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Getting Direct with State Health Information Exchange

Posted Apr 15 2011 7:20pm
I have been working on a contract to help the Office of the National Coordinator (ONC) State HIE Program host a Direct Boot Camp in Chicago, IL on April 12 – 14, 2011. So I spent a few days this week working at the Boot Camp helping the ONC bring states up to speed on the Direct Project. But the Boot Camp went well beyond Direct basics to focus on implementation details to help States who are planning on implementing Direct learn from experiences in the field and take their next implementation steps. The Boot Camp was geared explicitly toward states that are implementing Direct as part of their strategic and operational plans under their cooperative agreement with the ONC. I was pleased to be part of the excellent team of ONC staff and consultants that organized and facilitated the event. The meeting agenda and materials are now posted on the Direct Project wiki and there was some good discussion using the #ONCDirect hashtag on Twitter. There was also some rich discussion during the Q&A portions of each session and I encourage you to read through the session notes available on the wiki.

Much of the impetus for incorporating the Direct Project into their state plans was the result of the Program Information Notice (Document Number: ONC-HIE-PIN-001), known as the PIN, sent to the states on July 6, 2010. One section of the PIN requires the states to
Set Strategy to Meet Gaps in HIE Capabilities for Meaningful Use — Develop and implement a strategy and work plan to address the gaps in HIE capabilities as identified in the environmental scan with a focus on delivery of structured lab results, e-prescribing and sharing patient care summaries across unaffiliated organizations. Gap-filling strategies might include
  • Policy, purchasing and regulatory actions, such as requiring e-prescribing or electronic sharing of lab results in state or Medicaid contracts with pharmacies and clinical labs.
  • Core services to reduce the cost and complexity of exchange including authoritative provider and plan directories and authentication services that would support both simplified and comprehensive interoperability.
  • Targeted infrastructure for gap areas such as shared services for small labs or pharmacies, or to serve rural providers, which could utilize both simplified and comprehensive interoperability solutions.
In filling these gaps, the state is not required to directly provide or construct technology infrastructure or services. A key role for states can be to provide leadership and direction to public and private stakeholders. States may also use policy and purchasing levers to extend and enhance existing HIE activities in the state so as to encourage key trading partners such as pharmacies and clinical laboratories to participate in electronic service delivery and to enable providers to meet meaningful use requirements.

States shall also establish a strategy and immediate next steps to address the following over the course of the project
  • Building capacity of public health systems to accept electronic reporting of immunizations, notifiable diseases and syndromic surveillance reporting from providers.
To meet these requirements many states have plans to use direct messaging in a phased approach as an onramp towards more robust HIE services. But due to the flexible nature of a cooperative agreement, as opposed to being a straight grant, the states have been working with the ONC to fine tune their plans. Many of these states had their plans approved before the Direct Project was able to provide working code. As the Direct Project has developed, some of the states thinking around deploying direct messaging services has evolved. And there is also continuing maturity in the marketplace, with vendors offering services that have allowed the states to back away from providing centralized services themselves and moving towards a more market based approach.

Therefore, many states that were originally planning to to act as a Health Information Service Provider (HISP) themselves are now moving towards creating a preferred vendor list for HISPSs and monitoring the market to ensure coverage for all the providers in their state. A HISP is an entity that provides services that are required for Direct Project exchange, such as the management of trust between senders and receivers. Using the HISP model, offerings are emerging that provide some of these services
  1. Provisioning of health domain addresses
  2. Certification issuance and management
  3. Global routing services 
The Best Practices for HISPs posted on the wiki is an excellent document for those interested in knowing more about organization structures that will allow these services to be provided.

There are also states planning to use Direct to help with interstate exchange. This is an area that will need further development, as we weave through the spaghetti of various consent laws around the country, but ultimately getting exchange happening at a broad scale will obviously include interstate exchange. Some of the nation networks being launched, such as AAFP/Surescripts and Verizon presented during the boot camp and helped the states to shape some of their thinking in this area. There was a lot of discussion about Provider Directories as well, which I will leave to a future post. It was a very interesting experience to work with the ONC and the various states to further integrate the Direct Project into their plans and I expect we will see this help to drive further adoption and use of these standards and specifications.

The list below shows the currently approved state specific strategic and operational plans for creating health information exchange capacity. Not all of these states are incorporating Direct Project into their plans.
StateStrategic /Operational Plans and State SummariesEntity Responsible for GrantPlan Approval Date
Alabama Strategic and Operational Plans External Web Site Policy

State HIE Plan Summary
Alabama Medicaid Agency 02/12/2011
Arizona Strategic and Operational Plans External Web Site Policy Arizona Governor’s Office of Economic Recovery 03/18/2011
Arkansas Strategic and Operational Plans External Web Site Policy Arkansas Department of Finance and Administration 02/24/2011
California Strategic and Operational Plans External Web Site Policy

To view the documents separately click here (easier download)
California Health and Human Services Agency 06/16/2010
Colorado Strategic and Operational Plans External Web Site Policy Colorado Regional Health Information Organization 12/3/2010
Connecticut Strategic and Operational Plans External Web Site Policy State of Connecticut Department of Public Health 03/18/2011
Delaware State Summary Delaware Health Information Network 05/17/2010
Florida Strategic and Operational Plans External Web Site Policy Florida Agency of Health Care Administration 02/04/2011
Georgia Strategic and Operational Plans External Web Site Policy Georgia Department of Community Health 03/23/2011
Hawai’i State Summary Hawaii Health Information Exchange 02/02/2011
Idaho Strategic and Operational Plans External Web Site Policy Idaho Health Data Exchange 12/07/2010
Illinois Strategic and Operational Plans External Web Site Policy Illinois Department of Healthcare and Family Services 12/10/2010
Indiana Strategic and Operational Plans External Web Site Policy

State Summary
Indiana Health Information Technology, Inc 01/21/2011
Iowa Strategic and Operational Plans External Web Site Policy Iowa Department of Public Health 01/25/2011
Kentucky State Summary Cabinet for Health and Family Services 02/17/2011
Maine State Summary State of Maine/Governor’s Office of Health Policy & Finance 08/16/2010
Maryland Strategic and Operational Plans External Web Site Policy The Maryland Department of Health and Mental Hygiene 05/14/2010
Massachusetts Strategic and Operational Plans External Web Site Policy Massachusetts Technology Park Corporation 11/03/2010
Michigan Strategic and Operational Plans External Web Site Policy

State Summary
Michigan Department of Health 11/29/2010
Minnesota Strategic and Operational Plans External Web Site Policy Minnesota Department of Health 02/24/2011
Mississippi Strategic and Operational Plans External Web Site Policy State of Mississippi 02/24/2011
Missouri Strategic and Operational Plans External Web Site Policy Missouri Department of Social Services 01/25/2011
Nebraska Strategic and Operational Plans External Web Site Policy

State Summary
Nebraska Department of Administrative Services 11/05/2010
New Hampshire Strategic and Operational Plans External Web Site Policy

State Summary
New Hampshire Department of Health and Human Services 12/10/2010
New Jersey State Summary New Jersey Health Care Facilities Financing Authority 01/13/2011
New Mexico Strategic and Operational Plans External Web Site Policy

State Summary
LCF Research, New Mexico 01/25/2010
New York Strategic and Operational Plans External Web Site Policy New York eHealth Collaborative 11/22/2010
North Carolina Strategic and Operational Plans External Web Site Policy

State Summary
North Carolina Department of State Treasurer 11/03/2010
Ohio Strategic and Operational Plans External Web Site Policy

State Summary
Ohio Health Information Partnership 01/25/2011
Oregon Strategic and Operational Plans External Web Site Policy State of Oregon 12/10/2010
Pennsylvania Strategic and Operational Plans External Web Site Policy Commonwealth of Pennsylvania 3/23/2011
Rhode Island Strategic and Operational Plans External Web Site Policy Rhode Island Quality Institute 12/06/2010
South Carolina Strategic and Operational Plans External Web Site Policy South Carolina Department of Health & Human Services 08/30/2010
South Dakota Strategic and Opeational Plans External Web Site Policy South Dakota Department of Health 02/24/2011
Tennessee Strategic and Operational Plans External Web Site Policy

State Summary
State of Tennessee 09/17/2010
Texas Strategic and Operational Plans External Web Site Policy

State Summary
Texas Health and Human Services Commission 11/03/2010
Utah Strategic and Operational Plans External Web Site Policy Utah Department of Health 05/12/2010
Vermont Strategic and Operational Plans External Web Site Policy

State Summary
Vermont Department of Human Services 10/26/2010
Virginia Strategic and Opeational Plans External Web Site Policy Virginia Department of Health 03/17/2011
Washington Strategic and Operational Plans External Web Site Policy

State Summary
Washington Health Care Authority 12/10/2010
West Virgina Coming Soon West Virgina Department of Health and Human Services 02/12/2011
Wisconsin Strategic and Operational Plans External Web Site Policy

State Summary
Wisconsin Department of Health and Family Services 12/10/2010
Wyoming Coming Soon State of Wyoming Office of the Governor 03/18/2011
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