Nys Hie Operational Plan 2010

8/8/2019 Nys Hie Operational Plan 2010

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New York eHealth Collaborative (NYeC)

New York State Health Information ExchangeOperational Plan

October 26, 2010


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TABLE OF CONTENTS

Glossary 4

Executive Summary 6

ACHIEVING TECHNOLOGY-ENABLED HEALTH CARETRANSFORMATION IN NEW YORK STATE: OPERATIONALPLAN FOR HEALTH INFORMATION TECHNOLOGY AND EXCHANGE

1. Background

New Yorks Vision of Technology-Enabled Health Care Transformation 13

Overarching Goals for Health IT in New York StateCore Values That Underlie New Yorks Approach to Health IT 16

Progress to Date 17

2. Governance 29

Statewide HIE and Health IT Leadership 31

Statewide Collaboration Process 33

Accountability and Oversight 38

Statewide HIE Utility 45

3. Technical Infrastructure 46

Health IT and HIE Gap Assessment and Corrective Strategies 48

HIE Architecture and Approach 54

HIE Standards and Certification 60

4. Business and Technical Operations 62

Statewide HIE Services Approach and Implementation Timeline 62

Broadband Access 67

Technical Assistance Services 68

Adoption Services 68

Standard Operating Procedures 69


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Identifying and Mitigating Potential Business Risks 70

Monitoring and Evaluation 70

Continuous Improvement 70

5. Legal and Policy Issues 72

Privacy and Security Framework for Statewide HIE 72

6. Finance 77

Financial Model 77

Detailed Cost Estimate and Staffing Plan 81

7. Coordination Among New Yorks Health IT Programs 86

Coordination with Medicaid 86

Coordination with REC Programs 88

Coordination with Public Health, Medicare and Federally Funded,State-Based Programs 89

Coordination with Federal Care Delivery Organizations (VA, DoD, IHS) 93

Coordination with Other New York Policy and Procurement Activities 94

Development of Trust Agreements for Interstate Data Sharing 95

Appendices

Appendix A New York Regional Health Information Organizations

Appendix B Minimizing and Managing Risk

Appendix C Current NYS DOH Electronic Data Systems for Public Health Reporting

Appendix D Commitment to Fair Information Sharing Principles

Appendix E Quality Monitoring & Reporting

Appendix F Letter of Support

Appendix G NYeC Board Membership

Appendix H Candidate HIE Services

Appendix I Project Management Plan


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GLOSSARY

CAC Consumer Advisory Council

CAHPS Consumer Assessment of Healthcare Providers and Systems

CCC Collaborative Care Community

CHITA Community Health Information Technology Adoption Collaborative

CHI2 Child Health Integration Initiative

DOHMH New York City Department of Health and Mental Hygiene

ECLRS Electronic Clinical Laboratory Reporting System

EHR Electronic Health Records

HEAL Health Care Efficiency and Affordability Law for New Yorkers

HIE Health information exchange

HIPSC Health Information Privacy and Security Collaboration

HITEC Health Information Technology Evaluation Collaborative

IIS Immunization Information System

IT Information technology

NHIN Nationwide Health Information Network

NYC New York City

NYeC New York eHealth Collaborative

NYS DOH New York State Department of Health

OHIP Office of Health Insurance Programs (NYS DOH)

OHITT Office of Health IT Transformation (NYS DOH)

PCIP Primary Care Information Project

PCMH Patient-Centered Medical Home

PHI Personal Health Information

PHR Personal Health Records


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POC Policy and Operations Council

NCQA National Center for Quality Assurance

REC Regional Extension Center

RHIO Regional Health Information Organization

SCP Statewide Collaboration Process

SDE State Designated Entity

SHIN-NY Statewide Health Information Network for New York

SPG Statewide Policy Guidance

UPHN Universal Public Health Node


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EXECUTIVE SUMMARY

Since 2004, more than $840 million in Federal, State and private sector funding hasbeen allocated toward efforts to harness health information technology (IT) and healthinformation exchange (HIE) to improve the effectiveness and efficiency of health care

delivery in New York State. In support of a technology-enabled health caretransformation, diverse stakeholders have united to forge a strong statewide consensusfor reform. A statewide infrastructure to support HIE has been established andsupported by policies and standards that have enabled early gains in the adoption ofhealth IT.

These innovations in New York are inspired by a vision of the patient at the center of acare community that collaborates to address the full array of each individual patientsneeds. The States strategic approach to HIE reflects a commitment to privacy andsecurity, a focus on improved medical outcomes, and an emphasis on continuousquality improvement, further innovation, and accountability in the public interest. This

emerging technology-enabled health care transformation in New York State will benefitpatients, primary and specialty care providers, hospitals, payers, and governments.

Notwithstanding the strides made in establishing a foundation for widespread HIE,important gaps remain both in the stakeholders adoption of these promising newtechnologies and in the implementation of the policies and procedures needed toensure full realization of the States health care vision. New Yorks Operational Plan forHealth Information Technology and Exchange (Operational Plan) aims to continue theadvances achieved to date, to address existing gaps, and to ensure the sustainability ofthese efforts.

The Operational Plan outlines specific steps New York will take in the coming months toexpedite progress through the strategic allocation and use of more than $300 million ingrant funds that will be programmed through 2013. Developed in close coordination withthe Office of Health IT Technology (OHITT) and the Office of Health InsurancePrograms (OHIP) in the New York State Department of Health (NYS DOH), the Plan issubmitted by the New York eHealth Collaborative (NYeC), a statewide public-privatepartnership that aims to advance health IT.

Governance

Leadership:New Yorks governance infrastructure is led by a collaborative statewide

leadership between NYSDOH and NYeC and is guided by the core value ofaccountable HIE governance in the public's interest. Under the guidance of these twoentities, New York developed an open, transparent, collaborative, multi-stakeholderprocess for developing health information policies, standards, protocols, and technicalapproaches. New York further relies on the implementation and governance of thesepolicies at the community level.


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Statewide HIE Governance Framework:New Yorks statewide HIE governanceframework aims to accelerate progress towards achievement of the required connectedcapabilities for effective HIE. The goals of the governance process include:

Ensure broad use and access of HIE services by all providers in New York

State Support collaborative care model through which multiple stakeholders work

together to measurably improve the quality and efficiency of care andtransform the health of the community

Accelerate market-driven interoperability Create a sustainable marketplace for HIE services that meets public policy

needs Strengthen core public health functions, including prevention, service

planning, outcomes research, disease surveillance, and early warningsystems for disease outbreaks

Advance New Yorks national leadership in statewide HIE

In an effort to maximize effective allocation of resources and strengthen successful localorganizations, New Yorks governance framework has expanded to include twocomplementary concepts: a Qualified Health IT Entity, which will serve as the technicalon-ramp to HIE services, and a Collaborative Care Community (CCC), which willfunction as a multi-stakeholder means for improving the quality and efficiency of careand transforming the health of the community.

Statewide HIE Utility:Examining New Yorks existing statewide HIE infrastructurerevealed that additional opportunities exist to leverage economies of scale, particularlythat of core infrastructure services and other value-added services that could be

procured and managed using a statewide, public utility model. NYS DOH and NYeCcontinue to evaluate options for creating a single statewide HIE utility, including theviability of NYeC serving in this capacity.

Technical Infrastructure

A statewide trend toward adoption of health IT and HIE is evident with respect to e-prescribing, electronic reporting for public health, electronic lab results delivery, andpatient care summary exchange. Yet considerable gaps remain in the uptake andutilization of health IT and HIE. To address these gaps, New York will develop anddeploy HIE services aligned with New York States Health Care Efficiency and

Affordability Law for New Yorkers (HEAL NY) health IT strategy, Federal health ITprograms, meaningful use mandates, and developments in the commercial marketrelated to health information exchange.

Core services:Core services will be made available on a uniform basis to supportconnected capabilities statewide. These services may be provided as a single statewideshared service or by standardizing regional approaches to developing and delivering theservices. In either scenario, NYeC will coordinate activities to ensure that all potential


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state HIE participants have access to them. Below is a list of core services that will bereleased in June 2011: Provider/HIE Directory coordinated to function with Message/Record Routing and

Identity Management and Authentication for provider enrollment and other securityfeatures

Record Locator Service/Master Person Index (Patient Matching) coordinated tofunction with Message/Record Routing, Consent Management and possibly withIdentity Management and Authentication (for patient enrollment and other securityfeatures)

Message/Record Routing focused on health information organization (HIO) to HIOintegration, providing access to participants not served by a qualified HIO, andenabling direct connection by participants and vendors capable of complying withSHIN-NY policy and standards

Identity Management and Authentication a full suite of security features forparticipants in statewide HIE, coordinated with RHIO and other qualified HIOinfrastructures and enrollment processes

Consent Management coordinated to function across HIO/HIO boundaries andwith all other services in the bundle

Public Health Reporting/Registry:The initial public health reporting/registry services, tobe released in August 2011, will focus on aligning the ongoing HEAL efforts toimplement a Universal Public Health Node (UPHN) with the statewide capabilities andwith requirements for the Public Health Reporting/Registry value-added service.

Value-Added Services: The below value-added services are necessary to supportconnected capabilities. These services may be implemented with more variability,depending on HIE objectives and regional capabilities.

Medication Management Collect prescription history for purposes of performingmedication reconciliation, detecting significant changes or overuse of medications,identifying and notifying patients at risk of adverse events, etc. Data can be de-identified with a key for re-identification for certain uses as required.

Personally Controlled Health Record Populate a patient-centered longitudinal /lifetime health record from primary data sources. Can be event / rules-driven,consumer-activated or a combination. Can provide storage and viewing capabilitiesor simply route to a consumer-directed service such as Google Health, Indivo, orMicrosoft Health. Also, provide patient / consumer with ability to request and route /download CCDs and other data to self and other participants. Can be accomplished

through a portal, secure e-mail, IVR, etc. Can be implemented through negotiatedoffer of commercial service to consumers.

Event Notification Route various notifications of patient status to authorized andinterested parties based on certain triggers. Possible candidates include FirstReport of Injury and / or Admission Notification to the patients payer and physicians;Death Notification to payer, physicians and public health; status changes such asadoption, protective services, marriage, hospice, PCP change, etc.


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E-prescribing Largely delivered through EMR vendor software in combination withSurescripts national network. A gap analysis will be conducted to determine ifRHIOs and other organizations require assistance to incorporate payer formulariesand pharmacies not available through Surescripts. The goal of this activity is toincrease adoption and volume among NYS providers of e-prescribing to commercial

pharmacies. Lab results Largely already delivered by national lab companies and RHIOs

through existing interfaces. A gap analysis will be conducted to determine requiredfor delivery of structured lab results uniformly statewide from local hospital, regionaland national labs. Depending on the results of this gap analysis, NYeC may providecoordination or integration assistance to standardize interfaces or to fill gaps,especially in delivering results from local hospital labs in some regions.

To support and strengthen the technical infrastructure strategies, New York will developand implement user-friendly technical assistance services, including a help desk, tosupport and expedite the ability of stakeholders to adopt health IT and HIE strategies.

Working closely with the New York REC programs, New York will provide adoptionsupport services to all providers, including primary care providers, mental healthproviders, long-term care providers, and home health providers to promote andfacilitate the usage and adoption of health IT and HIE.

Legal and Policy Issues

In developing a comprehensive, standardized set of privacy and security policies andprocedures, New York aims to improve health care delivery and health outcomes for allNew Yorkers by achieving the following goals:

Implement HIE that is secure and protects patient privacy

Orchestrate levers of state policy to advance Health information Exchange

Advance state law, policies, and procedures that are aligned with secure healthinformation exchange within and beyond state borders

Advance trust agreements that enable parties to share and use data

Pursue strong oversight and enforcement to ensure compliance with federal andstate laws and policies applicable to HIE.

To ensure a robust and comprehensive legal and policy framework for health IT andHIE, New York will continue to develop long-term legal and contractual protocols tomaintain the collaborative multi-stakeholder trust that has been nurtured through theSCP. In addition, investigating strategies to enable interstate data sharing withneighboring states is underway.


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Consistent with one of the core principles of New Yorks approach to health IT and HIE,the State will implement a rigorous plan of action to address gaps or shortcomings inapplicable laws and regulations pertaining to privacy and security.

To ensure that NY Policies and Procedures are consistent with evolving Federal and

State laws and regulations, New York will continue to utilize the SCP processes toupdate the Policies and Procedures to bring them into alignment with changes inexisting laws and regulations.

Finance

Building upon the financial investments that have enabled New York to achieve theprogress it has made so far, New York will advance strategies to continue, accelerateand sustain these advances. Given the need for self-sustaining sources of long-termfunding, New York particularly aims to encourage and facilitate market dynamics thatare consistent with Federal policy as well as New Yorks policy objectives.

New York will identify and create incentives to encourage the adoption andsustainability of health IT. Specific efforts will focus on incentivizing health IT adoptionby key stakeholder groups, including specialty clinicians in ambulatory settings, largeprimary care practices, long-term care facilities and nursing homes, home healthagencies, inpatient facilities, hospital emergency departments, mental health providers,and other segments of the clinical community. A cost-benefit analysis of a sharedservices (or public utility) approach will be undertaken, and Qualified Health IT Entitiesand coordinated care projects will be supported to ensure long-term regionalsustainability. Consistent with current practices, NYS DOH and NYeC will implementand enforce rigorous financing controls and issue detailed financial reports.


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that describe New Yorks overall approach to health IT and identify progress to date, theOperational Plan sets forth future directions with respect to governance, finance,technical infrastructure, business and technical operations, and legal and policy matters,devoting individual chapters to each functional area.

Individual appendixes address risk management, the project management plan,performance monitoring and reporting, proposed timeline, and relevant statements ofsupport. Additional appendixes sketch key use cases for New Yorks technology-enabled health transformation and provide additional information relevant to thecontents of the Operational Plan.


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1. Background

The combined efforts of the Federal and State governments, as well as the privatesector, have already generated important advances in New York State toward healthcare transformation through better use of health IT. Gains achieved to date include

progress toward a strong statewide consensus for reform, establishment of an HIEinfrastructure, and early gains in the adoption of technologies that have the potential tomarkedly improve the effectiveness and efficiency of health care services.

NYeC is a statewide public-private partnership that seeks to define a strategic roadmapfor New York State to advance health IT and realize the vision of more effective,collaborative care. Established in 2006 by leaders in the health care field in NYS, NYeCis a key strategic player in New Yorks efforts to capitalize on the potential of technologyto drive health care transformation in the State. With funding and policy support fromNYS DOH, NYeC is charged with facilitating development of a statewide healthinformation network, using a multi-stakeholder collaborative process to develop policy

guidance for stakeholders in the health care field. New York State has designatedNYeC to be the State Designated Entity (SDE) for the State HIE program, andseparately awarded NYeC $53 million to pursue complementary initiatives to furtherdevelop statewide health IT policy and enhance the states HIE infrastructure.

NYeC Focus Areas

As a statewide public-private partnership dedicated to the achievement of a technology-enabled healthcare transformation in New York State, NYeC has three primary responsibilities. First, NYeC convenes,educates and engages key constituencies, including health care and health IT leaders across the State.Second, NYeC facilitates an interoperable health information exchange through the Statewide HealthInformation Network for New York (SHIN-NY), supporting the establishment of health information policies,

standards and technical approaches and aiding stakeholders at the regional and local levels to implementsuch policies and standards. Third, NYeC partners with organizations across NYS to evaluate theeffectiveness of, and establish accountability measures for, the States health IT strategy.

NYeC and NYS DOH have collaborated to develop this Operational Plan. Within NYSDOH, OHITT and OHIP have participated in the development of the plan. In addition,OHITT has consulted other offices within NYS DOH, including leadership of the Statespublic health programs. This collaborative effort has contributed to a common vision forusing health IT to make measurable improvements in the quality and cost-efficiency ofhealth care services.

This Operational Plan emerges at a critical juncture for New York State. More than $300million in State and federal funds will be allocated to accelerate the adoption andeffective use of health IT and HIE in New York over the next three years, and the Stateis in the process of significantly realigning incentives in the Medicaid program topromote improvements in the quality and efficiency of health services. This momentumfor health care reform, aligned with broad health IT adoption in New York, offers anunprecedented opportunity to accelerate the transformation of health care delivery inthe State for the benefit of consumers, providers and the State at large.


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New Yorks Vision of Technology-Enabled Health CareTransformation

New Yorks Operational Plan is animated by a vision of the patient at the center of a

care community that collaborates to address the full array of each patients needs. Asthe figure below illustrates, reforms currently being implemented will ensure that eachpatient is served through a collaborative approach that engages the entire health carecommunity, including primary and specialty care physicians; pharmacies; health plansand pharmacy benefit managers; laboratories, radiology clinics, and the like; long-termcare providers; hospitals; public health and other public sector health and social serviceagencies; and physical therapy, nutrition and other supportive services.

The concept of the patient-centered medical home, or PCMH, has informed the

thinking reflected in this Operational Plan. PCMH ensures that each patient benefitsfrom consumer-friendly provider relations and system protocols to facilitate promptdelivery of the high-quality, coordinated, client-centered services patients need to obtainoptimal health outcomes.

The PCMH vision relies on widespread adoption by diverse providers of interoperableelectronic health records (EHRs), a well-designed system of HIE, and meaningful useby all providers of these mechanisms, protocols and systems. The health ITinfrastructure that New York has created has catalyzed early adoption of health IT andwill facilitate even more widespread adoption of these protocols and practices. ThisOperational Plan sets forth specific directions to further implement this system and to

accelerate its broad adoption and uptake.

Coordination of policy development and implementation support is a central focus forNew Yorks health IT strategy. The policies and practices associated with New YorksHIE strategies are intended to promote alignment of diverse stakeholders within thehealth system to improve the efficiency and quality of health care service delivery. Forexample, the implementation of a well-designed, seamless network of EHRs willestablish the foundation for health care organization and payment models designed to

Physical Therapy, NutritionServices, Etc.

Labs, X-Rays, etc.PATIENT / INDIVIDUAL

Pharmacies

Health Plans, PBMsConsultant Physicians

Long Term Care

Hospitals

Public Health and OtherAgencies


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encourage more effective and efficient care delivery practices that will optimize healthcare outcomes, maximize the impact of health care resources, and promote patient-friendly cost containment.

Key stakeholders across New Yorks health care system will derive concrete benefits

from the technology-enabled heath care transformation:

Patients:Consumers of health care services will become active partners in theirhealth care through better access to information and tools. Over time, they canexpect to receive improved health care services and obtain enhanced medicaloutcomes. The transition to a comprehensive, well-regulated system will alsoincrease patients confidence in the confidentiality and security of their medicalrecords.

Primary and Specialty Care Providers:Health care providers will be able to provideimproved care to their patients by accessing and using timely, comprehensive and

accurate information specific to each patient. They will also be able to coordinatecare better due to improved communication channels with other providers and theirpatients. Inefficiencies associated with the collection and management of paperrecords will be reduced, as will medical errors.

Hospitals:Facilities responsible for the care of patients, including many admittedthrough emergency departments, will be able to access the patient information fromoutside sources needed to improve and coordinate care. Health IT systems willfacilitate superior transitions of care among hospitals, private practices and sub-acute facilities, leading to fewer readmissions and further reductions in medicalerrors.

Payers:A robust statewide health IT infrastructure will enable payers to implementcoverage schemes that incentivize efficiency and intensify systemic focus on patientoutcomes. The technology-enabled health care transformation in New York willincrease payer confidence that they are not paying for wasteful, duplicative orerroneous services. Payer strategies and activities should be coordinated to ensurealignment of incentives and reduce administrative complexity for consumers andproviders.

Governments:As a major payer of health care services, governments will reap theefficiency and quality benefits to payers generally. In addition, a statewide health IT

infrastructure will advance the public goal of facilitating sound research methods toanswer critical health questions. Public health efforts will be strengthened throughsimplified and more comprehensive disease reporting, earlier identification ofpotential outbreaks, and enhanced capacity for rapid communication with the entirecommunity of health care providers.


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Overarching Goals for Health IT in New York State

Through robust, strategic investments in health IT, New York State will continue to focuson the following overarching goals, which were articulated in the original Strategic Planadopted in 2007:

Improve the Efficiency and Effectiveness of Care: Provide the rightinformation to therightclinician at the righttime regardless of the venue where the patient receivescare.

Improve the Quality of Care: Ensure access to clinical information to supportimprovements in care coordination and disease management, help reorient thedelivery of care around the patient, and support quality-based reimbursement reforminitiatives.

Reduce Health Care Costs: Minimize costs associated with medical errors,

duplicative tests and therapies, uncoordinated and fragmented care, and preparingand transmitting data for public health and hospital reporting.

Improve Health Care Outcomes: Mobilize health information to evaluate theeffectiveness of health care interventions and monitor quality outcomes.

Engage New Yorkers in Their Care: Lay the groundwork for New Yorkers to haveaccess to their health information and communicate electronically with theirproviders to improve the quality, affordability and impact of health care services.

Core Values That Underlie New Yorks Approach to Health IT

New Yorks strategic approach to HIE is guided by a set of core values. These corevalues are consistent with the common set of principles that have shaped efforts inother states and at the Federal level. They not only point the way toward the specificstrategies which New York is pursuing, but also help define the ways in which thesestrategies will be implemented, monitored and sustained.

These core values include the following:

Support privacy and security:New York has undergone substantial collaborativeefforts to establish a comprehensive set of privacy and security policies and

procedures. It is committed to continually evaluating and updating those policiesand aligning them with similar efforts at the national level.

Focus on desired outcomes:New York shares the Federal governments goal ofenabling more providers to achieve meaningful use of health IT. It is also committedto continuing to advance efforts to support more complex data exchange necessaryfor coordinated care models, and characteristic of future stages of meaningful usecriteria.


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Like other states, however, New York has struggled to optimize health care outcomesand to ensure good value for the money spent on health care services. A majorimpediment to the optimization of health care quality and efficiency has been thefragmented, decentralized, low-tech approach to health care delivery in the State. Dueto these weaknesses, health care delivery in New York State has too often been

characterized by waste and duplication, insufficient coordination between key serviceproviders for individual patients, and approaches that are inadequately patient-centeredand sometimes poorly grounded in evidence of best practices.

In recent years, New York State has taken unprecedented steps to address these andother related factors, with the aim of improving both the quality and efficiency of healthcare delivery. At the same time that the State has made unprecedented investments inhealth IT, a broad range of other regional/local and private sector initiatives has arisento harness information technology to improve health services.

The remaining portions of this background section review the States environment for

health IT and exchange and summarize the advances that have been achieved throughState leadership and essential Federal support.

New York States Health Care Transformation

New York States strategy for health care transformation has been built on acomprehensive governance, policy and technical infrastructure for statewide HIE. Thekey components of this infrastructure are illustrated in the figure below.


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Figure 1: New York States Health IT and Exchange Infrastructure

Governance and Organizational Infrastructure

Diverse partners collectively work together to drive progress towards technology-

enabled health care transformation in New York State:

NYS DOH:In support of the States health care transformation, NYS DOH in 2007created OHITT. The Governor has designated the Deputy Health Commissioner wholeads OHITT as the State Health Information Technology Coordinator for purposes ofimplementing the State HIE program. OHITT is charged with coordinating health ITprograms and policies across the public and private health care sectors, with the aim ofestablishing an infrastructure to support clinicians in quality and population healthimprovement, quality-based reimbursement programs, new models of care delivery, andprevention and wellness initiatives.

NYS DOH also chairs the New York State Health and Human Services CIO Council,which was established in 2009 to gather and share information to promote adoption ofcommon policies and standards across health and human services programs andagencies. Under this umbrella, diverse State agencies have developed a conceptualmodel to link their systems, including those related to Medicaid, public health, andpublic-sector and private-sector health care settings. One emerging example ofagency-wide coordination of health IT activities is the development of a Public HealthInformation Master Plan for HIE.

NYS Dept of HealthFund health IT

Set Policiesbig PEnforce regulations

NYeCStatewide collaboration process

Statewide Policy GuidanceAssist RHIOs/CHITAs

Statewide Policy GuidancePolicies & Technical Protocols

RHIO

Local

Region

State

RHIO

Funding and contractualobligations

$

HITECCreate evaluation toolsAssess sustainability

Measure progress$

RHIO

CHITA

Evaluation tools, otherresources

Statewide Health Information Network for NY (SHIN-NY)

RHIO RHIO

CHITA: A collaboration supporting EHR adoption;emphasis on primary care and Medicaid providers

RHIO:A governance entity that implements statewidepolicy guidance and oversees SHIN-NYimplementation in its region

CHITA

CHITA

CHITA

CHITA


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NYeC:As a statewide public-private partnership dedicated to achievement oftechnology-enabled health care transformation in New York State, NYeC has threeprimary responsibilities. To date, NYeC has focused on facilitating the StatewideCollaboration Process(SCP), which has led to the development of a comprehensive set

of statewide policies, known as the Statewide Policy Guidance(SPG). Second, NYeCis leading the next phase of development and implementation of the Statewide HealthInformation Network for New York (SHIN-NY), supporting the establishment of health ITpolicies, standards and technical approaches and aiding stakeholders at the regionaland local levels to implement such policies and standards. Third, NYeC evaluates andestablishes accountability measures for the States health IT strategy.

Regional Health Information Organizations (RHIOs):RHIOs are independentgovernance entities consisting of multiple stakeholders that support secure andinteroperable exchange of health information. Their mission is to govern and providehealth exchange services for the public good in order to support improvements in health

care quality, affordability and outcomes. In that role they participate in the SCP to helpset policies for the state and then oversee implementation of those policies in theirregions. Currently, there are 12 RHIOs that are part of New Yorks governancestructure. A full list of New Yorks RHIOs is provided in Appendix A.

Community Health Information Technology Adoption Collaboratives (CHITAs):CHITAsprovide implementation and wrap-around services to physician practices adoptingEHRs. CHITAs work with providers to ensure proper configuration and implementationof EHRs and HIE services, as well as effective use of health information to attain qualityand efficiency goals.

Regional Extension Center (REC): The Regional Extension Centers offer statewideEHR adoption services that will supply providers with the knowledge, training, andconfidence they will need to successfully select and deploy an EHR and use healthinformation meaningfully. In New York, there are two RECs: The first REC is operatedby NYeC and provides services to practices throughout NYS with the exception of NewYork Citys five boroughs. The other REC, operated by the NYC REACH, supports theproviders of New York City.

Health Information Technology Evaluation Collaborative (HITEC): HITEC is a multi-institutional, academic collaborative of New York State institutions including CornellUniversity, Columbia University, the University of Rochester, and the State University ofNew York at Albany, and serves in a research and evaluative role with respect to healthIT initiatives in NYS. HITEC was formed to evaluate and develop evaluationinstruments for HIT initiatives across the State, while integrating a variety ofstakeholders. The State has committed $12 million to HITEC for evaluation andresearch activities. These activities include real-time formative generation of resultswith rapid feedback to involved stakeholders and policy makers, and longer termsummative generation of results leading to peer reviewed publications. HITEC is an


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important and distinguishing health IT asset in NYS, allowing independent and objectiveevaluations of activities.

Legal and Policy Infrastructure

New York States health IT and HIE efforts are guided by a transparent and inclusiveprocess that includes the following components:

Statewide Collaboration Process (SCP):New York has developed an open, transparent,multi-stakeholder process for developing health information policies, standards,protocols, and technical approaches governing the health IT infrastructure. NYeC, inpartnership with the NYS DOH, manages the SCP in order to forge consensus onrequirements in the form of Statewide Policy Guidance (SPG).

Policy and Operations Council (POC):To date, the POC has been composed of theleaders of the RHIOs and CHITAs that have led the State-funded health IT and HIE

implementation efforts. The POC reviews and approves recommended work grouppolicies and products for presentation to NYeC and NYS DOH. The POC also reviewsand makes recommendations about the SCP structure and processes and supportsNYS DOH/NYeC leadership in making strategy decisions.

Statewide Policy Guidance:As described above, the SCP is the vehicle for thedevelopment of New Yorks Statewide Policy Guidance. Existing SPG (summarizedbelow in the Section 2 discussion of governance) is available online athttp://www.nyehealth.org/index.php/resources/nys-policies.

Through the collective efforts of these key stakeholders, the foundation has beenestablished for momentous changes in New York States approach to health caredelivery. Additional work remains to ensure that new mechanisms, systems, protocolsand procedures are rapidly adopted, fully integrated, and used effectively.

Technical Infrastructure

Under the Health Care Efficiency and Affordability Law for New Yorkers (HEAL) 5program, NYS DOH outlined a vision and technical strategy for advancing New Yorkshealth information infrastructure, the SHIN-NY.1 Built on a service-orientedarchitecture, SHIN-NY is a network of networks through which regional HIEs and theirparticipants may share data and services within and across regions using commonstandardized protocols. SHIN-NY incorporates and extends Federal standards such asthose adopted by the Nationwide Health Information Network (NHIN)

As part of the HEAL 5 program, NYS DOH engaged NYeC to facilitate the developmentof an architecture and a set of technical specifications for SHIN-NY through the SCP.The various RHIOs awarded HEAL 5 grants were contractually required to implement

1Additional details of the statewide technical strategy advance through HEAL 5 is available online athttp://www.health.state.ny.us/technology/projects/docs/technical_discussion_document.pdf.
http://www.health.state.ny.us/technology/projects/docs/technical_discussion_document.pdfhttp://www.health.state.ny.us/technology/projects/docs/technical_discussion_document.pdfhttp://www.health.state.ny.us/technology/projects/docs/technical_discussion_document.pdf


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SHIN-NY specifications in their regional HIEs. To complete their HEAL 5 projects, theywill have to demonstrate successful use of those SHIN-NY specifications. (SHIN-NYarchitecture and specifications are available athttp://www.nyehealth.org/index.php/resources/nys-policies

One of the goals of SHIN-NY has been to enable the development of an interoperablenetwork through which New York can deploy so-called statewide shared services inaddition to standardized regional approaches. The development of shared servicesprovides the opportunity for economies of scale, through the unified development of aservice accessible to all users in the State. Under HEAL 5, New York tested potentialtechnical approaches to shared services by facilitating a providers query and retrievalof a test Medicaid medication history data to an EHR system from SHIN-NY.

In addition to this infrastructure and set of technical resources, the State will alsoleverage several important operational systems operated by State agencies, including:

Medicaid eMedNY MMIS System: This Medicaid claims processing system allowsMedicaid providers to submit Medicaid claims and claim transactions and receivepayments electronically. eMedNY offers several innovative technical andarchitectural features, facilitating the adjudication and payment of claims andproviding extensive support and convenience for its users. Medicaid recentlylaunched a service that will allow providers to electronically retrieve the medicationhistory for Medicaid patients into their EHRs. NYeC prototyped delivery of thatservice through its SHIN-NY architecture as part of the HEAL 5 program.

Electronic Public Health Data Exchange: NYS DOH is working with the New YorkCity Department of Health and Mental Hygiene (NYC DOHMH) on developing and

testing a technical architecture and set of specifications for the Universal PublicHealth Node (UPHN). UPHN is a collection of services and operational policiesdesigned to fulfill designated public health reporting and monitoring objectives.UPHN is narrowly intended to describe the relevant interactions between HIEpartners such as RHIOs and NYS DOH. UPHN transactions support activities andinteractions with other entities, such as local health departments (LHDs) within NewYork, other health and human service (HHS) agencies, the Centers for DiseaseControl and Prevention (CDC), health care data sources (e.g. hospitals, physicianpractices, etc.), and health care consumers. UPHN standards and a workingprototype were developed through the SCP, facilitated with seed funding from CDCHIE. Three RHIOs are planning to provide this functionality as part of their HEAL 5

projects. In addition, four HEAL 17 projects have committed to facilitate informationexchange through the UPHN, and several more will adopt the service.

New York State Health Commerce System: This statewide, web-based infrastructureprovides services and support for 24x7, reliable, redundant and secure datatransport and communications between public health and external agencies and aplatform for the successful implementation and deployment of major public health
http://www.nyehealth.org/index.php/resources/nys-policieshttp://www.nyehealth.org/index.php/resources/nys-policieshttp://www.nyehealth.org/index.php/resources/nys-policies


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information systems in NYS. This infrastructure provides the current capacity forsecure information exchange activities between NYS DOH and all regulated healthentities in NYS, with more than 100,000 users, including all 58 LHDs, 230 hospitals,663 nursing homes, 1,481 clinical and environmental labs, 2,259 pharmacies andmore than 50,000 physicians.

Electronic Clinical Laboratory Reporting System (ECLRS):The Electronic ClinicalLaboratory Reporting System (ECLRS) provides laboratories that serve New YorkState with a single electronic system for secure and rapid transmission of reportablecondition information to NYS DOH, LHDs and NYC DOHMH. ECLRS enhancespublic health surveillance by providing timely reporting; improving completeness andaccuracy of reports; and generally facilitating the identification of emergent publichealth problems by monitoring communicable diseases, lead poisoning, HIV/AIDS,cancer, and congenital malformations. ECLRS (for lab reporting and ED data)processes approximately 4.3 million reports per year.

Immunization Information System:Public Health Law requires health care providersto report all immunizations administered to persons under 19 years of age, alongwith the person's immunization histories, to NYS DOH, using a web-basedimmunization information system (NYSIIS) which serves all of NYS outside of NewYork City (as NYC has a separate system of its own). NYSIIS provides numerousbenefits to all those involved in the health care of children, contributing to a higherimmunization rate and a healthier population. Immunization reporting is alreadyunderway on the reporting side but has been limited to submission through a portalor proprietary EHR vendor connections. Once the transition is complete to asysterm that permits bi-directional data exchange, physicians will be able to submitimmunization information to the NYSIIS through RHIOs and the UPHN and receive

immunization history, recommendations, and guidance from NYSIIS.

Syndromic Surveillance Systems:All emergency departments in NYS, excludingNYC, are required to participate in the NYS DOH electronic syndromic surveillancesystem. NYS DOH routinely monitors data categorized into eight syndromes:Respiratory, GI, Fever, Asthma, Neurological, Rash, Carbon Monoxide poisoning,and Hypothermia. Summary and case-level counts, signals (CuSum analysisresults), short- and long-term trend graphs as well as patient listings are all availableby syndrome, hospital, county, and region. Hospital users may view data for theirhospital and aggregated for their surveillance region, and LHD users may view datafor all hospitals in their county, as well as aggregated data for their county and

region.

Finance Infrastructure

In order to develop and maintain the health IT and HIE foundations needed to supportNew York States health care objectives, a two-pronged approach to financing has beenemployed. Capital investments in key infrastructural components from Federal, State,


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and private sector sources have been combined with policy, procurement, and financinglevers to create a path for sustainability.

State and Federal Investments in New Yorks Health IT and HIE Infrastructure

Established in 2004, the Health Care Efficiency and Affordability Law for New Yorkers(HEAL NY) provided capital funding to reform and reconfigure New York States healthcare delivery system in order to improve patient outcomes and increase efficiency.

More than 25% of the HEAL NY budget is allocated to health IT, with $398 million inState funds invested in four rounds of funding by NYS DOH. Through theseinvestments, an additional $280 million in private sector matching funds have beenleveraged, yielding a total investment to date that exceeds $600 million dollars.

The following table details HEAL investments to date:

Activity Recipients HEAL 1 HEAL 5 HEAL 10 HEAL 17 TotalCommunityHealth IT / HIEProjects

Various $53M $95M $60M $120M $328M

StatewideCollaborationProcess

NYeC $5M $5.3M $4M $14.3M

Statewide SHIN-NY Infrastructure

NYeC $22.8M $12M $34.8M

Education andCommunication

NYeC $3.5M $3.5M

Health ITAdoptionServices

NYeC $3.4M $3.4M

HIE Accreditation NYeC $2M $2MEvaluation HITEC $5M $5M $2M $12M

Total $53M $105M $100M $140M $398M

Figure 2: HEAL investments to date

HEAL 1 grantsprovided start-up capital funding for many regional health IT entities(described below) and other health IT projects. HEAL 5 grants built upon that foundationand marked the beginning of the development and implementation of the keyorganizational, clinical and technical building blocks for New York States healthinformation infrastructure, also described in more detail below. Acceleration of

momentum stemming from these early State investments in health IT was furthersupported by $180 million in additional HEAL 10 and HEAL 17 grants in 2009 and 2010.These grants were intended to capitalize on initial progress in developing a statewidehealth information infrastructure to transition to a new care delivery and reimbursementmodel the patient-centered medical homes.

HEAL NY has provided extensive funding (to be augmented under HEAL 10 and HEAL17) to NYeC to support policy development, ensure the smooth operation of the


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processes required to support the envisioned health care transformation, and provideimplementation guidance and support. Through its open and transparent governanceprocess, NYeC will also oversee the next stage of development of New Yorks HIEinfrastructure, SHIN-NY, described in more detail below.

HEAL NY also supports a collaborative research and evaluation platform, HITEC. Anacademic collaborative that includes Cornell University, Columbia University, theUniversity of Rochester, and the State University of New York at Albany, HITECevaluates and develops evaluation instruments for health IT initiatives, includinginteroperable health information exchange and EHR adoption across the State.

New Yorks progress to date in reconfiguring its approach to health care has benefitednot only from these unprecedented State investments, but also in the support of privatesector partners. In addition, New York received a $20 million grant from CDC in 2008 toimprove public health surveillance and reporting through the emerging health careinformation infrastructure. The States efforts have also been strengthened by a $4.7

million contract that NYeC received from the U.S. Department of Health and HumanServices to support the NHIN Trial Implementations Project, as well as grant support forpolicy development from the federally supported Health Information Security andPrivacy Collaboration (HISPC).

The various health IT-related programs funded by the American Recovery andReinvestment Act (ARRA) have provided New York with additional opportunities toadvance its initiatives. Under the State HIE program, NYeC was awarded $22 million toenhance the States HIE infrastructure and ensure the broad availability of options forproviders to meet the HIE requirements of meaningful use. New York has receivedfunding for two RECs to provide EHR adoption support services to providers, with aninitial focus on "priority" primary care providers working in small practices or treatingunderserved populations. The first REC is operated by NYeC and provides services topractices throughout the entire State with the exception of NYC. The second REC,operated by the Primary Care Information Project, supports providers in NYC. OHIP willalso receive funding from the Centers for Medicaid & Medicare Services (CMS) tosupport the administration of the Medicaid EHR Incentive program.

New York payers have implemented or supported various provider incentive programsto directly or indirectly reward their use of health IT systems.

OHIP:NYS DOH has been a leader in advancing new types of reimbursement touse its purchasing power and reward providers for the use of health IT tools. OHIPhas also implemented various financial incentive programs within the NYS Medicaidprogram to encourage providers effective use of health IT systems. Notableinitiatives include:

o e-Prescribing:To encourage the use of electronic prescribing (e-prescribing), OHIP instituted a program on May 1, 2010, to providefinancial incentives to providers that issue prescriptions electronically and


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pharmacies that accept e-prescriptions. Under this program, eligibleproviders (including physicians, dentists, nurse practitioners, podiatrists,optometrists, and licensed midwives) receive incentive payments of $0.80per dispensed Medicaid e-prescription (including refills), and retailpharmacies receive incentive payments of $0.20 per dispensed e-

prescription.

o Patient-Centered Medical Homes:Effective July 1, 2010, NYS Medicaidbegan to provide incentives to office-based physician and registered nursepractitioner practices, Federally Qualified Health Centers (FQHCs), andDiagnostic and Treatment Centers (D&TCs) recognized by NYS Medicaidand the NCQA as operating a PCMH. NYS Medicaid has chosen toadopt medical home standards that are consistent with those of theNational Committee for Quality Assurances (NCQA) Physician PracticeConnections - Patient-Centered Medical Home Program (PPC-PCMH).

Other Payer Initiatives:Several other initiatives, either sponsored by single-payer ormulti-payer collaboratives, also incentivize providers to implement patient-centeredmedical homes. These include:

o Hudson Headwaters:With $7M in funding, the Adirondack Medical HomeMulti-payer Demonstration Program seeks to establish a demonstrationPCMH to serve recipients of public medical assistance, as well asenrollees and subscribers of commercial managed care plans. In thisendeavor, the Adirondack Health Institute Care Improvement Initiative willwork in tandem with the Adirondack PCMH Pilot to improve and enhance

the provision of healthcare services in the region.

o THINC P4P Medical Home Project:This project is a multi-payercollaborative pay-for-performance effort involving 237 primary carephysicians with EHRs in the Hudson Valley region of New York. THINCreceived a pay-for-performance grant from NYS DOH in 2007, andbroadened it to include a medical home component. Six health plans,representing 65% of the commercial market, and one major employer(IBM) pay incentives to practices, based on the PCMH recognition levelreceived from NCQA, and for meeting HEDIS quality benchmarks.

o Rochester Medical Home Initiative:This pilot, a partnership betweenExcellus BlueCross BlueShield and MVP Healthcare, was launched inMarch 2009 and involves 20 primary care physicians (PCPs) from 7practices. It is designed to test how changes in the business practices ofboth the health plan and the primary care office can support establishingMedical Home practices. A central component is changing thereimbursement model for participating practices to compensate for time


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spent in care coordination and to increase PCP income to be morecompetitive with medical specialists.

o CDPHP:CDPHP launched a PCMH initiative in 2008 involving threepractices. As part of the initiative, CDPHP tested a new payment model

that paid these providers operating PCMHs additional money for treatingsicker patients. The initiative has proven so successful that it is beingexpanded to include 21 new practices.

o EmblemHealth Medical Home High Value Network Project:TheEmblemHealth project includes 38 primary care practices, the majority ofwhich are solo and small practices, from NYC and the surroundingcounties. The payment structure includes three components: a fee-for-service payment, a care management payment and a performance-basedpayment.

Business and Technical Infrastructure

As the summary above illustrates, NYS has made considerable progress advancing itshealth IT and HIE infrastructure. However, it recognizes that significant gaps remain.To address these gaps, the State will need to continually collect and analyze data totrack its progress. New York recently launched a RHIO dashboard to track individualRHIOs, and the whole States, performance in advancing adoption and use of HIE toolsand services. Much of the RHIO data included in the following section is gathered fromthat dashboard.

Geographic HIE Coverage:According to a recent survey, 59 of New Yorks 62 countiesare currently covered by at least one RHIO. Thus, in terms of geographic breadth,todays infrastructure provides a gateway for local access to the SHIN -NY from everycorner of the state. An overview of the statewide and regional participation levels ofhospitals and physicians in RHIOs is illustrated in the map below. The following tableprovides information on the types of key HIE services being provided by the RHIOs.


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RHIO Participation by Region

Figure 3: RHIO Participation by Region

Key

Y=Service currently offered P=Service planned within next year

D=Service in development N=Service not offered

Figure 4: HIE Services Offered by RHIOs

BHIX

Bronx

eHealthNetworkLI

HealtheConnections

HEALTHeLINK

HIXNY

Interboro

LIPIX

NYCLIX

Rochester

STHL

THINC

Patient history "pull" queries Y Y Y D Y Y Y Y Y Y Y PElectronic eligibility and claims N N N D Y P N N N N N N

E-prescribing applications N Y N D Y Y Y D N Y N N

Medication history Y Y Y D Y Y Y D N Y Y NElectronic lab results delivery (1:1

exchange) N Y D D Y Y N D N Y D Y

Electronic lab orders N N N D N N N N N N N YElectronic radiology results delivery

(1:1 exchange) N Y P N Y D N D N Y N NElectronic transcribed reports

delivery (1:1 exchange) N Y N N Y D N D N Y N NRecord exchange for e-referral / care

coordination (1:1 exchange) N D Y D D D D Y Y D D DElectronic public health reporting D D N N P N P D N P D D

Quality reporting D D N N P D N D N P D DInformation delivery to/from

personal health records D P D D P D P D D D D P

Clinical decision support D Y N N P N N Y N N N N

WesternRHIOs: HEALTHeLINK, RochesterHospital Access Data: 10% (3/31)Hospital Supply Data: 52% (16/31)Total Provider Users: 29%

CapitalRHIOs: HIXNYHospital Access Data: 28% (8/29)Hospital Supply Data: 38% (11/29)

Hudson ValleyRHIOs: THINCHospital Access Data: 3% (1/36)Hospital Supply Data: 3% (1/36)

Long IslandRHIOs: LIPIX, eHealth Network of LIHospital Access Data: 65% (15/23)Hospital Supply Data: 91% (21/23)

New York CityRHIOs: NYCLIX, BHIX, Bronx, InterboroHospital Access Data: 32% (20/62)Hospital Supply Data: 52% (32/62)

New York StateHospital Access Data: 34% (79/232)Hospital Supply Data: 46% (107/232)

CentralRHIOs: Rochester, STHL,HealtheConnnectionsHospital Access Data: 29% (15/51)Hospital Supply Data: 43% (22/51)Total Provider Users: 47%


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2. Governance

Guided by the core value of accountability in the public's interest, New Yorks

governance infrastructure is built on four key components:

Effective statewide leadership through two entities, the NYS DOH and NYeC, amulti-stakeholder public-private partnership.

A transparent and inclusive Statewide Collaborative Process for policydevelopment and decision-making.

Statewide Policy Guidance that provides a common and consistent technical,privacy, security, and legal framework for participants in HIE.

Independent and objective evaluation and research of health IT initiatives toprovide formative and summary data to inform activities.

New Yorks governance infrastructure continues to evolve and adapt to the changinghealth care landscape. Recent policy developments will drive further evolution in NewYorks governance approach. At the State level, a new law (Chapter 58, Laws of 2010)grants the Health Commissioner broad authority to regulate health IT activity, includingthe issuance of rules and regulations to implement federal policies, disburse funds, andpromote the development and adoption of SHIN-NY. The statute provides the following:

The commissioner shall make such rules and regulations as may be necessary

to implement federal policies and disburse funds as required by the AmericanRecovery and Reinvestment Act of 2009 and to promote the development of astatewide health information network of New York (SHIN-NY) to enablewidespread interoperability among disparate health information systems,including electronic health records, personal health records and public healthinformation systems, while protecting privacy and security. Such rules andregulations shall include, but not be limited to, requirements for organizationscovered by 42 U.S.C. 17938 or any other organizations that exchange healthinformation through the SHIN-NY.

As part of the collective effort for continuous improvement, NYeC and NYS DOH

assessed the existing statewide health IT and HIE infrastructure, reaching the followingconclusions:

Provision of Technical and Clinical Functions. As the pace of technology andtransformation of care delivery quickens, it is apparent that providing thesefunctions requires staff with different expertise, varying levels of capital intensity,and different relationships with vendors, providers, payers and otherstakeholders.


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Value of HIE Utility Models. Procuring HIE services through a utility reduces theper-unit cost of services and promotes consistency by reducing duplication ofservice. This approach has worked successfully at the regional level, whereRHIOs are currently aggregating requirements and collectively providing cost-

effective HIE solutions for participants.

Costs for Creating and Sustaining Governance Infrastructure. The creation andmaintenance of governance entities and processes requires time and resourcesand can be expensive to establish and maintain. Governance infrastructureshould be developed in circumstances and at levels where it is needed and notredundant.

In light of these findings, NYeC and the NYS DOH began a process in July 2010 toidentify and evaluate options to enhance the statewide HIE governance framework.Alternative approaches were assessed against the following criteria:

Protect Public Interest: Core values maintained and protected throughappropriate oversight and accountability.

Promote Widespread Access to HIE Services: Maximize breadth and depth ofparticipation in HIE Services.

Advance Overall System Efficiency: Ensure: (1) governance is not created whereit is not needed; (2) widespread adoption of core services is promoted withoutunnecessary duplication of effort/resources.

Promote Organizational Efficiency: Minimize duplication of roles and avoidredundant staffing and allocation of resources.

Encourage Innovation: Ensure capacity to adapt to a rapidly changing technicaland regulatory market.

Leverage Existing Investments: To the extent they accelerate progress towardidentified goals, existing infrastructure and investments should be built upon asopposed to disrupted.

Ensure Data Liquidity: Advances interoperability objectives.

Promote collaboration in care delivery across institutional boundaries.

Ensure broad stakeholder involvement in the development of networkmanagement and policy.

Promote development of financially self sustaining model for operation of thenetwork.


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Below are additional detail on each of these governance components, recentadaptations, and next steps to meet the evolving needs of a dynamic health caredelivery, regulatory, technical and financial environment.

Statewide HIE and Health IT Leadership

New York States HIE and Health IT efforts are led by two entities, the NYS DOHsOffice of Health Information Technology Transformation (OHITT) and the New YorkeHealth Collaborative (NYeC).

NYS DOH OHITT

As noted in Section 1, the Governor designated the Deputy Health Commissioner wholeads OHITT as the State Health Information Technology Coordinator for purposes ofimplementing the State HIE program. OHITT is charged with coordinating health IT

programs and policies across the public and private health care sectors, with the aim ofestablishing an infrastructure to support clinicians in quality and population healthimprovement, quality-based reimbursement programs, new models of care delivery, andprevention and wellness initiatives. As also described in Section 1, the NYS DOH-chaired NYS Health and Human Services CIO Council, established in 2009, hasdeveloped a conceptual model and Public Health Information Master Plan to link thesystems of diverse State agencies and programs.

NYS DOH has begun to develop an agency-wide governance structure for overseeinghealth IT adoption and related decision-making across State agencies. This internalstructure will support OHITTs multi-disciplinary and cross-office capacity to streamline

health IT policies across all programs, including but not limited to public health. Inmoving forward, the emerging internal structure will support all NYS DOH stakeholdersin their efforts to assess their needs, identify priorities, and develop strategic plans forhealth IT, including but not limited to meaningful use. Program activities will beintegrated to increase coordination and collaboration within and among NYS DOHprograms, with particular attention to processes that optimize resource allocation. NYSDOH will launch cross-disciplinary health IT decision-making within the Department tofacilitate priority-setting and coordination. Guidance and assistance on strategicalignment for funding opportunities will be ensured.

NYS DOH launched the Public HIE Initiative to organize and coordinate public health

HIE activities, with the aim of ensuring alignment with public health goals andsupporting meaningful use requirements. Developed through close collaboration withPublic Health and OHITT, the Initiative adheres to a vision of improved populationhealth and patient clinical care through public health information system integration andelectronic information exchange with the health care community. The Initiativecoordinates Public Healths participation in HIE initiatives to ensure that public healthpractice operates effectively and efficiently.


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Through this Initiative, NYS DOH will integrate program activities to increasecoordination and cooperation with public health programs. A project managers groupwill develop a dashboard for current and future public health projects; develop specificimplementation deliverables related to project status, communications, and otheractivities; hold weekly meetings to report on project status and review cross-project

coordination issues; and ensure that all initiatives pursue sound project managementtechniques and adhere to NYS DOH technology and data standards. A separate projectcoordinators group will review and approve implementation approaches proposed byproject managers and hold bi-weekly meetings with project managers to ensureaccelerated progress, coordination and quality control. A third group the projectsponsors group will review and ultimately approve implementation approachesendorsed by project coordinators, hold monthly meetings with project coordinators, andprovide guidance and assistance on strategic alignment for funding opportunities.

In support of further integration of State health and human services programs, top near-term priorities for data sharing including development of a cross-agency unified privacy

policy, building a unified approach to authentication and access control across Stateagencies, development of a State-level client and organization/provider identificationmanagement system, and developed of shared services for both primary care andmental health, improving the coordination and management of care through a PCMHmodel. Having focused to date on information sharing and communication, the groupwill place increasing emphasis in moving forward on the advantages of statewideshared services, determining a formal decision-making process, a resource plan, andnext steps in implementation. A finalized HHS-CIO roster will be agreed, and aformalized evaluation plan forged.

NYeC

As a statewide public-private partnership dedicated to achievement of technology-enabled health care transformation in New York State, NYeC has three primaryresponsibilities. As described in Section 1, these include facilitation of the StatewideCollaboration Process, which has produced Statewide Policy Guidance; thedevelopment and implementation of SHIN-NY, supporting the establishment of healthinformation policies, standards and technical approaches and aiding stakeholders at theregional and local levels to implement such policies and standards; and evaluates andestablishes accountability measures for the States health IT strategy.

As one of the two RECs in New York, NYeC provides technical assistance, guidance,and information on best practices to support and accelerate health care providersefforts to become meaningful users of EHRs. A list of NYeC membership is provided inAppendix G. The Board by-laws is available online athttp://www.nyehealth.org/index.php/about-us/board
http://www.nyehealth.org/index.php/about-us/boardhttp://www.nyehealth.org/index.php/about-us/boardhttp://www.nyehealth.org/index.php/about-us/board


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Statewide Collaboration Process (SCP)

New Yorks governance model aims to accelerate progress toward achievement of therequired connected capabilities and effective HIE. This collaborative governance modelunites key stakeholders, clarifies roles and responsibilities, and provides a fair and

transparent means of reaching key decisions and resolving potential disputes andbottlenecks.

New York has developed an open, transparent, multi-stakeholder process fordeveloping health information policies, standards, protocols, and technical approaches.NYeC, in partnership with the NYS DOH, manages the SCP in order to forge consensuson requirements that are reflected in Statewide Policy Guidance (SPG).

The SCP is designed to facilitate collaborative and transparent development of commonpolicies and procedures, standards, technical approaches and services for New Yorkshealth information infrastructure. The SCP is largely driven by the efforts of its

collaborative workgroups, which recommend policies and procedures, standards,technical approaches and services to the NYeC POC, the NYeC Board and NYS DOH.Recognizing that ongoing input from key stakeholders is critical to success, NYeC willcontinue to work collaboratively with SCP workgroups and other key constituents.

To date, workgroups have used the analytical process illustrated below to developrelevant requirements and policies:

Figure 5: New Yorks Statewide Collaborative Process Workflow

Policy Approval Process

New Yorks governance process provides for four key stages in the development andapproval of any relevant policy:

RankRequirements

Define foundationpolicy objectives toguide projects

Distill technologicaland processrequirements frompolicy foundation

Score requirementsby key prioritizationdimensions

Prioritizerequirements toassess phasing:

Importance Urgency Feasibilit

Map priority ranking toproject phasing

SetPolicy

DetermineRequirements

DecidePriorities

PhaseRequirements

What? How? When


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Policy Development: SCP work groups develop policies by consensus. For majorpolicies, a public comment period is conducted to ensure maximum public input.

POC Review: The work groups advance the policies to the POC for consideration,summarizing the key issues and decisions in a decision memo. The POC

considers the policies and votes whether to recommend its passage or not.

NYeC Board Review:The results of the POC vote are advanced together with thepolicy and decision memo to the NYeC Board. The NYeC Board votes whether toapprove the policy.

NYS DOH Review:Upon approval by the NYeC Board, the policy, including thedecision memo and votes, is advanced to NYS DOH. NYS DOH has final approval.

Policy Amendment Process

The opportunity to regularly review policies based on experience gained during theimplementation process is an important component of New Yorks approach. NYeC hasinitiated a semi-annual review process for this purpose. NYeC meetings are open to thepublic to seek community participation and input to the SPG. The community has theopportunity to suggest amendments to the existing SPG. Those requests are thensubmitted to the respective work groups, which initiate a similar process to the onedescribed above for initial development of policies.

Statewide Policy Guidance (SPG)

As noted above, the final component of New Yorks statewide HIE governance

infrastructure is SPG, which provides a common and consistent technical, privacy,security, and legal framework for participants in HIE.

Through the Statewide Collaborative Process, NYeC and NYS DOH have developedSPG for the following:2

RHIO Privacy and Security Policies and Procedures

EHR Functional Requirements

Vendor Contract Requirements

SHIN-NY Technical Specificationso SHIN-NY Core Services Web Services Implementation Specificationso SHIN-NY Information Security Architecture and Implementation

Specifications

2Statewide Policy Guidance is available online at http://www.nyehealth.org/index.php/resources/nys-policies


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o SHIN-NY Medicaid Medication Management (MMM) Web ServicesImplementation Specifications

o SHIN-NY Universal Public Health Node (UPHN) Web ServicesSpecifications

o SHIN-NY Quality Reports Implementation Specifications

RHIO Consent Formso Standard RHIO Consent Formo Level 1 Multi-Provider Consent Formo Level 1 Payer Consent Formo Level 2 Payer Consent Form for Payment

In recent months, New York updated its SCP structure to strengthen the SPG and torefine models and policy issues relating to access to and use of shared services, withrecommendations to be considered in accordance with agreed SCP approvalprocesses. The updating of the SCP has resulted in clearly defined roles and

responsibilities of all entities involved in governance and technical support, includingfinalized criteria for RHIOs and other qualified organizations.

Consistent with current practice, the SCP will be used to develop statewide policies thatgovern HIE in the public interest. Input will be gathered from existing and new HEALprojects and other stakeholders, and specific efforts will focus on aligning State policiesand requirements with Federal criteria for meaningful use and PCMH. Plans fordeployment of shared services will be analyzed to identify specific policy issuesrequiring resolution. Work groups under the SCP umbrella will be convened to developrecommendations to be advanced through the SCP approval process.

The diagram below illustrates the collaborative governance model.


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Figure 6: New York SCP Structure

SHIN-NY Architecture Work Group: The Work Groups mission is todevelop strategies, standards and requirements for an enhanced SHIN-NY thatleverages shared services and standardized regional services to enable broad adoptionand use of interoperable HIE tools among providers and consumers across the Statewhile protecting privacy and security.

Privacy & Security Work Group: The Work Groups mission is To ensure that privacyand security industry standards are employed across all NYS HIE initiatives through thedevelopment of policy recommendations that protect the health information interests ofall users.

Consumer and Provider Engagement Work Group: The Work Groups mission is toprovide leadership on the development and implementation of provider and consumereducation and outreach programs/campaigns towards the promotion and utilization ofHIT to achieve health outcomes.

Public Health Work Group: The Work Groups mission is to improve population andpublic health in NYS through the planning, development, and implementation of aUPHN infrastructure for HIE utilizing a statewide collaboration process.


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Collaborative Care Work Group: The Work Groups mission is to plan and developpolicies & strategies designed to improve coordination of care through promotion ofclinical care standards, including quality & efficiency, for payment reform

Health IT Strategy Group: The Groups mission is to provide leadership and

coordination to the Statewide Collaboration Process (SCP) Work Groups through theestablishment of overall strategies and roadmaps that provide a process for work groupactivities.

Policy and Operations Council: The Councils mission is to provide guidance andparticipate in developing and implementing comprehensive and coordinatedinteroperable health information technology policies at the state level to driveimprovements in health care quality, affordability and outcomes.

Next Steps

NYeC and the NYS DOH will advance enhancements to the SCP in accordance withthe following timeline:

Fourth Quarter 2010:

Establish the Health IT Strategy Council and the POC.o Recruit and identify council members.o Draft and adopt council charters and bylaws.

Establish SCP work groups.o Recruit and identify work group members.o Draft and adopt work group charters and bylaws.

Reconvene NYS SCP.

First Quarter 2011:

Continue to utilize the SCP to develop statewide policies that govern HIE in thepublic interest.

o Gather input from HEAL projects and other stakeholders participating inSHIN-NY on outstanding issues requiring resolution.

o SCP Work Groups to develop and recommend standards policies. Establish clear and measurable goals for the NYS HIE and develop a monitoring

tool.o Finalize clinical/population health goals and health IT adoption/usage

goals.

o Develop a monitoring plan.o Develop a communication plan to inform providers of the statewide goals.

Develop communication tools to educate consumers and providers of thestatewide health IT and HIE strategies and activities.

o Convene the Consumer and Provider Engagement Work Group.o Research available effective communications and education toolso Implement identified communication tools.


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Accountability and Oversight

New Yorks governance model aims to accelerate progress towards achievement of therequired connected capabilities and effective HIE. The goals of the governance processare multi-faced and include:

Ensure broad use and access of HIE services by all providers in New York State.

Support a collaborative care model through which multiple stakeholders worktogether to measurably improve the quality and efficiency of care and transformthe health of the community.

Accelerate market-driven interoperability.

Create a sustainable marketplace for HIE services that meets public policyneeds.

Strengthen core public health functions, including prevention, service planning,

outcomes research, disease surveillance, and early warning systemsfor disease outbreaks.

Advance New Yorks national leadership in statewide HIE.

While policies and technical specifications are developed and defined at the statewidelevel, New Yorks current governance and technical approach relies on RHIOs andCHITAs for implementation at the local level. The current alignment of entities, roles andresponsibilities are highlighted in the illustration below.

Figure xx: New Yorks Existing Alignment of Governance Components

Figure 7: Existing Governance Infrastructure in New York


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In their current form, RHIOs support multiple functions, including the establishment andmaintenance of a collaborative multi-stakeholder mechanism at the local level, theprovision and oversight of technical services for participants in regional exchange, and

enforcement of SPG. State oversight of RHIOs is currently maintained via contractsthrough HEAL and other State programs.

With the rapid pace of technical change and the imminent implementation of nationalhealth reform, providers still require assistance at the local level to connect with HIEservices and to navigate new health delivery and financing models. While RHIOs could,and in some cases do, serve in both these capacities, the skills and resources neededto support the technical services and the clinical services vary considerably.

To maximize effective allocation of resources and simultaneously strengthen successfullocal organizations, New Yorks governance framework has expanded to include two

complementary concepts: a Qualified Health IT Entity, which will serve as the technicalon-ramp to HIE services, and a Collaborative Care Community, which will function asa multi-stakeholder means for improving the quality and efficiency of care andtransforming the health of the community.

The diagram below illustrates at a macro-level the roles and relationships between aQualified Health IT Entity, a Collaborative Care Community and vendors that provideHIE services. A detailed discussion follows.

Figure 8: Proposed Relationship between Qualified Health IT Entities, Collaborative CareCommunities and HIE Vendors


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Qualified Health IT Entities

Qualified Health IT Entities will focus on technical services and the rapid diffusion ofthose services consistent with SPG. Ideally, the creation of Qualified Health IT Entitieswill increase the supply of on-ramps to HIE services, which, in turn, will address gaps in

technical capabilities; create a flexible, adaptive set of HIE suppliers that can respond tofuture policy requirements; and accelerate innovation and reduce costs as QualifiedHealth IT Entities compete on the basis of quality of service, functionality, and pricing.

A number of benefits will accrue to Qualified Health IT Entities, including eligibility forgrant funds or contracts for provision of HIE services; access to SHIN-NY and data fromState sources (e.g., public health information, Medicaid data); and the ability to satisfyCertificate of Need (CON) requirements for health care providers undertaking health ITprojects.

In designing a framework for Qualified Health IT Entities, NYeC and NYS DOH sought

to develop criteria that balanced a free-market model with appropriate regulatoryoversight. Accordingly, organizations seeking designation as Qualified Health IT Entitiesmust demonstrate their ability to serve as technical on-ramps and also meet a numberof public interest objectives. Criteria currently under consideration include the ability ofan entity to demonstrate proven technical capabilities, the ability to maintain and expandthose technical capabilities, a willingness to comply with SPG and Fair InformationSharing Principles, a commitment to population and public health, and support ofCollaborative Care Communities.

Because adequate governance mechanisms exist at the statewide level in New York,Qualified Health IT Entities will not be required to maintain multi-stakeholdergovernance for technical implementation. However, as noted above, Qualified Health ITEntities must agree to participate in the SCP and abide by applicable elements of theSPG and New Yorks Fair Information Sharing Principles (see Appendix D).

Collaborative Care Communities

While Qualified Health IT Entities will support the development and expansion of HIEtechnical services, Collaborative Care Communities (CCCs) will focus on thecoordination of care within a geographic region or a specific population.

The definition of CCCs is based on attributes of a number of State-based and nationalinitiatives, including:

New Yorks HEAL 10 and HEAL 17 programs.

Beacon Communities.

Medicare Accountable Care Organizations (ACOs).


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Patient centered medical home (PCMH) initiatives.

Program elements, as they relate to CCCs, include the following:

HEAL 10:Organizations receiving funding within the HEAL 10 grant program

focus on supporting and/or accelerating the development and implementation ofNew Yorks health IT infrastructure. HEAL 10 Integrates this infrastructure withPCMH payment incentives and delivery system reforms. In addition, HEAL 10aims to establish clinical capacity for providers and patients to be prepared andaccountable for models based on quality-based outcomes and care coordinationand management.

HEAL 17:Initiatives receiving HEAL 17 funds have developed projects toimprove care coordination and management through PCMH componentscombined with interoperable health IT infrastructure. This infrastructure includesthe technological building blocks, clinical capacity and policy solutions necessary

to transition to an interconnected health care system encompassing the fullcontinuum of care at the community level. HEAL 17 projects focus on disease-specific improvements in chronic conditions and mental health diagnoses.

Medicare ACOs:Medicare ACOs are accountable for the quality, cost, andoverall care of a defined Medicare FFS population. ACOs must have a formallegal structure to receive and distribute payments for shared savings, in additionto bothclinical and administrative infrastructure and leadership. ACOs must havein place defined processes to promote evidenced-based medicine, report qualityand cost measures, coordinate care, and demonstrate patient-centeredness.

Beacon Community Program:Beacon communities build on an existinginfrastructure of interoperable health IT and standards-based informationexchange to advance specific health improvement goals. Communities strive toachieve measurable improvements in health care quality, safety, efficiency, andpopulation health. Most Beacon communities have a disease-specific focus, suchas projects to improve care for patients with diabetes.

Medicare Advanced Primary Care Practice Demonstration (APCP):APCP is amulti-payer initiative in a region or state that provides enhanced payment tomedical practices in exchange for providing continuous, comprehensive,coordinated, and patient-centered health care to the majority of patients. An

APCP must include Medicare, Medicaid, and commercial plans. The APCP isindicative of the PCMH trend toward regional/state efforts (as compared toexplicitly practice-based activities, such as those receiving recognition by theNational Center on Quality Assurance).

When combined, the elements of each of the above-noted programs will work togetherto support provider adoption of health IT; enhance care coordination across and amongsettings; improve clinical outcomes and patient experience; support data-driven


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improvement efforts; rely on both strong and transparent governance; and engagepatients and community stakeholders.

Based on this analysis, the following key attributes will serve as the foundational criteriafor organizations seeking to lead CCCs:

Multi-stakeholder governance structure, reflecting a broad range of communitystakeholders and strong clinical leadership.

Defined clinical and efficiency objectives and a commitment to use measures thatreflect these two domains.

Use of health IT consistent with State and Federal standards and requirements.

Minimum provider participation requirements such that the majority of providerswithin a given geography must participate in the collaborative care community.

Support from both public and private payers, via payment reform, to supportactivities across the majority of a patient population.

Based on these attributes, NYeC proposes the following definition of a collaborativecare community:

A multi-stakeholder initiative through which the majority of providers, plans andpatients work together to measurably improve the quality and efficiency of care andtransform the health of the community. Within this co

Nys Hie Operational Plan 2010

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