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2010 HIMSS Advocacy Day - Jonah Frohlich
- 1. eHealth and Health Reform April 29, 2010 HIMSS Advocacy Day 1
- 2. 1- Bay Area Population: 7.3 million 6th largest metropolitan area 2- Los Angeles County Population: 10.4 million 8th most populous State 1 3 Southern California Population (LA, San Diego, Orange, Riverside and San Bernardino): Rural 20.7 million 75% of 2nd most populous landmass is State (bigger than rest of rural 2 California, only Texas is - Larger than bigger) land mass of 45 3 States 2
- 3. Successes and Failures Kaiser Permanentes $4+ Billion EHR initiative Santa Barbara Countys $10 million Care Data Exchange Teachable moments The power of market forces HIE Planning effort mantra: provide value 3
- 4. Market Forces in the Federal HIE Program Medicare and Medicaid meaningful use incentives are anticipated to create demand for products and services that enable HIE among eligible providers The resulting demand for health information exchange will likely be met by an increased supply of marketed products and services to enable HIE, resulting in a competitive marketplace for HIE services. -Federal HIE Cooperative Agreement FOA 4 4
- 5. Get it Done Yesterday The four-year project period is intended to allow recipients time to complete the goals of the program. However, applicants are strongly encouraged to plan projects and budgets that accomplish most of the project goals and milestones within the first two years of the project period to best enable HIE capacity. -Federal HIE Cooperative Agreement FOA 5 5
- 6. Medicare Incentives Medicare may provide up to $44,000 per provider for meaningful use. Calendar Year First CY in which the EP Receives Incentive Payments 2011 2012 2013 2014 2015 + 2011 $18,000 ------ ------ ------ ------ 2012 $12,000 $18,000 ------ ------ ------ 2013 $8,000 $12,000 $15,000 ------ ------ 2014 $4,000 $8,000 $12,000 $12,000 ------ 2015 $2,000 $4,000 $8,000 $8,000 $0 2016 ------ $2,000 $4,000 $4,000 $0 TOTAL $44,000 $44,000 $39,000 $24,000 $0 6
- 7. Regional Center (REC) Cooperative Agreement Program Health IT RECs Funding-Partnership Summary Year Federal Amount of Costs Recipient Amount of Costs 1 90 percent 10 percent 2 90 percent 10 percent 3 10 percent 90 percent 4 10 percent 90 percent 7
- 8. Stage 1 HIE Priorities Pushing messages from point to point Critical Functions: Lab Hospital, Provider (and patient) document (CCD) delivery Public health reporting (immunization registries and surveillance) Required core services: Provider identity registry Directory service (aka: phone book/routing service) 8
- 9. Cal eConnect Formed when the California eHealth Collaborative (CAeHC) and CalRHIO submitted a joint proposal in response to the RFI Role: Manage a collaborative process to develop and enforce policy guidance (privacy and security policies) through grants and contracts Support grant making and procurement processes Revise strategic and operational plans as needed Develop sustainability model and business plan Carry out additional requirements described in state grant 9
- 10. Board of Directors Constituency 1. California Assembly Committee on 10. Employer Health Chair 11. Health Informatics 2. California Senate Committee on Health 12. Health information exchange Chair organization 3. California Secretary of the Health & 13. Health information exchange Human Services Agency organization 4. California State Administrator 14. Health Plan private (determined by State, may include the 15. Health Plan - public Department of Health Care Services, Department of Managed Health Care or 16. Hospital - private other departments) 17. Hospital - public 5. CEO of the HIE-GE 18. Labor 6. Co-chair (at-large 1) 19. Physician Independent 7. Co-chair (at-large - 2) 20. Physician Medical Group 8. Consumer (1) 21. Public health (local public health 9. Consumer (2) officer) 22. Safety net clinic 10
- 11. Governance Entity Initial Board of Directors 1. David Lansky (Co-chair) 2. Don Crane (Co-chair) 3. Marge Ginsburg (Consumer) 4. Bill Beighe (Health Information Exchange Organization) 5. Howard Kahn (Public Health Plan) 6. David Joyner (Private Health Plan) 7. Tom Priselac (Private Hospital) 8. Brennan Cassidy, MD (Independent physician) 9. Ron Jimenez, MD (Public Hospital) 10. Ralph Silber (Community Clinic) 11
- 12. Proposed Technical Architecture Other HIE Services Identity management for Addressing and formatting Identity management and HIOs legal entities information for intended authentication for principals recipients of HIE transactions in HIE transactions PHRs Core SureScripts Cooperative Entity Registry Provider Directory Provider Identity EHR-Specific Shared Service Service Service Networks HIE Services Secure Messaging CS-HIE Service Others IDN Patients and Families Enterprise-A IPA Enterprise-B IDN Solo Practice Physician Principal-1 Principal-3 Principal-5 Hospital Laboratory Principal-2 Principal-4 Physician Principal-6 Physician Hospital Group Practice 12
- 13. Entity Registry Service A trusted Certificate Authority for legal entities that wish to exchange health information using the CS-HIE resources Legal Entity = Physician practice, hospital, pharmacy, lab, immunization registry, etc. Not individual physicians, administrative staff, or consumers Certificate Authority provisions entities in a widely trusted manner Certifies legitimacy of the entity and its conformance to security/privacy policies Revokes certification for entities when appropriate Entity Registry = repository of valid, active certificates for provisioned legal entities 13
- 14. Legal Entity Responsibilities Maintain internal registry of its providers Reliably authenticate these providers when they log in within the entitys domain Providers may be authenticated locally by their entities Provide an electronic directory of the providers within the legal entity The directory must be accessible in a standard format as a web service, available to all other entities with access to the Entity Registry Service 14
- 15. Provider Directory Service Centrally hosted repository of Provider Directory entries Intended for entities that cannot or choose not to host their own Provider Directory Any legal entity can choose to use it The source entity (not the service) is responsible for accuracy and timeliness of the entries Smaller organizations may especially benefit from this service 15
- 16. Provider Identity Service Centralized, trusted service for provisioning and authenticating providers involved in HIE transactions Intended for entities that are not trusted to authenticate their own providers Use of Provider Identity Service is entirely optional Entities may provision and authentication their own providers May or may not prove to be needed 16
- 17. 17 Proposed Technical Architecture Other HIE Services HIOs Identity management for Addressing and formatting Identity management and legal entities information for intended authentication for principals PHRs recipients of HIE transactions in HIE transactions SureScripts Core Cooperative Entity Registry Provider Directory Provider Identity EHR-Specific Shared Networks Service Service Service HIE Secure Services Messaging Others IDN Enterprise-A IPA Enterprise-B IDN Legend Transactions involving Solo Practice CS-HIE Services and using the protocols and standards Physician Principal-1 Principal-3 Principal-5 Hospital required by these services Laboratory Principal-2 Principal-4 Physician Principal-6 Physician Transactions not involving Hospital Group Practice CS-HIE Services and not necessarily using the protocols and standards required by these services
- 18. 18 Example: Hospital Discharge Summary Legal Entity Principal Transaction Address Protocol Montrose Internist Group Dr. Jonah Hill Receive Hospital Discharge Summary www.valleyIPA.org/InBox/DcSummary CCD Level 2 Core Cooperative Entity Registry Pointer Provider Directory Provider Identity Shared Service Service Service HIE Services Look up Look up Montrose Internist Dr. Jonah Hill Group John Smith is a patient, Valley IPA Legend His PCP is Dr. Jonah Hill Formulate and Send at Montrose Internist Transactions involving Transaction CS-HIE Services and using Group the protocols and standards required by these services Dr. Beth Cramer Dr. Jonah Hill Transactions not involving CS-HIE Services and not Seaview Hospital Montrose Internist Group necessarily using the protocols and standards required by these services
- 19. 19 Example: Hospital Discharge Summary Transaction: Header Certificate for Authentication Assertion Authorization Assertion Seaview Hospital for Dr. Beth Cramer for Dr. Beth Cramer (with public key) (Signed by Seaview Hospital) vis--vis John Smith (Signed by Seaview Hospital) Payload Discharge Summary as CCD (with patient identifiers for John Smith) Core Cooperative Entity Registry Provider Directory Provider Identity Shared Service Service Service HIE Services Validate Inspect Transaction Seaview Hosps Certificate Header Valley IPA Legend Formulate and Send Transactions involving Transaction Deliver to CS-HIE Services and using Recipients the protocols and standards EHR required by these services Dr. Beth Cramer Dr. Jonah Hill Transactions not involving CS-HIE Services and not Seaview Hospital Montrose Internist Group necessarily using the protocols and standards required by these services
- 20. 20 Proposed Technical Architecture Non-Core Lab Result Router/Translator Other Cooperative Eligibility Determination Hub HIE Shared TBD, as needed Services NHIN Gateway HIE Others HIOs Services PHRs SureScripts Core Cooperative Entity Registry Provider Directory Provider Identity EHR-Specific Shared Networks Service Service Service HIE Secure Services Messaging Others IDN Enterprise-A IPA Enterprise-B IDN Legend Transactions involving Solo Practice CS-HIE Services and using the protocols and standards Physician Principal-1 Principal-3 Principal-5 Hospital required by these services Laboratory Principal-2 Principal-4 Physician Principal-6 Physician Transactions not involving Hospital Group Practice CS-HIE Services and not necessarily using the protocols and standards required by these services
- 21. Summary The Core CS-HIE Services are intended to provide A trust infrastructure in which parties can determine the authenticity of HIE transactions that they receive from arbitrary counterparties A directory infrastructure in which parties can determine where and how to direct HIE transactions intended for specific recipients via the internet Much technical and policy work remains to flesh out the design of these services Define the policies surrounding the HIE certificate authority and the granting of Entity Registry entries Define the technical design of Entity Registry entries and Provider Directory entries Define the technical design of authentication and authorization assertions Functions not addressed in current architecture: Master Patient Index Record Locator Service Patient Consent Registry Why not? Vexing technical, business and privacy issues Not needed for majority of Stage 1 meaningful use functions 21
- 22. 22 22
- 23. Whats in it (potentially for Health IT) Grants for long-term care facilities for EHRs: Nationally, only $67.5 million over four years Insurance Exchange Enrollment modernization and administrative simplification Accountable Care Organizations Primary Care Extension Programs 23
- 24. Why we need to understand Medical Loss Ratios What is it? The proportion of premium dollars that must be spent on medical care Why its important in HCR: Requires plans in the individual and small group market to spend 80 percent of premium dollars on medical services, and plans in the large group market to spend 85 percent. Insurers that do not meet these thresholds must provide rebates to policyholders. Effective on January 1, 2011. Implications: If health IT is considered an administrative expense, the incentives for plans is to reduce this expense Secretary Sebelius has the authority to make the determination if HIT is an administrative or clinical expense 24
- 25. And why 2011 will be a watershed year HITECH: First checks for incentive programs will issued Health Reform: 7.3 million CA residents who do not currently have insurance could begin to get affordable coverage HIPAA 5010 transactions required by January 1, 2011 Prerequisite for ICD-10; required by October 2013 for payment! 25
- 26. Health Information Exchange (HIE) Timeline Submitted Narrative Application & Landscape Assessment October 16, 2009 Letters of Support Strategic Plan Budget (over 4 years) Announced Intent to select Planning grant in April Governance Entity Cal eConnect on Full grant and ONC approval in March 8, 2010 June eHealth Summit March 11 Submitted: Public comment through Operational Plan March 22 April 6, 2010 Submit to ONC on April 6 Revised four year budget Begin: Initiate grant and HIE Implementation procurements July, 2010 Fully staffed and operational 26
- 27. Two issues to consider for Advocacy Day 1. Ensure that we meet our timelines here in the State Appropriate funding for HIE as quickly as possible, dont let it get caught up in budget delays 2. Health Reform: Ensure the Health IT is not incorporated into administrative overhead in the medical loss ratio calculation 27
- 28. Government 2.0 Twitter: http://Twitter.com/CAeHealth Website: www.ehealth.ca.gov Operational and strategic plan: http://www.ehealth.ca.gov/eHealthPlan/tabid/72/Default.aspx Sign up for listserv, bulletins, send comments and questions: ehealth@chhs.ca.gov Next Public Webinar Thursday May 13 1pm 2pm webinar sign-up: https://www1.gotomeeting.com/register/778130384 28