Massachusetts has made significant progress in its statewide HIE in recent months. As recently as August 2011, the statewide HIE effort was proceeding slowly. After two years of planning, relatively little progress had been made to turn strategies into production systems. Today, a mere 10 months later, the Commonwealth is poised to go live on October 15, 2012, with a statewide HIE service available to all providers and health plans in the Commonwealth. What accounted for such rapid acceleration? What lessons are suggested for others in similar circumstances?
There is a long history of HIE in MA. The New England Health Exchange Network (NEHEN), which was founded in 1998, now has more than 60 dues-paying members and manages hundreds of millions of administrative and clinical transactions per year. It remains one of the few credibly self-sustaining HIEs in the country, which to this day has never been supported by state or federal government funds. In 2008, the state of Massachusetts allocated $25 million for statewide EHR and HIE programs.
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And in 2010, the state was awarded $14 million from the federal HIE cooperative agreement and challenge grants. Add to all of that some of the most highly regarded healthcare institutions and CIOs in the world, and well-established collaborative organizations such as the Massachusetts Health Data Consortium and the Massachusetts eHealth Collaborative, and one would think that statewide HIE would be a slam-dunk.
Well, it wasn’t. Aligning state and federal programs with each other and with existing, long-established private efforts turned out to be a herculean task of leadership, governance and management, especially in the Massachusetts market where the government had historically played little to no role in HIE efforts.
The major shift in direction took place in September 2011, when the state’s HIE strategy was reevaluated in light of two new developments. First, with strong and assertive leadership from the Executive Office of Health and Human Services, an advisory committee was formed to embrace and engage the private sector and broaden the pool of expertise informing the statewide effort. Almost immediately upon its formation, that group expressed the need for a more focused and actionable HIE plan than what had been generated to date.
The second development was CMS’s announcement of opportunities to receive 90 percent federal subsidies through Medicaid for statewide HIE infrastructure programs. This program offered the prospect of solving the sustainability question, which has stopped many valiant HIE efforts in their tracks.
September through December was a flurry of collaborative decision-making. Among the first tasks that was undertaken was to align the ONC-funded and MassHealth (state Medicaid) HIE plans, and then evaluate and set priorities among the 26 discrete projects that emerged from that reconciliation. These projects were divided into two batches, those that were well enough defined to be executable (15), and those that were not (11). Of those that were deemed to be executable, screening criteria were used to create three phases of HIE implementation. Details of this process can be found here.
The second task was to evaluate the state Medicaid organization’s ability to meet the federal Medicaid program requirements for 90/10 subsidies. A number of factors needed to be considered, including:
• Market confidence. The state government already manages a variety of complex IT systems, and with high Medicaid penetration across the state, providers and patients are not uncomfortable with having Medicaid manage the HIE infrastructure according to best practices in privacy, security and service levels.
• Matching funds. 90 percent subsidies are great, but one still needs to come up with the 10 percent. In the case of Massachusetts, we were fortunate enough to have approximately $10 million still available from state funds allocated in 2008 to provide matching funds for a robust HIE program.
• Private sector funding. Medicaid, like any other public or private organization, does not like to be the sole investor in efforts that benefit many others. We needed to estimate what share of the total HIE costs should appropriately be borne by Medicaid based on benefits that it would receive, and of the remainder, determine whether the private sector would see enough value to pay for the rest.
Many of these considerations were more art than science and required considerable judgment along the way. After evaluating all of these questions and many others, documentation was developed and submitted to the federal government in November 2011, and approval for Phase 1 services was given by CMS on February 7, 2012.
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The state government issued a Request for Responses on February 17, 2012, and contracted with a vendor to implement the Phase 1 HIE services on June 21, 2012. The Phase 1 statewide HIE services will go live on October 15, 2012, soon to be followed by Phases 2 and 3.
• Phase 1 will create the “information highway” that will leverage the NwHIN Direct standard and other industry standards to make available the ability for any provider or health plan in the Commonwealth to securely send and receive clinical documents from any other provider or health plan. Users will be able to integrate their EHR system directly into the network, or use a webmail service if they do not have an EHR capable of direct integration.
• Phase 2 will launch a statewide master patient index as well as other services to facilitate users’ ability to conduct population health management or quality data aggregation.
• Phase 3 will create a query and-retrieve service founded on a centralized patient consent database to allow automated, permission-based search and retrieval of medical records.
The statewide HIE will not have a central repository of clinical information. The plan remains open to ongoing adjustment because many of us have learned from hard experience to be humble in the face of ever-evolving technologies and business requirements. The phased approach allows the state to proceed in discrete steps to achieve incremental, near-term, confidence-building value while at the same time staying flexible to the inevitable changes that will be experienced in technology, law, business and clinical processes over the coming years.
Micky Tripathi is president and CEO of the Massachusetts eHealth Collaborative.
