Texas Council Interoperability Strategy Health!Information!Technology …€¦ ·...

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January!5,!2015!

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Health!Information!Technology:!

A!Learning!Imperative!for!Success!in!

the!Healthcare!Environment!

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!Prepared!by!!

Healthcare!Intelligence!Partners!

For!

The!Texas!Council!for!Community!Centers!

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HealthcareIntelligencePartners

of 1

Texas Council Interoperability Strategy

Throughout most of 2013, the Data Work Group of the Texas Council of Community Centers has been meeting to review and endorse an approach with regard to the exchange of clinical data elements for all Texas Council members. This process was explicitly intended to build on a document prepared by Health Level Seven (HL7), a standards-making organization in healthcare, and to identify data elements that are of interest to the behavioral health sector in Texas. This effort was undertaken in concert with similar efforts to identify clinical quality measures, and regarding an approach for the exchange of clinical information consistent with obligations under §42 CFR part 2, the federal regulations governing the exchange of substance abuse treatment information. Background: In the months leading up to May 2013, HL7 prepared and published a series of documents in support of development of a Clinical Document Architecture (CDA) specific to Behavioral Health. This document format itself was used to support development of the same Continuity of Care Document (CCD) that was endorsed by the Federal government as a required component for the EHR incentive program. The CCD is an implementation standard that is used to support care coordination for patients. To this end, the CCD contains a great deal of information—including demographic information, lab and test results, prescriptions, diagnoses, a problem list, utilization, dates, etc.; however, it lacks an ability to convey information critical to behavioral healthcare. As a result, HL7 began a community-based effort to codify discrete data elements and to bring them together in document known as the Behavioral Health CCD (BH-CCD). The use of a standardized, machine-readable document format is critical to the effective use of electronic health records, since it facilitates the exchange of information about a patient. Information standards are important both for encoding (i.e. the EHR) and decoding a document since there must be perfect alignment between how and in what format data is sent, and how and in what format data is expected by a recipient. The challenge here is that historically, behavioral health providers have struggled to participate in exchange of data, both because most standards do not promote data elements that are germane to behavioral health, and because there is no standard about what data to exchange. The Data Work Group of the Texas Council began by both reviewing documents from HL7 related to the emerging BH-CCD and initiating discussions with other agencies nationwide who were involved in the exchange of clinically relevant behavioral health data. Among the content reviewed by the Data Work Group was a presentation by Shaun Alfreds the COO of HealthInfoNet, the HIE for the State of Maine, and Laura Adams, the CEO of the Rhode Island Quality Institute (RIQI), the HIE for Rhode Island. Both of these HIEs operate on a central data repository HIE model, meaning they consume and store data from multiple sources, and make this information available when requested.

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—Private!and!Confidential—!

Healthcare!Intelligence!Partners!©!2015!

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Health!Information!Technology!....................................................................................!4!

A!Learning!Imperative!for!Success!in!the!Healthcare!Environment!...............................!4!Understanding!the!Environment!........................................................................................................................!5!Defining!Health!Information!Technology!........................................................................................................!6!Health'Information'....................................................................................................................................................'7!Understanding'Health'Information'Exchanges'.........................................................................................'11!

The!Role!of!the!Texas!Health!Services!Authority!......................................................................................!13!Policy;making'entity'..............................................................................................................................................'14!Grant'making'entity'...............................................................................................................................................'14!THSA'as'an'HIE'.........................................................................................................................................................'14!

Understanding!your!local!Health!Information!Exchange!......................................................................!15!

Conclusion!.................................................................................................................!17!

Appendix!A:!HITECH!Act!.............................................................................................!19!EHR!Incentive!Program!........................................................................................................................................!19!ONC’s!Programs!.......................................................................................................................................................!19!Regional'Extension'Centers'.................................................................................................................................'20!State'HIE'Program'..................................................................................................................................................'20!

Other!Major!HITECHKFunded!Programs!from!ONC!.................................................................................!22!Other'Important'ONC'Work'................................................................................................................................'22!

Appendix!B:!Interoperability!......................................................................................!24!Data!Standards:!Enabling!Exchange!...............................................................................................................!25!

Appendix!C:!Health!Information!Exchange!.................................................................!28!HIE!Models!.................................................................................................................................................................!28!Consent'in'HIEs'.........................................................................................................................................................'28!Other'HIE'Issues'.......................................................................................................................................................'28!

Appendix!D:!Texas!Council!Endorsed!Privacy!and!Security!Policy!...............................!32!Emergency!Only!Consent!Flag!...........................................................................................................................!34!Exchange!between!Council!Members!............................................................................................................!35!

Appendix!E:!Texas!Council!Endorsed!Interoperability!Policy!.......................................!36!Episode!of!Care!Type!.............................................................................................................................................!41!Primary!Residence!Setting!..................................................................................................................................!42!Risk!Behavior!............................................................................................................................................................!44!Domestic!Violence!Trauma!.................................................................................................................................!45!Assessment!Type/Score!.......................................................................................................................................!46!Behavioral!Health!Critical!Flag!.........................................................................................................................!47!

Appendix!F:!Texas!Council!Endorsed!Measurement!Policy!.........................................!48!

Required!Measures:!...................................................................................................!52!NQF!#105:!Antidepressant!Medication!Management!.............................................................................!52!Definition:'...................................................................................................................................................................'52!Description:'................................................................................................................................................................'52!

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Included'Population(s)'.........................................................................................................................................'52!Excluded'Population(s)'.........................................................................................................................................'52!Local'Modification:'.................................................................................................................................................'52!

NQF!#1932:!Diabetes!screening!for!people!with!schizophrenia!or!bipolar!disorder!who!are!

prescribed!antipsychotic!medications!(SSD)!..............................................................................................!53!Definition:'...................................................................................................................................................................'53!Description:'................................................................................................................................................................'53!Included'Population(s)'.........................................................................................................................................'53!Excluded'Population(s)'.........................................................................................................................................'53!

NQF!#0576!FollowKup!after!Hospitalization!for!Mental!Illness!.........................................................!54!Definition:'...................................................................................................................................................................'54!Description'.................................................................................................................................................................'54!Included'Population:'..............................................................................................................................................'54!Excluded'Population(s)'.........................................................................................................................................'55!Local'Modification:'.................................................................................................................................................'55!

NQF!#1879:!Adherence!to!Antipsychotic!Medications!for!Individuals!With!Schizophrenia!.!56!Definition'....................................................................................................................................................................'56!Description:'................................................................................................................................................................'56!Included'Population:'..............................................................................................................................................'56!Excluded'Population(s):'.......................................................................................................................................'56!Local'Modification:'.................................................................................................................................................'56!

Care!Improvement:!CANS/ANSA!or!DLA20/GAF!Score!Improvement!...........................................!57!Child'and'Adolescent'Needs'and'Strengths/Adult'Needs'and'Strengths'Assessment'(ANSA)57!Daily'Living'Activities'20/Global'Assessment'of'Functioning'(GAF)'Score'....................................'57!

High!Value!Menu!.......................................................................................................!58!NQF!#1934:!!Diabetes!monitoring!for!people!with!DM!and!Schizophrenia!..................................!58!Definition:'...................................................................................................................................................................'58!Description:'................................................................................................................................................................'58!Included'Population(s):'........................................................................................................................................'58!Excluded'Population(s)'.........................................................................................................................................'58!Local'Comments:'......................................................................................................................................................'58!

Decrease!in!mental!health!admissions!and!readmissions!to!criminal!justice!settings!such!as!

jails!or!prisons!..........................................................................................................................................................!59!Description:!...............................................................................................................................................................!59!Goal:!..............................................................................................................................................................................!59!Author/Source!.........................................................................................................................................................!59!Local!Comments:!.....................................................................................................................................................!59!

Development!Measures!.............................................................................................!60!Crisis!Episodes:!The!proportion!of!crisis!episodes!that!result!in!admission!to!a!State!hospital!or!DSHSKfunded!community!hospital!within!30!days!of!the!first!crisis!episode!.........................!60!Denominator:'............................................................................................................................................................'60!Numerator:'.................................................................................................................................................................'60!Local'Approach:'.......................................................................................................................................................'60!Exclude:'........................................................................................................................................................................'60!

Behavioral!Health!Readmission!Rate:!............................................................................................................!61!Description:!...............................................................................................................................................................!61!

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Denominator:!............................................................................................................................................................!61!Numerator:!................................................................................................................................................................!61!Comments:!.................................................................................................................................................................!61!

Appendix!G:!Glossary!.................................................................................................!62!

Appendix!H:!HIEs!in!Texas!..........................................................................................!66!!

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Health!Information!Technology!!!A!Learning!Imperative!for!Success!in!the!Healthcare!Environment!!

Health!Information!Technology!has!been!a!major!thrust!of!federal!policy!for!the!last!

several!years.!!In!this!time,!the!adoption!of!electronic!health!records!(EHRs)!by!

physicians!and!hospitals!has!increased!dramatically.!!In!2008,!for!example,!fewer!than!

fifteen!percent!(15%)!of!hospitals!were!using!EHRs;!yet!by!2013,!that!number!had!risen!

to!more!than!seventy!percent!(70%)1.!!Meanwhile,!physician!adoption!rose!from!fortyW

two!percent!(42%)!2009,!to!seventyWeight!percent!(78%)!in!2013.2!

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At!the!same!time,!payment!systems!have!begun!to!move!away!from!payments!for!

services,!and!towards!payments!for!health!outcomes!as!measured!by!clinical!quality!

indicators.!!Payment!models!like!Accountable!Care!Organizations,!initiatives!like!the!

Physician!Quality!Reporting!Initiative!(PQRI),!and!other!payWforWperformance!programs!

are!driving!care!providers!to!focus!on!delivering!high!quality,!highly!effective!care!at!a!

lower!cost.!!

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These!two!tectonic!shifts!in!healthcare!delivery!and!reimbursement!are!closely!linked!to!

one!another.!!Tightly!coordinated!care,!and!effective!population!health!management!

that!drive!quality!outcomes!are!only!possible!on!this!scale!through!the!use!of!health!

information!technology.!!!The!right!tools!enable!care!providers!to!quickly!identify!high!

cost!patients!and/or!patients!with!multiple!chronic!illnesses,!and!to!communicate!with!a!

range!of!providers!regarding!patients!needs.!

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These!developments!are!of!critical!importance!for!behavioral!health!providers!because!

they!are!collapsing!historical!barriers!between!mental!and!physical!healthcare.!!Nearly!

thirty!percent!(30%)!of!people!with!a!chronic!medical!condition!have!a!coWoccurring!

behavioral!health!condition,!and!nearly!seventy!percent!(70%)!of!people!with!a!

behavioral!health!condition!have!a!coWoccurring!medical!condition.3!!!

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However,!the!coWmorbidity!of!physical!and!mental!health!issues!is!made!more!

substantial!by!the!costs!associated!with!these!individuals.!!In!fact,!the!cost!of!care!for!

people!with!coWmorbid!physical!and!mental!health!conditions!is!greater!than!the!cost!of!

treating!people!with!just!physical!or!just!mental!health!conditions4.!!Unless!ACOs,!

hospitals,!and!other!providers!are!effective!at!coordinating!care!for!these!coWmorbid!

individuals,!they!stand!to!place!significant!dollars!at!risk.!!This,!in!turn,!puts!behavioral!

health!agencies!in!a!great!position!to!support!financial!goals!of!the!overall!healthcare!

system.!

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In!order!to!be!attractive!partners!for!ACOs,!hospitals!and!health!systems,!community!

centers!must!look!and!feel!like!every!other!specialty!provider—oncologists,!

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nephrologists!and!endocrinologists.!To!put!a!finer!point!on!it,!community!centers!must!

have!and!use!electronic!health!records!in!ways!that!promote!seamless!care!integration,!

including!participation!in!health!information!exchange.!!And!finally,!centers!must!be!

capable!of!clearly!communicating!the!value!of!the!services!they!provide!in!the!form!of!

concise!descriptions!of!quality!outcomes.!

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This!primer!is!designed!to!support!Texas!Council!members!throughout!Texas!in!

understanding!what!health!IT!is,!key!stakeholders!in!the!health!IT!space,!issues!specific!

to!behavioral!health!and!health!IT,!and!how!to!influence!adoption!of!policies!that!will!

address!the!interests!of!Council!members.!!Although!this!is!a!very!complex!environment,!

there!are!many!ways!to!make!a!significant!contribution.!!It!is!important!to!take!a!

targeted,!focused!approach!and!to!have!a!realistic!understanding!of!what!kinds!of!

results!are!possible.!

Understanding!the!Environment!At!its!root,!Health!Information!Technology!(HIT)!describes!an!intimate!relationship!

between!health!information!and!information!technology.!!Painting!with!broad!

brushstrokes,!it!describes!how!health!information!is!contained!in!information!

technology!in!accordance!with!interoperability,!privacy,!and!security!standards!that!are!

adopted!and!implemented!by!healthcare!entities!(which!could!include!a!clinic,!a!hospital,!

an!HIE,!and!others).!Adoption!of!HIT!is,!in!turn,!affected!by!a!range!of!invested!parties!

who!try!to!ensure!that!health!IT!is!consistent!with!their!shortW!and!longWterm!objectives.!!!

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Part!of!what!makes!the!

HIT!environment!so!

complex!is!that!these!

invested!parties!are!often!

at!crossWpurposes.!!

Consumers!may!want!

personal!health!data!

classified!as!highly!private,!

while!providers!want!

relaxed!privacy!standards!

to!ensure!better!care!

coordination.!!Sometimes!

the!tension!exists!within!a!

single!group!like!

technology!vendors.!!One!

vendor!might!want!

interoperability!standards!

to!remain!consistent!with!

Invested(Par,es(

Researchers(

Trade(Associa.ons(

State(Government(

Federal(Government(

Payers(Providers(

Technology(Vendors(

Consumers(

Health(Informa,on(Technology(Environment(

En.ty(Policies(and(Procedures(

Health(Informa.on(

Informa.on(Technology(

Privacy/Security(Framework(

Interoperability(Standards(

Figure!1:!Health!IT!Environment!

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the!work!they!have!already!completed,!while!another!vendor—using!a!different!

approach—wants!the!standard!to!reflect!its!alreadyWcompleted!work.!

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In!order!to!have!a!meaningful!impact!on!the!health!IT!environment,!Community!Centers!

need!to!be!broadly!aware!of!the!orientation!of!these!other!entities,!and!to!understand!

where!and!how!to!apply!pressure!to!promote!their!clinical,!operational,!and!financial!

interests.!!In!order!to!do!that,!this!primer!will!describe!efforts!moving!from!the!center!of!

the!diagram!out,!starting!with!Health!Information.!

Defining!Health!Information!Technology!According!to!David!Blumenthal,!the!former!National!Coordinator!for!Health!Information!

Technology,!“Information!is!the!lifeblood!of!modern!medicine.”5!The!‘Health!

Information’!in!Health!IT!includes!a!range!of!information!that!could!include!diagnosis,!

height,!weight,!prescriptions,!procedures,!and!lab!values,!among!others.!!!Meanwhile,!

the!‘Information!Technology’!in!health!IT!commonly!includes!Electronic!Health!Records!

(EHRs),!Health!Information!Exchanges!(HIEs)!or!any!other!electronic!system!that!

generates,!manipulates!or!stores!health!information.!!!

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Health!Information!! Information!Technology!Clinical!information!such!as!diagnosis,!weight,!

prescriptions,!procedures,!lab!values.!

Electronic!systems!that!generate!or!store!

health!information!such!as!electronic!health!

records!or!health!information!exchanges.!

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These!two!concepts—health!information,!and!information!technology—are!distinct,!but!

closely!linked.!For!example,!when!two!different!information!technology!systems!‘talk’!to!

each!other,!they!send!health!information!back!and!forth;!however,!in!order!for!this!

exchange!of!health!information!to!be!successful,!the!information!technology!systems!

have!to!be!configured!to!send!and!receive!health!information!in!exactly!the!same!way.!!!

Leadership!Opportunity!With!healthcare!consuming!nearly!20%!of!the!nation’s!gross!domestic!product,!

there!are!innumerable!invested!parties!with!‘skinWinWtheWgame’.!!Community!

Centers!need!to!stay!engaged!and!follow!HIT!developments!closely,!particularly!

at!the!local!level,!where!the!impact!can!be!greatest!on!dayWtoWday!operations.!!

Look!for!strategic!partners!like!hospitals!and!ACOs!who!understand!that!their!

goals!around!cost!containment!cannot!be!met!without!more!effective!

integration!with!behavioral!health.!!But!remember,!they’ll!also!be!looking!for!

partners!who!are!sophisticated!users!of!health!IT!who!can!demonstrate!the!

quality!outcomes!that!are!important!to!overall!health.!

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Health!Information!There!are!two!key!concepts!involved!in!using!health!information:!!interoperability!

standards!and!privacy/security!standards.!

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• Interoperability!standards.!!The!‘configuration’!of!information!technologies!into!

a!common!format!to!enable!two!different!information!technologies!to!

communicate!effectively.!!!

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• Privacy!and!Security.!These!are!often!spoken!of!together,!but!convey!different!

concepts.!!Privacy!is!an!attribute!of!health!information;!security!describes!the!

means!through!which!private!data!is!kept!private.!Private!data!is!like!what!

happens!inside!a!house,!and!the!security!takes!the!form!of!the!locks!on!the!

doors—keeping!unwanted!observers!out.!

Interoperability-Interoperability!is!the!attribute!of!data!that!allows!it!to!be!understood!within!different!

electronic!systems!according!to!an!agreed!upon!standard.!!In!order!for!data!to!be!

interoperable,!every!data!element!must!be!recorded!and!transmitted!on!the!sender’s!

side!in!a!way!that!is!expected!on!the!receiver’s!side.!!

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Without!agreed!upon!standards,!IT!systems!cannot!appropriately!accept!and!manage!

data.!!In!the!table!below,!it!is!easy!to!see!the!problems!created!when!one!provider!

chooses!to!exchange!data!in!a!different!way!than!another!provider.!

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But!even!here!there!are!two!layers.!!On!the!one!hand!there!is!the!issue!of!which!data!elements!are!sent,!and!in!what!order.!!On!the!other,!there!is!the!issue!of!what!the!

content!of!each!data!element!is.!!Both!of!these!issues!are!resolved!through!the!

application!of!standards.!!The!first!set!of!standards!concerns!the!document!format,!

while!the!second!deals!with!nomenclature!or!semantics!of!the!information!contained!in!

the!document.!!!

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Order%of%Fields Mountain%%Clinic Valley%Clinic1 FirstName LastName2 LastName FirstName3 Phone Date4 Date Email5 Email Phone

Table!1:!Exchange!of!data!without!an!interoperability!framework!

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Thinking!more!broadly!about!healthcare,!it!is!easier!to!see!how!complex!healthcare!

interoperability!is.!!After!all,!this!example!looks!at!the!exchange!of!information!between!

just!two!facilities!and!for!only!five!data!elements.!!Healthcare!involves!many!different!

kinds!of!‘documents’,!hundreds!of!fields,!different!electronic!healthcare!systems,!and!

thousands!of!healthcare!providers.!!All!of!this!data!must!be!in!perfect!alignment!to!

achieve!full!data!interoperability.!!

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One!approach!to!interoperability!is!the!use!of!the!Clinical!Document!Architecture,!or!

CDA.!!A!CDA!is!a!generalized!format!for!exchanging!clinical!information.!!Perhaps!the!

most!common!use!of!the!CDA!is!for!a!Continuity!of!Care!Document!(CCD)!which!

expresses!a!range!of!information!about!the!kind!and!quality!of!care!that!was!recently!

delivered.!!However,!CDAs!can!also!be!used!to!express!additional!information!some!of!

which!is!an!expansion!of!a!standard!CCD.!!For!example,!this!might!include!a!Behavioral!

Health!Continuity!of!Care!Document!(BHWCCD)!that!sets!a!standardized!approach!to!the!

data!fields!and!definitions!for!clinical!data!exchange!germane!to!behavioral!health.!

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To!better!understand!how!a!CDA!works,!it!may!be!helpful!to!use!an!analogy.!!In!many!

ways,!a!CDA!is!like!a!business!letter!format.!!This!conventional!format!contains!the!name!

and!address!of!the!sender,!the!name!and!address!of!the!recipient,!the!date!and!perhaps!

a!salutation.!!In!other!words,!knowing!that!it!is!a!business!letter!means!that!senders!are!

required!to!put!specific!information!in!certain!places,!and!that!recipients!expect!to!see!

certain!kinds!of!information!in!specific!places.!!Building!on!this!analogy,!a!business!letter!

could!still!express!a!wide!range!of!content—a!bill,!a!policy!change!or!a!statement.!!A!

CCD!or!a!BHWCCD—as!unique!types!of!CDAs—represents!a!business!letter!format!

expressing!a!specific!content!type—for!clinical!information.!!!

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For!a!more!detailed!discussion!on!Interoperability,!see!Appendix!B:!Interoperability.!!

Privacy-and-Security-Privacy!standards!are!specific!to!a!data!type!alone!or!in!combination,!the!conditions!

under!which!it!can!be!shared,!and!with!whom!it!can!be!shared.!!Sometimes,!data!is!

defined!as!private!in!statute—like!the!Health!Information!Portability!and!Accountability!

Act!(HIPAA)!or!§42!CFR!part!2;!at!other!times!it!is!related!to!how!an!entity!defines!

private!data.!!!

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While!HIPAA!is!the!general!legal!framework!for!disclosing!clinical!information!under!any!

circumstances,!!§42!CFR!part!2—which!preWdates!HIPAA!by!several!decades—references!

the!specific!privacy!obligations!incumbent!upon!federally!funded!substance!abuse!

treatment!services.!!Although!there!are!many!commonalities!between!HIPAA!and!§42!

CFR!part!2,!the!most!significant!difference!is!that!§42!CFR!part!2!agencies!must!obtain!

consent!to!share!information!with!providers!by!name!and!title.!!Operationally,!this!makes!it!a!challenge!for!agencies!subject!to!§42!CFR!part!2!to!participate!in!health!

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information!exchanges!since!the!providers!participating!in!the!HIE!change!on!a!daily!

basis.!

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Security!standards!are!not!limited!to!health!IT!since!they!govern!how!any!protected!

health!information!is!released—whether!that!disclosure!occurs!via!a!fax,!an!EHR,!or!

through!discussing!a!patient!in!a!public!place.!!For!information!technology,!this!concerns!

the!ways!in!which!an!information!technology!system!is!required!to!ensure!that!only!

authorized!individuals!can!get!in!and/or!see!private!data.!!!

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For!the!Texas!Council’s!strategy!on!privacy!and!security,!see!Appendix!D:!Texas!Council!

Endorsed!Privacy!and!Security!Policy.!

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Information!Technology!Most!providers!experience!HIT!through!an!Electronic!Health!Record!(EHR).!Although!

many!providers!experience!challenges!in!using!EHRs,!articles!consistently!demonstrate!

that!EHR!use!leads!to!improved!practice!efficiency!and,!in!many!cases,!increased!

revenue!through!more!efficient!coding!of!claims.!!In!part,!this!is!due!to!the!wide!range!

of!functions!that!can!be!performed!using!EHRs.!!So!while!an!EHR’s!core!function!might!

be!related!to!storing!clinical!notes—much!like!a!paper!chart—the!EHR!operates!as!more!

of!a!clinical!hub!through!which!providers!perform!and!direct!a!range!of!activities!related!

Leadership!Opportunity!!

In!January!2014,!the!Texas!Council!adopted!strategies!for!Interoperability!and!

Privacy/Security.!!Community!Centers!should!be!actively!working!with!the!local!

HIEs!to!educate!stakeholders!on!the!Council’s!recommendations!and!to!work!

towards!an!integrated!approach!to!both!issues.!!Centers!should!consider!

proposing!review!of!‘use!cases’!that!highlight!the!need!for!more!comprehensive!

data!that!facilitates!integrated!care,!particularly!where!Centers!have!integrated!

care!capabilities.!

!

As!a!general!rule,!§42CFR!pt.!2,!the!Federal!substance!abuse!treatment!privacy!

regulations,!set!a!higher!standard!for!data!privacy!than!HIPPA.!!As!a!result,!many!

healthcare!entities—including!HIEs—avoid!dealing!with!these!complexities!and!

focus!instead!on!data!that!has!fewer!complications.!!However,!there!are!strong!

financial!incentives!for!resolving!these!issues!since!the!highest!cost!individuals!

tend!to!have!both!chronic!medical!and!behavioral!health!conditions.!!

Emphasizing!the!needs!of!high!cost!individuals!can!help!bring!key!stakeholders!

around!to!focusing!on!data!integration!issues!for!behavioral!health!and!primary!

care!services.!

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to!the!providerWpatient!relationship:!sending!prescriptions,!informing!billing,!retrieving!

lab,!image!and!diagnostic!results.!!Furthermore,!many!EHRs!are!capable!of!scanning!and!

summarizing!patient!information!to!suggest!treatments!or!interventions!that!are!tightly!

aligned!with!validated!treatment!guidelines.!!!

!

And!yet,!EHRs!are!not!without!their!challenges.!!The!thing!that!makes!EHRs!so!valuable!

also!makes!them!cumbersome!to!use:!the!fact!that!they!record!information!as!

structured!data!in!discrete!fields.!!Capturing!information!in!this!way—as!opposed!to!

unstructured!data!in!a!‘free!text’!field—means!that!the!data!are!clean!and!consistent!

and!capable!of!supporting!deep!analysis.!!!But!this!requires!that!providers!using!EHRs!to!

be!meticulous!about!checking!boxes,!selecting!terms!from!menus,!and!engaging!in!other!

‘point!and!click’!kinds!of!activities!that!can!be!tedious!and!time!consuming!when!

compared!to!a!few!scribbled!notes!on!a!ruled!notepad.!!And!yet,!these!are!the!very!

same!things!that!enable!important!patient!safety!checks,!like!drugWdrug,!drugWallergy,!or!

drugWcondition!incompatibilities,!to!say!nothing!of!calculating!quality!measures.!

!

Many!of!these!challenges!can!be!particularly!acute!for!behavioral!health!providers!who!

use!a!wide!range!of!screening!and!assessments!tools!that!do!not!readily!integrate!with!

an!EHR.!!This!can!lead!to!a!substantial!amount!of!development,!and,!once!in!an!EHR,!

may!not!be!easily!transmitted!or!manipulated.!!According!to!Camis!Milam,!Vice!

President!for!Medical!Services!at!Center!for!Health!Care!Services,!“To!date!we!have!not!

found!an!EHR!that!has!templates!ready!made!to!accommodate!required!reporting!to!

payers!and!regulatory!agencies.!!We!don't!have!templates,!clinical!analytics,!registries!or!

any!capacity!for!trending.”!

!

Thinking!of!an!EHR!as!simply!an!electronic!replacement!for!a!paper!chart!will!almost!

certainly!lead!to!challenges,!which!is!why!selecting!the!right!EHR!is!so!important.!!The!

EHR!will!alter!virtually!every!workflow!as!part!of!care!delivery.!!If!providers!or!other!EHR!

users!are!expecting!the!same!workflows!and!processes!as!with!paper!recordWkeeping,!

this!will!be!a!rude!awakening.!!However,!the!good!news!is!that!the!new!workflows!will!

become!intuitive!and!secondWnature.!!Documentation!suggests!that!this!occurs!

approximately!18!months!after!implementation,!but!this!also!assumes!an!adequate!fit!

between!the!practice!and!the!EHR.!

!

Although!many!practices!experience!efficiency!improvements!in!transitioning!to!EHRs—

through!ePrescribing,!or!remote!access!to!records,!and!other!conveniences—the!real!

value!of!EHRs!is!revealed!in!the!data!analytics!they!make!possible,!and!in!their!ability!to!

share!data.!!The!investment!of!more!time!upWfront!making!sure!data!are!captured!and!

recorded!appropriately!yields!substantial!returns!by!enabling!quick!and!easy!

identification!of!consumers!by!condition,!acute!needs,!clinical!care!gap(s),!or!other!

identifying!characteristics.!!These!consumer!cohorts,!in!turn,!can!be!powerful!tools!in!

targeting!interventions!to!improve!quality!outcomes.!

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Of!course,!the!other!reason!EHRs!are!so!powerful!is!their!ability!to!connect!with!and!

share!information,!particularly!with!a!health!information!exchange.!!EHRs!are!now!in!use!

by!a!majority!of!practitioners!and!hospitals!around!the!country,!who!are!seeking!

partners!that!are!similarly!equipped!and!with!whom!they!can!coordinate!care.!!Only!

those!practices!that!are!using!EHRs!will!therefore!be!capable!of!continuing!to!support!

consumers!with!comorbid!behavioral!and!medical!conditions.!

!

Understanding!Health!Information!Exchanges!Health!Information!Exchanges!(HIE)!primarily!function!as!conduits!of!health!information!

and!enable!transmission!of!the!data!from!one!provider!to!another.!!There!are!two!basic!

models!of!HIEs—centralized!and!federated—though!many!use!a!hybrid!model!that!

combines!elements!of!these!two.!!In!a!centralized!model,!providers!send!patient!health!

information!to!the!HIE!where!it!is!cleaned,!sorted!and!stored.!!In!a!federated!model,!

providers!send!notification!to!the!HIE!that!a!clinical!record!is!available!and!when!


Selecting!an!EHR—whether!transitioning!from!an!EHR!to!another!EHR,!or!making!

an!initial!selection!of!an!EHR—is!a!major!challenge!for!leaders!of!Centers!and!in!

no!way!should!be!rushed!or!hurried.!!The!EHR!is!a!tool!that!will!be!used!every!

single!day!for!many!years!to!come!and!should!be!approached!with!the!same!

magnitude!as!the!remodeling!of!a!clinic!layout.!!Moreover,!in!the!event!of!a!

‘mistake’!the!cost!of!switching!is!nonWtrivial,!especially!when!taking!into!account!

lost!productivity!and,!potentially,!the!loss!of!access!to!historical!data.!

!

The!important!thing!is!to!approach!the!selection!process!by!obtaining!buyWin!

from!a!wide!range!of!stakeholders.!!This!is!a!task!that!cannot!be!delegated!to!the!

IT!staff,!and!it!is!not!the!sole!domain!of!care!providers.!!The!selection!process!

should!bring!together!representatives!of!a!range!of!roles,!including!support!staff,!

billing,!and!reporting—in!short,!anyone!who!will!use!the!EHR!or!data!from!it.!

From!there,!it!is!a!matter!of!clearly!articulating!requirements!and!evaluating!the!

EHR!on!the!basis!of!whether!it!meets/does!not!meet!the!requirements.!!!

!

Finally—and!importantly—there!is!no!such!thing!as!the!perfect!EHR.!!Each!will!

have!strengths!and!weaknesses,!advantages!and!disadvantages.!!The!Leadership!

Challenge!here!is!to!evaluate!which!weaknesses!you!can!live!with,!and!which!

strengths!you!can’t!live!without.!!!

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another!provider!requests!the!information,!the!HIE!authorizes!the!requesting!provider!

to!see!the!information.!!!

!

A!third!exchangeWtype!function!known!as!“Direct”!enables!a!simple!pointWtoWpoint!

delivery!of!information.!!This!mode!functions!much!like!a!secure!email!system,!or!an!

electronically!facilitated!fax!where!providers!can!package!clinical!content!and!send!it!to!

a!specific!named!provider.!!This!model!requires!minimal!infrastructure!to!support,!but!

only!works!for!“push”!based!services—i.e.!when!a!provider!with!clinical!content!wants!

to!send!or!“push”!their!information!to!another!provider.!!If!a!provider!wants!to!obtain!or!

“pull”!information!about!a!specific!patient,!there!is!no!way!to!request!information!about!

that!patient.!!!

!

Although!Direct!is!not!considered!a!true!exchange,!it!can!still!play!an!important!role!in!

care!coordination—so!much!so!that!the!Texas!Council!has!adopted!it!as!an!interim!

approach!for!centerWtoWcenter!exchange.!!Direct!services!can!be!set!up!very!quickly!and!

easily,!and!leverage!the!implementation!of!Federal!requirements!that!support!pointWtoW

point!exchange!of!clinical!information.!!Direct’s!ability!to!quickly!convey!clinical!

information!between!facilities!that!have!no!other!clinical!or!technological!connection!

facilitates!cheaper!and!easier!care!coordination.!However!because!it!relies!on!one!

center!“pushing”!data!to!another,!and!cannot!be!used!to!look!up!data!on!a!new!

consumer,!it!is!more!accurately!thought!of!as!an!interim!solution,!and!not!an!ultimate!

goal.!

Standards-and-Implementation-In!both!centralized!and!federated!models!of!health!information!exchange,!the!HIE!entity!

must!determine!interoperability,!privacy,!and!security!standards!that!will!be!applied.!!

These!are!typically!defined!at!a!combination!of!levels.!!!!

!

For!interoperability!standards,!there!are!many!standard!development!organizations!

(SDOs)!who!develop!and!promote!data!interoperability.!!However,!often!these!

standards!require!modifications!at!the!entity!level—either!because!the!standard!

provides!some!level!of!flexibility,!or!because!the!‘standard’!is!not!quite!specific!enough!

to!be!functional!as!is.!!

!

Privacy!and!security!standards!are!similar,!in!that!there!are!statutory!and!regulatory!

requirements!that!originate!at!both!the!Federal!and!State!levels.!!However,!many!HIE!

entities!use!these!statutory!and!regulatory!requirements!as!the!floor,!and!define!

additional!kinds!of!private!data,!additional!security!requirements,!and!the!process!and!

terminology!for!communicating!patient!wishes!about!the!sharing!of!their!health!data.!

!

Along!with!privacy!and!security,!HIEs!must!also!develop!approaches!for!patients!to!

permit!the!sharing!of!their!data!with!other!providers!through!an!HIE.!!Most!HIEs!in!the!

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country!operate!on!a!relatively!simple!“all!or!nothing”!approach.!!In!other!words,!when!

patients!consent!to!sharing!their!health!information,!they!agree!to!have!all!their!data!go!in,!or!none!of!their!data.!!!This!poses!problems!for!individuals!who!have!sensitive!data—

like!substance!abuse!or!mental!health!treatment!information—that!they!want!shared!

more!selectively!since!they!cannot!specify!what!should!or!should!not!be!shared.!

!

There!are!efforts!underway!to!explore!more!granular!consent—i.e.!the!ability!for!

consumers!to!determine!which!aspects!of!a!medical!record!to!share!and!with!whom.!!

This!ability!would!enable!a!Center!to!share!all!of!a!patient’s!medical!data,!but!redact!

their!substance!abuse!treatment!or!mental!health!treatment,!which!could!be!important!

for!compliance!with!§42CFR.!!However,!there!are!no!currently!deployed!HIEs!in!the!

country!that!have!granular!consent!enabled.!

!

With!a!range!of!participating!stakeholders!like!hospitals,!health!systems,!labs,!

pharmacies,!and!individual!providers,!it!should!be!clear!why!health!information!

exchanges!are!often!deeply!engaged!in!defining!interoperability!standards!since!all!of!

these!entities!need!to!communicate!with!one!another!via!the!HIE.!!An!HIE,!through!an!

open,!collaborative!process,!will!publish!a!standard!to!which!all!participants!must!

adhere.!!In!these!cases,!the!participants!will!write!system!interfaces!that!will!encode!and!

transmit!data!according!to!the!interoperability!standard!as!defined!by!the!HIE.!

!

All!facilities!that!use!multiple!systems!to!capture!and!record!data!must!ensure!that!the!

data!from!these!different!systems!can!be!used!effectively!across!the!different!platforms.!

Deciding!what!format!and!order!to!use!for!different!data!elements!is!functionally!the!

same!as!defining!a!local!interoperability!standard,!albeit!with!far!narrower!

consequences!than!for!an!HIE.!!When!a!single!clinic!integrates!information!from!two!

different!systems!like!a!practice!management!system!and!an!EHR—the!goal!is!to!simply!

enable!to!different!systems!to!talk!to!one!another.!!For!an!HIE,!the!standard!is!ultimately!

published!and!used!to!support!integration!of!data!from!multiple!entities!and/or!systems.!

The!Role!of!the!Texas!Health!Services!Authority!The!Texas!Health!Services!Authority!(THSA)!was!created!by!the!Texas!Legislature!in!2007!

as!a!publicWprivate!partnership.!!It!supports!the!improvement!of!the!Texas!health!care!

system!by!promoting!and!coordinating!HIE!and!HIT!throughout!the!state.!!Its!goal!is!to!

ensure!that!the!right!information!is!available!to!the!right!health!care!providers!at!the!

right!times.6!

!

At!its!broadest!level,!the!Texas!Health!Services!Authority!convenes!stakeholders!in!order!

to!develop!the!overall!framework!for!exchangeWlike!services!throughout!the!State!of!

Texas.!!As!such,!it!has!three!distinct!functions!as:!

• A!policyWmaking!entity;!!

• A!grantWmaking!entity;!and!

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• A!(Federated)!Health!Information!Exchange.!!!

PolicyXmaking!entity!!THSA!develops!requirements!concerning!interoperability!standards,!privacy!and!security!

requirements,!and!an!approach!to!consumer!consent.!!Some!of!these—like!privacy!and!

security—were!accomplished!by!offering!certification!from!third!party!entities.!!

Others—like!interoperability—were!developed!through!a!stakeholder!participation!

process!intended!to!address!acute!needs!among!participating!entities.!HIEs!receiving!

funding!through!THSA!must!adhere!to!THSA!standards.!

!

However,!perhaps!more!importantly,!THSA!has!created!the!overall!framework!for!

exchange!in!the!State!by!aligning!local!HIE!availability!with!specific!counties!and!

developing!a!plan!for!addressing!exchangeWtype!needs!for!counties!lacking!a!local!HIE.!

Grant!making!entity!!THSA!used!its!grantWmaking!function!to!support!HIE!development,!where!HIEs!are!

providing!centralized,!federated,!or!hybrid!HIE!services.!!In!the!Texas!“White!Spaces”—

i.e.!the!areas!not!currently!covered!by!an!HIE—THSA!used!its!policy!making!function!to!

designate!service!providers!called!health!information!service!providers!(HISPs)!who!

provide!“Direct”!services.!!THSA!has!provided!funding!to!local!HIEs!around!the!state!via!

the!HITECH!Act,!a!Federal!law!designed!to!support!HIE!development!and!deployment!

around!the!country.!!In!total!THSA!received!more!than!$28!million!from!the!federal!

government,!the!majority!of!which!went!to!support!local!HIEs!in!Texas.!!Amounts!not!

devolved!to!local!HIEs!supported!THSA!operations!and!the!building!of!HIETexas!(see!

below).!!

THSA!as!an!HIE!THSA!has!established!HIETexas,!which!enables!HIEs!to!exchange!information!with!other!

HIEs!in!Texas.!!This!is!a!classical!federated!model!where!no!protected!health!information!

actually!resides!at!the!THSA,!stateWwide!level.!!Rather,!participants!in!a!local!HIE!can!

obtain!information!about!patient!records!in!other!HIEs.!!As!of!this!writing,!there!are!only!

two!HIEs—(Greater!Houston!Healthconnect!(HEALTHCONNECT)!and!Integrated!Care!

Collaboration!(ICC)!of!Austin)—who!have!connected!to!HIETexas,!but!this!number!is!

expected!to!grow!as!more!HIEs!develop!connections!with!HIETexas.!!!

!

In!becoming!an!HIE,!THSA!used!its!stakeholder!participation!framework!to!address!the!

three!major!components!of!Privacy!and!Security:!privacy!standards,!security!standards,!

and!patient!consent!requirements.!!THSA!has!also!developed!an!implementation!

specification!to!support!interoperable!data!exchange.!!It!is!important!to!emphasize,!

however,!that!this!work!is!not!complete.!As!new!technologies!become!available,!new!

therapies!are!validated!and!introduced,!and!laws!change,!these!stakeholder!committees!

continue!to!make!changes!to!standards.!!It!is!therefore!extremely!important!that!

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Community!Centers!monitor!and!stay!engaged!with!these!stakeholder!groups.!!The!

Texas!Council!is!a!voting!member!of!THSA’s!Collaboration!Council,!in!part!because!it!

uniquely!represents!the!needs!of!entities!subject!to!§42!CFR!pt.!2.!

Understanding!your!local!Health!Information!Exchange!Most!counties!in!Texas!are!covered!by!one!of!six!HIEs!that!are!currently!operational,!or!

will!be!soon!by!one!of!the!four!under!development.!!The!six!operating!HIEs!include!

Integrated!Care!Collaborative!(ICC),!Healthcare!Access!San!Antonio!(HASA),!Greater!

Houston!Healthconnect,!North!Texas!Accountable!Healthcare!Partnership!(NTAHP),!First!

Net,!and!Paso!Del!Norte!Health!Information!Exchange7.!!All!of!the!HIEs!in!Texas!cover!

specific!regions!around!the!state,!none!of!which!covers!the!entire!state.!!!

!

Given!the!vast!geography!of!Texas,!there!is!still!a!substantial!“white!space”!where!HIEs!

do!not!operate!but!approved!Health!Information!Service!Providers!(HISPs)!make!direct,!

pointWtoWpoint!exchange!services!available.!THSA!is!actively!working!to!support!creation!

of!an!HIE!in!some!of!the!West!Texas!white!space,!but!this!work!is!in!its!early!stages.!

!


The!Texas!Health!Services!Authority!serves!as!a!convening!body!for!all!public!HIEs!

in!the!State,!and!establishes!interoperability!and!privacy/security!policies!for!

public!HIEs.!!By!design!THSA!makes!every!effort!to!articulate!the!minimal!

requirements!so!that!local!HIEs!can!become!more!expansive!in!the!data!they!

exchange.!!

!

It!is!extremely!important!for!Community!Centers!to!stay!abreast!of!THSA!

activities!since!they!can!have!important!trickleWdown!effects!on!local!HIEs.!!

However,!Community!Centers!should!only!expect!minimal!impact!at!the!THSA!

level,!unless!the!issue!is!a!major!obstacle!or!problem!for!Community!Centers.!!

This!is!because!THSA!accepts!input!from!a!wide!range!of!stakeholders,!including!

hospitals,!hospital!systems,!payers!and!consumers.!!

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!

See!Appendix!H:!HIEs!in!Texas!for!more!information!and!covered!geography!for!each!HIE!

in!Texas.8!

!

Although!HIEs!were!originally!funded!through!federal!and!state!grants,!sustainability!of!

the!HIE!is!dependent!on!participant!fees.!!Providers!participating!in!an!HIE!are!generally!

charged!a!user!fee.!!In!addition!to!paying!use!fees,!providers!are!required!to!configure!

data!so!that!it!is!consistent!with!how!the!HIE!is!expecting!to!receive!it.!!Most!EHRs!

approach!a!true!interoperability!standard,!but!minor!modifications!may!be!necessary!

based!on!specific!implementation!standards!defined!at!the!HIE!level.!Additionally,!

participating!entities!may!be!required!to!conduct!a!security!audit!or!in!some!other!way!

validate!appropriate!protection!of!patient!records.!

!

Figure!2:!HIEs!in!Texas!

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Despite!the!investment!in!HIE!capabilities!over!the!last!several!years,!there!are!still!a!

number!of!challenges!that!HIEs!face.!!Many!HIEs,!for!example,!are!still!struggling!to!

transition!from!grantWfunded!entities!to!entities!with!sustainable!business/operational!

models.!!Many!began!by!focusing!on!relatively!narrow!use!cases!that!bring!shortWterm!

value,!but!are!harder!to!translate!into!longWterm!sustainable!operations.!!A!major!appeal!

of!HIEs!is!the!future!promise!they!hold!to!securely!and!efficiently!transmit!data!between!

entities.!!Expanding!capabilities!in!some!cases!requires!substantial!new!investment!in!

technology!and/or!infrastructure,!and!is!often!a!political!process!fraught!with!competing!

interests.!!Yet!failure!to!expand!jeopardizes!credibility,!too.!!And,!as!is!true!of!many!

operations,!too!much!expansion!too!soon,!can!undermine!core!functions.!

!

The!most!significant!challenge!Community!Centers!have!in!engaging!with!an!HIE!is!

ensuring!that!the!HIE!has!the!infrastructure!to!support!Center!requirements!around!§42!

CFR!part!2.!!Assuming!this!is!possible—perhaps!as!outlined!in!Appendix!D:!Texas!Council!

Endorsed!Privacy!and!Security!Policy—a!Center!would!have!little!to!lose!and!much!to!

gain!in!participating!in!an!HIE.!!Should!the!HIE!cease!operations,!the!data!could!be!

destroyed!and!the!Center!would!only!have!lost!time!and!money.!!But!if!it!continues!to!

operate,!it!has!the!potential!to!become!the!mechanism!through!which!all!care!

coordination!in!that!community!will!occur.!

Conclusion!Over!the!last!five!years,!there!have!been!significant!changes!in!the!deployment!and!use!

of!health!information!technology.!!Some!of!this!change!is!a!function!of!improved!

technology.!!The!overwhelming!majority!is!due!to!federal!investments!through!the!

Health!Information!Technology!for!Economic!and!Clinical!Health!(HITECH)!Act.!!By!design,!

the!HITECH!Act!created!programs!and!a!funding!mechanism!to!spur!the!adoption!and!

use!of!electronic!health!records!and!health!information!exchanges,!the!twin!backbones!

of!the!health!IT!infrastructure.!!As!a!result,!all!healthcare!entities!now!expect!care!


Community!Centers!should!play!an!active!role!in!the!local!HIE.!!All!HIEs!have!

stakeholder!engagement!groups,!which!allow!providers!an!opportunity!to!bring!

expertise!and!experience!to!the!table!as!decisions!are!being!made.!!Participation!

by!Community!Center!leaders!is!important,!as!HIEs!have!often!delayed!decisions!

related!to!accepting!behavioral!health!data!due!to!concerns!about!privacy!and!

security!issues.!!There!is!a!growing!recognition!that!integrated!data!is!needed!to!

truly!address!the!complex!needs!of!the!most!costly!patients.!

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partners!to!be!conversant!in!health!IT,!and!to!effectively!coordinate!care!using!health!

IT—even!though!the!behavioral!health!sector!was!largely!ineligible!to!receive!incentive!

funding.!!

!

Since!the!adoption!of!the!HITECH!Act,!many!changes!have!continued!to!affect!the!health!

IT!world,!particularly!as!technology!has!become!more!integrated!into!our!everyday!lives.!!

New!wearable!devices—like!the!Apple!Watch!or!a!Fitbit™—make!capturing!and!sharing!

health!information!easier!than!ever!before.!!And!more!formally!dedicated!health!IT!

tools—including!telemedicine,!remote!monitoring!systems!and!smart!phone!

technology—mean!that!amount!of!information!available!for!care!coordination!and!

outcome!improvement!purposes!will!only!continue!to!grow.!!!

!

As!appealing!as!some!of!these!newer!tools!are—and!as!exciting!as!it!might!be!to!deploy!

them!in!an!innovative!setting!like!a!Community!Center—it!would!be!a!major!distraction!

to!a!Center!to!deploy!them!in!advance!of!an!effectivelyWused!EHR!and!that!Center’s!robust!exchange!of!clinically!relevant!content!through!an!HIE.!!After!five!years!of!

attention!to!EHR!adoption,!using!an!EHR!hardly!feels!like!an!innovation,!but!without!it!

information!from!‘wearables’!and!smartWphone!applications!will!function!in!

disconnected!silos,!unable!to!leverage!the!robust!clinical!content!in!an!EHR.!

!

The!changes!wrought!by!heath!IT!have!only!just!begun,!so!it!should!come!as!no!surprise!

that!the!industry!continues!to!experience!a!great!deal!of!flux.!!New!medical!science!

emerges,!including!new!tests!and!procedures,!requiring!new!data!standards,!technology!

changes,!reimbursement!systems!change,!and!care!providers!become!more!

sophisticated!users!of!HIT.!!All!of!these!mean!that!entities!involved!in!care!delivery!must!

reject!thinking!of!health!IT!utilization!as!a!static!goal!and!more!like!something!that!

requires!constant!care!and!feeding!to!grow!and!adapt!to!new!clinical,!technological,!and!

operational!realities.!!The!changing!approach!to!behavioral!health!services!and!

behavioral!health!data!is!one!of!them.!

!

Clearly,!technology!for!technology!sake!is!not!the!answer;!but!standing!by!the!wayside!

will!only!mean!that!Community!Centers!will!be!increasingly!unable!to!communicate!

effectively!with!other!care!providers.!Health!IT!is!unquestionably!the!future!of!care!

delivery,!and!EHRs,!personal!health!records,!HIEs,!and!other!tools!will!be!the!means!

through!which!care!is!coordinated!for!consumers.!!With!recent!changes!to!payment!

structures—ACO!riskWsharing,!and!incentives!to!eliminate!hospital!admissions!and!reW

admissions—there!is!a!growing!awareness!of!the!role!that!mental!illnesses!play!in!

exacerbating!cost!and!acuity!for!established!chronic!medical!conditions.!!!The!time!will!

come!when!these!entities!will!be!seeking!partners!to!provide!high!quality!behavioral!

health!services!that!look!and!feel!like!the!specialty!care!delivered!by!oncologists,!

nephrologists,!or!cardiologists.!Clearly,!the!payment,!technology,!and!infrastructure!

stars!are!beginning!to!align,!and!Community!Centers!should!be!ready!for!when!they!do.!

!

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Appendix!A:!HITECH!Act!Any!discussion!of!Health!IT!would!be!remiss!if!it!did!not!include!a!recent!history,!

particularly!of!the!Health!Information!Technology!for!Economic!and!Clinical!Health!Act,!

or!HITECH!Act.!!!Passed!as!part!of!the!American!Recovery!and!Reinvestment!Act!in!early!

2009,!HITECH!created!the!Office!of!the!National!Coordinator!for!Health!Information!

Technology!(ONC),!and!the!EHR!Incentive!Program.!!Since!the!passage!of!the!HITECH!Act,!

use!of!EHRs!around!the!country!has!improved!dramatically.!!In!2008,!for!example,!fewer!

than!15%!of!hospitals!were!using!EHRs;!yet!by!2013,!that!number!had!risen!to!more!

than!70%9.!!Meanwhile,!physician!adoption!rose!from!42%!2009,!to!78%!in!2013.

10!!

EHR!Incentive!Program!The!EHR!Incentive!Program!makes!incentive!funding!available!to!providers!(clinicians!

and!hospitals)!for!the!adoption!and!use!of!electronic!health!records.!!In!order!to!be!

eligible!for!the!EHR!incentive!program,!providers!must!meet!a!Medicare!or!Medicaid!

billing!threshold.!!Additionally,!they!must!use!a!certified!EHR!to!achieve!a!standard!

called!Meaningful!Use!(MU)!that!requires!progressively!more!sophisticated!EHR!

utilization!over!the!years!of!the!program.!

!

Although!the!EHR!incentive!program!is!administered!by!the!Centers!for!Medicare!and!

Medicaid!Services!(CMS),!ONC!plays!a!strong!role!in!defining!MU!through!its!Health!IT!

Policy!Committee.!The!Policy!Committee!makes!the!initial!MU!recommendations!that!

are!then!provided!to!CMS!for!final!operationalization.!ONC!also!developed!the!criteria!

for!certifying!EHR!products,!and!oversees!certification!compliance!via!contracts!with!

other!entities.!!The!certification!process!is!necessary!to!ensure!that!EHRs!capable!of!

performing!the!tasks!associated!with!each!MU!stage.!

!

To!date,!there!are!two!published!standards!for!MU—Stage!1!and!Stage!2.!!Stage!3!is!

expected!some!time!in!2017.!!Stage!1!MU!requires!use!of!an!EHR!for!basic!data!capture!

and!the!testing!of!interoperability!capabilities!as!well!as!electronic!prescribing!of!

medications!(eRx).!!Stage!2!requires!more!robust!use!of!the!data!exchange!capabilities!

of!an!EHR!for!care!coordination!purposes.!Stage!3!is!expected!to!focus!more!on!the!use!

of!EHRs!to!support!improvements!in!outcomes.!

ONC’s!Programs!Through!the!HITECH!Act,!ONC!funded!and!administered!five!major!HIT!programs.!!The!

two!most!significant!for!introductory!purposes!are:!!!

• The!Regional!Extension!Center!Program;!and!

• The!State!HIE!Program!

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Regional!Extension!Centers!Regional!Extension!Centers!(RECs)!are!local!agencies!responsible!for!supporting!primary!

care!providers!in!the!adoptoption!and!meaningful!use!of!certified!electronic!health!

records.!!Nationwide,!there!are!62!REC!programs!covering!the!entire!country,!each!of!

whom!is!responsible!for!supporting!a!specific!number!of!primary!care!providers,!

typically!between!1,000,!and!5,000.!!!

!

REC!programs!provide!a!range!of!technical!support!and!guidance!to!practices!in!the!

selection,!implementation,!and!use!of!their!EHR.!The!initial!goal!of!the!REC!program!was!

to!help!providers!achieve!Stage!1!Meaningful!Use;!however,!they!are!well!equipped!and!

trained!to!assist!with!a!range!of!additional!activities.!!In!addition!to!the!REC!funding!

from!ONC,!RECs!in!Texas!contracted!with!Texas!State!Medicaid!Office!to!provide!

technical!support!and!services!to!any!Medicaid!provider!(not!just!primary!care!providers,!

per!original!program!requirements),!which!means!Medicaid!psychiatrists!who!are!

employed!by!Centers!may!be!eligible!for!REC!support.!

!

In!the!last!several!years,!ONC!and!a!number!of!other!stakeholders!have!been!focusing!

significant!attention!on!patient!engagement,!since!the!ultimate!responsibility!for!care!

management!resides!with!the!individual!receiving!care.!!Stage!2!MU,!for!example,!

makes!providers!responsible!for!some!demonstrable!engagement!of!patients,!which!can!

occurs!through!a!webWbased!Patient!Portal!that!is!often!attached!to!an!EHR!system.!

RECs-in-Texas-In!Texas!there!are!four!REC!programs:!

• West!Texas!Health!Information!Technology!Regional!Extension!Center!

(WTxHITREC)!(at!Texas!Tech!University)!

• CentrEast!(at!Texas!A&M)!

• Gulf!Coast!REC!(at!UT!Houston)!

• North!Texas!REC!(at!the!Dallas!Fort!Worth!Hospital!Council!Foundation)!

State!HIE!Program!HIEs!are!part!of!the!essential!infrastructure!supporting!the!safe!and!secure!transmission!

of!health!data.!!In!recognition!of!this,!ONC!made!HIEs!a!major!thrust!of!the!HITECH!Act!

by!funding!the!program!with!more!than!$545M.!!These!grants!went!to!States!or!“State!

Designated!Entities”!like!THSA!to!coordinate!and!create!stateWwide!capability!for!the!

exchange!of!health!information.!

!

In!a!parallel!process,!ONC!also!developed!and!promoted!the!Direct!Protocol,!a!means!of!

enabling!pointWtoWpoint!exchange!of!electronic!information!through!Health!Information!

Service!Providers!(HISPs).!!This!functions!much!like!a!secure!email!system!that!allows!a!

provider!in!one!facility!to!send!a!patient!record!to!a!provider!in!another!facility.!!This!is!

useful!because!it!requires!minimal!infrastructure!beyond!internet!access,!and!certified!

!

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EHRs!are!required!to!support!the!Direct!protocol.!!Operationally,!this!is!useful!for!

referring!or!transferring!a!patient,!but!not!for!obtaining!a!comprehensive!view!of!

patient!history!since!it!is!a!oneWtime!compilation!of!patient!history!from!a!single!facility.!

HIE-in-Texas-In!Texas!at!the!time!of!this!writing,!there!are!ten!HIEs!operating!or!in!development!

around!the!state.!!The!six!operating!HIEs!include!Integrated!Care!Collaborative!(ICC),!

Healthcare!Access!San!Antonio!(HASA),!Greater!Houston!Healthconnect,!North!Texas!

Accountable!Healthcare!Partnership!(NTAHP),!First!Net,!and!Paso!Del!Norte!Health!

Information!Exchange11.!!All!of!the!HIEs!in!Texas!cover!specific!regions!within!the!state,!

leaving!some!areas!without!HIE!services.!!The!Texas!Health!Services!Authority,!or!THSA,!

serves!as!a!grantWmaking!body!that!facilitates!and!coordinates!the!efforts!of!local!HIEs!

around!the!state.!!According!to!its!website,!!

!

The!THSA!was!created!by!the!Texas!Legislature!in!2007!as!a!public!private!

partnership,!legally!structured!as!a!nonprofit!corporation,!to!support!the!

improvement!of!the!Texas!health!care!system!by!promoting!and!coordinating!

HIE!and!health!information!technology!(HIT)!throughout!the!state!to!ensure!that!

the!right!information!is!available!to!the!right!health!care!providers!at!the!right!

times.12!

!

Functionally,!THSA!serves!three!roles:!

1) a!grantWmaking!body!

2) a!policyWmaking!body!that!coordinates!the!work!of!the!HIEs!throughout!the!

State;!and!!

3) a!federated!HIE!linking!HIEs!in!the!state!to!each!other.!!

In!2010,!Texas!received!a!$28.8M!grant!from!the!Federal!Government!as!part!of!the!

HITECH!Act,!and!began!a!yearsWlong!effort!to!oversee!the!development!of!HIEs!in!Texas.!!

Most!of!this!funded!early!HIE!grants!around!the!state,!work!that!is!onWgoing.!!For!

example,!THSA!is!currently!spearheading!an!effort!to!create!an!HIE!in!the!West!Texas!

area.!!By!receiving!funding!via!THSA,!the!HIE!grantees!around!the!state!agreed!to!

conform!to!the!policy!and!implementation!approaches!as!defined!by!THSA.!

!

THSA’s!primary!orientation!in!Texas!is!to!facilitate!the!exchange!of!health!information!

across!different!providers.!!Much!of!its!efforts!focus!on!creating!the!technical!policy!

requirements!and!framework!for!successful!data!exchange!in!Texas,!and!on!building!the!

technological!infrastructure!to!support!HIEWtoWHIE!exchange.!!THSA!hosts!a!variety!of!

committee!meetings!to!foster!collaboration!among!key!constituents!and!stakeholders,!

and!establish!technical!approaches!to!emerging!issues.!!!

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Recent!developments!include!the!development!of!a!certification!program!for!

participating!HIEs!in!Texas,!and!another!for!participating!providers!to!ensure!compliance!

with!privacy!and!security!standards.!

!

For!areas!not!covered!by!an!HIE—currently!called!the!“White!Space”—THSA!has!

established!relationships!with!HISPs!to!enable!use!of!the!Direct!Protocol!for!pointWtoW

point!exchange.!

Other!Major!HITECHXFunded!Programs!from!ONC!• Beacon!Community!Program!

The!Beacon!Community!Program!provided!approximately!$15M!to!each!of!17!

different!communities!around!the!country.!!At!the!time!of!application,!these!

Beacon!Communities!had!to!have!a!relatively!advanced!level!of!HIT!adoption!in!

their!communities.!!Each!community!was!required!to!identify!quality!measures!

and!quality!goals.!

!

• SHARP!Grants!In!an!effort!to!advance!the!technology!for!EHRs!and!HIEs,!ONC!made!four!grants!

available!as!part!of!its!Strategic!Health!IT!Advanced!Research!Project!(SHARP)!

grant!program.!!Each!of!these!was!designed!to!address!a!challenging!aspect!of!

the!use!of!technology.!

o Security!and!Technology!(University!of!Illinois!at!UrbanaWChampaign)!

o Usability!and!alignment!of!technology!to!physician!cognition!and!

decisionWmaking!(UT!Houston)!

o EHR!information!architecture!(Harvard);!and!

o Integration!and!utilization!of!EHR!data!for!quality!improvement!purposes.!

(The!Mayo!Clinic!College!of!Medicine)!

!

• Workforce!Development!(University!and!Community!College!Training)!The!HITECH!Act!also!recognized!that!the!emerging!HIT!ecosystem!would!require!

substantial!support!from!a!workforce!with!skills!that!were!neither!widely!

available,!nor!easy!to!quantify.!!To!address!this,!ONC!developed!a!series!of!

programs—one!to!develop!a!community!collegeWbased!training!curriculum!with!a!

corresponding!certificate!program,!funding!for!community!college!slots!

nationwide,!and!a!more!advance!health!IT!training!program!for!university!

students.!

!

Other!Important!ONC!Work!Prior!to!the!HITECH!Act,!ONC!predominantly!functioned!as!a!convening!body!and!

worked!through!two!officially!constituted!advisory!committees:!!the!Health!IT!Policy!

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Committee!(HITPC),!and!the!Health!IT!Standards!Committee!(HITSC),!both!of!which!

continue!to!operate!using!a!range!of!subcommittees.!!!

!

• The!HITPC!addresses!issues!including!consumer!engagement,!strategy!and!

innovation,!Meaningful!Use,!and,!importantly,!privacy!and!security.!!!

• The!HITSC!addresses!mostly!technical!issues!related!to!content,!semantics,!

testing!and!certification.!!!The!HITSC!also!reviews!and!comments!on!

recommendations!from!the!HITPC,!particularly!concerning!privacy!and!security.!

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Appendix!B:!Interoperability!Interoperability!is!the!attribute!of!data!that!allows!it!to!be!understood!within!different!

electronic!systems!according!to!an!agreed!upon!standard.!!In!order!for!data!to!be!

interoperable,!every!data!element!must!be!recorded!and!transmitted!on!the!sender’s!

side!in!a!way!that!is!expected!on!the!receiver’s!side.!!

!

But!even!here!

there!are!two!

layers.!!On!the!

one!hand!there!

is!the!issue!of!

which!data!elements!are!

sent,!and!in!

what!order.!!On!

the!other,!

there!is!the!issue!of!what!the!content!of!each!data!element!is.!!Both!of!these!issues!are!

resolved!through!the!application!of!standards.!!The!first!set!of!standards!concerns!the!

document!format,!while!the!second!deals!with!nomenclature!or!semantics.!!!

!

In!order!to!better!understand!the!

importance!of!a!document!format,!

imagine!The!Mountain!Clinic!

wants!to!send!information!about!

an!enrolled!consumer!to!the!Valley!

clinic.!!These!facilities!agree!

they’re!going!to!send!five!data!

elements:!!First!Name,!Last!Name,!

enrollment!Date,!Patient!EWMail,!

and!Phone!Number.!!!However,!

without!discussing!it!with!Mountain!Clinic,!the!Valley!Clinic!each!prepares!their!system.!!!

!

Of!course,!if!Mountain!and!Valley!had!gone!through!the!exercise!of!data!mapping,!they!

would!have!identified!the!misalignment.!!Such!a!data!mapping!exercise!might!have!

looked!like!Figure!3:!Data!Mapping,!in!which!case,!the!error!would!have!been!obvious.!!

!

When!Mountain!Clinic!does!sends!data!to!Valley!Clinic,!the!file!goes!through!successfully,!

but!all!is!not!well.!!When!Valley!Clinic!opens!the!file,!it!looks!like!Figure!4:!Mountain!

Clinic!data!in!Valley!System.!

!!

Figure!3:!Data!Mapping!

Order%of%Fields Mountain%%Clinic Valley%Clinic1 FirstName LastName2 LastName FirstName3 Phone Date4 Date Email5 Email Phone

Figure!4:!Mountain!Clinic!data!in!Valley!System!

Mountain(Clinic(Computers Patient(Information

Last%Name: SallyFirst%name: Thompson

Date: (512)%123<1234Email: 4/21/14Phone: [email protected]

!

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A!human!looking!at!this!will!immediately!see!that!there!is!a!problem!and!will!be!able!to!

read!this!information,!but!computers!by!and!large!lack!this!sophistication.!!As!a!result,!

this!will!cause!a!host!of!errors.!

!

Even!assuming!

that!the!data!

mapping!is!

correct,!there!is!

still!another!

layer!of!

complexity!that!

must!be!

addressed!concerning!nomenclature,!or!semantics.!!It!is!how!each!field!is!populated.!!Let’s!say!that!the!Mountain!Clinic!is!in!Greece,!and!the!Valley!Clinic!is!in!Texas.!!The!

Mountain!Clinc!sends!the!information!in!Figure!5:!Mountain!Clinic!in!Greece.!

!

Notice!three!things!about!this!information:!

1. The!FirstName!and!LastName!fields!are!in!Greek;!

2. The!Phone!field!uses!an!international!exchange;!and!

3. The!Date!field!uses!a!European!format!of!DD/MM/YYYY.!

!

Now,!even!if!the!Mountain!Clinic!and!the!Valley!Clinic!had!agreed!on!the!right!order!of!fields,!the!data!within!those!fields!could!not!be!consumed,!or!read!into,!the!Valley!

System.!!In!other!words,!the!nomenclature!or!semantics!of!the!field!was!not!agreed!

upon.!!It!is!critical!to!reach!agreement!not!only!on!the!order!of!the!fields,!but!the!content!of!the!fields,!too.!!

Thinking!more!broadly!about!healthcare,!it!is!easy!to!the!complex!nature!of!healthcare!

interoperability.!!After!all,!this!example!looks!at!the!exchange!of!information!between!

just!two!facilities!and!for!only!five!data!elements.!!Healthcare!involves!many!different!

kinds!of!‘documents’,!hundres!of!fields,!different!electronic!healthcare!systems,!and!

thousands!of!healthcare!providers.!!All!of!this!data!must!be!in!perfect!alignment!to!

achieve!full!data!interoperability.!!

!

Fortunately,!there!are!a!number!of!organizations—Standards!Development!

Organizations!(SDOs)—that!are!dealing!with!these!issues.!!Unfortunately,!there!are!

many!of!these!organizations,!and!they!may!have!different!ways!of!approaching!the!

issue.!!

Data!Standards:!Enabling!Exchange!The!way!most!SDOs!work!is!to!build!from!general!characteristics!to!more!specific!

characteristics.!!One!such!example!of!this!is!the!Clinical!Document!Architecture!(CDA)!

Figure!5:!Mountain!Clinic!in!Greece!

Order%of%Fields Mountain%Clinic Data1 FirstName Σαλλι2 LastName Θωμπσοη3 Phone +30.21.623.82034 Date 21/4/20145 Email [email protected]

!

!

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that!was!created!by!Health!Level!7!(HL7).!!The!CDA!is!designed!to!convey!clinical!

information!with!seven!characteristics:!

• Persistence!

• Stewardship!

• Potential!for!authentication!

• Context!

• Wholeness!

• Human!readability!

This!document!format!was!intended!to!support!the!exchange!of!a!range!of!clinical!

information,!and!was!designed!using!an!extensible!format.!!Files!that!are!extensible!are!

capable!of!being!extended!with!no!or!minimal!impact!on!existing!content.!!For!

healthcare!this!is!important!because!it!means!that!as!the!science!of!healthcare!evolves,!

the!document!can!be!expanded!to!accommodate!new!data!sources!and!new!clinical!

concepts!without!jeopardizing!existing!data!structures!or!content.!

!

Although!the!CDA!is!important!as!a!framework,!it!is!not!sufficiently!specific!to!fully!

enable!the!exchange!of!data.!!Sometimes,!this!lack!of!specificity!can!occur!because!an!

SDO—in!this!case!HL7—recognizes!there!are!multiple!legitimate!ways!of!dealing!with!

health!information.!!!At!other!times,!it!is!because!a!standard!is!still!emerging.!!

Additionally,!specific!fields!can!be!either!mandatory!or!optional—meaning!they!must!be!

preset!or!they!may!be!present.!!As!a!result,!may!documents!require!the!use!of!

implementation!specifications,!a!specific!set!of!implementation!instructions!that!will!

fully!enable!interoperability.!

!

One!such!implementation!specification!of!the!CDA!is!called!the!CCD,!or!Continuity!of!

Care!Document.!!The!CCD!itself!represents!a!harmonized!approach!to!clinical!documents!

that!evolved!from!HL7’s!CDA!and!the!Continuity!of!Care!Record!(CCR)!that!was!

developed!by!the!American!Society!for!Testing!and!Materials!(ASTM).!!The!CCD!

implementation!specification!was!eventually!adopted!as!part!of!the!standard!for!

exchange!of!clinical!documentation!for!Stage!2!of!Meaningful!Use.!

!

The!most!widely!used!version!of!the!CCD!is!currently!the!C.32!version,!but!there!is!

increasing!use!of!the!ConsolidatedWCDA!(CWCDA)!which!includes!some!important!

contextual!information!about!the!data,!as!well!as!some!additional!fields.1!

!

As!discussed!above,!the!broader!CDA!also!makes!reference!to!other!systems!of!

nomenclature!for!many!of!the!fields!it!uses!because!they!are!capable!of!expressing!

!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!1!http://www.healthit.gov/sites/default/files/glidepath_hitsp_c83_to_ccda.pdf,!

accessed!10/3/2014!

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important!clinical!concepts.!!For!example,!the!CCD!does!not!use!ICDW9!or!ICDW10!codes,!

but!rather!Systematized!Nomenclature!of!Medicine—Clinical!Terms!(SNOMEDWCT),!to!

reflect!clinical!concepts!that!are!important!for!care!coordination!and!delivery.!!By!

contrast,!International!Classification!of!Disease!v.9!(ICDW9)!and!ICDW10!codes!are!used!

primarily!for!billing!purposes.!!!Still!other!fields!in!the!CDA!are!populated!using!a!

terminology!for!lab!tests!and!resulting!values!called!Logical!Observation!Identifiers!

Names!and!Codes,!or!LOINC™.!!!

!

The!purpose!of!this!recitation!is!not!to!overwhelm!the!casual!user!of!Health!IT,!but!to!

emphasize!the!intricate!web!of!interactions!between!and!among!different!SDOs!all!in!

the!service!of!clearly!articulating!information!about!the!delivery!of!healthcare.!!!

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Appendix!C:!Health!Information!Exchange!Transmitting!health!information!from!one!setting!to!another,!it!turns!out,!is!fraught!with!

challenges.!!These!activities!are!typically!undertaken!by!a!health!information!exchange,!

which!is!responsible!for!addressing!a!range!of!legal!and!operational!issues.!!This!section!

provides!a!deeper!exploration!of!how!health!information!exchanges!operate,!and!how!

they!address!some!of!the!technical!challenges!of!moving!data!from!one!place!to!another.!

HIE!Models!There!are!two!basic!models!of!HIEs—centralized!and!federated—though!some!use!a!

hybrid!model!that!combines!elements!of!these!two.!!!

!

In!a!centralized!HIE,!each!of!the!participating!care!delivery!organizations!sends!patient!

health!information!to!the!HIE!where!it!is!cleaned,!sorted,!and!stored.!!In!this!sense!a!

centralized!HIE!is!much!more!like!a!large!database!or!data!warehouse!that!can!be!

queried!for!patient!information.!A!centralized!HIE!requires!substantial!infrastructure!in!

the!form!of!hardware!and!software!since!it!collects!so!much!information.!!A!centralized!

HIE!is!what!people!refer!to!when!they!call!HIE!a!“noun”.!

!

The!other!common!model!for!HIEs!is!the!federated,!or!decentralized!model.!!

Decentralized!HIEs!require!much!less!in!the!way!of!hardware!and!software!and!are!

entirely!transactional!in!nature.!!In!this!model!the!HIE!functions!as!a!record!locator!

service.!This!is!the!model!that!is!referred!to!when!describing!HIE!as!a!“verb.”!!In!other!

words,!the!focus!of!this!HIE!is!on!the!transactions!of!exchange,!not!on!the!place!of!

exchange.!

Consent!in!HIEs!The!other!axis!on!which!HIEs!operate!has!to!do!with!patient!consent.!!Most!HIEs!operate!

on!an!“optWin”!basis.!!This!means!that!patients!must!affirmatively!consent!to!have!their!

data!shared!with!an!HIE.!!Alternatively,!some!HIEs!operate!on!an!“optWout”!basis.!!These!

HIEs,!assume!patient!consent,!and!thereby!allowing!all!data!to!automatically!flow!into!

the!HIE!unless!the!patient!elects!to!have!their!data!withheld.!!This!orientation!really!

reflects!the!default!approach!to!the!collection!of!personal!health!information.!!Often!the!

decision!about!optWin!or!optWout!reflects!state!or!local!laws!around!data!privacy.!

Other!HIE!Issues!Regardless!of!model,!there!is!a!set!of!core!issues!that!HIE!must!address!early!in!their!

operations.!!Some!of!these!are!simply!operational!decisions;!others!reflect!a!range!of!

onWgoing!activities.!!Among!the!questions!that!HIEs!must!address!are:!!

• What!information!will!be!exchanged?!

• How!will!patients!be!uniquely!identified?!

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• How!will!providers!be!uniquely!identified?!

• How!will!identities!be!authenticated?!

• How!will!consent!be!handled?!

What-information-will-be-exchanged?-This!issue!is!actually!far!more!complex!that!it!may!initially!seem,!owing!in!large!part!to!

the!complexity!of!healthcare!data.!!In!any!event,!HIEs!typically!decide!on!a!discrete!set!

of!data,!or!a!type!of!virtual!document!they!will!request!of!participants!in!order!to!start!

exchanging!data.!!!

!

Many!HIEs!largely!began!by!focusing!on!a!specific!kind!of!message!called!an!ADT,!or!

Admit,!Discharge,!Transfer!notice.!!This!is!a!specific!kind!of!notice!or!alert!that!is!sent!by!

a!hospital.!!The!notice!will!contain,!among!other!things,!demographic!and!clinical!

information!for!the!patient,!and!can!be!used!to!notify!other!providers!involved!in!the!

coordination!of!care!for!the!patient.!!!

!

The!business!case!for!using!ADT!notices!is!the!growing!focus!on!reductions!in!inpatient!

stays!and!readmissions.!!And!ADT!notice!can!be!used,!for!example,!to!quickly!notify!a!

cardiologist!that!a!COPD!patient!has!been!admitted!to!the!hospital!with!chest!pains!or!

pneumonia.!!Similarly,!an!ADT!notice!can!also!go!electronically!to!a!primary!care!

provider!when!a!patient!is!discharged!in!order!to!facilitate!post!discharge!followWup.!

These!simple!notifications!can!significantly!improve!the!coordination!of!care,!which!can!

lead!to!reductions!in!readmissions.!

!

Other!HIEs!focus!on!the!exchange!of!a!Continuity!of!Care!Document!(CCD).!!CCDs!

contain!a!wider!range!of!information!than!an!ADT,!and!are!intended!to!describe!recent!

patient!history!and!treatment.!!Importantly,!CCDs!are!closely!tied!with!Meaningful!Use!

(See!EHR!Incentive!Program!in!Appendix!A:!HITECH!Act)!since!all!EHRs!certified!to!meet!

Meaningful!Use!Stage!2!standards!must!be!capable!of!producing!them.!!For!a!longer!

discussion!of!standards!and!clinical!documents,!see!Data!Standards:!Enabling!Exchange!

on!page!25.!

How-will-patients-be-uniquely-identified?-One!challenge!faced!by!HIEs!is!to!accurately!collate!patient!records!from!multiple!

facilities.!!Hospitals!and!other!direct!care!providers,!of!course,!can!assign!a!unique!

record!number!to!each!patient!to!ensure!that!records!are!kept!separate,!and!use!that!

unique!identifier!across!multiple!facilities.!!If!there!is!ever!a!question,!they!can!validate!

the!content!with!a!patient!in!real!time!by!looking!at!a!driver’s!license,!an!insurance!card,!

or!validating!past!information..!!But!a!problem!arises!in!an!HIE’s!ability!to!join!records!

for!the!same!person!from!different!facilities,!and!to!keep!separate!similar!records!from!

different!individuals!from!different!facilities!

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To!do!this,!HIEs!require!the!use!of!an!Enterprise!Master!Patient!Index!or!(EMPI).!!In!

addition!to!being!an!actual!feature!of!the!patient!record!unique!to!that!patient!record,!

the!EMPI!suggests!the!existence!of!a!process!to!ensure!that!two!different!patient!

records!are!appropriately!linked.!!It!is!conceivable,!after!all,!that!John!Smith!was!seen!by!

multiple!facilities!and!multiple!providers.!!But,!of!course,!not!all!John!Smiths!are!the!

ones!that!should!have!their!patient!records!merged.!!This!process,!known!as!patient!

matching!is!commonly!done!on!the!basis!of!multiple!demographic!fields—name,!

address,!date!of!birth,!social!security!number!(where!available),!etc.—in!order!to!ensure!

that!the!records!for!the!right!John!Smiths!are!merged,!and!those!for!the!wrong!John!Smith!are!kept!separate.!

How-will-providers-be-uniquely-identified?-A!corollary!of!the!EMPI!is!the!Master!Provider!Index.!One!of!the!ways!that!providers!and!

patients!use!HIT!is!to!refer!patients!and!to!send!patient!records!from!one!provider!to!

another.!!HIEs!play!a!key!role!in!this.!!However,!in!order!to!achieve!this!goal!HIEs!must!

collect,!curate,!and!maintain!accurate!information!about!which!providers,!and!which!

facilities,!are!participating!in!the!HIE.!!This!will!allow!a!referring!provider!to!‘lookWup’!a!

provider,!and!to!send!appropriate!information!to!him!or!her.!!Master!Provider!indices!

are!important!for!HIEs!and!the!HISPs!that!provide!Direct!services!in!the!Texas!‘White!

Space’.!

Who-can-participate-in-the-HIE?-Because!of!the!sensitive!nature!of!the!data!contained!in!an!HIE,!HIEs!must!be!very!

careful!about!whom!they!allow!to!participate.!!Physicians,!for!example,!must!have!a!

state!license!to!practice!medicine,!which!determines!their!eligibility!for!participation!in!

the!HIE.!!Effectively,!this!creates!a!concept!called!a!circle!of!trust!within!which!

participating!providers!and!facilities!can!feel!comfortable!sharing!information!with!

trusted!partners.!!Part!of!the!agreement!to!participate!in!an!HIE!requires!adherence!to!a!

set!of!standards!about!privacy!and!security!standards.!

!

In!Texas,!most!Community!Centers!do!not!currently!participate!in!local!health!

information!exchange.!!Although!they!are!technically!eligible!as!healthcare!providers,!

HIEs!are!mostly!not!capable!of!accommodating!the!privacy!and!consent!issues!

associated!with!health!information!from!Community!Centers.!!However,!there!is!a!

growing!recognition!that!in!order!to!address!the!complex!needs!of!the!most!costly!

patients!in!Texas!will!require!truly!integrated!data!that!supports!integrated!care.!!The!

Texas!Council!began!exploring!these!issues!and!developed!an!approach!that!is!intended!

to!support!Community!Center!participation!in!HIE!while!maintaining!compliance!with!

obligations!under!§42!CFR!pt.!2!(See!Appendix!D:!Texas!Council!Endorsed!Privacy!and!

Security!Policy).!Additionally,!the!TX!Council!is!initiating!a!pilot!project!between!one!HIE!

and!one!Community!Center!to!create!and!test!the!infrastructure!within!the!HIE!to!

address!all!security!aspects!of!Community!Center’s!data.!

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Many!HIEs!have!begun!to!recommend!external!certification!that!participating!agencies!

are!adhering!to!privacy!and!security!standards,!and!there!are!a!number!of!organizations!

that!provide!this!certification.!!In!Texas,!the!Texas!Health!Services!Authority!(THSA)!has!

established!both!security!standards!and!a!certification!process!that!is!administered!and!

enforced!by!a!third!party,!the!Health!Information!Trust!Alliance!(HITRUST).!!This!helps!to!

ensure!that!participating!agencies!are!meeting!common!standards.!

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Appendix!D:!Texas!Council!Endorsed!Privacy!and!Security!Policy!!

The!Data!Work!Group!(DWG)!of!the!Texas!Council!of!Community!Centers,!a!project!of!

the!Health!Opportunities!Workgroup!(HOW),!has!been!meeting!since!early!2013!to!

support!the!health!IT!readiness!needs!of!Texas!Council!Members.!!One!of!the!major!

challenges!that!behavioral!health!agencies!face!in!participating!robustly!in!a!health!IT!

environment!is!how!do!to!so!while!maintaining!compliance!with!§42!CFR!part!2,!the!

federal!substance!abuse!treatment!privacy!regulations.!

!

By!and!large,!§42CFR!regulations!are!only!incumbent!on!federally!funded!substance!

abuse!treatment!services—such!as!those!through!Medicare!and!Medicaid—but!there!is!

some!disagreement!about!which!agencies!meet!this!definition.!!As!a!first!step,!it!would!

be!worthwhile!to!revisit!whether!and!to!what!extent!Texas!Council!members!must!abide!

by!these!regulations.!!!

!

Most,!if!not!all,!Texas!Council!members!operate!as!if!they!are!obligated!to!meet!these!

regulations.!!Regarding!their!engagement!with!HIEs,!the!main!challenge!comes!in!

operationalizing!them!both!for!providers!of!multiple!services!and!for!HIEs!who!want!to!

accept!content.!!For!providers,!there!is!no!easy!way!to!segment!substance!abuse!

treatment!data!that!would!allow!it!to!be!treated!differently!than!data!related!to!other!

services.!!As!a!result,!providers!have!generally!adopted!an!approach!of!adhering!to!the!

most!restrictive!standard!for!all!their!data,!not!just!substance!abuse!treatment!data.!!

!

For!HIEs,!on!the!other!hand,!the!major!challenge!comes!in!the!form!of!operationalizing!

the!“named!provider”!component!of!the!consent!requirement.!!The!Health!Insurance!

Portability!and!Accountability!Act!(HIPAA)!and!subsequent!updates!is!the!general!

framework!for!requiring!informed!consent!from!consumers!when!healthWrelated!data!is!

shared—regardless!of!with!whom.!!As!a!result,!HIEs!must!obtain!consent!from!

consumers!in!order!to!accept!and!distribute!individually!identifiable!health!information!

such!as!a!consumer’s!clinical!data.!!Typically,!HIEs!use!consent!language!that!permits!an!

HIE!to!obtain!data!and!share!it!with!all!providers!who!“participate!in!the!HIE.”!

!

If!the!providers!participating!in!an!HIE!was!perfectly!stable,!this!provision!might!be!

sufficient!for!§42CFR!purposes.!!However,!the!reality!is!that!HIEs!experience!significant!

churn!among!participating!providers.!As!a!result,!a!patient!consent!to!participate!would!

only!be!relative!to!providers!in!the!HIE!on!the!date!the!consent!was!signed.!!In!order!to!operationalize!this!in!a!manner!consistent!with!§42!CFR,!an!HIE!would!have!to!maintain!

a!list!of!which!providers!were!participating!on!which!day,!and!prevent!the!flow!of!

patient!data!to!providers!who!were!not!participating!on!the!day!the!consent!was!signed.!

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Functionally,!most!HIEs!have!adopted!an!approach!of!being!“all!or!nothing”—meaning!

they!either!accept!and!distribute!all!data,!or!the!accept!and!distribute!no!data.!!The!net!

result!of!this,!and!the!high!standard!adhered!to!by!Council!members,!is!that!almost!no!

HIE!can!accept!behavioral!health!data.!

Nonetheless,!there!is!a!strong!clinical!case!for!getting!HIEs!to!accept!behavioral!health!

data.!!Nearly!70%!of!individuals!with!a!behavioral!health!condition!have!a!chronic!

medical!condition,!and!nearly!30%!of!individuals!with!a!chronic!medical!condition!have!a!

coWmorbid!behavioral!health!condition.!!Additionally,!individuals!with!behavioral!health!

conditions!and!chronic!medical!conditions!have!costs!that!are!more!than!the!sum!of!

their!individual!conditions.!

!

The!Data!Work!Group!began!exploring!privacy!and!consent!by!reviewing!efforts!

underway!elsewhere!around!the!country.!!In!addition!to!studying!materials!from!HIEs!

including!the!Rhode!Island!Quality!Institute,!and!Maine’s!HealthInfoNet,!the!workgroup!

also!reviewed!content!from!different!federal!agencies.!!For!example,!the!Substance!

Abuse!and!Mental!Health!Services!Administration!(SAMHSA)!presented!on!a!consent!

management!tool!they!are!developing!called!Consent2Share.!!This!tool!is!designed!to!

enable!patientWmanaged!granular!consent,!as!well!as!the!active!participation!of!both!

THSA!and!the!12!different!HIEs!in!Texas.!!Although!this!tool!had!some!impressive!

functionalities,!after!much!discussion!was!deemed!not!operationally!feasible!in!the!

short!term!in!Texas—in!part!because!the!tool!was!still!in!development!and!would!

require!betaWtesting.!

!

The!Data!Work!group!also!reviewed!some!of!the!work!of!the!Data!Segmentation!for!

Privacy!(DS4P)!workgroup!of!ONC’s!Security!and!Interoperability!(S&I)!Framework.!!This!

public!workgroup,!which!is!comprised!of!volunteers!from!various!constituencies!like!

HIEs,!EHR!vendors,!researchers,!government!agencies!like!SAMHSA!and!ONC,!and!

clinicians,!is!developing!standards,!approaches,!and!use!cases!for!the!parsing!of!data!

into!segments,!the!attachment!of!security!metaWdata!to!segments,!and!the!alignment!of!

patient!consent!with!the!segments.!!The!consensus!of!the!Data!Work!Group!was!that!

this!work!was!extremely!important;!however,!the!group!also!acknowledged!that!these!

efforts!will!require!a!marriage!of!technological!changes!to!HIEs!and!EHRs!not!likely!to!

occur!for!several!years,!as!well!as!changes!to!how!consent!is!managed!for!clients.!!Given!

that!the!urgency!the!Data!Work!Group!felt!about!progressing!on!a!solution,!this!was!not!

deemed!to!be!a!viable!option.!

!

After!much!discussion,!including!conversations!with!Texas!Privacy!expert!Pam!Beach,!

the!Data!Work!Group!has!decided!to!pursue!a!scaled!down!version!that,!it!believes,!will!

pave!the!way!for!a!complete!resolution!and!will!achieve!many!of!the!objectives!of!full!

participation!with!an!HIE,!but!in!a!way!that!is!consistent!with!obligations!under!§42CFR.!!!

!

The!Data!Work!Group!has!endorsed!a!twoWpronged!approach:!

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Emergency!Only!Consent!Flag!The!Data!Work!Group!believes!that!the!most!prudent!approach!in!the!short!term!is!to!

encourage!THSA!and!HIEs!in!Texas!do!adopt!an!approach!enabling!HIEs!to!consume!

patient!records!with!a!specific!consent!flag!indicating!that!the!data!is!available!on!an!

emergency!only!basis.!!All!HIEs!have!a!provision!allowing!providers!to!“break!the!glass”!

in!emergency!situations!to!view!protected!patient!information,!and,!critically,!§42CFR!

permits!the!release!of!even!substance!abuse!treatment!information!in!emergency!

situations.!!Such!a!flag!would!enable!all!Texas!Council!members!(with!appropriate!

patient!consent)!to!make!all!their!clinical!data!available!within!an!HIE.!

!

This!is!a!critical!development!that!would!go!a!long!way!towards!addressing!a!host!of!

shortcomings!in!the!current!health!IT!environment.!To!begin!with,!it!would!get!HIEs!

accustomed!to!accepting!the!full!measure!of!behavioral!health!data,!particularly!if!they!

choose!to!adopt!the!additional!data!elements!recommended!by!the!Data!Work!Group.!!

Today,!there!is!no!reliable!source!of!healthcare!data!that!combines!behavioral!health!

and!chronic!medical!data!other!than!claims!data.!!With!a!substantial!lag!between!the!

delivery!of!services!and!the!availability!of!this!data,!however,!claims!data!is!rarely!

actionable!at!the!individual!care!level.!!However,!an!HIE!that!combines!behavioral!health!

and!chronic!medical!care!would!be!able!to!prepare!and!deliver!reports!that!reflect!the!

full!measure!of!an!individual’s!care.!!Admittedly,!these!reports!with!individually!

identifiable!health!information!would!only!be!available!to!behavioral!health!agencies,!

but!this!would!enable!a!much!higher!level!of!care!coordination!than!exists!today.!

!

Furthermore,!HIEs!accepting!behavioral!health!data!with!an!emergencyWonly!flag!will!be!

able!to!run!population!health!reports!using!anonymized!data!that!look!at!the!

intersection!of!behavioral!health!and!traditional!medical!care.!!These!reports!could!be!

used!for!a!host!of!purposes!including:!community!benchmarking,!calculating!measures!

for!DSRIP!projects,!identifying!trends!and!characteristics!of!high!utilizers!in!the!

community,!and!others.!

!

As!noted!above,!this!approach!will!also!allow!providers!in!emergency!situations!to!

access!the!full!measure!of!patient!data.!!A!use!case!developed!by!the!Data!Work!Group!

highlights!how!this!could!critically!affect!patient!care.!!In!this!use!case,!a!consumer!with!

schizophrenia!on!clozapine!presents!in!an!emergency!room!with!a!high!fever.!!

Behavioral!health!data!in!the!HIE,!reviewed!by!a!provider!through!a!standard!“break!the!

glass”!process,!enables!the!provider!to!immediately!cease!the!use!of!clozapine,!thereby!

preventing!a!potentially!fatal!side!effect.!

!

Finally,!with!regard!to!future!development,!HIEs!accepting!this!data!with!an!emergency!

only!flag!starts!the!HIEs!down!the!path!of!accepting!behavioral!health!data.!!If,!in!the!

future,!there!are!changes!§42CFR!requirements!(for!example!by!rescinding!the!“named!

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provider”!provision)!or!to!the!underlying!EHR!and!HIE!technology!(for!example!by!

enabling!granular!segmentation!and!consent),!the!HIE!will!already!have!all!of!the!data!at!

its!disposal.!!Thus,!it!will!only!require!the!proverbial!“flip!of!the!switch”!to!enable!the!

free!flow!of!the!data.!!At!this!point,!however,!the!only!function!not!enabled!will!be!the!

viewing!of!combined!data!by!nonWbehavioral!health!providers!participating!in!the!HIE.!

Exchange!between!Council!Members!Even!beyond!a!traditional!health!information!exchange,!Council!Members!have!a!unique!

need!to!communicate!with!one!another!regarding!consumers.!!In!this!case,!the!

providers!are!known!specifically,!enabling!the!sharing!of!full!patient!records!including!

information!protected!by!§42CFR!(assuming!consent!is!provided).!!To!facilitate!this,!the!

Data!Work!Group!recommends!using!a!secure!form!of!pointWtoWpoint!information!

exchange!such!as!“Direct”!(the!national!standard!for!secure!pointWtoWpoint!exchange!of!

individually!identifiable!health!information),!or!some!other!secure!email!system!that!is!

consistent!with!HIPAA!requirements.!!!

!

Initially!the!DWG!considered!the!Direct!protocol!alone.!!However,!many!Council!

Members!report!that!they!already!have!a!secure!email!system!enabling!the!exchange!of!

sensitive!information.!!As!a!result,!the!Data!Work!Group!did!not!want!to!recommend!

duplicating!services.!!Additionally,!the!Direct!process—enabled!for!“White!Spaces”!in!

Texas!through!Health!Information!Technology!Service!Providers!(HITSPs)—lacked!some!

expected!functionality!like!a!providerWlookWup!function.!!As!currently!executed,!HITSPs!

allow!provider!lookWups!only!for!providers!participating!in!the!same!HITSP.!!With!four!

different!HITSPs!for!the!white!spaces!alone,!the!DWG!did!not!feel!comfortable!

endorsing!this!as!the!sole!approach!for!pointWtoWpoint!exchange.!

!

On!January!17,!2014!the!Texas!Council!Executive!Directors’!Consortium!reviewed!and!

approved!this!twoWpronged!approach—an!emergency!only!flag!through!HIEs,!and!secure!

email!for!Council!Member!to!Council!Member—the!DWG!expects!to!promote!exchange!

of!clinical!data!and!to!fully!comply!with!obligations!under!§42CFR!part!2.!!What!is!more,!

this!approach!paves!the!way!for!a!time!when!the!regulatory!and!technological!

framework!is!more!supportive!of!the!appropriate!exchange!of!sensitive!health!

information.!

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Appendix!E:!Texas!Council!Endorsed!Interoperability!Policy!!

Throughout!most!of!2013,!the!Data!Work!Group!of!the!Texas!Council!of!Community!

Centers!has!been!meeting!to!review!and!endorse!an!approach!with!regard!to!the!

exchange!of!clinical!data!elements!for!all!Texas!Council!members.!!This!process!was!

explicitly!intended!to!build!on!a!document!prepared!by!Health!Level!Seven!(HL7),!a!

standardsWmaking!organization!in!healthcare,!and!to!identify!data!elements!that!are!of!

interest!to!the!behavioral!health!sector!in!Texas.!!This!effort!was!undertaken!in!concert!

with!similar!efforts!to!identify!clinical!quality!measures,!and!regarding!an!approach!for!

the!exchange!of!clinical!information!consistent!with!obligations!under!§42!CFR!part!2,!

the!federal!regulations!governing!the!exchange!of!substance!abuse!treatment!

information.!

!!

Background:!In!the!months!leading!up!to!May!2013,!HL7!prepared!and!published!a!series!of!

documents!in!support!of!development!of!a!Clinical!Document!Architecture!(CDA)!

specific!to!Behavioral!Health.!!This!document!format!itself!was!used!to!support!

development!of!the!same!Continuity!of!Care!Document!(CCD)!that!was!endorsed!by!the!

Federal!government!as!a!required!component!for!the!EHR!incentive!program.!!The!CCD!

is!an!implementation!standard!that!is!used!to!support!care!coordination!for!patients.!!To!

this!end,!the!CCD!contains!a!great!deal!of!information—including!demographic!

information,!lab!and!test!results,!prescriptions,!diagnoses,!a!problem!list,!utilization,!

dates,!etc.;!however,!it!lacks!an!ability!to!convey!information!critical!to!behavioral!

healthcare.!!As!a!result,!HL7!began!a!communityWbased!effort!to!codify!discrete!data!

elements!and!to!bring!them!together!in!document!known!as!the!Behavioral!Health!CCD!

(BHWCCD).!

!

The!use!of!a!standardized,!machineXreadable!document!format!is!critical!to!the!effective!use!of!electronic!health!records,!since!it!facilitates!the!exchange!of!information!about!a!patient.!!Information!standards!are!important!both!for!encoding!

(i.e.!the!EHR)!and!decoding!a!document!since!there!must!be!perfect!alignment!between!

how!and!in!what!format!data!is!sent,!and!how!and!in!what!format!data!is!expected!by!a!

recipient.!!The!challenge!here!is!that!historically,!behavioral!health!providers!have!

struggled!to!participate!in!exchange!of!data,!both!because!most!standards!do!not!

promote!data!elements!that!are!germane!to!behavioral!health,!and!because!there!is!no!

standard!about!what!data!to!exchange.!

!

The!Data!Work!Group!of!the!Texas!Council!began!by!both!reviewing!documents!from!

HL7!related!to!the!emerging!BHWCCD!and!initiating!discussions!with!other!agencies!

nationwide!who!were!involved!in!the!exchange!of!clinically!relevant!behavioral!health!

!

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data.!!Among!the!content!reviewed!by!the!Data!Work!Group!was!a!presentation!by!

Shaun!Alfreds!the!COO!of!HealthInfoNet,!the!HIE!for!the!State!of!Maine,!and!Laura!

Adams,!the!CEO!of!the!Rhode!Island!Quality!Institute!(RIQI),!the!HIE!for!Rhode!Island.!!

Both!of!these!HIEs!operate!on!a!central!data!repository!HIE!model,!meaning!they!

consume!and!store!data!from!multiple!sources,!and!make!this!information!available!

when!requested.!!!!!

!

HealthInfoNet!in!particular!began!to!explore!with!behavioral!health!agencies!in!Maine!

what!information!they!wanted!to!obtain!to!better!coordinate!care.!!The!response!of!the!

behavioral!health!sector!was!to!request!the!inclusion!of!two!additional!data!elements:!

one!on!housing!status,!and!one!on!suicidality.!!For!Data!Work!Group!members!this!was!a!

promising!development!showing!a!strong!partnership!between!HIEs!and!behavioral!

health!agencies!that!held!promise!for!Texas.!

!

Building!off!of!documents!prepared!by!the!Substance!Abuse!and!Mental!Health!Services!

Administration!(SAMHSA),!the!Data!Work!Group!reviewed!summary!documentation!

describing!the!data!elements!in!the!BHWCCD!that!were!not!already!in!a!standard!CCD.!!All!

told,!there!were!ninetyWfour!(94)!additional!data!elements,!broken!up!into!eight!(8)!

domains,!or!content!areas,!with!seven!subWdomains.!!These!include:!

• Client!Demographics!Domain!

• Episode!of!Care!Domain!

• Document!Management!Domain!

• Social!History!Domain!

o Criminal!Justice!SubWDomain!

o Education!SubWDomain!

o Homelessness!SubWDomain!

o Veteran!Status!SubWDomain!

o Income!SubWDomain!

o Trauma/Domestic!Violence!SubWDomain!

o Peer!Group!Support!SubWDomain!

• Assessments!Domain!

• Problems!Domain!

• Substances!of!Abuse!Domain!

• Procedures!Domain!

!

One!of!the!major!challenges!of!this!group!was!to!differentiate!between!data!elements!

that!were!objectively!important!from!those!that!would!make!a!difference!as!part!of!the!

exchange!of!clinical!content.!!After!all,!a!strong!case!could!be!made!for!the!inclusion!of!

many!if!not!most!of!the!data!elements!associated!with!each!of!the!proposed!domains!

for!the!BHWCCD.!!However,!many!critical!elements—such!as!diagnosis—are!already!part!

of!the!existing!standard!for!a!CCD;!others,!may!be!readily!obtainable!from!the!patient!

!

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upon!transfer,!or!through!a!standard!operating!procedure!for!an!intake.!!Additionally,!

the!DWG!wanted!to!be!as!parsimonious!as!possible!in!selecting!supplemental!data!

elements!since!it!would!potentially!require!development!effort!on!the!part!of!both!HIEs!

and!EHR!vendors.!

!

Approach:!The!DWG!began!efforts!by!having!a!subWwork!group!review!the!nearly!100!additional!

elements!identified!as!part!of!the!proposed!BHWCCD.!!This!data!element!work!group!

used!a!threeWpoint!scoring!system!for!each!element:!

1. High!urgency;!

2. Moderate!urgency;!and!

3. Low!urgency.!!!

!

Ultimately,!the!group!chose!to!frame!this!in!terms!of!urgency!out!of!the!observation!

that!all!elements!were!deemed!clinically!relevant!and,!in!a!perfect!world,!behavioral!

health!providers!would!want!them;!however,!given!the!development!effort!this!would!

require,!the!workgroup!wanted!to!make!the!project!achievable!in!a!relatively!short!

period!of!time!for!all!relevant!stakeholders.!

!

Additionally,!the!data!element!work!group!also!began!a!review!with!the!three!EHR!

products!in!use!by!Texas!Council!members!to!ensure!that!the!data!elements!being!

requested!were!capable!of!being!captured!with!existing!systems.!!The!results!of!this!

process!would!drive!the!operational!feasibility!of!this!effort.!

!

After!an!initial!review,!the!data!element!work!group!identified!five!high!urgency!data!

elements,!closely!aligned!with!the!effort!in!Maine.!!These!elements!were:!

• Primary!Residence!Setting!

• Criminal!Justice!System!Involvement!

• Domestic!Violence!Trauma!

• Behavioral!Health!Critical!Problem;!and!

• Behavioral!Health!Critical!Flag.!

!

However,!the!data!element!work!group!lacked!any!clinicians.!!As!a!result,!the!data!

element!work!group!went!back!to!the!DWG!to!request!additional!support,!specifically!

from!clinicians.!!Although!this!resulted!in!some!reWwork,!the!clinicians,!having!gone!

through!the!same!exercise,!identified!a!number!of!different!elements!that!they!deemed!

urgent.!!

!

Over!the!next!several!weeks,!the!data!elements!work!group!continued!to!meet!in!an!

effort!to!harmonize!the!disparate!findings!of!the!two!different!cohorts.!!The!clinical!

review,!after!all,!provided!the!group!with!new!critical!information!on!how!clinicians!

!

!

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valued!information!from!specific!data!elements.!!Ultimately,!the!data!elements!work!

group!sought!to!strike!the!right!balance!of!obtainable!change,!standardized!data,!and!

clinically!relevant!content.!!In!the!final!analysis,!these!data!elements—in!addition!to!

those!contained!as!part!of!a!standard!CCD—represent!a!strong!step!forward!for!

behavioral!health!care!coordination!in!Texas.!!

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!

The!DWG!has!discussed!and!endorsed!the!following!seven!data!elements:!

• Episode!of!Care!Type!

• Primary!Residence!Setting!

• Risk!Behavior!

• Domestic!Violence!Trauma!

• Assessment!Type!

• Assessment!Score!

• Behavioral!Health!Critical!Flag!

!


approved!the!workgroups’!recommended!strategy!for!interoperability.!!The!Texas!

Council!believes!that!these!data!elements—in!addition!to!those!contained!in!a!standard!

CCD—are!of!strong!clinical!relevance!to!behavioral!health!agencies.!!Additionally,!the!

Texas!Council!believes!they!will!bring!strong!value!to!care!coordination,!particularly!as!

Community!Centers!support!the!transfer!of!consumers!from!one!facility!to!another.!The!

Texas!Council!further!believes!that!adding!these!data!elements!will!be!relatively!

straightWforward!for!the!EHRs!that!are!currently!in!use!among!Community!Centers.!!!

Finally—and!perhaps!most!significantly—the!inclusion!of!these!data!elements!will!

enable!recipients!of!a!referral!to!quickly!and!narrowly!identify!key!information!about!

consumers,!as!opposed!to!looking!for!fragments!among!various!other!data!fields.!!This!

alone!will!facilitate!care!coordination!and!collaboration!among!a!host!of!stakeholders.!!

!

Details!of!these!data!elements!form!the!HL7!Documentation!are!described!below.!

!

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Episode!of!Care!Type!• HL7!Recommendation:!Optional/Once!

• Quickly!and!clearly!differentiates!the!content!as!being!germane!to!a!crisis!or!a!

routine!visit!

• Information!classifies!a!single!encounter!

!

Definition! Meaning!

Crisis!Encounter!Describes!a!Crisis!encounter!as!the!reason!for!Behavioral!Health!

Report!submission!

RoutineBHEncounter!Describes!a!routine!Behavioral!Health!client!encounter!as!the!

reason!for!Behavioral!Health!Report!submission!

!

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Primary!Residence!Setting!• HL7!Recommendation:!Optional/Once!per!encounter!

• This!value!set!is!used!to!specify!the!place!where!the!client!has!spent!most!of!

his/her!time!in!the!past!30!days!prior!to!intake!or!any!change!thereafter.!

!

Meaning! Definition!

Independent!living!! Client!lives!in!a!private!residence!with!or!without!support!in!

activities!of!daily!living.!Living!arrangement!may!be!with!a!

roommate,!housemate,!and!spouse!or!by!self.!Use!only!with!

individuals!15!years!or!older.!

Supervisory!

care/assisted!living!!

A!facility!licensed!by!state!Assisted!Living!licensure.!Use!only!

with!individuals!18!years!or!older.!

State!Hospital!! A!publicly!funded!inpatient!facility!for!clients!with!mental!

illness.!Use!only!with!individuals!18!years!or!older.!

Jail/Correctional!facility!! When!an!individual!resides!in!a!jail!and/or!correctional!facility!

with!care!provided!24!hours,!7!days!a!week!basis.!This!

includes!jail,!correctional!facility,!prison,!youth!authority!

facility,!juvenile!hall,!boot!camp!or!Boys!Ranch.!

Homeless/homeless!

shelter!!

A!client!is!considered!homeless!if!he/she!lacks!a!fixed,!regular!

and!adequate!nighttime!residence!and/or!his/her!primary!

nighttime!residence!is!either!of!the!following:!(1)!a!supervised!

publicly!or!privately!operated!shelter!designed!to!provide!

temporary!living!accommodations;!(2)!an!institution!that!

provides!a!temporary!residence!for!individuals!intended!to!be!

institutionalized;!or!(3)!a!public!or!private!place!not!designed!

for,!or!ordinarily!used!as,!a!regular!sleeping!accommodation!

for!human!beings!(e.g.,!on!the!street).!

Foster!Home!! When!a!client!lives!in!a!home!other!than!that!of!the!client’s!

family.!This!includes!therapeutic!foster!care!facilities/home.!

Home!with!family!! When!a!client!lives!with!parents,!relatives,!adopted!family,!or!

legal!guardian.!

Private!Residence! !!

Level!1!!treatment!

setting!

Level!1!facility!includes!the!following!subcategories:!(a)!

hospitals;!(b)!subWacute!facilities;!and!(c)!residential!treatment!

centers.!

Level!2!treatment!

setting!

Level!2!Behavioral!Health!Residential!facilities!provide!

structured!treatment!setting!with!24Whour!supervision!and!

counseling!or!other!therapeutic!activities!for!clients!who!do!

not!require!onWsite!medical!services,!under!the!supervision!of!

!

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an!onWsite!or!onWcall!behavioral!health!professional.!

Level!3!treatment!

setting!

Level!3!Behavioral!Health!Residential!facilities!provide!

continuous!24Whour!supervision!and!treatment!in!a!group!

residential!setting!to!clients!who!are!determined!to!be!

capable!of!independent!functioning!but!still!need!some!

protective!oversight!to!insure!they!receive!needed!services.!

Transitional!housing!

(Level!IV)!!

Transitional!housing!(Level!IV)!or!DES!group!homes!for!

children!refers!to!a!shelter/housing!arrangement!for!shortW

term!care.!This!includes!DES!children!group!homes,!halfW

way/threeWquarter!way!house,!rural!substance!abuse!

transitional!center,!and!all!others!not!included!in!Levels!I,!2,!

and!3!treatment!settings.!

Dependent!living! !!

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Risk!Behavior!• HL7!Recommendation:!Optional/Repeating!

• This!attribute!is!used!to!represent!the!client's!risk!behaviors.!!It!will!enable!

agencies!to!identify!and!understand!key!risks!associated!with!an!individual.!

!

Concept! Definition!

Suicide!Risk!

0!=!no!evidence!

1!=!history,!watch/prevent!

2!=!recent,!act!

3!=!acute,!act!immediately!

Self!Injurious!

Other!Self!Harm!

Gambling!

Exploitation!

Danger!to!Others!

Criminal!Behavior!

Sexual!Aggression!

Drug!Use!

IV!Drug!Use!

!

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Domestic!Violence!Trauma!• HL7!Recommendation:!Optional/Repeating!

• Knowing!the!size!of!the!population!that!has!experienced!domestic!violence!is!

critical!to!determining!the!resources!needed!to!address!the!problem!in!the!

population.!

!

Meaning! Definition!

Any!Violence!

Have!you!ever!experienced!violence!or!trauma!in!any!

setting!(including!community!or!school!violence;!

domestic!violence;!physical,!psychological,!or!sexual!

maltreatment/assault!within!or!outside!of!the!family;!

natural!disaster;!terrorism;!neglect;!or!traumatic!grief?)!!

Nightmares!Have!had!nightmares!about!it!or!thought!about!it!when!

you!did!not!want!to?!

Tried!Hard!Tried!hard!not!to!think!about!it!or!went!out!of!your!way!

to!avoid!situations!that!remind!you!of!it?!

Constant!Guard!Were!constantly!on!guard,!watchful,!or!easily!startled?!

Numb!And!Detach!Felt!numb!and!detached!from!others,!activities,!or!your!

surroundings?!!

Physically!Hurt!How!often!have!you!been!hit,!kicked,!slapped,!or!

otherwise!physically!hurt?!

!

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Assessment!Type/Score!• Assessment:!

o HL7!Recommendation:!Required/Once!

o This!attribute!identifies!the!type!of!assessment!that!was!applied!to!the!

client!and!is!intended!to!be!specified!using!a!LOINC!code!and!uses!the!

BehavioralHealthAssessmentType!value!set.!

• Score:!

o HL7!Recommendation:!Required/Once!

o Value:!Integer!

! Concept ScoringACE The$higher$the$score,$the$greater$the$

exposure,$and$therefore$the$greater$the$risk$of$negative$consequences.$$These$consequences$are$discussed$throughout$the$publications$also$available$for$download$from$this$site.

ANSAASSISTAUDIT3CAUDIT4BDIBPRS418CAGECASII4CANSCD3RISC

DASTDAST10DSM4AXIS4V4GAFScaleDSM4AXIS4VCGSScale4GAD324 Two$items$scored$0$to$3$(total$score$of$0?

6)$GAD374 Seven$items,$each$of$which$is$scored$0$to$

3,$providing$a$0$to$21$severity$score.$GAD37GAIN4GDSHAMDM3

MADRSMMPI32Brief4PHQ4 See$scoring$for$PHQ$above.$Stressor$and$

women‘s$health$items$are$not$diagnostic$or$scored.$

PHQ4 Selected$(but$provisional)$DSM?IV$diagnoses$for$all$types$of$disorders$except$somatoform.$

PHQ324 Two$items$scored$0$to$3$(total$score$of$0?6)$

PHQ344PHQ384 Eight$items,$each$of$which$is$scored$0$to$3,$

providing$a$0$to$24$severity$score.$PHQ394 Nine$items,$each$of$which$is$scored$0$to$3,$

providing$a$0$to$27$severity$score.$PHQ3154 Fifteen$items,$each$of$which$is$scored$0$to$

2,$providing$a$0$to$30$severity$score.$PHQ3SADS4 $See$scoring$for$these$scales$above$PHQ3A4 Diagnostic$scoring$described$in$manual,$

available$upon$request.$

BAI3PCCAPS

PC3PTSDSF3PTSDSSS3PTSDSPANSPRINTPCLTSQSBIRTMental4Status4Exam

The$CAGE$can$identify$alcohol$problems$over$the$lifetime.$Two$positive$responses$are$considered$a$positive$test$and$indicate$further$assessment$is$warranted.

Adverse$Childhood$$Experience(ACE)The$ACE$Score$attributes$one$point$for$each$category$of$exposure$to$child$abuse$and/or$neglect.$$Add$up$the$points$for$a$Score$of$0$to$10.$$

Beck$Depression$Inventory

Assessment,$Adult$Needs$and$Strengths$Assessment$(ANSA)

Alcohol$Use$Disorders$Identification$Test:$to$detect$alcohol$problems$experienced$in$the$last$

Geriatric$Depression$Scale$(GDS)

Brief$Psychiatric$Rating$Scale$(BPRS)

Alcohol,$Smoking$and$Substance$Involvement$Screening$Test

Hamilton$Depression$Rating$Scale

Montgomery?Asberg$Depression$Rating$Scale

U.S.$Department$of$Veterans$Affairs$links$to$multiple$PTSD$screening$instruments

$PHQ?9,$GAD?7,$and$PHQ?15$measures,$plus$panic$measure$from$original$PHQ.$

This$code$identifies$the$"Child$and$Adolescent$Service$Intensity$Instrument".$The$CASII$

Definition

This$code$identifies$the$"Global$Appraisal$of$Individual$Needs$assessment$instrument".

Screening,$Brief$Intervention,$and$Referral$to$Treatment

Drug$Abuse$Screening$Test;$modified$version$of$10$question$(DAST10)

3?Question$screening;$modified$version$of$10$question$AUDIT

M3$Screen$$

Child$and$Adolescent$Need$and$Strengths$(CANS)Connor?Davidson$Resilience$Scale$(CD?RISC)(Besides$the$full$25?item$CD?RISC$(or$CD?RISC$25),$there$are$two$briefer$versions,$the$10$item$

All$items$of$PHQ?9$except$the$9th$item$on$self?harm.$Mainly$used$in$non?depression$research$studies.$

PHQ?9$and$panic$measures$from$original$PHQ$plus$items$on$stressors$and$women‘s$health.$

First$2$items$of$PHQ?9.$Ultra?brief$depression$screener.$

First$2$items$of$GAD?7.$Ultra?brief$anxiety$screener.$

Five$modules$covering$5$common$types$of$mental$disorders:$depression,$anxiety,$somatoform,$alcohol,$and$eating.$

Anxiety$measure$developed$after$PHQ$but$incorporated$into$PHQ?SADS.$

Minnesota$Multiphasic$Personality$Inventory®?2$(MMPI®?2)

Axis$V$identifies$the$patient's$level$of$function$on$a$scale$of$0?100,$(100$is$top?level$functioning).$This$is$known$as$the$Global$The$clinician’s$judgment$of$the$client’s$overall$level$

General$Anxiety$Disorder$Screener$?$7$Questions

Drug$Abuse$Screening$Test

Axis$V$identifies$the$patient's$level$of$function$on$a$scale$of$0?100,$(100$is$top?level$functioning).$This$is$known$as$the$Global$The$clinician’s$judgment$of$the$client’s$overall$level$

Trauma$Screening$Questionnaire$(TSQ)

Beck$Anxiety$Inventory$?$Primary$Care$(BAI?PC)

Primary$Care$PTSD$Screen$(PC?PTSD)

Short$Screening$Scale$for$PTSD

Patient$Health$Questionnaire$?$4$Questions

Substantially$modified$version$of$PHQ$developed$for$use$in$adolescents.$Moderate$data$exists$for$validity$but$much$less$than$for$original$PHQ.$

Depression$scale$from$PHQ.$

Somatic$symptom$scale$from$PHQ.$

Short$Form$of$the$PTSD$Checklist$?$Civilian$Version

PTSD$Checklist$(PCL)

Startle,$Physically$upset$by$reminders,$Anger,$and$NumbnessShort$Post?Traumatic$Stress$Disorder$Rating$Interview

Clinician?Administered$PTSD$Scale$(CAPS)

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Behavioral!Health!Critical!Flag!• HL7!Recommendation:!Optional/Repeating!

• This!value!set!is!used!to!identify!the!immediate!risk!of!a!clinical!nature.!

!

Concept! Definition!Suicidal!behavior! SNOMEDWCT!CID:!425104003!

Homicidal!behavior! SNOMEDWCT!CID:!424241004!

At!risk!for!violence! SNOMEDWCT!CID:!65108000!

At!risk!for!selfWdirected!violence! SNOMEDWCT!CID:!!129709009!

At!risk!for!selfWmutilation! SNOMEDWCT!CID:!!129708001!

At!risk!violence!in!the!home! SNOMEDWCT!CID:!!161051006!

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Appendix!F:!Texas!Council!Endorsed!Measurement!Policy!!

During!2013,!the!Data!Work!Group!of!the!Texas!Council!of!Community!Centers!met!to!

identify!a!set!of!clinical!quality!measures!that!can!be!used!across!the!entire!behavioral!

health!sector.!!What!began!with!a!wideWscale!process!to!review!scores!of!measures,!

resulted!in!concise!list!of!measures!adopted!by!the!Texas!Council!members.!

!

As!stated!in!the!Data!Work!Group!Charter,!the!goal!of!the!Measurement!Task!Force!was!

to!Endorse!5W7!clinical!quality!measures!for!Texas!Council!members!that!are!aligned!

with:!

• DSRIP!requirements!and!MU!measures;!

• Needs!of!DSRIP!partner!agencies;!

• Based!on!national!research!and/or!a!national!dataset;!

• Clinically!relevant!to!Texas!Council!members;!and!

• Operationally!feasible!for!Texas!Council!members.!

!

In!order!to!achieve!these!ends,!the!Measurement!Task!Force!started!with!a!list!of!more!

than!100!measures!related!to!outpatient!behavioral!health.!!These!were!gleaned!from!

various!sources!including!quality!measures!associated!with!Federal!Programs!like!

Accountable!Care!Organizations!(ACO),!Meaningful!Use!(MU)!Stage!2,!and!CMS’s!Health!

Care!Innovations!Awards!(HCIA).!!Additionally,!the!group!looked!at!measures!as!

identified!by!thirdWparty!quality!organizations!like!the!National!Quality!Forum!(NQF),!the!

National!Council!for!Quality!Assurance!through!their!Healthcare!Effectiveness!Data!and!

Information!Set!(HEDIS)!measures,!and!the!Center!for!Quality!Assessment!and!

Improvement!in!Mental!Health!(CQAIMH).!!Finally,!the!group!also!reviewed!measures!

included!in!the!State!of!Texas’!1115!Demonstration!Waiver!for!its!Delivery!System!

Reform!Incentive!Payment!(DSRIP)!program.!!!

!

Through!multiple!discussions,!The!Data!Work!Group!identified!key!objectives!for!a!

measurement!approach,!and!charged!a!Measurement!Task!Force!(MTF)!broad!

responsibilities!for!evaluating!different!measures.!!At!a!high!level,!the!measures!must!be!

both!clinically!relevant!and!operationally!feasible;!however,!the!MTF!was!given!leeway!

to!interpret!this.!!Although!no!single!measure!was!expected!to!embody!all!of!the!

objectives,!collectively!the!endorsed!measures!and!must!represent!the!approach!as!

described!by!the!Data!Work!Group.!!To!this!end,!the!Data!Work!Group!requested!

measures!that:!

!

• Can!be!readily!produced!with!information!and!systems!as!they!currently!exist;!

• Employ,!where!possible,!outcome!(not!merely!process)!measures;!

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• Effectively!convey!to!other!care!providers!the!value!of!behavioral!health!services!

in!terms!that!are!germane!to!other!care!providers;!!

• Communicate!to!the!entire!state!how!behavioral!health!providers!would!like!to!

encourage!systemWwide!development.!

!

The!initial!list!contained!more!than!100!measures.!!The!MTF!then!engaged!in!a!series!of!

efforts!to!winnow!down!the!list.!!After!multiple!meetings!and!discussions,!the!MTF!

reached!an!initial!consensus!to!limit!subsequent!discussion!to!just!30!measures!broadly!

aligned!with!the!Data!Work!Group!approach.!

!

Using!these!30!measures,!the!MTF!scored!each!measure!with!two!separate!scores!on!a!

1W10!scale—one!axis!concerns!“clinical!relevance”,!the!other!“operational!feasibility”.!!

For!both!scales,!1!was!lowest!and!10!the!highest.!!These!measures!were!then!plotted!on!

a!chart!as!a!way!to!drive!additional!discussion!among!the!MTF!and!the!Data!Work!Group.!

!

!

!

Finally,!from!this!list!of!30!measures,!the!MTF!settled!on!just!12,!with!the!intention!of!

bringing!them!back!to!the!entire!Data!Work!Group!for!discussion!and,!eventually,!

endorsement.!

!

An#depressant+Medica#on+Management++

Bipolar+Disorder+(BD+and+Major+Depression+(MD):+Appraisal+for+alcohol+

or+substance+use+

Diabetes+screening+for+people+with+schizophrenia+or+bipolar+disorder+who+

are+prescribed+an#psycho#c+medica#ons+(SSD)++

FollowBup+aCer+Hospitaliza#on+for+Mental+Illness+

BBD+and+MD:+Assessment+for+Manic+or+hypomanic+behaviors+

Assignment+of+Primary+Care+Physician+to+Individuals+with+Schizophrenia+

Adherence+to+An#psycho#c+Medica#ons+for+Individuals+With+

Schizophrenia+

Cardiovascular+Monitoring+for+People+With+Cardiovascular+Disease+and+

Schizophrenia+

Diabetes+Monitoring+for+People+With+Diabetes+and+Schizophrenia+

Annual+Physical+Exam+for+Persons+with+Mental+Illness+

Assessment+for+Psychosocial+Issues+of+Psychiatric+Pa#ents+

Assessment+for+Substance+Abuse+Problems+of+Psychiatric+Pa#ents+

Assessment+of+Major+Depressive+Symptoms+

Assessment+of+Risk+to+Self/Others+

Care+Planning+for+Dual+Diagnosis+

Housing+Assessment+for+Individuals+with+Schizophrenia+

Ini#a#on+of+Depression+Treatment+

Voca#onal+Rehabilita#on+for+Schizophrenia+

Depression+Screening+By+18+years+of+age++

FollowBUp+Care+for+Children+Prescribed+ADHD+Medica#on+

Depression+Remission+at+12+months+

Independent+Living+Skills+Assessment+for+Individuals+with+Schizophrenia+

Decrease+in+mental+health+admissions+and+readmissions+to+criminal+jus#ce+

seWngs+such+as+jails+or+prisons+

Assessment+for+Medical+Problems+of+Psychiatric+Pa#ents+

Behavioral+Health+/Substance+Abuse+30+day+readmission+rate+

Cardiovascular+health+monitoring+for+people+with+cardiovascular+disease+and+

schizophrenia+(SMC)++

Diabetes+monitoring+for+people+with+diabetes+and+schizophrenia++

Screening+for+clinical+depression+and+f/u+plan+

6+

6.5+

7+

7.5+

8+

8.5+

9+

9.5+

10+

6+ 6.5+ 7+ 7.5+ 8+ 8.5+ 9+ 9.5+ 10+

Clinical'Relevan

ce'

Feasibility'

Scored'BH'Clinical'Measures'

Lower ' ' ' ' ' ' 'Higher'

Lower

''

''Highe

r'

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From!among!these!12!measures,!the!Data!Work!Group!took!an!approach!of!looking!for!a!

combination!of!measures!to!reflect!the!overWall!orientation!of!the!Texas!Council.!!As!a!

result,!some!measures!are!more!clinical!in!focus;!some!are!process!measures;!some!are!

aspirational!in!that!they!require!data!not!currently!available!to!Council!members.!!

Collectively,!however,!they!demonstrate!the!commitment!of!Council!Members!to!using!

health!information!to!drive!quality!improvements.!!The!Work!Group!believes!that!

individuals!served!by!community!centers!deserve!the!highest!caliber!of!care!for!the!

totality!of!their!health!conditions—regardless!of!whether!the!benefit!is!accrued!to!

behavioral!health!providers.!!These!measures!are!intended!to!communicate!the!value!of!

behavioral!health!services!to!all!stakeholders!in!the!continuum!of!care.!

!


approved!an!Endorsed!Measurement!Strategy!an!approach!to!clinical!quality!measures!

that!reflects!a!balanced!approach!to!quality.!!This!strategy!identifies!a!core!set!of!quality!

measures!that!all!community!centers!must!tract,!and!provides!one!of!two!options!to!

reflect!local!implementation!of!assessment!tools.!!!The!strategy!further!identifies!two!

measures!that!require!additional!refinement!before!they!can!be!effectively!

implemented—either!because!the!measure!lacked!clarity,!or!because!data!was!not!

currently!available!to!make!the!measure!most!valuable.!!Finally,!for!centers!desirous!of!a!

stretch!goal,!the!strategy!approved!also!recommends—but!does!not!require—two!

additional!measures.!

!

Required!Measures:!• NQF!#105:!Antidepressant!Medication!Management;!and!• NQF!#1932:!Diabetes!Screening!for!people!with!schizophrenia!or!bipolar!disorder!

who!are!prescribed!antipsychotic!medications!(SSD);!and!• NQF!#0576:!FollowWup!after!Hospitalization!for!Mental!Illness;!and!• NQF!#1879:!Adherence!to!Antipsychotic!Medications!for!Individuals!With!

Schizophrenia.!

• Either/or!

o Improvement!as!demonstrated!through!CANS/ANSA!scores;!or!o Improvement!as!demonstrated!through!DLA20/GAF!score.!

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Development!Measures!• Proportion!of!crisis!episodes!that!result!in!an!admission!to!a!state!hospitals!and!

DSHSWfunded!community!hospitals!within!30Wdays!of!the!first!day!of!the!crisis!

episode!

o Needs!a!more!precise!definition!of!a!“crisis!episode”!• Behavioral!Health!ReWadmission!Rate:!

o Needs!better!information!from!the!State!with!regard!to!discharge!data!from!all!hospitals.!

!

High!Value!Menu!Measures!• NQF!#1934:!Diabetes!monitoring!for!people!with!DM!and!Schizophrenia!

• Decrease!in!mental!health!admissions!and!readmissions!to!criminal!justice!

settings!

!

Details!for!these!measures!are!include!in!subsequent!pages.!

!

Implementation!With!regard!to!operationalizing!this!approach,!measures!will!begin!to!be!calculated!

monthly!on!a!rolling!twelveWmonth!(RTM)!basis!starting!with!a!measurement!year!that!

begins!with!the!next!fiscal!year,!or!September!1,!2014.!!The!strategy!is!to!have!individual!

centers!integrate!these!measures!into!each!agency’s!existing!quality!improvement!

process,!track!measures!on!a!monthly!basis,!and!report!measures!that!conform!to!NQF!

standards!to!the!Texas!Council!for!the!prior!calendar!year.!!Ideally!this!will!be!done!

within!30!days!of!the!close!of!a!calendar!year!so!that!the!first!set!of!measures!for!2014!

will!be!produced!by!the!end!of!January!2015.!

!

Furthermore,!the!Texas!Council!will!produce!an!annual!“Quality!Report!Card”!that!will!

be!made!public.!!This!report!card!could!prove!valuable!both!for!public!relations!and!

advocacy!purposes.!

!

Finally,!there!will!be!periodic!review!of!these!quality!measures.!Once!the!measures!are!

implemented,!this!review!will!take!place!at!least!biannually.!!This!review!will!take!into!

consideration!various!changes!to!the!healthcare!milieu!including!(but!not!limited!to):!

• Progress!agencies!have!made!towards!these!measures;!

• Changes!to!the!health!IT!sector!for!example!through!additional!HIE!

functionalities;!

• Development!of!new!quality!measures,!particularly!related!to!outcomes;!and!

• Needs!of!key!stakeholders!such!as!payers,!consumers,!and!other!health!care!

providers.!

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Required!Measures:!

NQF!#105:!Antidepressant!Medication!Management!HEDIS/DSRIP/MU!Stage!2!

Strong!measure,!but!difficulty!will!be!in!obtaining!the!“fill!rate”!especially!for!non<insured!consumers.!

Definition:!Percentage!of!patients!18!years!of!age!and!older!who!were!diagnosed!with!major!

depression!and!treated!with!antidepressant!medication,!and!who!remained!on!

antidepressant!medication!treatment.!Two!rates!are!reported.!

a. Percentage!of!patients!who!remained!on!an!antidepressant!medication!for!at!

least!84!days!(12!weeks).!

b. Percentage!of!patients!who!remained!on!an!antidepressant!medication!for!at!

least!180!days!(6!months).!

Description:!Numerator!1:!Patients!who!have!received!antidepressant!medication!for!at!least!84!days!

(12!weeks)!of!continuous!treatment!during!the!114W!day!period!following!the!Index!

Prescription!Start!Date!

!

Numerator!2:!Patients!who!have!received!antidepressant!medications!for!at!least!180!

days!(6!months)!of!continuous!treatment!during!the!231W!day!period!following!the!Index!

Prescription!Start!Date!

Included!Population(s)!Patients!18!years!of!age!and!older!with!a!diagnosis!of!major!depression!in!the!180!days!

(6!months)!prior!to!the!measurement!period!or!the!first!180!days!(6!months)!of!the!

measurement!period,!who!were!treated!with!antidepressant!medication,!and!with!a!

visit!during!the!measurement!period.!

Excluded!Population(s)!Individuals!are!excluded!from!the!denominator!if!they!have!diabetes!(during!the!

measurement!year!or!the!year!prior!to!the!measurement!year).!

Local!Modification:!1. Only!report!on!“fill”/pickWup!rates!for!patients!for!whom!you!have!pickWup/fill!

information.!

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NQF!#1932:!Diabetes!screening!for!people!with!schizophrenia!or!bipolar!disorder!who!are!prescribed!antipsychotic!medications!(SSD)!

Definition:!The!percentage!of!individuals!18!–!64!years!of!age!with!schizophrenia!or!bipolar!disorder,!

who!were!dispensed!any!antipsychotic!medication!and!had!a!diabetes!screening!during!

the!measurement!year.!

Description:!One!or!more!glucose!or!HbA1c!tests!performed!during!the!measurement!year.!

Included!Population(s)!Adults!ages!18!to!64!years!of!age!as!of!December!31!of!the!measurement!year!with!a!

schizophrenia!or!bipolar!disorder!diagnosis!and!who!were!prescribed!any!antipsychotic!

medication.!

Excluded!Population(s)!Have!Diabetes!

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NQF!#0576!FollowXup!after!Hospitalization!for!Mental!Illness!DSRIP/HEDIS!

Full!compliance!will!requires!that!behavioral!health!agencies!receive!notification!of!hospital!discharges,!perhaps!through!an!HIE!or!some!other!means.!!Currently,!agencies!are!only!notified!of!state!psychiatric!hospital!discharges.!

Definition:!This!measure!assesses!the!percentage!of!discharges!for!members!6!years!of!age!and!

older!who!were!hospitalized!for!treatment!of!selected!mental!health!disorders!and!who!

had!an!outpatient!visit,!an!intensive!outpatient!encounter!or!partial!hospitalization!with!

a!mental!health!practitioner.!Two!rates!are!reported.!!

!

1. The!percentage!of!members!who!received!followWup!within!30!days!of!discharge!!

2. The!percentage!of!members!who!received!followWup!within!7!days!of!discharge.!

Description!1. An!outpatient!visit,!intensive!outpatient!encounter!or!partial!hospitalization!with!

a!mental!health!practitioner!within!30!days!after!discharge.!Include!outpatient!

visits,!intensive!outpatient!encounters!or!partial!hospitalizations!that!occur!on!

the!date!of!discharge.!

!

2. An!outpatient!visit,!intensive!outpatient!encounter!or!partial!hospitalization!with!

a!mental!health!practitioner!within!7!days!after!discharge.!Include!outpatient!

visits,!intensive!outpatient!encounters!or!partial!hospitalizations!that!occur!on!

the!date!of!discharge.!

Included!Population:!Members!6!years!and!older!as!of!the!date!of!discharge!who!were!discharged!alive!from!

an!acute!inpatient!setting!(including!acute!care!psychiatric!facilities)!with!a!principal!

mental!health!diagnosis!on!or!between!January!1!and!December!1!of!the!measurement!

year.!The!denominator!for!this!measure!is!based!on!discharges,!not!members.!Include!

all!discharges!for!members!who!have!more!than!one!discharge!on!or!between!January!1!

and!December!1!of!the!measurement!year.!!

!

Mental!health!readmission!or!direct!transfer:!

If!the!discharge!is!followed!by!readmission!or!direct!transfer!to!an!acute!facility!for!a!

mental!health!principal!diagnosis!(within!the!30Wday!followWup!period),!count!only!the!

readmission!discharge!or!the!discharge!from!the!facility!to!which!the!member!was!

transferred.!Although!rehospitalization!might!not!be!for!a!selected!mental!health!

disorder,!it!is!probably!for!a!related!condition.!!!

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Excluded!Population(s)!Exclude!both!the!initial!discharge!and!the!readmission/direct!transfer!discharge!if!the!

readmission/direct!transfer!discharge!occurs!after!December!1!of!the!measurement!

year.!!

!

Exclude!discharges!followed!by!readmission!or!direct!transfer!to!a!nonacute!facility!for!a!

mental!health!principal!diagnosis!within!the!30Wday!followWup!period.!These!discharges!

are!excluded!from!the!measure!because!readmission!or!transfer!may!prevent!an!

outpatient!followWup!visit!from!taking!place.!Refer!to!Table!FUHWB!for!codes!to!identify!

nonacute!care.!

!

NonWmental!health!readmission!or!direct!transfer:!

Exclude!discharges!in!which!the!patient!was!transferred!directly!or!readmitted!within!!

30!days!after!discharge!to!an!acute!or!nonacute!facility!for!a!nonWmental!health!principal!

diagnosis.!This!includes!an!ICDW9WCM!Diagnosis!code!or!DRG!code!other!than!those!in!

Tables!MPTWA!and!MPTWB.!These!discharges!are!excluded!from!the!measure!because!

rehospitalization!or!transfer!may!prevent!an!outpatient!followWup!visit!from!taking!place.!

Local!Modification:!Operationalize!“members”!to!mean!individuals!who!are!already!known!to!the!LMHA!

who!are!discharged!from!DSHS!Beds!or!where!the!LMHA!receives!a!referral.!

!

Strong!runway!possibilities!to!communicate!care!coordination!with!other!care!providers!

and/or!the!state.!

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NQF!#1879:!Adherence!to!Antipsychotic!Medications!for!Individuals!With!Schizophrenia!HEDIS!

Definition!The!measure!calculates!the!percentage!of!individuals!18!years!of!age!or!greater!as!of!the!

beginning!of!the!measurement!period!with!schizophrenia!or!schizoaffective!disorder!

who!are!prescribed!an!antipsychotic!medication,!with!adherence!to!the!antipsychotic!

medication![defined!as!a!Proportion!of!Days!Covered!(PDC)]!of!at!least!0.8!during!the!

measurement!period!(12!consecutive!months).!

Description:!Individuals!with!schizophrenia!or!schizoaffective!disorder!who!filled!at!least!two!

prescriptions!for!any!antipsychotic!medication!and!have!a!Proportion!of!Days!Covered!

(PDC)!for!antipsychotic!medications!of!at!least!0.8.!

Included!Population:!Individuals!at!least!18!years!of!age!as!of!the!beginning!of!the!measurement!period!with!

schizophrenia!or!schizoaffective!disorder!with!at!least!two!claims!for!any!antipsychotic!

medication!during!the!measurement!period!(12!consecutive!months).!

Excluded!Population(s):!Individuals!with!any!diagnosis!of!dementia!during!the!measurement!period.!

!

Local!Modification:!1. Only!report!on!“fill”/pickWup!rates!for!patients!for!whom!you!have!pickWup/fill!

information.!

!

!

!

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Care!Improvement:!CANS/ANSA!or!DLA20/GAF!Score!Improvement!

Child!and!Adolescent!Needs!and!Strengths/Adult!Needs!and!Strengths!Assessment!(ANSA)!Intention!is!to!build!towards!use!of!the!CANS/ANSA!as!a!tool!to!assess!efficacy!of!on<going!treatment.!!Initially!must!establish!a!benchmark!completion!rate!for!Texas/Texas!Council!Members.!

Numerator:--Adult:!Patients!18!and!older!who!had!any!improvement!in!their!ANSA!score!between!

two!ANSA!assessments!more!than!3!months!apart!in!the!last!12!months.!

!

Children:!Patients!older!than!6!and!younger!than!18!who!had!any!improvement!in!their!

CANS!score!between!two!CANS!assessments!more!than!3!months!apart!in!the!last!12!

months.!

!

Denominator:-Adults:!All!patients!18!and!older!with!two!ANSA!assessments!more!than!3!months!apart!

in!the!last!12!months.!

!

Children:!Patients!older!than!6!and!younger!than!18!with!with!two!CANS!assessments!

more!than!3!months!apart!in!the!last!12!months.!

Exclusions:-

Local-Implementation-Mathematical!adjustment!for!%!of!population!!

!

Daily!Living!Activities!20/Global!Assessment!of!Functioning!(GAF)!Score!Like!the!CANS/ANSA,!the!intention!is!to!build!the!use!of!the!DLA!20/GAF!score!into!standard!practice!so!agencies!can!report!on!changes!(reductions)!to!the!GAF!scores!over!time.!!Initially,!however,!this!measure!will!look!at!the!percentage!of!patients!treated!in!the!last!12!months!with!a!GAF!score!present.!!The!DLA20!is!validated!for!frequent!use!(monthly)!and!is!relatively!inexpensive.!!Also!like!the!CANS/ANSA!completion!rate,!a!benchmark!or!target!rate!will!need!to!be!established.!

Numerator:--#!of!Patients!18!and!older!who!had!any!improvement!in!their!GAF!score!at!least!3!

months!apart!in!the!last!12!months.!

!

!

!

!

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Denominator:-All!patients!18!and!older!with!at!least!one!visit!in!the!last!12!months.!

High!Value!Menu!

NQF!#1934:!!Diabetes!monitoring!for!people!with!DM!and!Schizophrenia!

Definition:!The!percentage!of!individuals!18!–!64!years!of!age!with!schizophrenia!and!diabetes!who!

had!both!and!LDLWC!test!and!an!HbA1c!test!during!the!measurement!year."!

Description:!One!or!more!HbA1c!tests!and!one!or!more!LDLWC!tests!performed!during!the!

measurement!year.!

Included!Population(s):!Adults!age!18!years!and!older!as!of!December!31!of!the!measurement!year!with!a!

schizophrenia!and!diabetes!diagnosis.!

Excluded!Population(s)!Members!with!a!diagnosis!of!polycystic!ovaries!(Table!CDCWO)!who!did!not!have!a!faceW

toWface!encounter,!in!any!setting,!with!a!diagnosis!of!diabetes!(CDCWB)!during!the!

measurement!year!or!the!year!prior!to!the!measurement!year.!Diagnosis!may!occur!at!

any!time!in!the!member’s!history,!but!must!have!occurred!by!December!31!of!the!

measurement!year.!!

!

Members!with!gestational!or!steroidWinduced!diabetes!(CDCWO)!who!did!not!have!a!faceW

toWface!encounter,!in!any!setting,!with!a!diagnosis!of!diabetes!(CDCWB)!during!the!

measurement!year!or!the!year!prior!to!the!measurement!year.!Diagnosis!may!occur!

during!the!measurement!year!or!the!year!prior!to!the!measurement!year,!but!must!have!

occurred!by!December!31!of!the!measurement!year.!

Local!Comments:!• High!value!menu!(i.e.!optional)!set!twinned!with!NQF!#1932.!!!

• Consider!future!modification!to!have!diagnosis!population!consistent!with!NQF!

#1932!(i.e.!include!BPD)!

!

!

!

!

!

Page!59!

!



Decrease!in!mental!health!admissions!and!readmissions!to!criminal!justice!settings!such!as!jails!or!prisons!This!measure!will!require!closer!electronic!coordination!between!the!criminal!justice!system!and!the!behavioral!health!sector.!!!Such!coordination!is!in!its!early!stages,!and!will!require!additional!development!to!be!fully!realized.!!Will!need!to!define!“admission”!to!a!criminal!justice!setting.!!Likely!will!be!a!challenge!to!implement!since!the!measure,!as!described!in!the!planning!document,!is!focused!on!decreasing!incarceration!rates!among!individuals!with!a!history!in!a!specific!agency!who!were!discharged!in!a!baseline!year.!

Description:!Decrease!in!mental!health!admissions!and!readmissions!to!criminal!justice!settings!such!

as!jails!or!prisons.!!!

Goal:!Reduce!the!number!of!individuals!receiving!project!interventions!who!had!an!

admission/readmission!to!criminal!justice!setting!by!15%!below!baseline!rate.!

Author/Source!Submitted!by:!MHMR!Authority!of!Brazos!Valley!!

“This!project!is!expected!is!expected!to!prevent!admissions/readmissions!into!the!

criminal!justice!system!of!individuals!with!primary!mental!health!issues,!and!help!to!

reduce!the!criminalization!of!mental!illness.”!

!

Local!Comments:!TLETS!system!is!currently!the!only!way!of!obtaining!information!on!people!with!

psychiatric!issues!being!discharged!from!criminal!justice!settings.!!Poor!data.!!!

!

Of!those!LMHA!patients!with!criminal!justice!history!in!the!last!12!months,!what!percent!

return!to!prison/jail!in!the!next!12!months.!

!

!

!

!

!

Page!60!

!



Development!Measures!

Crisis!Episodes:!The!proportion!of!crisis!episodes!that!result!in!admission!to!a!State!hospital!or!DSHSXfunded!community!hospital!within!30!days!of!the!first!crisis!episode!

Denominator:!!The!number!of!Crisis!Episodes!that!result!in!an!admission!to!State!hospitals!and!DSHS!

funded!community!hospitals!within!30!days!of!the!first!day!of!the!Crisis!Episodes.!

Numerator:!The!number!of!Crisis!Episodes.!

!

Local!Approach:!Look!at!something!with!a!higher!level!of!validity!on!how!to!define!an!episode.!!

Communicate!to!state!where!we!want!to!get!with!this!measure—it!should!ultimately!be!

expanded!so!that!it!is!not!limited!to!stateWfunded!psychiatric!hospitals!and/or!DSHSW

funded!beds.!

Exclude:!!Substance!abuse!crisis!treatment!

!

!

!

!

!

!

Page!61!

!



Behavioral!Health!Readmission!Rate:!

Description:!Behavioral!Health!30Wday!Readmission!Rate!

Denominator:!Adults!discharged!who!are!readmitted!to!a!public!mental!health!bed!with!a!principal!

diagnosis!of!a!behavioral!health!condition!within!30!days.!

Numerator:!Adults!discharged!from!any!hospital!with!a!principal!diagnosis!of!a!behavioral!health!

condition.!

Comments:!This!is!a!critical!measure!for!hospitals!and!other!healthcare!providers,!yet!LMHAs!

currently!lack!adequate!connectivity!to!achieve!this.!!

!

!

!

!

!

Page!62!

!



Appendix!G:!Glossary!Term! Definition!

42CFR!Part!2! Federal!Substance!Abuse!Treatment!Privacy!Regulations!!

Accountable!Care!

Organization!(ACO)!

A!funding!and!service!delivery!model!in!which!a!group!of!

providers!accept!a!large!capitated!payment!for!a!cohort!of!

patients.!!The!provider!groups!must!then!manage!quality!and!

cost!for!the!cohort.!!If,!after!a!specified!period!of!time!

(typically!3W5!years)!there!are!cost!savings!for!the!cohort,!then!

the!providers!and!the!payers!share!in!the!savings.!

Analytics!

The!use!of!analytic!techniques!to!derive!insight!from!large!

data!sets!dealing!with!health!and!to!identify!and!quantify!

individual!characteristics!of!entities!of!interest.!!Areas!of!

interest!could!be!operational,!clinical,!or!demographic!in!

nature,!and!in!any!combination.!

Behavioral!Health!

Continuity!of!Care!

Document!(BHWCCD)!

An!HL7Wballoted!document!standardWWan!addWon!to!a!CCDWWthat!

contains!additional!data!fields!germane!to!the!delivery!and!

coordination!of!behavioral!health!services.!

C32!

A!specific!implementation!standard!of!a!CDA!and!CCD.!!!EHR!

products!had!the!option!to!produce!either!the!C32!CCD!or!the!

CCR!to!become!certified!to!support!State!1!MU.!

Care!Coordination!

Document!(CCD)!

CCD!is!the!general!term!for!a!class!of!constraints!on!the!HL7!

Clinical!Document!Architecture!(CDA).!!CCDs!typically!contain!a!

range!of!content!that!is!important!for!transitioning!a!patient!

from!one!care!provider!to!another,!including!name,!sex,!

problems,!medications,!referral!reason,!labs/tests,!lab/test!

results,!etc.!

Consolidated!Care!

Coordination!

Document!(CWCDA)!

A!more!contemporary!constraint!on!the!CCD!that!was!included!

in!requirements!for!EHRs!to!support!State!2!Meaningful!Use!!

Continuity!of!Care!

Record!(CCR)!

An!alternative!to!the!CCD,!the!CCR!contains!much!of!the!same!

information,!including!the!patient!name,!main!problem(s),!

medications,!etc.!!EHR!products!had!the!option!to!produce!

either!the!C32!CCD!or!!the!CCR!to!become!certified!to!support!

State!1!MU.!

Clincal!Document!

Architecture!(CDA)!

!An!HL7!document!framework!for!conveying!a!range!of!clinical!

information.!!The!C32!CCD!is!one!use!of!the!CDA.!

Consent!Permission!given!by!a!patient!to!capture/view!their!protected!

medical!data.!

!

!

!

!

!

Page!63!

!



DIRECT!A!national!standard!promoted!by!ONC!to!enable!pointWpoint!!

exchange!of!clinical!content!

Electronic!Heath!

Record!(EHR)!

!An!electronic!tool!for!capturing!and!recording!a!range!of!

clinical!content!about!a!patient.!

EHR!Incentive!

Program!

An!initiative,!included!under!the!HITECH!Act,!in!which!which!

providers!meeting!eligibility!requirements!are!given!federal!

funds!to!support!the!adoption!and!effective!use!of!EHRs.!

Enterprise!Master!

Patient!Index!(EMPI)!

A!unique!identifier!for!all!records!uniquely!associated!with!a!

specific!patient.!!Typically!used!by!an!HIE!to!consolidate!a!

patient!record!from!multiple!providers.!

EMR! Electronic!Medical!Record!

Electronic!Prescribing!

(eRx)!

The!prescribing!of!medications!using!electronic!means!(not!

fax)!

Health!Information!

Exchange!

An!entity!that!facilitates!the!exchange!of!protected!health!

information!between!trusted!partners.!

Centrlized!

An!HIE!model!of!operations!in!which!data!is!stored!and!

managed!in!a!central!location!before!being!distributed!upon!

request.!

Federated!

An!HIE!model!of!operations!in!which!the!availability!of!

protected!health!information!is!sent!to!a!central!clearing!

house.!!Requests!for!patient!information!are!then!routed!to!

local!entities.!

Hybrid!An!HIE!model!of!operations!that!combines!elements!of!

Centralized!and!Federated!models.!

(Health!Insurance!

Portability!and!

Accountability!Act)!

HIPAA!

Federal!statute!dealing!with!privacy!and!security!for!personal!

health!information.!

Health!Information!

Sevice!Provider!(HISP)!A!vendor!who!provides!standWalone!EHR!support.!!!

Health!Information!

Tenholoy!for!

Economic!and!Cliical!

Health!Act!(HITECH!

Act)!

Passed!in!2009!as!part!of!the!American!Reinvestment!and!

Recovery!Act,!the!HITECH!Act!includes!important!provisions!

for!health!IT!including!the!statutory!creation!of!the!Office!of!

the!National!Coordinator!for!Health!IT,!the!EHR!Incentive!

Program,!and!funding!authorization!for!all!ONCWfunded!

programs!like!RECs,!Beacon!Communities,!and!the!State!HIE!

program.!

Health!Level!Seven!

(HL7)!A!standards!development!organization.!

!

!

!

!

!

Page!64!

!



Interoperability!A!quality!of!data!that!allows!it!to!be!transmitted!and!

immediately!understood!as!intended!in!the!new!environment.!

Logical!Observation!

Identifiers!Names!and!

Codes!(LOINC)!

A!nomenclature!that!is!typically!used!for!lab!tests!and!values.!

Master!Provider!Index!

(MPI)!

A!unique!identifier!for!all!records!uniquely!associated!with!a!

specific!provider.!!!

Meaningful!Use!(MU)!

The!specific!standard!to!which!eligible!providers!and!eligible!

hospitals!must!attest!in!order!to!qualify!for!incentive!dollars!as!

part!of!the!EHR!Incentive!Program.!!Stage!1!largely!covers!HIT!

adoption!and!initial!connectivity,!State!2!requires!more!

intensive!use.!!Stage!3!has!not!been!released!yet.!

Nomenclature!A!defined!set!of!values!that!are!associated!with!a!specific!field!

on!a!specific!document.!LOINC,!for!example.!

Office!of!the!National!

Coordinator!for!

Health!Information!

Technology!(ONC)!

A!Federal!division!within!the!Department!of!Health!and!

Human!Services!devoted!to!supporting!nationwide!HIT!

adoption!and!use.!

Personal!Health!

Record!(PHR)!

A!record,!maintained!and!curated!by!an!individual,!often!

comprised!of!clinical!data!from!multiple!physicians.!

Privacy!An!attribute!of!data!that!must!be!guarded!with!security!

measures.!

Regional!Extension!

Center!(REC)!

A!federally!funded!program!providing!technical!support!and!

advice!to!primary!care!providers!in!the!adoption!and!use!of!

EHRs.!

Security!The!tools!that!are!deployed!to!maintain!the!privacy!of!key!

data.!

Systematized!

Nomenclature!of!

Medicine—Clinical!

Terms!!(SNOMEDWCT)!

A!terminology!nomenclature!for!the!electronic!exchange!of!

clinical!data.!

Standards!A!formalized,!agreedWupon!and!validated!approach!for!

enabling!the!smooth!electronic!transmission!of!data.!

Standard!

Development!

Organization!

Any!organization!predominantly!engaged!in!a!stakeholder!

process!to!develop,!codify,!and!define!the!standards!through!

which!they!will!enable!the!exchange!of!data!

Structured!Data!

Information,!typically!captured!via!a!defined!list,!at!the!most!

detailed!level!possible!where!the!data!elements!have!defined!

relationships!to!other!data!elements.!!

!

!

!

!

!

Page!65!

!



Unstructured!Data!

Data!that!is!captured!typically!in!a!freeWtext!format!making!it!

difficult!to!review/explore!content!across!multiple!input!

sources.!

White!Space!Term!used!to!describe!the!areaWWlargely!in!West!TexasWWthat!

has!no!HIE!coverage.!

!

!

!

!

!

!

!

Page!66!

!



Appendix!H:!HIEs!in!Texas!The!documents!in!this!section!are!presented!for!convenience!purposes!only.!!They!were!

taken!in!their!entirely!from!the!THSA!website!(http://www.hietexas.org/howWtoW

connect/hieWnetworks)!on!December!11,!2014,!where!the!most!upWtoWdate!information!

will!be!located.!

12/11/14, 1:06 PMHIETexas.org - FirstNet Exchange

Page 1 of 2http://www.hietexas.org/how-to-connect/hie-networks/firstnet-exchange

Search... Go

About THSA Sunset Review Newsletter Contact

Contact InformationPatrick Maloney

FirstNet Exchange

P. O. Box 6400

Tyler, Texas 75711

800-328-1638

[email protected]

www.firstnetexchange.com

Business & Operations Plans

B & O Plan

B & O Plan Addendum

Outreach/Education Materials

FirstNet Marketing Materials

Tentative Grant Amount*$1,438,710

Ownership ModelNon-Profit

Current Stage of HIEDevelopment**eHealth Initiative Stage 5

Technical Model***Hybrid-Federated

# of Physicians Targeted toConnect2,629

# of Hospitals Targeted toConnect65

Counties Served by HIEAnderson, Angelina, Bowie, Camp,

Cass, Cherokee, Delta, Fannin,

Franklin, Freestone, Gregg,

Harrison, Henderson, Hopkins,

Houston, Hunt, Kaufman, Lamar,

What is HIETexas? How To Connect Privacy & Security Certification Resources FAQs

FirstNet Exchange (FirstNet), located in Tyler, Texas (East Texas), wasformed in 1996 by ETMC Regional Healthcare System (a nonprofithealth system) as a regional Health Information Exchange (HIE) with amission to "optimize quality care, service, and cost management bystreamlining the exchange of healthcare information." It started byconnecting ETMC hospitals and physicians,but grew quickly over theyears to provide a data exchange for numerous East Texas providers.Today, FirstNet's stakeholders include 15 hospitals and over 600physicians, and its exchange spans 21 counties with data on over onemillion patients.

HIE ObjectivesFirstNet seeks to be the premiere HIE in East Texas with a mission to facilitate the secure, community-based, electronic

communication of clinical, financial, and administrative information among the providers in its service area. FirstNet believes these

services are vital to the achievement of positive and measureable quality, cost, and patient safety outcomes and to improvements in

the coordination of health care services to area residents.

As a network that has been operational for almost 15 years, FirstNet Exchange is uniquely positioned to extend its coverage to 37

contiguous counties in East Texas. With a population of approximately 1,600,000 residents, this area includes approximately 65

hospitals and over 2,600 physicians. As interoperability and patient privacy policies evolve, FirstNet will lead the effort to securely

link to other Texas HIEs, and ultimately, to a national framework for information exchange.

FirstNet's interactions with its key stakeholders shall be guided by its focus on value (delivery of functionality that provides value for

stakeholders), capacity (services that allow FirstNet's stakeholders to efficiently manage the cost and quality of healthcare

services), and low risk (an easy-to-install and -use solution that is non-intrusive and supports future needs). Additionally, FirstNet is

confident in its ability to assist East Texas providers in the achievement of their "meaningful use" objectives.

GovernanceStructure

Legal Structure Composition Committees

Texas Nonprofit/501(c)(3) 2 hospital representatives

3 of physician representatives

1 of payer representatives

1 of lab representatives

1 of pharmacy representatives

1 of consumer representatives

Provider Engagement

Privacy/Security

Patient Communication

TechnicalModel &Services

Architecture Services Vendor

Hybrid-federated VHR, EMR, Bi-directional clinical

and administrative data

exchange, analytics, Image

Exchange, PHR gateway

services

Optum

FirstNet(Exchange

http://www.hietexas.org/how-to-connect/hie-networks/firstnet-exchange#

http://www.hietexas.org/how-to-connect/hie-networks/firstnet-exchange#

https://twitter.com/#!/HIETexas

http://www.hietexas.org/about-thsa/overview

http://www.hietexas.org/sunset-review/overview

http://www.hietexas.org/summer-2014

http://www.hietexas.org/contact

mailto:[email protected]

http://www.firstnetexchange.com/

http://www.hietexas.org/component/docman/doc_download/51-b-o-plan-firstnet?Itemid=

http://www.hietexas.org/component/docman/doc_download/91-b-o-addendum-firstnet?Itemid=

http://www.hietexas.org/component/docman/doc_download/397-firstnet-marketing-materials?Itemid=

http://www.hietexas.org/what-is-hietexas/overview

http://www.hietexas.org/how-to-connect/overview

http://www.hietexas.org/privacy-and-security-certification/overview

http://www.hietexas.org/resources/overview

http://www.hietexas.org/frequently-asked-questions/faqs

12/11/14, 1:06 PMHIETexas.org - FirstNet Exchange

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Leon, Marion, Morris, Nacogdoches,

Navarro, Panola, Rains, Red River,

Rockwall, Rusk, Sabine, San

Augustine, Shelby, Smith, Titus,

Trinity, Upshur, Van Zandt and Wood

Texas Health Services Authority5900 Southwest ParkwayBuilding 2, Suite 201 Austin, Texas 78735

512-814-0321 (phone)512-814-0322 (fax)[email protected]

HomeWhat is HIETexas?How to ConnectResourcesPrivacy & Security CertificationFAQ

About THSAContactSite Admin

Open Records PolicyOpen Meeting and Public Testimony PolicyInternet Policies

© 2014 Texas Health Services Authority

HIE Services Direct Services / Timeline Core Query-BasedExchange Services

Additional Query-Based ExchangeServices

Clinical Summary Exchange,

March 2012

Lab Results Delivery, April 2012

VHR, February 2013

Analytics, February 2013

PHR Gateway Services,

February 2013

Image Exchange, May 2013

Privacy &Security

Privacy Security Consent

FirstNet understands and will

facilitate the electronic exchange

of health information in a manner

that is consistent with the privacy

and security guidelines and

policies such as HIPAA, HITECH,

etc.

Our technology model has in

place and will comply with the

current security standards

adopted by HIPAA, HITECH and

the THSA.

Opt-out

SustainabilityApproach

Finance Participation Cost Value Statement

Hospital investment, subscription

fees and government grant

Please contact us at

[email protected]

FirstNet will provide

physicians with an HIE that

allows for prompt access to

health information originating

from other providers. This

access will allow physicians

to spend more time using

health information rather than

looking for it.

<< Back to HIE Service Areas

*This amount represents the tentative amount of funding awarded for planning and implementation of the project. The organization’s finalaward will be based on the number of hospitals and physicians that commit to connect through the HIE.

**An HIE at eHealth Initiative Stage 5 is a fully operational health information organization; transmitting data that is being used by healthcare stakeholders.

***A hybrid technical model provides the interface engine for which organizational entities in the HIE communicate across the network. Thehybrid model stores key record identifiers and requests for the information that is distributed across the network. The decentralized orfederated model provides organizational control of the healthcare record and provides the framework for data-sharing capability toenterprises, perhaps widely distributed across regions or even nationally. The local entity owns their data and the Record Locator Servicesmanages the pointers to the information.

mailto:[email protected]?subject=HIETexas%20Website%20Inquiry

http://www.hietexas.org/








http://www.hietexas.org/site-admin

http://www.hietexas.org/open-records-policy

http://www.hietexas.org/open-meeting-and-public-testimony-policy

http://www.hietexas.org/internet-policies


http://www.hietexas.org/local-hies/hie-service-areas-and-info

12/11/14, 1:08 PMHIETexas.org - Greater Houston HEALTHCONNECT

Page 1 of 3http://www.hietexas.org/how-to-connect/hie-networks/greater-houston-healthconnect

Search... Go


Contact InformationJim Langabeer, PhD

Robin Mansur

1213 Hermann Drive

Suite 135

Houston, TX 77004

(832) 564-2599

[email protected]

[email protected]

http://ghhconnect.org/


B&O Plan

B&O Plan Addendum


Connecting For a Healthier

Community

GHH Timeline

GHH Fast Facts

Community Health Record

GHH Media Kit




Technical Model***Federated


# of Hospitals Targeted toConnect


Founded through the collaboration of the Center for Houston'sFuture and the Harris County Healthcare Alliance, Greater HoustonHealthconnect was launched in 2010. The organization wasinspired by the vision of Houston area business and communityleaders to work hand-in-hand with local healthcare providers toachieve a decisive gain in community health. Greater HoustonHealthconnect was developed with the support of numerousorganizations and interested individuals, including the area's majorhealthcare systems and medical schools, along with the HarrisCounty Medical Society.

Two regional HIEs, Galveston County HIE and HIE of South East Texas have

merged with Healthconnect, expanding the service area to 20 counties.

HIE ObjectivesThe Greater Houston Healthconnect will:

Develop and implement an electronic health information exchange for the greater Houston region that will enable all patients and

health care and wellness service providers to easily access patient records for true continuity of care.

Promote the efficient use of health information technology providers throughout the region.

Act as a neutral broker to enhance collaboration between the community, hospital systems, physician providers, independent

hospitals and other health and wellness organizations across the Greater Houston area with the goal of broad-based community

support and participation by public and private healthcare providers.

Improve the efficiency, quality, and safety of patient care.

GovernanceStructure



4 physician

representatives

1 payer representative

1 pharmacy

representative

8 consumer

representatives

Advocacy and Development

Executive Committee

Finance

Governance and Nominating

Clinical and Quality Advisory Council

Technology Advisory Council



Federated EMPI; RLS; Consent

Management; Direct

Secure Messaging;

Referral Management;

Image Transmission,

Medicity

Greater&Houston&HEALTHCONNECT

http://www.hietexas.org/how-to-connect/hie-networks/greater-houston-healthconnect#

http://www.hietexas.org/how-to-connect/hie-networks/greater-houston-healthconnect#








http://ghhconnect.org/

http://www.hietexas.org/component/docman/doc_download/52-b-o-plan-greaterhouston?Itemid=

http://www.hietexas.org/component/docman/doc_download/60-b-o-addendum-greaterhouston?Itemid=

http://www.youtube.com/watch?v=rwcXcjBB-oQ

http://www.flipdocs.com/showbook.aspx?ID=10011180_310378

http://www.hietexas.org/component/docman/doc_download/673-ghh-fast-facts-october-2013?Itemid=

http://www.hietexas.org/component/docman/doc_download/672-ghh-proaccess-flyer?Itemid=

http://www.hietexas.org/component/docman/doc_download/671-ghh-press-kit-october-2013?Itemid=






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133

Counties Served by HIEAustin, Brazoria, Chambers,

Colorado, Fort Bend, Galveston,

Hardin, Harris, Jasper, Jefferson,

Liberty, Matagorda, Montgomery,

Newton, Orange, San Jacinto, Tyler,

Walker, Waller, Wharton







Image Transmission,

Delivery of Lab Orders

HIE Services DirectServices/Timeline

Core Query-BasedExchange Services

Additional Query-BasedExchange Services

Patient Referrals, December

2011

Clinical Summary Exchange,

December 2011

Lab Results Delivery,

Expected March 2013.

All Other HIE Services

Expected April 2013

Privacy &Security


Through a collaborative

process with multiple

stakeholders Healthconnect

has developed:

-Patient Authorization

-Privacy Manual

-Participation Agreement

-Business Associated

Agreement

Fully Compliant with

HIPAA and HITECH

Opt-in



Transitioning from grant

funding to a blended model

based on service fee

revenues and private support

with minor government based

funding.

Balanced Model with

Financial Participation

from Payers, Hospitals,

and Physicians

Healthconnect will serve as a neutral

convener of networks to enable providers

to access patient information across a

broad geographic coverage area,

enhancing quality and efficiency of care.

Back to HIE Service Areas

*This amount represents the total amount of funding awarded for the planning phase of the project. The organization is eligible to receiveadditional funding for development and implementation upon completion and approval of an HIE business and operational plan.

**An HIE at eHealth Initiative Stage 6 is fully operational; transmitting data that is being used by healthcare stakeholers and have asustainable business model.

***The decentralized or federated model provides organizational control of the healthcare record and provides the framework for data-sharing capability to enterprises, perhaps widely distributed across regions or even nationally. The local entity owns their data and theRecord Locator Services manages the pointers to the information.















12/11/14, 1:08 PMHIETexas.org - Health Information Network of South Texas

Page 1 of 3http://www.hietexas.org/how-to-connect/hie-networks/health-info-south-texas

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Contact InformationHank Fanberg

Executive Director, HINSTX

361-881-3421-838-1550

Valerie Bartelt, PhD

Director of Operations

[email protected]

http://www.hinstx.org/


B&O Plan

B&O Plan Addendum

Tentative Grant Amount*$531,400



Technical Model***Hybrid



Counties Served by HIEAransas, Bee, Brooks, Jim Wells,

Karnes, Kenedy, Kleberg, Live Oak,

Nueces, Refugio, and San Patricio


The Health Information Network of South Texas (HINSTX) is a not forprofit organization comprised of public, private and non-profitorganizations around the Corpus Christi metroplex and rural CoastalBend that is committed to providing the health informationtechnology infrastructure to expand access to quality health care,enable patient engagement and improve health outcomes for allpeople in the region. HINSTX will accomplish this through theestablishment of a health information exchange (HIE) that iscontinually adapting, transparent and accountable, community-based, and self-sustaining and demonstrates quantifiable social,clinical, and economic benefits for patients and providers. TheHINSTX is building on past health IT initiatives in South Texas andleveraging existing resources to create a foundation for a health information exchange that will assistproviders and patients across the entire continuum of care - including the essential connectivity withstate and federally-based HIE initiatives and networks, such as the Texas Health Services Authority(THSA) and the National Health Information Network (NwHIN).

The HINSTX's membership includes formal representation from such key stakeholders as CHRISTUS Spohn Health System,

Corpus Christi Medical Center, Driscoll Children's Heath System, area medical societies, and Coastal Bend Rural Health

Partnership, Texas A&M Health Education Center, Texas A&M University Kingsville, Texas A&M University Corpus Christi, Del Mar

College, Emergency Services, U.S. Naval Clinic and Veterans' Affairs, Mental Health, Health Departments and others. This list

underscores HINSTX's unique features: broad-based stakeholder representation and significant focus on population / public health

research functionality and desired improved outcomes based on research of regional health trends.

HIE ObjectivesThe overreaching objectives include, but are not limited to, the following: 1) improve the quality of medical decision-making and

coordination of care, 2) provide accountability and a safeguarding privacy and security of medical information, 3) reduce

preventable medical errors and avoid duplication of treatment, 4) improve public health outcomes, 5) reduce health care costs, and

6) empower patients to take a more active role in their health care.

GovernanceStructure


Texas Nonprofit/501(c)(3) 4 of hospital representatives

4 of physician representatives

4 community based social services

oranizations and MHMR

1 payer representatives


3 of pharmacy representatives

2 of consumer representatives

3 Educational and research

Clinical Advisory

Committee

Finance and

Resource Commitee

Engagement and

Participation

Commitee

Technology and

Security Committee

Information

Health'Information'Network'of'South'Texas

http://www.hietexas.org/how-to-connect/hie-networks/health-info-south-texas#

http://www.hietexas.org/how-to-connect/hie-networks/health-info-south-texas#







http://www.hinstx.org/

http://www.hietexas.org/component/docman/doc_download/461-hinstx-b-o-plan?Itemid=

http://www.hietexas.org/component/docman/doc_download/462-hinstx-b-o-plan-addendum?Itemid=








Governance and

Privacy Committee



Hybrid EMPI/RLS/Consent Management,

Direct Secure Messaging, etc.

TBD


AdditionalQuery-BasedExchangeServices

Clinical Summary Exchange/ Lab

Results Delivery, referral

management,Direct Exchange Q2 2012

Enterprise HIE to HIE connectivity

Q1 2013

PHR

Data Repository for

research and public

health Q4 2012

Privacy &Security


HINSTX agrees to facilitate the

electronic exchange of health

information consistent with privacy and

security guidelines and policies adopted

by the Texas Health Services Authority

(THSA) in accordance with state and

federal law and regulations.

HINSTX agrees to follow the HIPAA

security requirement to implement

administrative, physical, and

technical safeguards and will reflect

the required Risk Analysis as a

foundational step in ensuring

security compliance.

Opt-out



HINSTX initial funding includes

government, private foundation

donations and contributions from its

member organizations.

Participation costs include both

member fees and subscription fees.

For more information contact Hank

Fanberg at

[email protected].

Providers that

participate with

HINSTX will enjoy

an ease of care

coordination and

quality of care

improvement with

better outcomes.


*This amount represents the tentative amount of funding awarded for planning and implementation of the project. The organization's

final award will be based on the number of hospitals and physicians that commit to connect through the HIE.

**An HIE at eHealth Initiative Stage 4 is well under way with implementation - technical, financial, and legal.

***A hybrid technical model provides the interface engine for which organizational entities in the HIE communicate across the

network. The hybrid model stores key record identifiers and requests for the information that is distributed across the network.



12/11/14, 1:09 PMHIETexas.org - Healthcare Access San Antonio

Page 1 of 3http://www.hietexas.org/how-to-connect/hie-networks/healthcare-access-san-antonio

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Contact InformationGijs van Oort, PhD

Executive Director

5535 Fredericksburg, Suite 220

San Antonio, Texas 78229

(210) 918-1357

[email protected]

www.hasatx.org


B&O Plan

B&O Plan Addendum


Stay Ahead With HASA

HASA Patient Brochure







Counties Served by HIEAtascosa, Bandera, Bexar, Comal,

DeWitt, Edwards, Frio, Kerr, Kendall,


Healthcare Access San Antonio (HASA) is a non-profitcommunity collaborative, including premier hospital systems,community health providers and the San AntonioMetropolitan Health Department. HASA's mission – toenhance access to care for community residents - is realizedby facilitating the exchange of patient information acrossproviders in a safe and secure environment. In working inclose partnership with its stakeholders, HASA intends toprovide health information exchange to the benefit ofresidents and providers in 22 counties in the Central andSouthwest Texas area.

HIE ObjectivesAs a safety net for the uninsured, HASA has provided a platform for patient information exchange since 2008. As a community

collaborative, HASA provides these services in complement to what providers have implemented for internal use. Additionally, a

portal for providers with limited or no electronic medical record capabilities is available.

HASA's objectives for 2013 include connecting providers in rural and urban Central and Southwest Texas and expand this

connectivity to all patient types. As a community collaborative, HASA intends to provide value to multiple community stakeholders

including providers, physicians, consumers, companies and payers. Through collaboration with other community providers, HASA

intends to assist in providing patient-centered, high quality and cost efficient care for its service area.

HASA will be primed to connect to regional HIE initiatives in order to meet the State's objective of Statewide patient information

exchange.

GovernanceStructure


Texas

Nonprofit/501(c)(3)

5 hospital

representatives

5 Community health

centers

2 physician group

representatives

1 of payer

representative

1 of lab

representative

1 of pharmacy

representative

1 of consumer

representative

HASA Board

IT-subcommittee

Medical Advisory Committee

Finance & Sustainability Committee

Analytics Committee

Ad hoc committees – nomination, HIE partnering

TechnicalModel &


Healthcare)Access)San)Antonio

http://www.hietexas.org/how-to-connect/hie-networks/healthcare-access-san-antonio#

http://www.hietexas.org/how-to-connect/hie-networks/healthcare-access-san-antonio#







http://www.hasatx.org/

http://www.hietexas.org/component/docman/doc_download/53-b-o-plan-hasa?Itemid=

http://www.hietexas.org/component/docman/doc_download/61-b-o-addendum-hasa?Itemid=

http://www.hietexas.org/component/docman/doc_download/512-stay-ahead-with-hasa?Itemid=

http://www.hietexas.org/component/docman/doc_download/674-hasa-patient-brochure-oct-2013?Itemid=








Gillespie, Guadalupe, Gonzales,

Hays, Medina, Mason, Mendard,

Karnes, Kinney, Real, Uvalde, Val

Verde, Wilson

Model &Services Hybrid HASAReferral

HASAProviderAssist

HASALite

HASAFacts

MyHASA

Medicity

HIE Services Direct Services/ Timeline

Core Query-BasedExchangeServices

Additional Query-Based Exchange Services

Lab results delivery,

Referrals, secure

messaging

First Quarter 2012

HASAProviderAssist,

HASALite

Fourth Quarter 2012

MyHASA, HASAFacts

Second Quarter 2013

Privacy &Security


HASA's security and

privacy policies

have been

developed and

reviewed and

approved by its

ITcommittee and

Executive Board.

These policies are

in compliance with

Federal and State

guidelines

HASA's security and

privacy policies have

been developed and

reviewed and

approved by its

ITcommittee and

Executive Board.

These policies are in

compliance with

Federal and State

guidelines

HASA has deployed an opt-out model at the point of

patient encounter with an authorization for sharing of

sensitive conditions.


Finance ParticipationCost

Value Statement

HASA has

submitted a 3-year

sustainability

budget, where

revenue sources

transition from State

funding to service

line revenues

Participation cost for

the HASA Service

lines vary with

service type,

provider size and

engagement with

HASA.

Stakeholders and members who agree to exchange

and/or view shared data, agree to enhance community

health status through non-commercial and collaborative

health information exchange, ensuring that patient

privacy and data security. Members agree to exchange

patient information to enhance care transparency in a

non-competitive manner. Stakeholders and members

commit to support and abide by established standards

and conditions of data integrity and data exchange.




** An HIE at eHealth Initiative Stage 7 is sustainable and fully operational; demonstrates expansion of organization to provide value-

add services, such as advanced analytics, quality reporting, clinical decision support, PACs reporting, EMS services.


12/11/14, 1:09 PMHIETexas.org - Integrated Care Collaboration

Page 1 of 3http://www.hietexas.org/how-to-connect/hie-networks/integrated-care-collaboration

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Contact InformationCarl Angel

8627 N Mopac Expressway,

Suite 140

Austin, Texas 78759

(512) 524-9248 x10215

[email protected]

http://www.icc-centex.org


B&O Plan

B&O Plan Addendum


ICC Brochure

ICC Texas Direct Brochure








The Integrated Care Collaboration (ICC) is a 501(c)(3) nonprofitalliance of healthcare organizations in Central Texas dedicatedto the collection, analysis, and sharing of health information.The ICC has been nationally recognized for its efforts in healthinformation exchange and community-wide care transformationto improve quality, increase access, and lower costs acrossunaffiliated providers throughout the spectrum of healthcaredelivery. The ICC upgraded its health information exchangeplatform to support technology-enabled, patient-centric caredelivery and the ability to measure Accountable CareOrganization's (ACOs) established outcomes. With federal andstate emphasis on health information technology, MeaningfulUse requirements, and ACOs, providers are now looking to ICare as the regional health informationexchange solution for Central Texas. The ICC's target patient population is all individuals regardless ofinsurance status, race, sex or age.

The ICC offers both query based and Direct-protocol based HIE solutions. ICare 2.0 is the ICC's second-generation query based

HIE solution and has been live and in-use by providers and hospitals since September 2011. With the development of ICare 2.0, a

Data Warehousing and Analytics solution has been coupled with the data to facilitate performance-based outcome analysis, validate

patient information and assist with community health research.

The ICC's Texas Direct secure messaging system, based on the ONC's Direct protocol, facilitates the electronic exchange of

referrals, test results, reports, and other clinical data over a secure network. Texas Direct allows providers on any electronic health

record (EHR), as well as those without an EHR, to quickly and easily exchange patient information without the burden of fax, phone

or traditional mail services.

HIE ObjectivesThe ICC's primary objective is to create a regional health information exchange that is trusted and valued by allstakeholders to enable improved care coordination. The overarching objectives of the ICC are as follows:

Improve continuity of care by providing rapid access to patient health information from multiple healthcare sites

Provide cost savings by reducing redundant clinical tests for the same patient

Increase the trust of consumers, patients, and providers in health information exchange by ensuring strong privacy andsecurity safeguards

Empower consumers to actively manage their own health by providing access to their health information through aneasily accessible patient portal

Encourage the adoption of electronic health record systems by economically facilitating secure sharing of informationover electronic networks

Facilitate the public reporting of patient outcomes and quality measures by establishing the Meaningful Use of healthinformation technology

Integrated)Care)Collaboration

http://www.hietexas.org/how-to-connect/hie-networks/integrated-care-collaboration#

http://www.hietexas.org/how-to-connect/hie-networks/integrated-care-collaboration#







http://www.icc-centex.org/

http://www.hietexas.org/component/docman/doc_download/54-b-o-plan-icc?Itemid=

http://www.hietexas.org/component/docman/doc_download/62-b-o-addendum-icc?Itemid=

http://www.hietexas.org/component/docman/doc_download/489-icc-2-pager?Itemid=

http://www.hietexas.org/component/docman/doc_download/490-icc-texas-direct-brochure?Itemid=








Counties Served by HIEAngelina, Bastrop, Bell, Blanco,

Bosque, Brazos, Burleson, Burnet,

Caldwell, Comal, Coryell, Falls,

Fayette, Freestone, Gillespe,

Gonzales, Grimes, Guadalupe,

Hamilton, Hays, Hill, Houston,

Jasper, Kendall, Lampasas, Lee,

Leon, Limestone, Llano, Madison,

McLennan, Milam, Mills,

Nacogdoches, Newton, Polk,

Robertson, Sabine, San Augustine,

San Jacinto, San Saba, Shelby,

Travis, Trinity, Tyler, Washington,

and Williamson

GovernanceStructure



2 physician representatives


1 lab representative

1 pharmacy representative

2 consumer representatives

Management

Committee

(including County

Collaboratives)

IT Committee

Physician Advisory

Board

Analytics

Committee

Finance Committee



Hybrid Query-based HIE services, including

Provider Portal (ICare)

Direct protocol-based HIE services

(Texas Direct)

Centex Systems

Support Services

(CSSS)

Mirth Corporation

HIE Services Direct Services / Timeline Core Query-Based ExchangeServices


Direct: 11/2011 Lab Results Delivery: 3/2012

Patient Portal: 4/2012

Facilitate ePrescribe: 6/2012

Quality Reporting: 9/2012

Public Health Reporting: 9/2012

Clinical Summary Exchange: 9/2011

Provider Portal: 9/2011

Analytics: 11/2011

Eligibility & Claims:

11/2012

Privacy &Security


The ICC is committed to ensuring the

privacy of personal health information

in accordance with federal and state

law. ICC members have agreed to

privacy standards and processes that

meet or exceed federal and state

requirements, to facilitate trusted data

sharing at the point of care, including

the HIPAA and HITECH Acts.

The ICC is committed to ensuring the

security of personal health information

in accordance with federal and state

law, including the HIPAA and HITECH

Acts. The ICC has implemented

security standards and processes that

meet or exceed federal and state

requirements to facilitate trusted data

sharing at the point of care.

Opt-in


Finance Participation Cost ValueStatement

The ICC is funded through a

combination of private and public

grants, including the Local HIE Grant

Program of the State of Texas. The

ICC is further sustained by contribution

from its founding members and

Participation costs depend upon the

services being used and extent of

participation.

Please contact [email protected]

for additional information.

The ICC is an

experienced non-

profit, community-

based asset with a

mission to improve

health outcomes












revenue generated through its analytic

capabilities.

through secure,

meaningful use and

analysis of

community health

data.


**An HIE at eHealth Initiative Stage 7 has demonstrated expansion of organization to encompass a broader coalition of

stakeholders than present in the initial operational model.

















12/11/14, 1:09 PMHIETexas.org - North Texas Accountable Healthcare Partnership

Page 1 of 2http://www.hietexas.org/how-to-connect/hie-networks/north-tx-accountable

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Contact InformationJoe Lastinger

1250 E Copeland Road, Suite 200

Arlington, Texas 76011

(817) 274-6300

[email protected]

http://ntahp.org/


B&O Plan

B&O Plan Addendum

Outreach/EducationalMaterials

Patient Brochure

Patient Brochure (español)

"Completing the Patient Picture"

Brochure

Posters


Ownership ModelNon-Profit, 501(c)3






The North Texas Accountable Healthcare Partnership (NTAHP)is a 501(c)(3) organization established in 2010 by leaders ofCIGNA, the Dallas Fort Worth Business Group on Health,Dallas County Medical Society and the Dallas-Fort WorthHospital Council with the purpose of promoting andrewarding local healthcare clinical performance for thecitizens of North Texas, that is coordinated, transparent, andvalue based. The Partnership will serve as the HealthInformation Exchange entity for North Texas covering 13counties and nearly 6.6 Million Texans.

HIE ObjectivesAt its core, the NTAHP seeks to be the Region's primary driver and champion of health care value through the establishment of four

critical standards: 1) Reporting of agreed-to evidence-based quality metrics specific to disease states; 2) Innovative redesign of

Care Coordination services through the physician's office; 3) Provision of new rewards and payment models that incentivize high

quality and cost savings; 4) Adoption of common health plan designs encouraging patient accountability consistent with the quality

metrics.

Fundamental to the success of this strategy is the creation and sustainment of a regional health information exchange. The HIE will

allow for the establishment of patient registries as well as point to point data exchange to improve the real time sharing of clinical

data.

NTAHP MissionTo promote and to reward local health care clinical performance for the citizens of North Texas, that is coordinated,

transparent, and value based.

GovernanceStructure


Texas Nonprofit/501(c)(3) The Board is comprised of individuals

representing: hospitals, physicians,

payers, labs, pharmacies, Public Health,

consumers, and employers.

HIE Steering Committee

Technology Workgroup,

Privacy/Security

Workgroup, Clinical

Advisory Workgroup



Hybrid Query-Based

Exchange and Direct

Exchange

Data aggregation from existing systems,

longitudinal pt. health record with query

search, and event notification functions.

Orion Health

HIE Services Direct Services /Timeline

Core Query-Based ExchangeServices


North&Texas&Accountable&Healthcare

12/11/14, 1:09 PMHIETexas.org - North Texas Accountable Healthcare Partnership

Page 2 of 2http://www.hietexas.org/how-to-connect/hie-networks/north-tx-accountable

Counties Served by HIECollin, Dallas, Denton, Ellis, Fannin,

Grayson, Hunt, Johnson, Kaufman,

Parker, Rockwall, Tarrant, and Wise







Direct Services – Live 1/2012

EMPI/CDR, Query Pt. Data,

Provider Portal, Alert

notifications – Q4 2012

Medication Reconciliation, Public Health

Integration/Reporting, HIE to HIE, -- Q1

2013

Analytics, Disease

Management-Image

Sharing, -TBD

Privacy &Security


NTAHP emphasizes the

privacy of all patients by

continually upholding and

adhering to all applicable

state and federal regulations

such as HIPAA, HITECH,

Privacy Legislation, etc.

NTAHP is highly focused on information

security for all data shared through the

HIE. NTAHP is implementing proven

security protocols for data and users of

HIE services. NTAHP subscribes to the

HITRUST Common Security

Framework.

Opt-out model with a focus

on the patient's ability to

easily opt out of data

sharing without barriers or

limitations.



Grant funding is used for

capital investment with a

subscription-based

sustainability model being

implemented in 2012.

The NTAHP HIE will utilize a

subscription based pricing model for

connecting entities. For detailed

information, Joe Lastinger 817-274-

6300

NTAHP HIE will promote

local healthcare clinical

performance that is

coordinated, transparent,

and value-based by

creating supportive

technologies for all

providers.




**An HIE at eHealth Initiative Stage 5 is fully operational and transmitting data that is being used by healthcare stakeholders.



12/11/14, 1:09 PMHIETexas.org - Paso del Norte HIE

Page 1 of 2http://www.hietexas.org/how-to-connect/hie-networks/paso-del-norte-hie

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Contact InformationMichael Hill

221 North Kansas, Suite 1900

El Paso, Texas 79901

(915) 544-7636

[email protected]

www.pdnhie.org


B&O Plan

B&O Plan Addendum


Working Together for the

Improvement of Patient Care







Counties Served by HIEEl Paso


The Paso del Norte HIE (PdN HIE) is a nonprofit corporationformed to benefit and promote the health of the residents of ElPaso County, Texas and surrounding communities. Themission of the PdN HIE is to improve the quality, safety, andefficiency of health care services in the Paso del Norte region,through privacy protected exchange of health information.Members of the Paso del Norte HIE act together as acollaborative of physicians, hospitals, health departments,clinics, mental health authorities, other providers, andconsumers through the secure exchange of privacy-protectedhealth information and the sharing of best practices for theimprovement of care.

HIE ObjectivesThrough interviews and focus groups with stakeholders, PdN HIE identified the following goals:

Prevent unnecessary test duplication

Enhance patient safety

Improve quality of medical treatment (and the ability to measure and report it)

Enable greater care coordination

Enable disease (and bioterrorism) surveillance

GovernanceStructure




1 payer representative

1 lab representative

1 consumer representative

1 public health representative

Business Planning

TeamPhysician

Advisory Committee

(in

development)Privacy

and Security

Committee



PdN HIE anticipates having a

hybrid technology model, a data

repository with federated

capabilities complementary of

providers' internal data systems.

Direct Secure Messaging and Direct-

enabled Referral Product

Medicity

HIE Services Direct Services / Timeline Core Query-Based ExchangeServices


Paso%del%Norte%HIE

12/11/14, 1:09 PMHIETexas.org - Paso del Norte HIE

Page 2 of 2http://www.hietexas.org/how-to-connect/hie-networks/paso-del-norte-hie







Services

Currently available Anticipated availability January 2013

Privacy &Security


PdN HIE understands and is

dedicated to adherence to

applicable state and federal

regulations (HIPAA/HITECH, TX

HB 300, applicable Texas Health

and Safety Codes, etc.).

PdN HIE understands and is dedicated to

adherence to applicable security

guidelines and policies adopted by the

Texas Health Services Authority (THSA)

in accordance with state and federal law

and regulations.

Opt-out



Subscription Fees and Grant

Funding

Subscription fees. For more information,

contact Jon Law at (915) 544-7636

The PdN HIE is a

resource to improve

the quality, safety,

and efficiency of

patient care.




**An HIE at eHealth Initiative Stage 5 is fully operational and transmitting data that is being used by healthcare stakeholders.

***A hybrid technical model provides the interface engine for which organizational entities in the HIE communicat across the


12/11/14, 1:10 PMHIETexas.org - Rio Grande Valley HIE

Page 1 of 3http://www.hietexas.org/how-to-connect/hie-networks/rio-grande-valley-hie

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Contact InformationAndrew Lombardo

1413 Stuart Place Road, Suite C

Harlingen, Texas 78552

(956) 622-5801

[email protected]

www.rgvhie.org


B&O Plan

B&O Plan Addendum





# of Physicians Targeted toConnect100


Counties Served by HIEBrooks, Cameron, Hidalgo, Jim

Hogg, Kenedy, Webb, Willacy, Starr

and Zapata


The Rio Grande Valley Health Information Exchange (RGVHIE) intends to provide services to extreme South Texas andis comprised of a multi-disciplined, multi-stakeholder, multi-county representative board designed to provide guidanceand oversight to the exchange of critical information. Workingin close partnership with its stakeholders, the RGV HIEintends to provide health information exchange to the benefitof residents and providers by expanding access to qualityhealth care and improving health outcomes for all people inthe service region. From Brownsville to Laredo, patients willhave the ability to provide medical information to those whoneed it most, just when they need it.

HIE ObjectivesThe goal of HIE is to facilitate access to, and retrieval of, clinical information to provide safer, more timely, efficient, and effective

patient-centered care. By having access to all patient data, health care providers can reduce time and expense associated with

duplicate tests and effort spent locating missing patient information such as referrals, consults, radiology and lab results and other

orders.

It provides the capability to electronically access clinical information across disparate health care information systems while

maintaining the meaning of the information being exchanged. HIE is part of an evolving strategy on the national, state, regional, and

local levels. These strategies may include telemedicine, social networking, patient-centered medical homes, and accountable-care

organizations.

When clinical records are available at the point of care, patients receive more accurate and timely service. Benefits include:

Improved patient safety.

Reduce chance of medical error.

Better workflow efficiency and lower administrative costs.

Enhanced communication between hospitals, laboratories, pharmacies and physicians.

Easier access and retrieval of clinical data.

Records come to you directly from the original source where they are stored.

Providers can make the right decision at the right time.

Improved audit trails and chain of custody.

Local control.

Reduced duplicate testing

GovernanceStructure


Texas Nonprofit/501(c)(3) 7 of hospital

representatives

2 of physician

Governance

Business & Finance

Clinical Data Sharing & Privacy

Rio$Grande$Valley$HIE



representatives

0 of payer

representatives


1 of pharmacy

representatives

1 of consumer

representatives

Infrastructure & Security

Public Outreach



Centralized EMPI/RLS/Consent

Management, Direct

Secure Messaging,

Care Alerts, Order

Results Delivery, E-

Prescribing)

RelayHealth

HIE Services Direct Services / Timeline Core Query-BasedExchangeServices


Clinical Summary Exchange/Lab

Results Delivery/Clinical

Messaging/E-Prescibing

Anticipated "Go Live" date is August

1, 2013

Personal Health

Records

Anticipated "Go Live"

date is October 2013

Data Analytics and Disease

Dashboards

Anticipated "Go Live" date January

2014

Privacy &Security


The privacy and security of patient

health information is of the highest

possible concern for the RGV HIE.

The RGV HIE will support the privacy

of protected health information

according to HIPAA, HITECH,

relevant state laws and applicable

policies

RGV HIE will establish

the appropriate

authentication,

credentials, and

consent management

mechanisms to ensure

the protection of

consumer privacy &

security.

Consent model is an opt-out

approach. An opt-out policy for

consumer consent simply stated

means the health information is in

the HIE unless the consumer takes

a signature required action to have

their information excluded from the

HIE.



Public HIE: semi-independent with

direct and temporary government

backing.

Membership Business

Model

For more information

please visit website

www.RGVHIE.org or

contact us at (956)

622-5801

The goal of HIE is to facilitate

access to, and retrieval of, clinical

information to provide safer, more

timely, efficient, and effective

patient-centered care.












**An HIE at eHealth Initiative Stage 4 is well under way with implementation - technical, financial, and legal. (Pilot project or

implementation with multiyear budget identified and tagged for a specific need)



12/11/14, 1:10 PMHIETexas.org - Rio One Network

Page 1 of 3http://www.hietexas.org/how-to-connect/hie-networks/rio-one-network

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Contact InformationIsrael Rocha, Hospital External

Affairs Officer

[email protected]

Ron Tupper, Project Director

[email protected]

Rene Hinojosa, Project Coordinator

[email protected]

http://rioonehie.com/

5501 South McColl

Edinburg, Texas 78539

(956) 362-3087


B&O Plan

B&O Plan Addendum




Technical Model***Federated




Rio One Network is a Texas non-profit corporation specificallyestablished to participate in the planning and subsequentdevelopment of a health information exchange organization inHidalgo and Starr Counties in compliance with state andfederal standards. Though we have the majority ofcomponents in place, part of our state funding request isspecifically for planning purposes. Subsequently, with ourpartners we will propose a multi-year effort to fully implementa compliant Business and Operation plan in order toeffectively serve this two county area.

The goal of this organization is to create an active exchange of healthcare

information between all participating entities and physicians for the benefit of

patients in this region that meets all security and privacy requirements for

patient information. Further, this network plan is intended to promote

cooperative cost reduction measures for these local providers, pharmacies and laboratories.

Rio One Health Network understands the challenge of sustainability and maintaining a positive dialogue with the medical

community on the benefits of a fully developed and compliant HIE in this region and intends to consistently promote that goal

through professional meetings and community education. This will insure that providers, patients and support services are all

engaged in a patient centric health exchange network designed to reduce costs, protect patient privacy, and promote the essential

need to conserve limited healthcare resources through a systematic exchange of reliable health information.

HIE Objectives

The primary objectives of this HIE are: to improve the quality of care and decision making for all network patients served; to directly

engage the patient in the healthcare treatment process to improve clinical outcomes; to avoid preventable medical errors and

reduce duplicated services; to reduce when possible costly re-admission rates through improved data sharing; to reduce overall

healthcare costs and conserve limited resources; and to improve patient information security and accountability through current

technology.

GovernanceStructure



3 of physician

representatives

1 of payer representatives


1 of pharmacy

representatives

1 of consumer

representatives

Governance

Information Services &

Security

Allied Health

External Affairs

Executive



Federated *Electronic prescribing Cerner

Rio$One$NetworkOverview

Core Principles

Texas HIE Plan

Statewide Network (HIETexas)

HIE Accreditation



Counties Served by HIEHidalgo and Starr

Services Federated *Electronic prescribing

*Electronic lab ordering &

results

*Clinical summary

exchange

Cerner



Clinical Summaries,

Anticipated Go Live date is March 2012

Clinical Summaries, & Add

Lab and Pharmacy Result.

Anticipated Go Live date is

March 2012

Currently under review

by Board for additional

services with Anticipated

Go Live date in April

2012

Privacy &Security


RioONE is committed to maintaining the

privacy and security of all Protected Health

Information it maintains in compliance with

all applicable state and federal regulations

as amended from time to time including, but

not limited, to HIPPA and HITECH

Cerner specifies a simple,

secure, scalable, standards-

based way for participants

to send encrypted

information directly to

known, qualified recipients

over the internet.

Opt-in



Funding for this project is through state

funds, local match through hospital support

and hospital and physicians fees beginning

in year two of the project.

A monthly fee charged to

providers in year two (2) will

be based on practice size

and hospital bed capacity.

Providers participating in

this exchange will be

able to improve the care

of their patients while

reducing costs and

unnecessary duplication

of services.




**An HIE at eHealth Initiative Stage 4 is well under way with implementation - technical, financial, and legal.

***The decentralized or federated model provides organizational control of the healthcare record and provides the framework for

data-sharing capability to enterprises, perhaps widely distributed across regions or even nationally. The local entity owns their data

and the Record Locator Services manages the pointers to the information.

12/11/14, 1:10 PMHIETexas.org - Southeast Texas Health Systems

Page 1 of 2http://www.hietexas.org/how-to-connect/hie-networks/southeast-tx-health-systems

Search... Go


Contact InformationShannon Calhoun

P.O. Box 947

Goliad, Texas 77963

(361) 645-1762

[email protected]

http://www.seths.info/


B&O Plan


SOPHIE Demo Presentation

SOPHIE Collateral







Counties Served by HIEArmstrong, Bailey, Brazoria, Briscoe,

Calhoun, Carson, Castro, Chambers,


Southeast Texas Health System (SETHS) is a non-profitcorporation equally owned by 9 hospitals whose purpose is tocollaborate to create economies of scale and scope in thedelivery of healthcare. "The Members share common goals ofoperating a cost-effective, quality healthcare delivery systemto provide a continuum of health care services and productsthat offer greater efficiency, economy, quality, and availabilityof such services than the individual providers can offeralone." SETHS aligns its collective works and the individualfacilities who own SETHS with current state and federalprograms, such as pay for performance, meaningful use, ITadoption and health information exchange specifically for rural and urban markets. SETHS' commitmentto successful HIE is based on the organization's goal to ultimately improve the health status ofindividuals and populations in the regions its members serve.

HIE Objectives

SETHS' ultimate objective is to develop and implement a sustainable technology solution for appropriate health information

exchange. During the planning phase SETHS objectives are to 1) complete an environmental scan to identify the baseline of work,

2) build consensus among the participating providers to identify supportable and sustainable technology solutions, 3) determine and

clarify the business model to support the technology solutions.

GovernanceStructure





2 lab representatives

2 pharmacy representatives

2 consumer representatives

HIE Advisory Board

Technical Advisory Group

Board of Directors



Hybrid Open Source HIE services,

Direct Messaging

Pronoia Health

HIE Services Direct Services /Timeline

Core Query-BasedExchange Services


SOPHIE Direct is currently

available.

Clinical Summary Exchange

and Lab Results Delivery are

currently available.

Other HIE Services. Enter

anticipated "Go Live" date for

each service.

Privacy & Privacy Security Consent

Southeast)Texas)Health)Systems

12/11/14, 1:10 PMHIETexas.org - Southeast Texas Health Systems

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Childress, Cochran, Collingsworth,

Colorado, Crosby, Dallam, Deaf

Smith, Dewitt, Dickens, Donley,

Floyd, Garza, Goliad, Gray, Hale,

Hall, Hansford, Hartley, Hemphill,

Hockley, Hutchinson, Jackson, King,

Lamb, Lavaca, Lipscomb, Lubbock,

Lynn, Matagorda, Moore, Motley,

Ochiltree, Oldham, Parmer, Potter,

Randall, Robert, Sherman, Swisher,

Terry, Victoria, Wharton, Wheeler,

and Yoakum







Privacy &Security


SETHS will facilitate the


information consistent with the

guidelines and policy adopted

by the THSA in accordance

with state and federal law and

regulations.

SETHS will facilitate the


information consistent with the

guidelines and policy adopted

by the THSA in accordance

with state and federal law and

regulations.

SOPHIE is utilizing a hybrid

consent model. Patient data is

loaded into SOPHIE, but will not

be made available until patient

provides consent.



Grant funding

Monthly subscription fees

The SETHS HIE is available for

an affordable monthly

subscription fee. For a detailed

quote , please contact Shannon

Calhoun at:

[email protected]

The SETHS HIE is designed for

the rural and suburban markets,

offered at a price that is

affordable for rural hospitals and

providers, yet commensurate with

the level of services that they

receive.




**An HIE at eHealth Initiative Stage 4 is well underway with implementation-technical, financial, and legal. (Pilot project or

implementation with multiyear budget identified and tagged for a specific need)


network. The hybrid model stores key record identifiers and requests the information that is distributed across the network.

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!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!1!Charles!D,!Gabriel!M,!Furukawa!MF.!“Adoption!of!Electronic!Health!Record!Systems!among!U.S.!NonW

federal!Acute!Care!Hospitals:!2008W2013,”!ONC!Data!Brief,!no.!16.!Washington,!DC:!Office!of!the!National!

Coordinator!for!Health!Information!Technology.!May!2014!2!Hsiao!CWJ,!Hing!E.!Use!and!characteristics!of!electronic!health!record!systems!among!officeWbased!

physician!practices:!United!States,!2001–2013.!NCHS!data!brief,!no!143.!Hyattsville,!MD:!National!Center!

for!Health!Statistics.!2014.!3!Druss,!B.G.!and!Walker,!E.R.!Mental!disorders!and!medical!comorbidity.!Robert!Wood!Johnson!

Foundation!Research!Synthesis!Project.!2011.!4!Ibid.!

5!Blumenthal,!David,!M.D.,!M.P.P.,!N!Engl!J!Med!2010;!362:382W385,!February!4,!2010!

6!http://www.hietexas.org/aboutWthsa/overview,!accessed!10/3/2014.!

7!2014!Texas!State!HIE!Strategic!Plan,!Texas!Health!Services!Authority,!2014!

8!Graphic!from!THSA!2014!Texas!State!HIE!Strategic!Plan,!THSA,!June!2014.!

9!Charles!D,!Gabriel!M,!Furukawa!MF.!“Adoption!of!Electronic!Health!Record!Systems!among!U.S.!NonW

federal!Acute!Care!Hospitals:!2008W2013,”!ONC!Data!Brief,!no.!16.!Washington,!DC:!Office!of!the!National!

Coordinator!for!Health!Information!Technology.!May!2014!10!Hsiao!CWJ,!Hing!E.!Use!and!characteristics!of!electronic!health!record!systems!among!officeWbased!

physician!practices:!United!States,!2001–2013.!NCHS!data!brief,!no!143.!Hyattsville,!MD:!National!Center!

for!Health!Statistics.!2014.!11!2014!Texas!State!HIE!Strategic!Plan,!Texas!Health!Services!Authority,!2014!

12!http://www.hietexas.org/aboutWthsa/overview,!accessed!10/3/2014.!

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