Sunday, January 10, 2010

Moving into HIE Implementation

The state of Maryland is in a good position to begin to implement their statewide HIE. The State’s health technology picture shows that there are 47 acute care hospitals with EHR adoption reported in around 80 percent of these hospitals. Nearly 60 percent have computerized physician order entry with 17 percent actively implementing technology to enable some electronic data sharing with appropriate users outside the hospital.

The state has roughly 1,795 physicians in active practices treating patients in 7,907 practices. Physician EHR adoption parallels the nation at 20 percent but many of these EHRs do not have clinical decision support, CPOE, or e-prescribing. The number of service area health information exchanges or community data exchanges where a hospital acts as the technology hub is increasing in numbers throughout the state.

In 2008, to move the process forward, the Maryland Health Care Commission (MHCC) funded two independent multi-stakeholder groups to develop two competing approaches for governance, architecture, privacy and security, access and authentication, financing, and to establish a sustainable business model. The information was consolidated and presented to the MHCC, and as a result, a Request for Application was released in April 2009.

The Maryland Health Services Cost Review Commission approved the funding August 2009, and the Chesapeake Regional Information System for our Patients (CRISP) was selected to receive $10 million in startup funding from Maryland’s all payer system to implement the statewide HIE.

After evaluating the funding models employed by other HIEs, CRISP decided to go with the state funding and rely on participant subscription fees to achieve financial sustainability. CRISP also has relied on philanthropic funding from the Erickson Foundation to support the medication history service and other HIE planning efforts. However, CRISP is not planning for philanthropic funding to continue and will seek additional funding from government and other philanthropic sources beyond the initial $10 million.

The HIE budget is comprised of infrastructure costs that include hardware and software costs to support the statewide HIE as a whole. Software licenses are calculated at $1,500,000 in the first year, $1,000,000 for licenses in the second year, and $600,000 for the third year with an anticipated increase of 3.5 percent in each successive year. The budget will be adjusted if open source software is provided by ONC’s Federal Health Architecture group.

The budget for equipment includes all of the hardware necessary to implement the HIE and the equipment budget is estimated at $1,017,704 over four years. Approximately, $500,000 has been budgeted in the first year for the contract to provide all hardware and supporting software for the exchange. The hardware and supporting software projected for the second year is $166,700 with increases anticipated.

If the statewide HIE must acquire computer hardware and incur installation and maintenance costs, a Maryland organization will be contracted for these services with the hardware to be leased through an agreement with the service provider.

The HIE will use a number of systems thinking design tools to conduct ongoing evaluations of the HIE. The key assessment tools will include causal loop diagrams, behavior over time graphs, systems archetypes, and flow diagrams. The systems thinking design tools will enable the HIE to to provide a realistic measurement of performance and to identify changes that may be needed.

The governance is comprised of the MHCC Policy Board, Board of Directors, and the Advisory Board. The Policy Board has 25 members with consumer backgrounds to provide oversight to the development of the HIE and to develop policies related to privacy and security.

The Board of Directors consists of nine individuals with overall management and governance responsibilities. The Advisory Board has 30 members who are divided into three committees that include the Exchange Technology Committee, the Clinical Excellence and Exchange Services Committee, and the Finance Committee.

The MHCC’s Center for Health Information Technology Center, Director David Sharp will serve as the Maryland Government HIT Coordinator. The Director is currently working with Medicaid to explore data sharing opportunities under the MITA transformation project and is actively involved with CMS as part of their EHR demonstration.