Devil in the Details

One rule of thumb about HIE policy seems to be that the earlier the state got started, the longer it took to work through policy issues (although now those pioneering states are in a much better position than others late to the game). When the Delaware Health Information Network (DHIN) was established in 1997, there was no playbook or other successful model to follow, says Jan Lee, M.D., DHIN’s current executive director. “They had to work through all the issues about architecture and policy from scratch,” she said. And despite the success DHIN has had in connecting all the hospitals and 93 percent of providers in the state, new policy issues will arise, Lee says. One on the horizon involves the secondary use of data. "We were set up in legislation explicitly to be used for clinical purposes at the point of care,” she explains. “But if there is a need to use the network for research purposes for population-level analytics, which is part of the ultimate vision, we will have to rework all the data-sharing agreements.”

Sometimes, the state-level organization takes a policy route unfamiliar to RHIOs in the state. That is the case in Virginia, where the Community Health Alliance, the nonprofit partner of MedVirginia, is managing the ConnectVirginia. Its independent governance body has chosen an opt-in consent policy for the commonwealth, says Matthews, so that it’s driving policy around creation of a statewide consent registry. The board is also examining how sensitive data is treated, exceptions for emergency situations, and policies around Direct protocol messaging. “Direct is the first technology to be deployed,” he says, “so they had to create a policy framework for it.”

Speaking at the State Healthcare IT Connect Summit in June, Arizona’s State HIT Coordinator Lorie Mayer said her state has struggled with many things in the area of HIE. Originally, exchanges were developed in both the Phoenix metropolitan area and in Tucson. Payers, however, only wanted to help pay for infrastructure for one exchange, and other stakeholders agreed that multiple governance bodies and regional health organizations (RHIOs) would not be effective. So the two exchanges were combined in 2010 to form the Health Information Network of Arizona, which now serves 70 percent of Arizona’s patients. Nevertheless, governance issues arise. Arizona still has five different organizations that support meaningful use, including the Arizona Governor’s Office of Economic Recovery (the state HIE grantee organization), the State Medicaid office (which administers the electronic health record incentive program), the Arizona Department of Public Health, the Arizona Health e-Connection (the state regional extension center), and the Health Information Network of Arizona (the state HIE organization). “It’s a five-ring challenge to make sure that we are all aligned and supporting the ultimate goal of meaningful use of EHR adoption,” Mayer said.

CERTIFYING HIEs IN MINNESOTA
The state of Minnesota chose to certify and regulate health information service providers (HISPs) that develop in the private sector, rather than creating a central organization to provide services, an approach that other states may end up following. An entity providing HIE services for clinical meaningful use transactions must apply for a certificate of authority to conduct business in Minnesota as either a health information organization (HIO) or a health data intermediary (HDI).

Marty LaVenture, director of the state’s Office of Health Information Technology, says that setting up the HISP certification process required enabling legislation and developing agency rules. “It was not a trivial task,” he says. “We had to create definitions of players and health information exchange so there is a level playing field.  We had to create a process for applications and fees. We have only one full-time-equivalent employee overseeing that process along with a voluntary review team, so it is fairly lightweight oversight.”

LaVenture and other HIE leaders are also watching closely the work being done on the federal level to try to standardize interoperability.  On May 15 the Office of the National Coordinator published a Request for Information (RFI) on governance of the nationwide health information network (NwHIN). ONC is considering an accreditation and validation system to make trusted exchange of health data easier. Based on the RFI, LaVenture believes the federal framework aligns nicely with what Minnesota already has set up. Yet organizations such as the eHealth Initiative and the College of Healthcare Information Management Executives (CHIME) have submitted responses questioning the need for such a regulatory framework at the federal level at this time.

THE GLASS IS HALF FULL
Tennessee recently announced it was winding down a statewide HIE effort and would instead focus on a state government program to promote Direct secure messaging. At least a few of the issues Tennessee faced were on the policy level, says Lynn Dierker, a principal consultant in Health Management Associations’ Denver office. “Part of what they encountered was a challenge on data-sharing agreements and the value proposition for ‘statewide-ness’ not being there,” she says.

Lynn Dierker