drug related

health records maintained in connection with any federally assisted

alcohol and drug abuse program. This includes the requirement for

patient consent for disclosure to include the name/title of the

individual‐ organization to whom/which disclosure is to be made.

The Substance Abuse and Mental Health Services Administration

(SAMHSA), under HHS, has interpreted this provision as requiring

that a patient’s consent for inclusion of these records on an HIE list

the names of each person or organization to whom disclosures are

authorized, as well as the purposes for the disclosure. A similar

requirement is included in the Ohio Administrative Code section

applicable to release of information by agencies certified to provide mental health services by the Ohio

Department of Mental Health (OAC 5122‐27‐08).

At this point, there is uncertainty as to whether the statewide HIE will be capable of permitting a selective/granular

exchange of records among specific participants in order to comply with the regulatory limitations outlined above.

Therefore, the Privacy and Policy Committee has recommended that alcohol, drug, and mental health records not

“…the Privacy and Policy Committee has

recommended that alcohol, drug, and

mental health records not be included in

the HIE until further relevant technical,

legal and policy considerations are

considered. This will take place in the

fourth phase of policy development.”


Q46


be included in the HIE until further relevant technical, legal and policy considerations are considered. This will take

place in the fourth phase of policy development.

6.1.2.3 HEALTH RECORDS OF MINORS

The consent required for a physician to access the health records of minors will be addressed in Phase III which will

take place in the first quarter of 2011.

6.1.2.4 ADMINISTRATIVE TRANSACTIONS

OHIP will address administrative transactions in the second quarter or 2011 during Phase IV of the Committee’s

work. OHIP’s original HIE RFP chose not to seek an administrative vendor.

6.1.3 POLICIES AS THE FLOOR FOR INTERSTATE EXCHANGE

The policies set forth in this document will serve as the floor, rather than the ceiling of consent policies required

for exchange between the statewide HIE and exchanging with other states. These states may choose to implement

less stringent policies for HIE within their state, but if their participants desire to exchange with Ohio, they will be

required to have patients sign OHIP’s HIE Consent form before any information is exchanged.

6.2 HIE PARTICIPANT REQUIREMENTS

6.2.1 BUSINESS ASSOCIATE AND TECHNICAL CERTIFICATE

In order for an entity to join the statewide HIE as a Participant, it must follow a two‐stage connection protocol.

The first stage of this protocol will require the entity to provide all policies and procedures surrounding patient

consent to OHIP for review. The entity will then be asked to sign a Participant Trust Agreement and Business

Associate Agreement.

During the second stage of the protocol, the entity will conduct a trial exchange of patient data with the statewide

HIE. The complexity of the exchange will determine the level of connectivity between the entity and the HIE. This

test will determine whether the entity will connect to the HIE via a web portal or directly through its EHR. This two‐

stage protocol is shown in Diagram 1: OHIP Connection Protocols.


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DIAGRAM 1: OHIP CONNECTION PROTOCOLS

6.2.2 POPULATION OF THE MASTER PATIENT INDEX

The MPI must be a single‐source of truth with the most accurate and validated information available. Currently,

the most validated information regarding patients is held at the provider level. As providers adopt EHRs, they will

begin to create and update their records electronically. Once these providers have successfully completed the

OHIP on‐boarding process, their “validated” records (patient demographic data) will be uploaded to an interim

data store within the MPI. As these records are added, they will then be scrubbed (e.g., verified against identity

sources like Lexus‐Nexus) and posted to the production MPI, ensuring the highest probability of validity. The

statewide HIE will only hold the demographic information necessary to provide the highest, deterministic match on

its MPI. HIPAA regulations do not require consent for a health care provider to store or otherwise share patient

information with HIPAA identified business associates that hold the information purely as a custodian for the

provider. Health care providers are not required to obtain consent from patients when they store the patient’s

information on that patient with data warehouses or remotely hosted medical record systems. They also are not

required to obtain consent when they share information with medical transcription services, software vendors or

other business associates.

According to guidance from the Office of Civil Rights, an HIE:

“may receive protected health information from multiple covered entities, and manage, as a

business associate on their behalf, a master patient index for purposes of identifying and

linking all information about a particular individual. Disclosures to, and use of, a HIE for such

purposes is permitted as part of the participating covered entities’ health care operations

under the HIPAA Privacy Rule, to the extent the purpose of the master patient index is to


Q48


facilitate the exchange of health information by those covered entities for purposes otherwise

permitted by the Privacy Rule, such as treatment.”

http://www.hhs.gov/ocr/privacy/hipaa/understanding/special/healthit/collectionusedisclosure.pdf

6.2.3 MOVEMENT OF A PATIENT HEALTH RECORD ACROSS THE STATEWIDE HIE

As previously mentioned, patient health records from multiple providers only will be available to a treating

physician if the patient has signed an HIE Consent form, identical to the current paper process for requesting

patient health records. If one thinks of the path that the health record will travel on as a highway, a patient’s

signature on the HIE Consent form allows the patient health record to board the on‐ramp and then the off‐ramp to

flow data into the office of a treating physician. A visual depicting the potential connections to the statewide HIE is

found in Diagram 2: Movement of a Patient Record Across the HIE. This diagram also shows that a treating

physician will only have accesses (after receiving patient consent) to the files of other HIE participants that have

met the OHIP two‐stage connection protocol process identified in Diagram 1 and have an executed Business

Associate Agreement, Participant Agreement and Technical Certificate with OHIP.

DIAGRAM 2: MOVEMENT OF A PATIENT HEALTH RECORD ACROSS THE HIE


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6.3 PATIENT ENGAGEMENT

OHIP will develop an educational campaign around patient consent and provide a policy and procedures toolkit.

OHIP recently hired a Communications Director who will lead the development of the plan. The Communications

Director has begun collaborating with the Privacy and Policy Committee, OHIP’s Regional Partners and the newly

formed Physician Association’s Advisory Council to develop the toolkit and campaign. The toolkit will be completed

by the end of December, with the campaign kicking off in January offering webinars and events and is planned to

continue through the July go live date. The campaign will include education on the state requirement for patient

consent for use and disclosure of patient information. A campaign to explain consent to the public also will be

developed.

6.4 CONSENT

The current laws that govern health information exchange were developed in a paper‐based world where the

decisions regarding what, how and to whom to communicate were generally made on a one‐to‐one basis by

clinicians and their patients. These current laws serve the patient’s privacy interests by restricting what can and

cannot be shared, and the terms which sharing takes place.

Human judgment and personal relationships play a major role

in information exchange decisions.

As previously stated, moving from a paper to an electronic

health system changes the information‐sharing dynamic. The

statewide HIE will facilitate a many to many relationship among

providers, enabling different information technology systems

and software applications to exchange information accurately,

effectively and consistently. This offers new opportunities to promote access to health care information, as well as

to facilitate the safety, quality and efficiency of health care. Patient control over health care information is

achieved through the requirement for HIE consent. Each participant in the statewide HIE must obtain an HIE

Consent from the patient that specifically references the statewide HIE prior to accessing her/his health

information.

Requiring patients to consent to the exchange of their information on the statewide HIE ensures that they know

how their information will be shared and used among statewide HIE entities. It also lets patients decide whether

to allow their information to be shared and used in this manner. Thus, the use of the HIE Consent form promotes

openness and transparency and stimulates patient choice as recommended by the Tiger Team. A provider or

payer organization participating in the statewide HIE must obtain an affirmative consent from the patient that

specifically references the statewide HIE prior to accessing the patient’s health information. This consent may be

executed by an electronic signature. The required consent may be obtained at the provider or payer organization

level and need not be at the individual clinician level. Once a provider or payer organization obtains patient

consent, it may access the patient’s information from any statewide HIE Participant that has information regarding

that individual. Diagram 3: Statewide HIE Patient Consent Process provides a visual to explain this process. It

depicts the consent process from the patient’s perspective. The first part of the process is explained in the pink

circle, obtaining consent for treatment and payment required by state and federal law. This currently should be

occurring in all provider offices. The second part of the process, identified in the grey circle, is the additional

“Each participant in the statewide HIE must

obtain a consent from the patient that

specifically references the statewide HIE

prior to accessing her/his health

information.”


Q50


consent required for a patient to participate in the statewide HIE. The HIE Consent form will be used for this step

in the process.

DIAGRAM 3: STATEWIDE HIE PATIENT CONSENT PROCESS

6.4.1 APPLICATION OF CONSENT

Once the participant obtains consent, the consent may be used by the HIE participant for internal purposes during

that specific episode of care.

6.4.2 INFORMATION ABOUT PARTICIPATING ENTITIES

At the time a participant obtains an HIE consent from a patient, the participant must reference the OHIP website

that lists all of the statewide HIE participants that have signed Business Associate and Trust Agreements with OHIP

will be found. This list will be updated as entities are added and removed.

6.4.3 EXCEPTIONS TO CONSENT

6.4.3.1 PUBLIC HEALTH REPORTING

If the participant is required to disclose a patient’s record to a government agency for purposes of public health

reporting, including monitoring disease trends, conducting outbreak investigations, responding to public health

emergencies, assessing the comparative effectiveness of medical treatments, conducting adverse drug event

reporting without patient consent under applicable state and federal laws and regulations, the statewide HIE may

make those disclosures on behalf of the data supplier without consent, in the same manner as required with paper

based records.


Q51


6.4.3.2 BREAK THE GLASS

Patient HIE consent will not be required for a provider to access a patient’s health record from the statewide HIE in

emergencies and the participant “may break the glass” if the following conditions are met:

Treatment may be provided to the patient without consent if in the practitioner’s judgment an emergency

condition exists.

The practitioner determines, in his or her reasonable judgment that information that may be held by the

Statewide HIE may be material to emergency treatment.

The practitioner attests that all of the foregoing conditions have been satisfied, and the OHIP software

maintains a record of this access.

6.4.3.3 CONVERTING DATA

Patient consent is not required for the conversion of paper records into electronic health record or for the

uploading of a health record from the records of a data supplier to the statewide HIE. If the statewide HIE is

serving as the Participant’s Business Associate (as defined in 45 C.F.R. 160.103), the statewide HIE does not make

the information accessible to participating entities until consent is obtained.

6.4.4 IMPROVEMENT AND EVALUATION OF STATEWIDE HIE

Affirmative consent is not required for the statewide HIE to access a patient’s record for the purpose of evaluation

and improving the operations of the statewide HIE for the benefit of the covered entities. Consistent with HIPAA,

access to a patient’s record should be limited to the minimum amount necessary to accomplish the intended

purpose of the use or disclosure.

6.4.5 TREATMENT AND COVERAGE NOT CONDITIONED ON CONSENT

Patients must be able to prevent any or all access to their personal health information from the statewide HIE

without being refused treatment or coverage. Provider or payer organizations must not condition treatment or

coverage on the patient’s willingness to provide access to the patient’s information through the statewide HIE.

6.4.6 CONSENT FORM

Consent to access information via the statewide HIE will be obtained using a model form developed by OHIP,

referred to as HIE Consent form in this document. Approval to access information will be denied in the absence of

this form. The form will include the elements identified in Table 5: HIE Consent Form Requirements.


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TABLE 5: HIE CONSENT FORM REQUIREMENTS

6.4.7 DURABILITY AND REVOCABILITY

The affirmative consent for accessing data on the statewide HIE has a time limit of one year. Revocation of

consent will prevent a participant from accessing information through the statewide HIE in the future. However,

any data that has been accessed by the participant in the past may remain part of the participants’ records.

6.4.8 AUDITS AND ENFORCEMENT

OHIP staff will implement the policies and procedures recommended by the Privacy and Policy Committee. With

the assistance of OHIP’s legal counsel, the Privacy and Policy Committee will develop a Participation Agreement

and Business Associate Agreement that will ensure all participants in the statewide HIE agree to adhere to the

policies and procedures when they are completed. OHIP staff will coordinate the execution and storage of all

required agreements and investigate any breaches, complaints and non‐compliance with the published policies

and procedures. System audit logs will be created and maintained for all events within the HIE. Utilizing IHE

Profiles ITI‐19 and ITI‐20, the HIE will preserve a consistent network time and record event data according to

recognized standards.

The HIE Consent form required to be signed for a physician to access a patient health record on the HIE will

include the following elements:

The information to which the patient is granting the participant access

The intended uses to which the information will be put by the participant

The relationship between the participant and the patient whose information will be accessed;

Certification that only those engaged in the intended uses may access the patient’s information;

Acknowledgement of the patient’s right to revoke consent and assurance that treatment will not be

affected as a result;

Whether and to what extent information is subject to re‐disclosure; information will be redisclosed

unless prohibited by state or federal law.

The consent will be valid for 365 days;

The signature of the patient or the patient’s Personal Representative; and

The date of execution of the consent.

Reference to all Participants at the time of the patient’s consent, as well as an acknowledgement that

Participants may change over time and instructions for patients to access an up to date list of

Participants through the OHIP website or other means


Q53


The contractual language of the participant agreements will include periodic audits that will be conducted by an

outside vendor. The final version of these agreements and the Policy and Procedure manual will be made available

on the OHIP website and the OHIP help desk will answer questions about the policies and procedures.

7. NEXT STEPS

After the OHIP Board and stakeholders review the recommendations included in this document, the Privacy and Policy Committee will draft formal Policies and Procedures needed for the statewide HIE. In the interim, the Committee will address sensitive health information, privacy rights of minors, research and the transfer of non‐treatment related information. The result of these discussions will also be submitted for stakeholder review.

The next two phases that will result in a formal Policy and Procedure Manual and final BAA and Participant Agreements are identified below.

Phase III ‐ First Quarter of 2011

90 day period to solicit stakeholder feedback on recommended consent policies and procedures

The document will be posted on the OHIP webpage, sent to provider associations, RECs and a summary of the document will be prepared for consumer associations

Recommendations will be adjusted if needed and resubmitted to OHIP board

Items not included in original recommendations will be addressed including sensitive health information, privacy rights of minors, research and the transfer of administrative data and stakeholder feedback will be solicited

During this period of public comment, the Privacy and Policy Committee will draft Business Associate Agreements, Participant Agreements and a formal Policy and Procedures Manual

Phase IV‐ Second Quarter of 2011

• Final Policy and Procedures Manual approved by OHIP Board • Final Participant Agreements, Business Associate Agreements, and Technical Certificate Agreements

approved by OHIP Board • The Privacy and Policy Committee will address the consent required for administrative transactions in this

time period and undergo a public review process similar to that performed for consent for treatment

8. TERMS AND DEFINITIONS

Break the Glass‐ The ability of a health care provider, in the case of an emergency to access a patient’s protected health information without obtaining the patient’s consent. Business Associate Agreement‐ Under HIPAA, a “business associate” is an entity that assists a covered entity, such as a health care provider in performing certain health‐related or administrative functions, and receives, creates or maintains health record information in connection with these activities. HIPAA allows health care providers to give health records to “business associates” for these permitted purposes, including for purposes of an HIE, in exchange for the Business Associate’s agreement to pro ide privacy and security protections for the information. Consent‐ An express permission given by a patient for the exchange of his or her personal health information through an HIE in response to a clear and specific request for such permission or at the individual’s own initiative. Health record‐ A health record often contains demographic, clinical, financial and socioeconomic data. This paper provides recommendations for the consent required to exchange the demographic and clinical information required for treatment that is found in a health record. Recommendations for the consent requirements to


Q54


exchange financial information about a patient will be forthcoming in later guidance from the OHIP Privacy and Policy Committee. HIE Consent Form‐ The form that must be read and signed by a patient before any HIE participant can access that patient’s health records on the HIE. HIE Participant‐ Hospitals, physician offices, community health centers, federally qualified health clinics, large academic medical centers, nursing homes, ambulatory surgery centers, labs and pharmacies are all potential participants in the OHIP HIE. HISPC‐ Health Information Security and Privacy Collaborative Ohio Law Consent form‐ The term “Ohio Law Consent” is used throughout the document to refer to the consent required by Ohio law for exchange of information for treatment and payment. This consent is the floor of consent in the state of Ohio and is a more thorough consent than that required by HIPAA. ONC‐ Office of the National Coordinator for Health Information Technology at the Department of Health and Human Services. Privacy and Policy Committee (Committee)‐ The Committee created by OHIP to address the privacy issues related to establishing OHIP’s HIE


Q55

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