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Texas

Texas

Health Information Exchange in Texas: Current Status and Future Potential

July 31, 2006

Submitted to:

Department of Health and Human Services

HHSP23320054104EE Deliverable: 2.14 Submitted by:

Foundation for e-Health Initiative

818 Connecticut Avenue, NW Washington, DC 20006

This report was made possible by Contract HHSP23320054104EE (Deliverable: 2.14) from the U.S. Department of Health and Human Services to the Foundation for eHealth Initiative.

Disclaimer: The content of this publication does not necessarily reflect the views or policies of the Department of Health and Human Services, nor does mention of trade names, commercial products, or organizations imply endorsement by the U.S. Government.

Health Information Exchange in Texas: Current Status and Future Potential

July 31, 2006

Creation of the Texas Assessment would not have been possible without the collaboration and contributions of the following organizations: Booz Allen Hamilton; Indiana Health Information Exchange; HIPAA Solutions, L.C. (Peter MacKoul); Texas Department of State Health Services' Health Information Technology Advisory Committee; Texas Governor's Health Care Policy Council, and Vanderbilt Center for Better Health. Their knowledge, assistance, dedication, and teamwork were essential to the successful completion of this document.

Table of Contents

I. Purpose ............................................................................................................................................................... 9 II. Executive Summary .......................................................................................................................................... 11 III. Understanding the National Agenda ..............................................................................................................15 A. Background.....................................................................................................................................................15 B. The Role of the Administration ...................................................................................................................... 17 C. The Role of Congress ..................................................................................................................................... 22 D. The Role of the States.................................................................................................................................... 24 E. The Leadership in the Private Sector ­ Quality Initiatives ...........................................................................27 F. Consumer-centric Health Care .......................................................................................................................31 IV. Overview Of Texas .......................................................................................................................................... 35 A. Texas Background ......................................................................................................................................... 35 B. Activities to Promote the Adoption of HIT and HIE in Texas ................................................................. 38 C. Inventory of HIT and HIE Initiatives in Texas ............................................................................................. 40 D. "What We Heard" From Select Texas Health Care Stakeholders ............................................................... 46 E. Organizational Readiness Assessment.......................................................................................................... 50 V. Privacy Regulations ...........................................................................................................................................57 VI. Conclusion .......................................................................................................................................................61

VII. Appendices .................................................................................................................................................... 63 Appendix A: Recent Federal Legislation ......................................................................................................... 63 Appendix B: Existing Statewide HIE Initiatives ............................................................................................. 68 Appendix C: Senate Bill 45 ­ Establishment of the Health Information Technology Advisory Committee ...................................................................................................................................... 82 Appendix D: Health Information Technlogy Advisory Committee Membership List .................................... 84 Appendix E: Catalogue of Texas Health Information Technology and Health Information Exchange Initiatives ..................................................................................................... 86 Appendix F: Interview Contributors ...............................................................................................................104 Appendix G: Glossary ......................................................................................................................................106

Texas Assessment

Texas

I. Purpose

The Foundation for eHealth Initiative will provide support to the public and private sector leaders within the five Gulf States in their efforts to: assess the readiness and needs related to health information technology (HIT) and health information exchange (HIE); achieve multistakeholder agreement on the common requirements and principles related to the implementation of interoperable HIT within the Gulf Coast Region; and develop an incremental roadmap for achieving healthcare goals through health information technology and exchange within each state that is aligned to interoperability at a regional level. The states to be supported include: Louisiana, Texas, Florida, Alabama, and Mississippi. The Foundation's support to each state includes strategic, operational, and planning support that will result in a high-level set of recommendations relating to regional HIE, including the organizational, legal, financial, clinical, and technical aspects of creating a health information network that could be aligned with a broader Gulf Coast Health Information Organization (GC-HIO). Along these lines, the Foundation will conduct a high-level assessment of the current environment within the state, facilitate the development of state-wide goals and requirements, and develop an incremental roadmap for leveraging HIT and health information exchange networks to address healthcare quality, safety, and efficiency within the state. Each state's roadmap will also provide an enhanced understanding of the principles and requirements for an integrated GC-HIO that is aligned with national standards and policies. This document discusses the state of Texas' current environment for the adoption of health information technology and health information exchange.

Texas Assessment

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II. Executive Summary

The Administration, a number of members of Congress, many states, and several private sector efforts have introduced policies and initiatives designed to improve the quality, safety, and efficiency of healthcare through information technology and the mobilization of information across organizations. Congress is also playing a significant leadership role in promoting health information technology, interoperability, and health information exchange.1 During the current sessions of the 109th Congress, unprecedented collaboration and bipartisan support for these efforts has accelerated with the introduction of thirteen bills within both the House and the Senate that include components related to HIT. These proposed laws address many areas including creating a national interoperable health information infrastructure, reducing barriers to adoption through modification to Stark and anti-kickback laws, and authorizing a standards setting process and codifying the Federal role of HIT adoption. While federal leadership is important, it must be integrated with efforts at the state and local levels. State legislatures and local governments play a critical part in the overall leadership through roles as regulators, safety net providers, and payers. Many state governments are beginning to engage HIT as a means to support health policy goals. Whereas most HIT legislation previously focused on removing barriers to the electronic transmission of data with regard to access, privacy, and confidentiality of electronic medical records, more and more state legislative agendas now presently include HIT initiatives such as disease management, telemedicine, adverse incident reporting, statewide electronic health records, and computerized physician order entry (CPOE). Although the vast majority of states have increased their level of activities, the implementation of statewide and multistate HIE remains an unproven endeavor. The state of Texas is looking at HIT and HIE as mechanisms to help improve its health care delivery and outcomes. The Texas Health Care Policy Council, comprised of ten state agencies, was established by the Texas legislature and is charged with promoting and coordinating the use of technology as a means to decrease administrative costs and improve health care. The Texas Department of State Health Services strategic plan for FY 2007 ­ 2011 includes recommendations for investigating the use of technology to improve health programs in the state and its impact on critical health service functions in such areas as electronic medical records and communitylevel health records.

1 Health Information Technology (HIT) - The application of information processing involving both computer hardware and software that deals with the storage, retrieval, sharing, and use of healthcare information, data, and knowledge for communication and decision making. Includes Electronic Medical Record (EMR). Health Information Exchange (HIE) - The mobilization of healthcare information electronically across organizations within a region or community. HIE provides the capability to electronically move clinical information between disparate healthcare information systems while maintaining the meaning of the information being exchanged.

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Texas Assessment

The Healthcare Information Technology Advisory Committee (HITAC) provides another example. Established through legislative authority, the HITAC was formed in late 2005 and charged, among other things, with developing a long-range plan for HIT in Texas, including the use of electronic medical records, computerized clinical support systems, computerized physician order entry systems, regional data sharing interchanges, and other methods of incorporating information technology in the pursuit of greater costeffectiveness and better patient outcomes. The committee is to present its recommendations, or Roadmap, to the Statewide Health Coordinating Council in July, 2006. A groundswell of local and regional Texas initiatives promoting the adoption of HIT and HIE are currently in operation or in the planning stages in various parts of the state. Most major metropolitan areas in Texas have an initiative underway. The Dallas Fort Worth Hospital Council, through its data initiatives and participation in the recently formed North Texas RHIO Project serves as a prime example. The Indigent Care Collaboration operating in the greater Austin metropolitan area and the Access to Care for the Uninsured in San Antonio, as well as the Houston Harris County Health Care Alliance are additional examples of local health care stakeholders organizing to promote HIT and HIE.

In direct response to the tremendous devastation and disruption caused by Hurricanes Katrina and Rita in the Gulf Coast region last fall, the U.S. Department of Health and Human Services initiated a program to provide support in the development of regional health information organizations and activities in this region. The goal of this program, contracted through the Foundation for eHealth Initiative, is to assist five primary Gulf Coast states (Alabama, Florida, Louisiana, Mississippi, and Texas) in the dissemination of health information technology ­ people, process, and technology ­ to support the movement of health care information electronically. To assist the development of the Roadmap and build upon previously conducted studies2, twenty-one Texas health care industry stakeholders (representatives from hospitals, physician groups, health plans, employers, and academic medical centers) were interviewed about the current status of HIT and HIE adoption and implementation in Texas and its potential to address the state's most pressing healthcare challenges. These interviews confirmed that HIT and HIE are viewed as critical tools to address the healthcare issues facing the state. The variety of existing regional approaches to HIT and HIE led to a split as to whether a uniform statewide approach to HIT adoption is the proper approach. Most interviewees support the development of independent regional health information networks, which are connected across the state by grassroots efforts led by provider and physician groups.

2 See, e.g., Texas Health Institute's "Health Information Technology: Creating a Health Information Network in Texas ­ Policy Brief," December 2005.

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Interviewees shared the view that a collaborative effort involving all healthcare industry stakeholders is necessary to successfully implement HIT and build a health information exchange. However, this leadership role remains undefined and most interviewees referenced the need for a convening body. Most supported the role of the HITAC in facilitating and elevating the HIT discussion and expressed the importance of transitioning this role to a representative group in the longer term. The barriers to HIT adoption identified by the interviewees include those often cited in other parts of the U.S. ­ namely, financing and the misalignment of benefits; lack of robust, interoperable standards; and competition between healthcare providers and organizations. To gauge Texas' organizational readiness for HIE adoption, a survey was conducted with health care leaders asking each to respond to questions relating to vision, governance, leadership, technical interoperability, and organizational capacity. Considering the early stage of HIE development in Texas, it is not surprising that many of the categories received low scores. While Vision received a high score for the efforts to date to facilitate discussion and education as to the benefits of HIE, most categories received low scores, based largely on the lack of interoperability, the lack of agreement on the need for HIE, and the lack of an understanding of what participation in an HIE means.

In summary, Texas has the potential to make significant progress in the widespread adoption of HIT and the implementation of HIE. While some level of broad guidance exists, there currently is no single strategy or mechanism to accomplish a statewide objective of improving healthcare quality, cost, and efficiency through use of HIT and HIE. The HITAC has elevated and facilitated the discussion of these topics and in coming months will present its Roadmap findings and recommendations. Moving forward, however, will require multi-stakeholder coordination across the state in order to establish state-level priorities, synchronize those priorities with national and regional priorities, mitigate common barriers, and establish the necessary policies to promote the design and development of state-specific HIE initiatives. The roadmap will begin to define processes for making these decisions.

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Texas Assessment

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III. Understanding the National Agenda

A. Background

The combination of "burning platform" issues around costs of healthcare, well publicized opportunities for improvement in quality of care in the United States, and political pressures have coalesced into the current environment of public and private support for Health Information Technology (HIT) and Health Information Exchange (HIE) at the national and local levels. First, with health care spending in 2004 increasing 7.9 percent over 2003 to a total of $1.9 trillion, the financial imperative for reducing our healthcare costs is clear.3 Second, recent threats related to severe acute respiratory syndrome (SARS), the West Nile virus, the potential for a pandemic Avian flu, and the ongoing threat of bioterrorism underscore the vital significance of disease surveillance and health information interoperability in protecting the public from natural and unnatural outbreaks. Third, recent natural disasters such as Hurricanes Katrina and Rita highlight the importance for HIT adoption and interoperability to provide continuing care to our citizens, regardless of where their health records were created. Another critical healthcare challenge is the high prevalence of medical errors and adverse events. Adverse events are estimated to occur in 3.7 percent of hospitalizations and up to 13.6 percent of those hospitalizations leading to death.4 Studies and reports sponsored by the Agency for Healthcare Research and Quality (AHRQ), the Institute of Medicine (IOM), and other highly regarded organizations show that patient safety is among the top healthcare system challenges. While there are many opportunities to improve care through the use of clinical guidelines and decision support, currently very few healthcare providers utilize the available resources. Bringing clinical knowledge and information about the patient to the point of care through HIT will help to close the gap between what the evidence tells us in accordance with guidelines and treatment protocols, and the care, interventions, and procedures that are actually delivered. The need for improvements to routine care are magnified in times of crisis. Leading authorities and some of the nation's largest employers, provider and physician groups across the country, Members of Congress and nearly every federal government healthcare agency have called for investment in electronic health information systems and health information exchange deployment.

3 Centers for Medicare and Medicaid Services, Office of the Actuary 4 Ibid

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B. The Role of the Administration

President Bush, in an address in April 2004, declared that every American would have an electronic health record within ten years.5 Towards that objective, the Administration has launched a number of initiatives to accelerate the development and adoption of both HIT and HIE. In addition to the work currently conducted and/ or sponsored by the Department of Health and Human Services (HHS), other agencies such as the Department of Defense, the Department of Veterans Affairs, and the Office of Personnel Management are leading initiatives.

The Framework described four objectives: Inform Clinical Practice; Interconnect Clinicians; Personalize Care; and Improve Population Health. In furtherance of this framework, HHS awarded four contracts in 2005 to public / private groups that will accelerate the adoption of HIT and the secure portability of health information across the U.S.7 These contracts involve: the architecture and design of a web-based National Health Information Network (NHIN); privacy and security assessment and solutions; developing a prototype for harmonizing standards; and evaluation criteria of electronic health records.8 Last November, HHS announced an agreement with the Southern Governor's Association and the Gulf states, including the State of Texas, to plan and promote an infrastructure that supports interoperable healthcare data exchange in the Gulf Coast regions affected by recent hurricanes.9 This plan includes establishing the Gulf Coast Health Information Task Force which will bring together local and national resources, including representatives from the participating Gulf Coast states to coordinate the planning for a digital health information recovery.

1. Department of Health and Human Services

In July 2004, the President created a new sub-Cabinet Level post: the National Coordinator for Health Information Technology, reporting to the Secretary of the Department of Health and Human Services (HHS). During his tenure as National Coordinator for Health Information Technology, David J. Brailer, MD, PhD has provided coordination and leadership within the federal government to accomplish the President's goal. In July 2004, Dr. Brailer unveiled the Framework for Strategic Action6, a ten-year initiative to promote the development and implementation of HIT.

5 M. Allen, "Bush Touts Plan for Electronic Medicine," Washington Post, May 28, 2004 6 "The Decade of Health Information Technology: Delivering Consumer-centric and Information-rich Health Care." http://www.hhs.gov/healthit/executivesummary.html.

7 http://www.os.dhhs.gov/news/press/2005pres/20051110.html 8 http://www.hhs.gov/healthit/proposals.html 9 http://www.hhs.gov/news/press/2005pres/20051117.html

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In March of this year, a HHS sponsored project was announced to identify the best practices and successful model(s) for state-level regional health information organizations (RHIOs) in the areas of governance, structure, financing, and health information exchange policies.10 This study is to be conducted by the Foundation of Research and Education (FORE) of the American Health Information Management Association (AHIMA) and will involve nine participating states. The states chosen were required to have an established public/ private organization operating either as a coordinator of local RHIOs or as an operational RHIO. Other significant activities include HHS Secretary Leavitt's efforts to express a clear vision of HIT that conveys the benefits to patients, providers, and payers; convening a national collaboration to further develop, set, and certify HIT standards and outcomes for interoperability, privacy, and data exchange; and realizing the near-term benefits of HIT in the focused areas of adverse drug-incident reporting, e-prescribing, lab and claims-sharing data, clinic registrations, and insurance forms.11 The Secretary chairs a 16-member federal advisory commission on HIT called the American Health Information Community (AHIC).12 Since the announcement of its Commissioners in September 2005, the AHIC has held multiple meetings and commissioned supporting work groups (electronic health records, biosurveillance, consumer empowerment and chronic care) to discuss and further develop breakthroughs for HIT and its use.

10 The nine states include California, Colorado, Florida, Indiana, Maine, Massachusetts, Rhode Island, Tennessee, and Utah. http://www.ahima.org/press/press_releases/06.0323.asp 11 http://www.hhs.gov/500DayPlan/500dayplan.html 12 http://www.hhs.gov/healthit/ahic.html 13 http://www.hhs.gov/healthit/ahic/workgroups.html 14 42 CFR Part 423 [ CMS 0011 ­ F] Federal Register / Vol. 70, No. 214 / Monday, November 7, 2005. http://www.cms.hhs.gov/QuarterlyProviderUpdates/downloads/CMS0011F.pdf

The work groups are scheduled to present final recommendations to HHS in mid-May on how to make health records interoperable and assure that the privacy and security of those records are protected.13

2. Centers for Medicare and Medicaid Services

The Centers for Medicare and Medicaid Services (CMS) has a number of initiatives underway that are designed to support the adoption of HIT. These initiatives include, but are not limited to: the Doctor's Office Quality-Information Technology (DOQ-IT) program; the upcoming Medicare Management Performance Demonstration (a "pay-forperformance" demonstration program which will provide funds to encourage physicians to adopt information technologies and evidence-based outcome measures to promote continuity of care, help stabilize medical conditions, and reduce adverse health outcomes such as adverse drug interactions); and the Medicare Health Support Program (demonstration program for chronic care and disease management, which is expected to leverage the use of IT within the healthcare system). The Office of the Inspector General released two proposed rules to help facilitate the adoption of HIT and HIE nationwide. The proposed rules involved exceptions to the Stark rule and safe harbors under the anti-kickback statute, thereby permitting the donation of items and services related to ePrescribing (eRx) and EHR technology and published the final rule on foundation eRx standards that are mandatory for Part D sponsors.14

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CMS has also funded eRx pilots to test a broader set of eRx standards and evaluate the impact of health care outcomes and solicited input on what role the agency should play in the development and use of Personal Health Records (PHRs).15 The Medicaid Information Technology Architecture (MITA), sponsored by CMS, is an initiative that is establishing national guidelines for interoperable systems unique to Medicaid programs, and providing a national framework to support improved systems development and healthcare management for the Medicaid enterprise. CMS has identified the following MITA goals16: · Develop seamless and integrated systems that effectively communicate, achieving common Medicaid goals through interoperability and standards · Promote an environment that supports flexibility, adaptability, and rapid response to changes in programs and technology · Promote an enterprise that supports enabling technologies aligned with Medicaid business processes and technologies · Provide data that is timely, accurate, usable, and easily accessible to support analysis and decision making for healthcare management and program administration

· Provide performance measurement for accountability and planning · Coordinate with Public Heath and other partners and integrate health outcomes within the Medicaid community

The Medicare Prescription Drug, Improvement and Modernization Act of 2003, now in the implementation stage, included several provisions designed to improve the quality, safety and efficiency of healthcare through information technology. The requirements include standards for electronic prescribing, the creation of a demonstration program for pay for performance that includes elements of IT, grants to physicians for electronic prescription programs, and a chronic care improvement demonstration program that includes elements related to IT.

15 Agency for Health Research and Quality report " Evolution of State Health Information Exchange: A Study of Vision, Strategy, and Progress" ,January 2006 16 CMS MITA Homepage: http://www.cms.hhs.gov/medicaid/mmis/mita.asp

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Texas Assessment

3. Agency for Healthcare Research and Quality

In October, 2004 the Agency for Healthcare Research and Quality (AHRQ) announced a multi-year $139 million program to drive adoption of health information technology, with an additional $22.3 million in funding provided in October 2005.17 Awards are spread across 41 states, targeting hospitals, healthcare systems, regional health information networks and communities. Approximately 50 percent of these projects include a health information exchange component to their health IT projects. Five-year contracts totaling approximately $30 million went to six states18 to help them develop statewide HIE networks.

To support AHRQ's grantees and other federal partners, the AHRQ National Resource Center for Health Information Technology was launched. The National Resource Center (healthit.ahrq.gov/home/index.html ) serves as a repository for best practices and disseminates needed tools to help providers explore the adoption and use of HIT. Led by the National Opinion Research Center (NORC) at the University of Chicago ­ and a unique partnership of organizations, including the eHealth Initiative and Foundation, the Center for Information Technology Leadership at Partners HealthCare System, Indiana University's Regenstrief Institute, the Vanderbilt Center for Better Health, and Computer Sciences Corporation--the National Resource Center will support AHRQ grant and contract awardees that are exploring the potential of HIT to help reduce medication errors; increase sharing of health information between providers, laboratories, pharmacies, and patients; ensure safer patient transitions between healthcare settings; and reduce duplicative and unnecessary testing.

17 Press Release, Department of Health and Human Services, HHS Awards $139 Million to Drive Adoption of Health Information Technology (October 13, 2004). 18 The states receive approximately $1 million per year. Colorado, Indiana, Rhode Island, Tennessee and Utah received grants starting in 2004; Delaware is a grant recipient in 2005. http://healthit.ahrq.gov/portfolio/index_thqit.html#map_section

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4. Centers for Disease Control

In September 2004, the Centers for Disease Control and Prevention announced the BioSense Program--a national initiative designed to enhance the nation's capability to rapidly detect, quantify and localize public health emergencies, particularly bio-terrorism, by accessing and analyzing health data. This program will establish near real-time electronic transmission of data to local, State, and Federal public health agencies from national, regional, and local health data sources.

5. Department of Veterans Affairs

The Veterans Health Administration within the Department of Veterans Affairs (VA) has built what is widely recognized by the IOM among others, as "one of the largest and most sophisticated health information systems in the nation."19 The system, currently known as VistA®, was initiated in 1985 and is now undergoing a complete systemic upgrade called HealtheVet. VistA® reaches all 1,320 sites of care in the large VHA system, serving 4.1 million consumers annually in a $22 billion health system that includes 174 medical centers and employs 180,000 healthcare staff. Access to complete patient information has been found to greatly reduce medical errors and facilitate patient adherence to chronic condition care protocols.20 The VA is now exploring ways in which private sector providers can access and implement the VistA® system.

19 Fostering Rapid Advances in Health Care: Learning from System Demonstrations. by Institute of Medicine (Corporate Author), Janet M. Corrigan (Editor), Ann Greiner (Editor), Shari M. Erickson (Editor) National Academies Press, January 2003 20 John Demakis, et al., "Quality Enhancement Research Initiative," Medical Care, 38 (6), 2000.

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Texas Assessment

C. The Role of Congress

In recent months, members of the Senate and House have introduced various health information technology bills to authorize standards-setting bodies, codify the role of the Federal government, provide grants for regional health information networks and initiatives, provide incentives for providers and clinicians who improve quality using IT, implement certification programs for healthcare software applications, and address laws that may impede the adoption of IT. One of these bills, The Wired for Health Care Quality Act of 2005 (Senate Bill 1418), was approved by the Senate on November 18, 2005. The Medicare Value Purchasing Act of 2005, which included provisions to create a pay-for-performance (P4P) program for Medicare, was placed into a budget bill and passed by the Senate in November 2005 as part of The Deficit Reduction Omnibus Reconciliation Act of 2005. The P4P provision was later dropped. In 2006, there have been several HIT related bills drafted and introduced for Congressional consideration. Remaining legislation likely to see action is HR 4157. Significant bills introduced and under consideration in the House and Senate as of May 22, 2006 are listed in Table 1.

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Table 1: Proposed HIT/HIE Bills Number

S. 2772

Short Title and Introduced By

Health Partnership Act (Voinovich ROH/Bingaman D-NM) Health Information Technology Promotion Act (Johnson R-CT and Deal R-GA) Assisting Doctors to Obtain Proficient and Transmissible Health Information Technology (Gingrey R-GA) Wired for Health Care Quality Act (introduced in House, Issa R-CA and was referred to the Committee on Energy and Commerce) Electronic Health Information Technology Act of 2006 (Clay D-MO, Porter R-NV)

Description

Provides grants to states and other entities to provide for innovation in health care through State initiatives that expand coverage and access and improve quality and efficiency in the health care system. Would authorize a standards setting process and codify the Federal role for HIT. The House passed the bill in July 2006. To amend the Internal Revenue Code of 1986 to increase the deduction under section 179 for the purchase of qualified health care information technology by medical care providers and to allow a credit against tax for applicable telecommunications charges paid or incurred by such providers. Same as S. 1418

H.R. 4157

H.R. 4641

H.R. 4642

H.R. 4832

To establish an Office of Health Information Technology for the purpose of creating a national interoperable health information infrastructure, to provide loans to health care entities seeking to implement such infrastructure, and to provide exceptions to certain health anti-kickback laws to encourage the dissemination of health information technology. To provide for the implementation of a system of electronic health records under the Federal Employees Health Benefits Program. For the establishment and maintenance of electronic personal health records that shall be based on standard electronic format and be available for electronic access through the Internet for the voluntary use and participation of the individual or family member to whom the record applies.

H.R. 4859 Draft Bill

Federal Family Health Information Technology Act of 2006 (Porter R-NV) Federal Employee Personal Health Records Act (Carper D-DE)

To date, there is strong bi-partisan interest in these legislative agendas. While these bills face additional procedural steps and enactment is not assured, the forward momentum of these bills is a positive sign. In the upcoming weeks Congress has the potential to pass significant enabling legislation for HIT.

While interest is strong and the opportunities to make policy during an election cycle favor the enactment of legislation, there are no guarantees that any HIT legislation will be enacted before Congress adjourns later this year. Refer to Appendix A: Recent Federal Legislation which represents a summary of recent federal legislative activity.

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Texas Assessment

D. The Role of the States

While federal leadership is important, it must be integrated with efforts at the state and local level. State legislatures and local governments play a critical role as regulators, safety net providers, and payers. Whereas most HIT legislation previously focused on removing barriers to electronic transmission of data with regard to access, privacy, and confidentiality of electronic medical records, more and more state legislative agendas include HIT initiatives such as disease management, telemedicine, adverse incident reporting, statewide electronic health records, and computerized physician order entry (CPOE). Today, many states have initiatives aimed at supporting policy goals and improving health care delivery through the adoption and use of HIE. See Appendix B: Statewide HIE initiatives for a listing of the various state activities. Statewide commitments to the adoption of HIE mark the beginning of many changes for that state. These changes range from the establishment of a formal governance structure to the assignment of dedicated resources and staffing. States with HIE initiatives convened under the direction of the state government more readily acquire a critical mass of collaborators. Without stable involvement, efforts to create a broad coalition may be slow or even dissolve into competing efforts. Expectations of success rise with state participation.

Some states have been able to build a broad base of participants without state government involvement; however those situations often have the presence of a credible, neutral convening body capable of addressing issues at a state level. State HIE initiatives require leadership with vision, credibility and determination. This leadership usually comes from an individual, but can be provided by a small group of visionaries able to facilitate collaboration between stakeholders, even those who normally compete with each other. This leadership often is a defining component of the state's success. Once chartered, a statewide initiative will often need to establish effective relationships with existing regional and / or local HIE initiatives. These initiatives may have been in existence for years and have well established governance, expectations, and processes. A state-wide HIE initiative then begins to balance the role of convener and overall coordinator while ensuring that the state-wide efforts do not accidentally stifle innovation at the local level. Common principles for addressing many of these challenges are beginning to emerge, but in many areas, there is no single identifiable solution. The following summarizes some of the themes that are beginning to emerge.

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(1.) Financing and Sustainability. In order to finance and sustain emerging health information organizations and initiatives, the value that accrues to each stakeholder in the system needs to be quantified, communicated, and recognized. Models are emerging that will assist in this process. Research indicates that a wide range of stakeholders, including health plans, hospitals, laboratories, practicing clinicians, researchers, and public health benefit from HIE. Translating this benefit into a sustainable business model will require collaboration and the creation of vehicles to facilitate both value and cost transfer. Work is now underway to further define value and cost and to develop replicable models that can be customized for each region's or community's use. In addition, it is clear that in some communities, upfront funding will be required, regardless of the sustainability model used. Grant and loan programs will play a critical role in supporting the upfront capital needs while a sustainable, long term financial model is developed and implemented. (2.) Organization and Governance. Many believe that health information organizations and initiatives should be led by a "neutral" and trusted governing body which includes representative members from the many diverse stakeholders in the system. The governance structures of the initiatives that have been successful to date reflect this attribute. Given the fragmented and highly competitive nature of our healthcare system, building trust among diverse entities has often been difficult and requires a great deal of process and attention.

(3.) Legal Issues. A wide range of legal issues beyond organization and governance need to be addressed including those related to user and vendor agreements, fraud and abuse, antitrust, liability and malpractice, data uses and rights, and compliance with HIPAA and state privacy laws. Based on the research performed to date, these legal issues do not present barriers; however, they should be addressed as the work of the HIE initiative unfolds. (4.) Engaging Clinical Stakeholders. The role of practicing clinicians in any HIE initiative is critical. Upfront inclusion and engagement of practicing clinicians in both the governance and the organization of the health information exchange initiative, will help pave the way for success. The value that is derived from the mobilization of data across organizations to support patient care will not be realized unless practicing clinicians actually use the system to access results, reminders, and other information related to the patient.

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Texas Assessment

(5.) Technical Aspects. A number of issues need to be agreed upon as part of the technical realm of sharing data and information. These include: functionality of the system, a technical architecture model, methods for accurately linking patient data, and security aspects including patient and provider authentication. Fortunately many models are now emerging to address these issues. In fact, the "Connecting for Health Common Framework" issued by Connecting for Health (www.connectingforhealth.org) is a methodology and implementation guide supporting the technical aspects of HIE and addressing issues such as patient and provider and provider authentication, a record locator service, and effective technical architectures to support responsible implementation and access. "The Common Framework" also includes policy guides and model contractual language. Additionally, the Foundation for eHealth Initiative's "The Connecting Communities Toolkit" (http://toolkit.ehealthinitiative.org) supports learning across and among diverse stakeholders including state, regional, and community-based organizations. The Toolkit is a distillation of the knowledge that the eHI has accumulated through its work with multiple stakeholders and various communities.

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E. The Leadership in the Private Sector ­ Quality Initiatives

The following is a representation of private sector programs by health plans, business coalitions, and large employer-purchasers of health care offering incentives for the purchase or usage of HIT.

2. The Leapfrog Group

The Leapfrog Group, which is made up of more than 170 companies and organizations that buy healthcare, is making strides in improving accountability in the hospital environment. Their overall goal is to reduce medical mistakes and improve the quality and safety of healthcare and to reward physicians and hospitals for improving the safety, quality, and affordability of healthcare. The Leapfrog Group (www.leapfroggroup. org) has implemented the Leapfrog Hospital Rewards Program (LHRP), a pay-for-performance program to recognize and reward hospitals for their performance in both the quality and efficiency of inpatient care. The LHRP can be licensed and implemented by private healthcare purchasers -- employers, healthcare coalitions, and health plans -- to reward hospitals for performance. These rewards include bonus payments to hospitals, higher reimbursement rates from health plan payers, public recognition, and/or increased patient market share. Recently, twenty-two hospitals across California were recognized for their outstanding commitment to health care quality and patient safety with a new award presented by four of the state's leading health plans. The award, "Excellence in Patient Safety & Health Care Quality Award," is based on results from the Leapfrog Hospital Quality and Safety Survey.21

1. Bridges to Excellence

Bridges to Excellence (BTE), a pay for performance initiative, was launched in 2003 to promote and reward higher quality patient care. The funding for this program is provided by employers, The Robert Wood Johnson Foundation and The Commonwealth Fund. Bridges to Excellence (BTE) is made up of physicians, health plans, and over 80 of the nation's largest employers, including General Electric, Procter & Gamble, Verizon, UPS, and IBM. The BTE programs are targeted towards primary care physicians, endocrinologists, cardiologists, and neurologists who have been identified by BTE as eligible based on participating health plan information and whether they pass the Recognition Criteria. Each program utilizes standard measurements and guidelines for specific diseases, including The National Committee for Quality Assurance's (NCQA) performance assessment criteria and The American Board of Internal Medicine. Additional information can be found at http://www. bridgestoexcellence.org.

21 Leapfrog website: Press Release May 2, 2006, 22 California Hospitals Earn Top Status for Outstanding Patient Safety and Health Care Quality

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Texas Assessment

3. The National Committee for Quality Assurance

The National Committee for Quality Assurance (www. ncqa.org) is an independent, 501(c)(3) non-profit organization whose mission is to improve healthcare quality everywhere. They aim to improve quality in three ways: 1) accreditation of managed care organizations; 2) development of Health Plan Employer Data and Information Set (HEDIS); and 3) collaboration with AHRQ for a member satisfaction survey of managed care plans. Recognition programs from the NCQA recognize structure, process, and outcomes of excellent care management, across an entire practice. More than two dozen of the nation's largest employers and consumer groups, representing millions of Americans, have endorsed the new Physician and Hospital Quality standards released on April 1, 2006 by the NCQA. The standards focus on how health plans measure the quality and efficiency of care provided by network physicians and hospitals and how the plans share the results with their members to help inform consumer choice. Forty-eight health plans, including five preferred provider organizations (PPOs) covering more than 20 million Americans, have committed to measuring the quality and cost of the care provided by their network physicians and hospitals and to be evaluated on how well they communicate the results to their customers.

Reviews against NCQA's new standards will begin this summer and continue throughout 2006.22 The NCQA efforts support the conclusions that having national measures helps reward programs get started and that measurement plus rewards equals real improvement.

22 NCQA Website: Press Release April 26, 2006 New NCQA program will help more than 20 million compare doctors and hospitals on quality and cost..

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F. Consumer-centric Health Care:

The consumer role in health care is changing. More and more, consumers are being encouraged, even required, to actively manage their health care and to be more responsible for the way their health care dollars are spent. Concurrent with this changing healthcare environment and to advance the Administration's goal of expanding HIT adoption, HHS's Framework for Strategic Action, as previously mentioned above, outlines four goals and strategies for shaping the use of HIT to deliver consumercentric health care.22 One of the key goals of this strategic plan is to personalize care, a critical requirement of which would be the active involvement of consumers in managing their health care and gaining the benefits of having their health information in a format that is easily accessible. Towards meeting this goal, the report recommends several strategies, including encouraging consumers to use personal health records (PHRs).

Key Potential Benefits of PHRs

The National Committee on Vital and Health Statistics (NCVHS) held six hearings on personal health records (PHRs) throughout 2002-2005 and issued its findings and recommendations in February 2006.23 Summarized key findings as to the potential benefits of PHRs from the perspective of various roles are as follows:

Consumers, Patients and their Caregivers

· Support wellness activities, improve understanding of health issues and increase control over health · Increase control over access to personal health information and verify accuracy of information in provider records · Strengthen communication with providers · Support home monitoring for chronic diseases · Support understanding and appropriate use of medications, reduce adverse drug interactions and allergic reactions · Manage insurance benefits and claims · Avoid duplicate tests

23 HHS, "The Decade of Health Information Technology: Delivering Consumer-centric and Information-Rich Health Care - A Framework for Strategic Action," July 2004.

24 NCVHS, the statutory public advisory Committee on health information policy to the Secretary of Health and Human Services, issued its report , "Personal Health Records and Personal Health Record Systems, A Report and Recommendations from the National Committee on Vital and Health Statistics," U.S. Department of Health and Human Services, National Cancer Institute.

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Healthcare Providers

· Improve access to data from other providers and the patients themselves · Increase knowledge of potential drug interactions and allergies · Avoid duplicate tests · Provide information to patients for both healthcare and patient services purposes · Provide patients with convenient access to specific information or services (e.g., lab results, Rx refills, e-visits) · Improve documentation of communication with patients · Improve medication compliance

Employers

· Support wellness and preventive care, provide convenient service · Improve workforce productivity · Promote empowered healthcare consumers · Use aggregate data to manage employee health

Societal / Population Health Benefits

· Strengthen health promotion and disease prevention, improve the health of populations · Expand health education opportunities NCVHS testimony found that "consumers and patients who use PHR systems express strong support for them." They appreciate having access to their personal health information to manage their own health and health care and to share information with their providers.24 Similar support for PHRs is found in research released in the fall of 2005 by the Markle Foundation which reports that the American public believes strongly that electronic medical records can make the difference between life and death in emergencies.25

Payers

· Improve customer service (transactions and information) · Promote portability of patient information across plan · Support wellness and preventive care · Provide information and education to beneficiaries

25 NCVHS report page 19. 26 From Markle Foundation press release, "Americans Support Online Personal Health Records; Patient Privacy and Control Over Their Own Information Are Crucial To Acceptance," October 11, 2005.

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Research findings showed nearly three out of four Americans (72 percent) favor the establishment of a nationwide electronic information exchange that would allow a patient's health information to be shared with authorized individuals quickly, privately, and securely via the Internet.26 However, ensuring patient privacy and control over their records is essential to full consumer acceptance of such an exchange. Other findings include: · More than three out of four Americans (79 percent) say making sure their records could be shared only after they provide permission is a priority. · Four in five Americans (80 percent ) believe that if physicians kept electronic medical records on their patients, health care quality would improve and medical errors would be reduced, because authorized doctors would be able to retrieve a patient's medical history in a matter of seconds. · An equal number (81 percent) believe that the ability of researchers to review millions of records anonymously to determine best treatment practices would help all doctors improve the quality of medical care. Despite these high levels of support for health information technology, keeping electronic medical information private and secure remains a top concern for consumers. The research indicates that people are much more likely to support online medical records if they have control over their own information and safeguards to protect privacy are in place.

27 Findings based on survey of 800 adults conducted by Public Opinion Strategies, Alexandria, VA, Sept. 20-22, 2005. The survey has a margin of error of +/- 3.46 percent.

A second Markle Foundation study showed that consumers would use their own secure, online "personal health record" account to better manage their health care.27 Nearly seven out of ten respondents said they would use this online service to check for mistakes in their medical records and to check and refill prescriptions. A majority of individuals indicated they would like to get medical results over the Internet or conduct secure and private email communications with their doctors. Taken together, these results show a strong interest among consumers in using health information technology to more fully participate in their own health care. PHRs will provide the tools to move us closer to a consumer-centric health care system. A majority of consumers understand the benefits of electronic records and how they can improve quality of care. Many issues, especially those surrounding access to and control of personal health information, however, need to be addressed before PHRs and health information exchange networks will be accepted by the consumer.

28 Findings based on survey of 800 adults conducted by Public Opinion Strategies on Sept. 28-Oct. 2, 2005. The survey has a margin of error +/- 3.46%.

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Texas

IV. Overview Of Texas

As part of this project, the Foundation for eHealth Initiative has conducted a high-level assessment of the current environment for HIT and HIE within the state of Texas. This assessment began with establishing an understanding of the demographic and healthcare landscape in the state. Building upon this landscape, the Foundation has become familiar with many of the HIT and HIE initiatives underway in Texas. Some of the information about HIT and HIE was gathered through structured interviews with select Texas healthcare stakeholders conducted during April and May 2006. The interviewees' participation in structured interviews and a quantitative assessment tool provided a source of perceptions about HIT and HIE. The results of this overview are presented below.

A. Texas Background

The State of Texas, home to over 22.8 million people, is the second largest state both in terms of physical size and population. Texas has more counties than any other state in the U.S. with 254. (174 counties of these are considered rural.)23 Texas has 25 metropolitan areas, as defined by the U.S. Office of Management and Budget, with Houston, San Antonio, Dallas, Austin, and Fort Worth being the state's largest five cities, respectively. Over 15 percent (approximately 3.45 million) of Texas' residents are foreign born of which an estimated 1.2 million are illegal aliens (comprising 5 percent of the total state population). More than a third of the population is of Hispanic origin and the state has significant AfricanAmerican and Asian populations as well. In 2005, the United Census Bureau indicated that Texas is the fourth minority-majority state in the U.S. (after Hawaii, New Mexico, and California). Some estimates indicate that Hispanics will become a majority in the state by 2030. Census data reports 31 percent of Texas' population is under 20, compared to 28 percent nationally, and 10 percent over 64 years compared to 12 percent nationally.

29 The U.S. Office of Management and Budget (OMB), defines a metropolitan area as an area with at least one city with a population of 50,000 or more, or an urbanized area with a population of 50,000 ore more and a total Metropolitan Statistical Area (MSA) population of 100,000 or more. Any area without metropolitan area and sufficient population density is considered rural.

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Texas Assessment

There are approximately 627 hospitals in Texas, with 578 general hospitals, 32 specialty hospitals, and 17 stateowned facilities.24 Additionally, Texas has 1,094 certified nursing facilities, 344 Rural Health Clinics, and 40 Federally-Funded Federally Qualified Health Centers.25 More than 68 percent of all hospitals in the state of Texas are located in urban areas.26 Of the 254 counties in Texas, 63 do not have a hospital. Based on federal guidelines27, 176 of the 254 counties (69 percent) in Texas are considered Medically Underserved Areas (MUA). Additionally, 48 counties (19 percent) contain partial MUAs.28 There are nine federal Medically Underserved Populations29 (MUPs) in the state of Texas as well as seven MUPs designated by the Governor of Texas. In 2005, Texas had 35,811 non-federal direct patient care physicians (155.7 per 100,000 population), 144,620 nurses (629 per 100,000 population), 4,066 Nurse Practitioners (17.7 per 100,000 population), and 3,375 physician assistants (14.7 per 100,000 population).31 Texas hospitals face several workforce challenges including an aging nursing population. Nurse vacancy and turnover rates are high throughout the state.30

According to the United Health Foundation's, America's Health RankingsTM 200532, the state of Texas ranked 39th among all states in terms of health status (as categorized by the United Health Foundation). Several strengths were noted for Texas. Texas spends $179 per person on public health initiatives, which is among the highest in the U.S. Additionally, Texas has a low rate of cancer deaths at 200.8 deaths per 100,000 population and a low infant mortality rate at 6.2 deaths per 1,000 live births. However, several health challenges exist that are unique for the state. Texas has one of the highest uninsured rates in the U.S., as more than 25 percent of the population does not have medical insurance (compared to the national average of 16 percent). Similarly, Texas has a high proportion of uninsured children with 20 percent of Texas' children do not have health insurance (compared to a national average of approximately 11 percent).33 Minority populations (mainly Blacks and Hispanics) have disproportionate rates of uninsured when compared to Whites. Many of the uninsured are, however, employed. Approximately 69 percent of small businesses (less than 50 employees) in Texas (compared to 57 percent nationally) do not offer health insurance with cost being the main deterrent.34

30 http://www.dshs.state.tx.us/HFP/Files/gsdirectory.xls and http://www.dshs.state.tx.us/ HFP/Files/psydirectory.xls 31 State Health Facts. The Henry J. Kaiser Family Foundation. Accessed on May 6, 2006 from http://www.statehealthfacts.org 32 Hospitals: Keeping the promise. 2005 Environmental assessment, Texas Hospital Association 33 A Medically Underserved Area (MUA) is a federal designation used to identify an area with inadequate access to personal health services, based on physician access, percentage of aged population, poverty rates and health status indicators. Areas with an Index of Medical Underservice (IMU) (which is a weighted aggregate of these variables) score equal or less than the national IMU (62.0) are designated as underserved. 34 State of Texas Department of Health Services, Center for Health Statistics, Health Professions Resource Center, MUA and MUP Designations, 2005. Accessed on May 12, 2006 via http://www.dshs.state.tx.us/chs/hprc/MUAlist.shtm.

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35 A Medically Underserved Population is a federal designation that describes a population that is within an area that is not considered in an MUA. This designation is based on an index score. These populations may encounter barriers to accessing primary care and examples include low income, those who quality for Medicaid, or those who have language or cultural barriers that prevent them from accessing care. 36 State of Texas Department of Health Services, Center for Health Statistics, Health Professions Resource Center, MUA and MUP Designations, 2005. Accessed on May 13, 2006 via http://www.dshs.state.tx.us/chs/hprc/MUAlist.shtm. 37 Supply and Distribution Tables for State-Licensed Health Professions in Texas Accessed on May 22, 2006 from http://www.dshs.state.tx.us/chs/hprc/health.shtm 38 America's Health RankingsTM 2005 Edition: A call to action for people and their communities. United Health Foundation. Accessed on May 6, 2006 from https://www. unitedhealthfoundation.org 39 UT System Health Affairs Code Red task force on uninsured in Texas access May 12, 2006 via http://www.utsystem.edu/hea/codered/ Accessed on XXXXX, via http://www.census.gov/hhes/hlthins/historic/index.html 40 Texas Department of Insurance. Working together for a healthy Texas. September 2005 Interim report. State Planning Grant Project. Accessed on May 12, 2006 via http://www. tdi.state.tx.us/reports/life/documents/spgint05.doc

In addition to the lack of adequate health insurance coverage, Texas faces several other issues that have a significant impact on the health status of its citizens. Texan exceeds the national rate for poverty, with 16 percent of Texans living in poverty compared to 12 percent nationally. Approximately 23 percent of children (persons under the age of 18) in Texas live in poverty, compared to 18 percent nationally.35 Given the rural nature of Texas, many residents face significant barriers to accessing healthcare. The State of Texas Office of Rural Community Affairs reported that there is a remarkable difference between rural and urban rates for many of the state's leading causes of death. Rural counties show a statistically higher rate of death in several categories and in some rural counties death rates for specific diseases (such as diseases of the heart, malignant neoplasms, and cerebrovascular diseases) exceed those in urban settings by as much as 30 to 50 percent.36 Results from the 2005 Texas Medical Association Special Survey on Electronic Medical Record System Implementation indicated that only 27 percent of physicians in Texas are currently using an electronic medical record (EMR) system.37 Younger physicians are somewhat more likely to use EMR systems, which includes 37 percent of physicians under the age of 40. Almost half, 46 percent, of all Texas physicians are planning an EMR implementation. The age of the physician in this instance has no effect on the decision to implement, as older physicians are almost as likely as younger physicians to be planning an EMR

41 U.S. Census Bureau, Current Population Survey, Annual Social and Economic Supplements. Poverty and Health Statistics Branch/HHES Division. Web: Access on May 12, 2006 on http://pubdb3.census.gov/macro/032005/pov/new46_100125_03.htm 42 Office of Rural Community Affairs. Work Plan for Rural Health, July 2003. Accessed on May 12, 2006, via http://www.orca.state.tx.us/pdfs/Workplan_Complete_Rural_Health. pdf. 43 Texas Medical Association (2006). 2005 TMA special survey: Electronic medical record system implementation. 2006 and 2005 are the two available dates for this citation.

implementation. A third of respondents over the age of 70 are planning to implement an EMR system. Of physicians that have implemented EMR systems, an overwhelming majority report that among the most important features are better medical record access, followed by improved work flow, and reduced medication errors. Physicians also value several features that could serve to improve financial performance of their practice, including improvements in charge capture, visit coding, claim submission, and reduced medical records storage and transportation costs. When asked what they liked least, physicians who have implemented EMR systems reported that it is difficult, awkward, or time consuming to input data, that there is no interface with hospital or ancillary providers systems, that new kinds of errors are possible, and that productivity is lost during implementation. Among physicians, who do not plan to implement an EMR, the most common reason given was that cost is prohibitive and that external funds would be necessary for them to reconsider that decision. All of these factors create a large, complex environment where the need for improvements in healthcare quality and efficiency are immediate and pervasive. However, the size and complexity of the Texas health care environment will require incremental changes, rather than wholesale changeovers.

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Texas Assessment

B. Activities to Promote the Adoption of HIT and HIE in Texas

The Texas legislature and other state level activities have been addressing these health care issues in recent years and furthering the promotion and adoption of HIT and HIE in the state. Listed below are several noteworthy activities.

The eleven member committee, appointed in late 2005, has established a subcommittee / work group structure with support from the Foundation for eHealth Initiative to accomplish its tasks.

2. Texas Health Care Policy Council

The Texas Health Care Policy Council was established by the Texas legislature to respond to issues referred by the Governor, Lieutenant Governor, and House Speaker. Comprised of 10 state agencies, its charge is to: include, facilitate, and promote the use of technology as a way to decrease administrative costs and improve health care; monitor research and promote initiatives relating to patient safety and use of Telemedicine and TeleHealth; and coordinate with other offices and agencies primarily focused on the use of technology in health care.

1. Health Information Technology Advisory Committee

In 2005, the Statewide Health Coordinating Council (SHCC) was mandated by the Texas legislature (Senate Bill 45) to form the Health Information Technology Advisory Committee, an advisory committee of representatives of interested groups including the public, academic community, health plans, pharmacies, and associations of physicians, hospitals, and nurses. (See Appendix C: Senate Bill 45). The HITAC is to develop a long-range plan for health care information technology in Texas, including the use of electronic medical records, computerized clinical support systems, computerized physician order entry, regional data sharing interchanges for health care information, and other methods of incorporating information technology in pursuit of greater cost-effectiveness and better patient outcomes in health care.

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3. Texas Medical Association

Texas Medical Association's Special Funds Foundation (TMASFF) is proposing a three-year action plan to enhance patient safety by accelerating physician adoption and use of clinically-focused health information technology in their office practices. The comprehensive Health Information Technology Initiative's overall goal is to move Texas medical offices from the era of standalone, paper-based medical records and transactions into the era of networked health information technology in which physicians can easily access their own practices' clinical information, find the current treatment protocols they need to make evidence-based decisions on patient care, and participate in data-based quality improvement activities in their own practices. In essence, physicians will be readily able to measure health status and outcomes through technology systems that enhance the clinical management of their patients. Moreover, the networking of the clinical information in physician office records will create a powerful tool in developing community data warehouses and in conducting and evaluating public health action plans.

The initiative is divided into three phases: Phase I creates a physician leadership for the initiative and reaches out to a mass audience of Texas doctors with a message about the importance of HIT to patient care. The goal is to create a critical mass that triggers the widespread adoption of HIT in Texas and the establishment of fully supported regional health information organizations. Phase II works on the principle of not overloading people with change, and educating through seminars, web-based courses, publications, and consulting on the specifics of acquiring the technology. The desired outcome is to increase physician adoption of electronic health records in Texas from 18 to 40 percent by 2010. Phase III focuses almost entirely on patient care as data is drawn from physician practices, allowing them to initiate quality improvement in their offices and contribute to community and regionally-based data warehouses.

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Texas Assessment

C. Inventory of HIT and HIE Initiatives in Texas

A groundswell of local and regional Texas initiatives promoting the adoption of HIT and HIE are currently in operation or in the planning stages in various parts of the state. See Appendix E: Catalog of Texas HIT and HIE Initiatives. These initiatives were identified through the interview process and represent a "starter" catalog of projects. Many of these initiatives are being led by health care participants including hospital and provider organizations. Seven of these projects have been identified as having the goal or potential of developing into regional health information exchange networks:

2. Access to Care for the Uninsured - San Antonio

The purpose of this project is to develop a shared patient database called ACU Information System that will significantly integrate and coordinate health care for the uninsured. The system will enable providers to share results of laboratory and other tests and help monitor diseases. Eventually, the system will allow authorized users to view a patient's medical record, improving patient care and health provider coordination. Finally, the system will improve analysis of uninsured patients' use of the health care system.

3. CriticalConnection ­ South Austin

CriticalConnection is a pilot program in South Austin that focuses on developing a community-accessible medical information database and providing an electronic link between patients, providers and payers. Their goal is to provide a community solution that creates a collaborative environment of secure, electronically shared healthcare information between patients, physicians, hospitals, other caregivers, and payors.

1. Access Medica ­ East Texas

Access Medica was founded in 2005 to provide healthcare IT services to physicians, hospitals, and patients of east Texas. The nonprofit RHIO includes members of the Physicians Contracting Organization of Texas and other independent practices. The result will be dramatically improved quality of care, countless lives saved, and reduced healthcare costs for the businesses and families of East Texas. Access Medica is deploying an Electronic Health Record system from Allscripts to 29 physicians in six clinics during the first phase of the rollout, with an additional 50 to 60 physicians expected on board by mid2006.

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4. Houston-Harris County Health Care Alliance

Recognizing the need for better coordination between public and private health care providers, the Greater Houston Partnership's Board of Directors has adopted a resolution in support of the Houston Harris County Healthcare Alliance (Alliance). The Alliance will facilitate public and private providers in Harris County working together to create and sustain a comprehensive care delivery model, and coordinate health care delivery by enhancing existing health care assets, developing additional assets, and working with other organizations interested in advancing the Alliance's mission.

6. North Texas RHIO Project

The goal of the North Texas RHIO is continually to improve the quality and safety of medical care through the sharing of accurate patient information. The DallasFort Worth Hospital Council, Tarrant County Medical Society, and Dallas County Medical Society agreed to create the North Texas RHIO Steering Committee. This Committee will oversee the governance and development of processes required to deliver accurate and secure patient information to participating North Texas RHIO members.

5. Indigent Care Collaboration

The ICC is an alliance of healthcare safety-net providers that work together to increase access, improve quality and impact financing solutions to provide care to the region's medically indigent. The goal of the system is to have an impact on obtaining "one-stop" health care for the patient and to better coordinate the needs of the medically under-served in Hays, Williamson, and Travis counties by improving continuity of care, reducing duplicate procedures, and reducing the time spent in seeking health care services. One noteworthy strategy is the Master Patient Index / Clinical Data Repository system, also known as I-Care, through which safety net providers build shared longitudinal electronic health records for uninsured and other low income patients to improve health care continuity and delivery.

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Texas Assessment

Access Media--East Texas Access to Care for the Uninsured--San Antonio Critical Connection--South Austin Houston--Harris County Health Care Alliance Indigent Care Collaboration--Central Texas (Hays, Travis, and Williamson County) North Texas RH10--Dallas and Tarrant County Area Southeast Texas Health System--South East Texas

Figure 1: Texas Project Map

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7. South East Texas Health System

The Southeast Texas Hospital System (STHS) is an organization consisting of 8 hospitals with associated referring physicians, clinics and other rural health facilities that is committed to improving patient access, quality of care and cost efficiencies among the healthcare providers in the middle Gulf Coast region. SHTS has partnered with HealthMeans, Inc. to launch a project involving the use of smart card technology as the backbone of an electronic health information exchange and will include a private patient personal health record and registration web portal for access by physician practices in the STHS network. This will be the first step towards building a virtually integrated Regional Health Information Organization and is specifically designed to deploy a set of clinically integrated pathways that provide a structured process for identifying and defining quality care, as well as providing a step-by-step guide to measurable positive outcomes. Figure 1 depicts the location of each of these seven projects. As indicated, the projects are all concentrated in the eastern and central portions of Texas. The circles highlight approximate areas of coverage by the HIE. The eHealth Initiative has categorized the stages of development of a regional health information exchange into six stages: These stages reflect a framework for assessing the maturity of development for HIE. Stages range from "recognition of the need for HIE among multiple stakeholders" (stage one) to "fully operational

and sustainable, and demonstrating expansion beyond the current operational model" (stage six). Each stage is further defined as follows: Stage 1: Recognition of the need for HIE among multiple stakeholders in state or region Stage 2: Getting organized; defining shared visions, goals and objectives; identifying funding sources; setting up legal and governance structures Stage 3: Transferring vision, goals, and objectives to tactical and business plans; defining needs and requirements; securing funding Stage 4: Implementation of technical, financial and legal well underway Stage 5: Fully operational health information organization; transferring data that is being used by health care stakeholders Stage 6: Demonstration of expansion of organization to encompass a broader coalition of stakeholders than present in initial model An attempt to categorize each of the above Texas HIE projects into its current stage of development (see Figure 2) indicates that two HIEs are operational (stage 5), two close to being operational (stage 4), and the other three are in various planning stages. Note: This categorization is based on publicly available information and has not been validated by the respective organizations.

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Texas Assessment

Stage 1

> Houston-Harris County Alliance

Stage 2

> Access to Care ­SA

Stage 3

> North Texas RHIO

Stage 4

> Critical Connection > Southeast Texas Health System

Stage 5

> Access Medica > Indigent Care Collaboration

Stage 6

Figure 2: Texas HIEs Stages of Development

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This list of projects highlights the potential for the widespread adoption of HIT and HIE in Texas. Public and private organizations are taking the initiative to organize locally and regionally towards the grassroots development of health information exchanges. They are blazing the trail of HIE adoption, proving that it can be done.

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Texas Assessment

D. "What We Heard" From Select Texas Health Care Stakeholders

In an effort to solicit input from Texas health care industry stakeholders, representatives (see Appendix F: Interview Contributors) from hospitals, physicians groups, health plans, employers, and academic medical centers participated in one-hour phone interviews. Included in the interviews was a discussion of the current status of HIT implementation and exchange initiatives in Texas, HIT and HIE's potential to address the state's most pressing healthcare challenges and what issues, if any, would need to be addressed or actions taken to move the state towards broader adoption and use of health information technology and exchange. Each interviewee, prior to the interview, was given a set of questions. Their feedback is summarized in this section.

1. Barriers to Adoption and Implementation of Health Information Technology and Health Information Exchange "Funding, Funding, Funding ­ who is going to pay for all this?"

Overall, the costs associated with HIT adoption and implementation were the greatest concern across all parties interviewed. The primary financial concerns focused on general misalignment of benefits to the initial investments required of the different stakeholder groups. While this was identified as a problem across the board, it was most often cited by the physician group. The lack of market competition within the HIT vendor market was also outlined as a barrier in the rural markets of Texas. Hospitals were the only stakeholder group not to identify cost as the largest barrier to adoption. Hospitals tended to express more concern around distrust and overt competition between major metropolitan markets within the state. Regulatory and privacy issues surrounding the prospect of using a general information database throughout the state which, as yet, has no identified governance structure was also outlined as a major concern by hospital groups. Many stakeholders described a need for more robust standards in HIT and HIE.

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These barriers are shared throughout the United States and are being overcome through the broad collaboration of multi-stakeholder initiatives and leadership of influential organizations on a local basis.

another complicating factor for the creation of regional health information exchanges. Some regions have made more progress than others overcoming this barrier, with San Antonio and Austin often cited as areas where hospitals are working together for HIT and HIE.

2. Competition within the Hospital Community "These hospitals won't even sit down with each other"

The current environment in Texas -- 25 percent uninsured, continuing pressures on reimbursement rates, and significant pressure from specialty hospitals -- produces a difficult environment in which to operate a hospital. As these environmental factors have increased in influence, many of the major hospitals have found themselves in strongly competitive regional battles for survival. The competitive environment provides yet

"When things get bad enough, collaboration DOES happen"

Examples of collaboration between strongly competitive hospitals exist both within Texas and outside Texas. While finding that common ground for collaboration is not always easy, in Memphis and Indianapolis, for example, competitive hospitals have found a common ground on subjects as diverse as outsourcing of laundry to collaborating for a community-wide reduction in CAT scans. Hospital treated patients frequently visit more than one hospital and HIT and HIE extend the promise of reducing duplicate testing, improving speed and quality of treatment, and reducing community wide costs associated with hospital treated patients. Delivering these benefits is a product of trust and collaboration built up over time through discovery of shared needs.

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Texas Assessment

3. Geographic Impacts on HIT and HIE "Twenty percent of trauma patients and 17 percent of medical patients treated statewide reside outside the county in which the hospital is located"

Texas is currently pursuing HIT and HIE at a local and regional level, with many rural areas of the state lagging behind. While there are a variety of programs in place to extend healthcare into the rural areas, the current potential for HIT and HIE to impact quality, safety, and efficiency of healthcare in the rural setting is limited. Some of those limits are a result of a sparse population of patients and the providers to treat them, poor internet connectivity, and even a lack of economic justification for nascent regional initiatives to include their rural neighbors. Region to region, a variety of approaches to HIT and HIE are underway, which helps explain the response received when interviewees were asked if a uniform statewide approach would be the best approach for HIT adoption. Generally speaking, opinions were split as to whether or not a uniform statewide approach would be the best approach for HIT adoption. Physicians were the only stakeholders to come to a fairly clear consensus, which was that imposing uniformity would complicate matters and not improve the likelihood of success.

Hospital groups were widely divergent in their attitudes on the subject of uniformity, with a general consensus that any uniformity must allow the currently existing initiatives to proceed unchecked. Some hospital representatives felt that the state was the only party powerful enough "to drive the (systemic) effort" while others shared the view of physicians that the state should "let the grassroots efforts flourish". Health plans and information technology specialists seemed to share the opinion that the state should be able to drive the effort through investments of time and money. Stakeholders, specifically those representing rural areas, felt as though regional organizations have been operating with too much freedom thus far and subsequently ignoring the concerns of the individual, particularly the isolated, rural individual. The state, according to these stakeholders, is the only body that can rectify this situation. Some stakeholders mentioned various hybrid approaches of both state and regional guidance. One such approach proposed having the state address issues such as governance and standardization where continuity is essential, while letting regions handle data-sharing, care delivery, and other more need-based issues. Another hybrid model suggested regions develop their own approaches initially, then assess the most productive regions and implement their best practices throughout the state. It must be noted that while many stakeholders supported some form of regional approach, the actual definition of a "region" varied greatly amongst interviewees.

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Those in urban areas, with far greater access to resources, seem to view regions as general catchment areas surrounding the state's major cities. On the other hand, those in rural settings tend to define regions by geography rather than a circle around a major metropolitan area.

4. What role should different stakeholders have? "Everyone has a role"

A consistent message of accountability was heard from the provider community (hospitals and physicians), all of whom took responsibility for adopting and implementing HIT in their environments. Providers often cited HIT's potential to improve the quality, safety, and efficiency of healthcare and HIT's likelihood to deliver administrative savings to their organizations as justification for their accountability. Other key roles commonly referred to were the desire for payers and purchasers to trade financial incentives for "proof of quality" as facilitated through the implementation of HIT. Ultimately, interviewees shared the view that each stakeholder has a responsibility to contribute. For example, government can use their influence and purchasing power, and consumers, purchasers and employers can use their resources (such as financial, policy, and personnel) to support HIT and HIE.

These descriptions of roles give a clear indication of the responsibility each group of stakeholders is willing to undertake. The leadership role remains undefined and most stakeholders referenced the need for a convening body. Respondents shared the view that a collaborative effort involving all health care industry stakeholders is necessary to successfully implement HIT and build a health information exchange network. Hospitals, physicians, medical associations and societies, as well as the large employers in Texas, were often cited as the groups that should be providing the leadership and facilitating the significant policy discussions. Some included the state government as a collaborative partner in providing the necessary leadership. Most respondents supported the role of the HITAC in facilitating and elevating the HIT discussion and expressed the importance of transitioning this role to a representative group in the longer term.

5. What We Heard - Conclusion

The interviewees were enthusiastic about the prospects for HIT and HIE to improve healthcare for Texans, while also remaining realistic about the challenges ahead. This mix of practical pragmatism is reflected in the incremental approach already underway in Texas. Many pockets of excellence in HIT exist in Texas and many regional initiatives are beginning to address HIE. Specific solutions built around these successes will begin to create the fabric for any appropriate statewide HIE efforts in the future.

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Texas Assessment

E. Organizational Readiness Assessment

1. Background

Successful creation of a health information exchange requires many different levels of organizational planning, leadership and task execution in the market to be served by the HIE. The Foundation's Organizational Readiness Assessment summarized perceptions of organizational readiness and dynamics among a small group of stakeholders in Texas. The purpose of the Organizational Readiness Assessment Tool is to help those who are either considering or in the formative stages of creating a HIE to assess not only where they are in that process, but perhaps even to get useful concepts that may suggest further areas of development. It is a high-level survey. It is not designed to be an empirically robust questionnaire that drills deeply into the technical details of data standards, server choices, portal types, financial operations or clinical metrics. Rather, it was designed having reviewed some of the best literatures and documents available in an effort to formulate some high-level commonalities that are generally present in many of the more successful HIE efforts across the nation.

The Organizational Assessment Tool asks questions that are focused on HIE formation itself. There are six categories critical to HIE formation and sustainability. They are: 1) leadership, 2) activation, 3) vision, 4) governance and management, 5) technical interoperability, and 6) organizational capacity. Each of these categories represent strengths that are critical to the successful operation of any HIE. The questions are designed to yield answers indicating whether or not these six higher level qualities are present or in the planning stages. Leadership: There is leadership at the institutional level to adopt clinical HIT and to establish businessto-business connectivity across and within physician practices and hospital systems. These leaders accept responsibility for change management and motivation of others. Activation: There is an objective, well-respected, authoritative agent, which convenes the community, organizes discussions and activities needed to address legal issues, establishes governance mechanisms, determines the business case, and develops approaches that address the range of stakeholder needs. Vision: There is a strong vision permeating the community to maintain focus and momentum, and prevent potential derailment by individual organizations that may have proprietary priorities. That vision includes moving to a fully interoperable health information exchange.

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Governance and Management: There is an inclusive structure with commitment by key leaders to develop and manage the appropriate governance mechanism. Governance establishes clear responsibilities and processes for executing organizational and community plans as well as for determining how fees will be structured and benefits distributed. Technical interoperability: Involved organizations understand and incorporate technical standards required for interoperability with the ultimate goal that physicians and hospitals must use EHRs as a precondition to connectivity and interoperability. Organizational Capacity: Qualified, consistent and dedicated staff exists within each of the involved institutions for implementation and training to complete the Health Information Exchange infrastructure

Six completed responses were received. Respondents included leaders from Blue Cross Blue Shield, Texas Hospital Association, Critical Connections (pilot program in Austin), and two leaders of academic medical centers. The responses to questions in the six key areas generated a readiness score. The readiness score has a number of meanings: 1. It communicates an across-the-board level of readiness when taking into consideration the organizational needs of successful HIE formation. 2. It allows users to zero in on one or more important attributes of HIE formation and analyze the relative strengths and weaknesses of individual attributes 3. By examining individual attributes, the leaders of a young HIE can use them to help understand what critical areas may need more time and development 4. The tool can be used over time to track progress as a type of high level Gap Analysis.

2. Methods

During the interview process, eHealth Initiative asked 17 health care stakeholders in Texas to complete our Organizational Assessment tool. The tool was provided as an interactive Microsoft® Office Excel document and estimated time for completion by each leader was 10-15 minutes. The tool was delivered by email after individual interviews were completed.

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Texas Assessment

Furthermore, each aspect is scored in two dimensions: development and dynamics. Development corresponds to inputs, which reflect that measured organizations have in place some feature or functionality important to HIE formation; this is indicated by an input of percentages or by a "yes." Dynamics corresponds to inputs in "Planning," which reveals that an organization is moving in a direction conducive to HIE formation. For analysis of survey responses, averages were calculated for each category of higher level qualities, as well as average development, dynamics, and overall scores.

3. Results

The overall organizational readiness score from all respondents is 44 percent. This score corresponds to a medium state of readiness. In early HIE initiatives, the dynamics score is often higher ("planned" responses) than the development score ("yes" responses). For Texas, the development score was 33 percent and the dynamic score was 15 percent. The most common response to questions was "no" and this is reflected in the difference between the development and dynamics score. The six qualities of successful HIE organizations are listed by category in Table 1 below and graphically displayed in Graph 1.

Table 1: Organizational Readiness Assessment Responses by Success Factor Category- overall % of responses Overall

Yes Planning No 33 15 51

Leadership

25 20 55

Activation

27 25 48

Vision

81 6 14

Governance

17 23 60

Interoperability

28 6 67

Org Cap

24 13 63

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100 90 80 70 60 50 Planning 40 No 30 Yes 20 10 0

Leadership

Activation

Vision

Governance

Interoperability

Org Cap

Graph 1: Texas Organizational Readiness Assessment Responses

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Texas Assessment

The quality which currently has the highest score and 81 percent of "Yes" is Vision. This was the only attribute category that recorded a high state of readiness. All other categories of success attributes received a low state of readiness score. For two respondents, the only "Yes" responses recorded were in the Vision category. Only one attribute of Vision earned "Planning" responses and that was "Community Champions are aware that HIE requires risk taking." Attributes related to relationship building, political processes, and trust recorded some "No" responses. However, the second highest attribute category overall, Interoperability, had low readiness scores. Four of 6 respondents, essentially answered "no" for all attributes of interoperability readiness. For the purposes of a statewide Texas HIE, a great amount of work remains in the future addressing interoperability. The qualities of success for Activation had 27 percent of responses recorded as "yes". The pattern of responses shows that the strongest attribute currently is participation in meetings. The weakest attribute is progress in development of a legal structure and contracts as there were no "Yes" responses recorded here. Leadership received a low readiness score. Of note, there is not a universal consensus on the need for HIE in Texas. Participants do not have clear agreement on what participation in an HIE means and at this point, participants have not clearly determined what the shared benefits of participation are.

Respondents indicated that no attention has been paid to financing the HIE system- both initially and in the future. Finally, respondents do not feel that clear and effective communication strategies are in place. Organizational Capacity received an overall low readiness score. Most respondents recorded all "No" responses in this category. The most frequent "Yes," at 50 percent of respondents, was recorded for the attribute "Routine meetings are scheduled to address management, clinical and technical issues." For governance, overall 17 percent of the responses overall were "yes" and this was the lowest scoring attribute category. As Texas is in the early stages of HIE development, there has been little work or planning performed around project management issues and overall schedule and implementation timelines. It is again noted that no work has been done to date on determining fees and benefits accruing to HIE participants, market and regulatory barriers to HIE, and linking of financial controls to project management and implementation schedules.

4. Discussion

Considering the early stage of HIE development in Texas, the overall score of 44 percent (low ­ medium readiness), is not surprising. Work has been done with setting and communicating its vision to participants across both markets. Although, Vision received the highest score of all the attribute categories, more work needs to be done with relationship building and trust.

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Political acceptance of HIE is recognized as being more critical than the technical challenges. Particular leadership concerns highlighted in the survey include an absence of strong planning on both initial and long term financing and the need to more clearly articulate benefits from participating in a HIE initiative. Respondents sense the need to advance agreement terms for participation in HIE. At this stage, most respondents do not perceive a strong sense of ownership and participation in the process. The low score in Interoperability most likely reflects the early stage of an HIE as functionalities have not been finalized. Likewise, low Governance scores are indicative of the early stages of planning for the HIE. Although early in these processes, Texas may want to take this time to study participation requirements, project planning, cost and revenue models that have successfully been used in other HIE initiatives to optimize their starting knowledge base. Although Organizational Capacity attributes were generally not in place at this time, most of these attributes represent needed elements when an HIE initiative is close to final delivery and use. However, prior knowledge of what the critical attributes will be for successful launch and early operation of an HIE initiative will help as Texas stakeholders begin planning now and anticipating the critical elements of success they will want to employ.

5. Recommended next steps

Based upon the responses to the organizational readiness assessment, there are several main areas for Texas stakeholders to focus on to maximize successful implementation and long term operations of an HIE initiative: 1. Dedicate resources and time to business model and long term sustainability development- gather knowledge from existing HIE initiatives. 2. Develop consensus on what participation in a HIE initiative means- determine what is required of members and clearly articulate the benefit and value that each stakeholder will receive in exchange for participation. Develop a legal structure for HIE operations. 3. Communicate to physicians the value of HIE- both to their practice and to their patients. Create awareness of needed criteria for successful communications on launch, user training, and user acceptance. 4. Communicate to communities the need for HIE-why an HIE initiative is valuable and how it will impact their lives. 5. Build participant and organizational awareness of the crucial success factors and attributes that contribute to the long term success of local and regional HIE.

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Texas Assessment

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Texas

V. Privacy Regulations

There are numerous laws and regulations both at the Federal and Texas state levels that impact the privacy and security of health information. Ideally, health care stakeholders need be informed as to the manner in which these laws may affect the use of HIT and / or their participation in a health information exchange that involves the sharing of patient information. This section highlights the potential for confusion and misunderstanding surrounding compliance with the Health Insurance Portability and Accountability Act of 1996 (HIPAA) Privacy Rule requirements and offers a listing of medical privacy laws (not an exhaustive list) that affect stakeholders in Texas. All organizations subject to HIPAA must fulfill all legal requirements relating to disclosures, recordation, and accounting of disclosures. Despite the fact that the Privacy Rule has been in effect for 3 years, there continues to be misunderstanding and confusion regarding the rules of disclosure. This statement is supported by the fact that the top allegation raised most frequently in complaints to the Office of Civil Rights of the Department of Heath and Human Services continues to be "the impermissible use or disclosure of an individual's identifiable health information."38 The "Accounting of Disclosures"39 rule outlines specific exceptions to the legal requirement to record disclosures along with other information and legal mandates. For example, the rule states:

"An individual has a right to receive an accounting of disclosures of protected health information made by a covered entity in the six years prior to the date on which the accounting is requested, except for disclosures..."40

The rule then lists exceptions to the general rule to account for disclosures. Another area relating to disclosures is 45 CFR § 164.514 (d) (ii) (A) which places a burden on covered entities that make non-routine disclosures to "develop criteria designed to limit the protected health information disclosed to the information reasonably necessary to accomplish the purpose for which disclosure is sought..." Consequently in order for covered entities to "develop" criteria they must be aware of these non-routine disclosures, or actually track these types of disclosures.

45 Please see http://www.hipaadvisory.com/news/NewsArchives/2005/sep05.htm. As of August 31,2005 Office of Civil Rights(OCR) had received over 14,900 complaints concerning improper disclosure - 68% of which have been closed. OCR has referred 231 cases to the Department of Justice for criminal investigation." 46 45 CFR § 164.528 47 45 CFR § 164.528 (a) (1).

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Texas Assessment

The Department of Health and Human Services stated in relation to non-routine disclosures and the `Accounting of Disclosures' rule:

A summary listing of medical privacy laws that affect stakeholders in Texas includes: · The Federal HIPAA Regulations; · The Family Education Rights and Privacy Act, or FERPA; · The Texas Health and Safety Code; · The Occupations Code of Texas; · The Texas Board of Medical Examiners Rules; · The Hospital Joint Commissions Standards relative to Privacy.

"The accounting requirement was designed as a means for the individual to find out the nonroutine purposes for which his or her protected health information was disclosed by the covered entity, so as to increase the individual's awareness of persons or entities other than the individual's health care provider or health plan in possession of this information."41

In other words these are the types of disclosures that need to be recorded in order to provide individuals with a proper accounting of all appropriate non-routine disclosures.

A more thorough assessment of the legal issues and Texas state laws and regulations that influence HIT and HIE will be necessary to ensure that HIE solutions designed in Texas have the highest probability of success. This assessment will take place at a later date. State law could be a help or a hindrance to Texas' HIT and HIE initiatives. Laws passed with consumer privacy or other worthy goals in mind might serve as roadblocks to technology that would provide consumers with better and more cost effective care. Elements to be considered, for example, in performing a complete legal assessment include laws and regulations dealing with privacy and security, fraud and abuse, and any Texas specific anti-trust issues. In some states, legislative and regulatory reform has been needed to facilitate the adoption of HIT and formation of HIE organizations.

48 Federal Register / Vol. 67, No. 157 / Wednesday, August 14, 2002 / Rules and Regulations 53245

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Texas Assessment

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Texas

VI. Conclusion

Overall, based on the landscape, interviews, and readiness assessment, it is evident that Texas has the potential to make significant progress in the widespread adoption of HIT and the implementation of HIE. While there are some broad common principles guiding current HIE efforts, currently there is no single strategy or mechanism to accomplish a statewide objective of improving healthcare quality, cost, and efficiency through use of HIT and HIE. There exists a "medium state" of readiness through Texas. The HITAC has elevated and facilitated the discussion of these topics and in coming months will present its Roadmap findings and recommendations. The Roadmap will require multi-stakeholder coordination across the state in order to establish priorities, synchronize with national and regional priorities, mitigate common barriers, and establish needed policies to promote the design and development of a state-specific foundation to enhance HIT adoption and the creation of HIE initiatives. There is a long road ahead for Texas to achieve widespread adoption of HIT and the implementation of HIE. Difficult decisions will be required to be made in regards to the role of the state, the influence of regions, participation of rural and underserved communities, and how HIT and HIE efforts may be funded. Processes for making these decisions will begin to be defined through the Roadmap over the next several months and should result in a combination of public and private action and commitment.

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Texas Assessment

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Texas

VII. Appendices

Appendix A: Recent Federal Legislation

1. Progress on HIT Legislation at the Federal Level

During the 109th Congress, health information technology (HIT) legislation made significant advances. In summary, twenty stand-alone bills have been introduced, most bi-partisan with unprecedented collaboration between Republicans and Democrats on the importance of leveraging HIT and the mobilization of information to address healthcare challenges. Specifically, these advances include: · Appropriations to fund the Office of the National Coordinator for Health Information Technology (ONC) nearly doubled from FY 2006 to 2007. · Passage of legislation establishing a federal role for HIT coordination and standards (S 1418) was approved by the Senate, the first time a stand-alone bill was passed by at least one House of Congress. · Pay-for-Performance legislation was included in Senate-passed Budget Reconciliation legislation, but later dropped in conference. Outlook for a House HIT bill in 2006 is brightening. Proposed legislation introduced by Republicans Nancy Johnson of Connecticut and Nathan Deal of Georgia would, among other things, increase the use of electronic medical records, reduce health care costs, and clarify current privacy rules applicable to health information stored or transmitted electronically (Health Information Technology Promotion Act - HR 4157). On June 15th, 2006 the House Ways and Means Committee voted 23-17 to approve HR 4157. The House Energy and Commerce Committee approved their version of the bill on the same day by a vote 28-1. If a final House vote occurs, then the House sponsored bill could be streamlined and reconciled with the Senate HIT bill (The Wired for Health Care Quality Act ­S. 1418) passed in 2005 into one uniform piece of proposed legislation to be voted on by both chambers of Congress and, eventually, the President. Given Congress' compressed schedule this year and mid-term elections looming, experts view the likelihood of a final bill being enacted into law as no higher than 50 percent. As is often the case in politics, however, anything can happen.

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Texas Assessment

The following pages summarize the previous year's key bills introduced to date. · (H.R. 747) National Health Information Incentive Act (McHugh, R-NY and Gonzalez, D-TX) ­ (February 2005): Amends title XI of the Social Security Act to achieve a national health information infrastructure, and amends the Internal Revenue Code of 1986 to establish a refundable credit for expenditures of healthcare providers implementing such infrastructure. The purposes of this legislation are to develop and test national standards and to create incentives to encourage physicians to adopt health information technology (including electronic health records, electronic prescribing systems, evidencebased clinical support tools, patient registries, and technology to improve patient care). It also authorizes the creation and the necessary funds for the Office of the National Coordinator for Health Information Technology. · (H.R. 2234) 21st Century Health Information Act (Kennedy D-RI, Murphy R-PA) ­ (May 2005): Calls for legislative provisions that transform the healthcare system by preventing medical errors, improving the use of best practices in medicine, reducing unnecessary duplication, streamlining administration, creating research and public health monitoring opportunities and changing quality reporting. It provides grants for regional HIE networks, allows for Medicaid payments for information infrastructure for health information

network and IT, adopts HIT products certification criteria and governance processes, provides for adjustments to Medicare payments to providers and suppliers participating in HIT, and amends Stark regulations. · (S.1227) Health Care Quality Improvement Act of 2005 (Stabenow ­ D-MI, Snowe ­ R-Maine) ­ (June 2005): Provides for grants for healthcare providers to adopt healthcare information technology and modifies Medicare's payment system to reward providers for using healthcare IT. The bill offers funding to providers to purchase, lease or install IT, improve or upgrade existing technologies or pay for electronic health records systems. In addition, the bill creates a reserve fund for rural hospitals to pay for IT and promotes the adoption of healthcare IT standards. · (S.1355) Health Information Technology Quality and Improvement Act (Enzi-R-WY, Kennedy-DMA) ­ (June 2005): The introduction of the Health Information Technology Quality and Improvement Act of 2005 and the Medicare Value Purchasing Act of 2005 (S. 1356) marks a major milestone in a three-year effort to drive improvements in healthcare quality and safety through the adoption of information technology. The bi-partisan legislation was jointly introduced late June in bills by Senators Chuck Grassley (R-IA) and Max Baucus (D-MT) of the Senate Finance Committee and Senator. Michael Enzi (R-WY) and Ted Kennedy (D-MA) of

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the Senate Health Education, Labor and Pensions (HELP) Committee. This legislation has the ability to accelerate the use of information technology to improve healthcare quality and patient safety, by recognizing the key policies that will accelerate its adoption, including those related to interoperability and data standards, privacy and security, incentives and grant programs, and the role of the Federal government. Together, the bills recognize the importance of the need for funding to support providers, states, and regional or local health information networks as they begin to invest in health information technology to support improvements in healthcare. The Medicare Value Purchasing Act of 2005 integrates the use of health information technology into its payment programs while the Health Information Technology Quality Improvement Act calls for grants and loan programs. · (S. 1356) The Medicare Value Purchasing Act of 2005 (Grassley, R-IA and Baucus, D-MT) ­ (June 30, 2005): This bill ntegrates the use of health information technology into its payment programs. A revised version of the bill was placed into budget legislation passed by the Senate on November 3, 2005 as part of The Deficit Reduction Omnibus Reconciliation Act of 2005.

· (S. 1418) The Wired for Health Care Quality Act (Enzi-R-WY, Frist-R-TN, Kennedy-D-MA, ClintonD-NY) ­ (July 2005): The Wired for Health Care Quality Act was passed by the Senate Health, Education, Labor and Pensions Committee on July 20, 2005 and was approved by unanimous consent in the Senate on November 18, 2005. The legislation contains health information technology-related provisions on development of quality measurement systems related to improve patient care, competitive grants for qualified health information technology and implementation of regional or local health information technology plans, state loan programs, demonstration projects, certification, interoperability, privacy and security, standards and other issues. It establishes the American Health Information Collaborative - public-private consultation on standards development. Codifies Office of the National Coordinator for HIT (ONCHIT). Provides grants to providers and regional health networks. Establishes grants for: - Implementation of regional/local HIT Plans - Physicians, hospitals, or other healthcare providers - State loan programs for sustainability Total grants: $125 million in '06, $150 million in '07 and such sums as needed thereafter.

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Texas Assessment

· (H.R 4157) Health Information Technology Promotion Act (Johnson-R-CT) ­ (July 2005): This bill, passed by the House in July 2006, proposes to codify ONCHIT, headed by the National Coordinator, which is responsible for activities, such as: - Principal advisor to Secretary on development and use of HIT - Standards harmonization for use in exchange of health information - Certification/inspection of HIT products, services and architecture This draft legislation also requires study for harmonization of state laws and regulations regarding security and confidentiality of health information and requires rule-making for adoption of ICD 10 codes. It also provides exemption from Stark, AntiKickback and other statutes for any non-monetary remuneration. It requires remuneration without regard to the number or value of physician referrals and requires HHS Secretary to conduct a study on safe harbor effectiveness in increasing HIT adoption. Effective 180 days after bill enactment. This large group of pending and passed legislation establishes an excellent framework for legislative action on the use of HIT to improve the safety, quality, and efficiency of healthcare.

2. Improving Quality of Care in Medicare

The Medicare Value Purchasing (MVP) Act of 2005 requires the Secretary of Health and Human Services to develop and implement value-based purchasing programs under Medicare for acute-care hospitals, physicians and practitioners, Medicare Advantage plans, end-stage renal disease (ESRD) providers, and home health agencies, and to take some initial steps toward value-based purchasing in skilled nursing facilities. This legislation takes a critical step toward addressing the problems of increasing healthcare costs and the need for improvement in patient safety and quality of care.

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3. Principles for Medicare Value Purchasing:

· Involve stakeholders: Involve providers, beneficiaries, payers, and other experts in developing and implementing the program. · Two-phase program: In the first stage, Medicare reimbursement updates will be tied to reporting data on quality measures. In the second stage, a portion of total payments will be tied to quality performance. Providers will be rewarded for meeting threshold levels of quality and for improving the quality of care they provide. · Phased-in approach: The portion of total payment tied to quality of care will be 1 percent in the first year, scaling up to 2 percent over a 5-year period. · Increase transparency: Data on quality of care will be made available in a useable manner to Medicare beneficiaries and the public.

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Texas Assessment

Appendix B: Existing Statewide HIE Initiatives

Provided as a summary of the statewide HIE Initiatives around the United States. While there is activity in the vast majority of states, implementation of statewide HIE remains elusive and progress towards that end is possible only through a broad statewide collaboration.

3. Arizona

Through executive order, in 2005, Governor Janet Napolitano requested a wide range of interests convene to determine a strategy to achieve a vision of 100% electronic health data exchange between payers, health care providers, consumers of health care, researchers and government agencies. Roadmap issued April 2006. Hundreds of Arizonans representing diverse interests and geographies voluntarily contributed to the process. www. azgita.gov/tech_news/2005/ehealth/E_Health.htm

1. Alabama

Alabama efforts are part of Gulf Coast response. Funded by Federal contracts.

4. Arkansas

State Department of Health and Human Services considering role as convener.

2. Alaska

The Alaska Telehealth Advisory Council (ATAC) was established in 1999 to provide a forum that enhances collaboration and communication between organizations involved in telehealth initiatives. ATAC members provide direction, leadership and coordination of telehealth efforts throughout Alaska. It includes representation from telecommunication companies, hospitals, health care organizations, the University of Alaska, the State of Alaska, the Alaska Native Tribal Health Cooperation, federal agencies and insurance agencies. ATAC is co-chaired by Karleen Jackson, Commissioner of the Department of Health and Social Services and Paul Sherry, Chief Tribal Officer of the Alaska Native Tribal Health Consortium (www.hss.state.ak.us/ COMMISSIONER/default.htm).

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5. Califormia

CALRHIO was assembled by the Health Technology Center (HealthTech). CALRHIO is a group of senior healthcare leaders - who share the vision for a safer health care system - to lead and guide this effort. These individuals serve on a statewide steering group and are organizing work groups to move the initiative forward Legislative action: SB1338 (Introduced February 17, 2006) This bill would require the department and the agency to jointly establish and operate the California Health Care Infrastructure Authority, to improve the quality of health care in California and to reduce the cost of health care through the advancement of health information technology. The bill would require the authority to develop a plan to ensure that every Californian will have an electronic health care record and would specify the required contents of the plan. www.calrhio.org

6. Colorado

The Colorado Regional Health Information Organization (CORHIO) Initiative is a statewide coalition of interested individuals, healthcare providers, agencies, organizations and community leaders, collaborating to build a statewide electronic health information network and launch a new type of non-profit entity ­ a regional health information organization or RHIO. Supporters from around the state are working together to develop a business plan and are seeking financial support to launch the nonprofit CORHIO by mid-2006 (www.coloradohealthinstitute. org/hot_issues/corhio.htm).

7. Connecticut

Gov. M. Jodi Rell (R), Rep. Nancy Johnson (R-Conn.), and a statewide health care coalition announced in January 2006 the launch of eHealth Connecticut, a health records network that will allow providers to share information electronically. A pilot program later in 2006 will begin to electronically gather and exchange outpatient records from three clinics, Waterbury Hospital, and St. Mary's Hospital. The pilot should help officials develop the statewide system, which is expected to start operating within the next two years.

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Texas Assessment

8. Delaware

The Delaware Health Information Network (DHIN) was created by an act of the General Assembly and signed into law in 1997 as a public instrumentality of the state to advance the creation of the statewide health information and electronic data interchange network for public and private use. The DHIN organization falls under the purview of the Delaware Health Care Commission. DHIN is a public / private partnership that provides the organizational infrastructure to support a clinical information sharing utility. The development of the clinical information sharing utility is the primary focus of DHIN at this time (www.dhin.org/default.cfm).

10. Georgia

Georgia executives -- representing providers, government agencies, insurers, and large employers --gathered June 15, 2005 to work toward making electronic medical records flow smoothly among health- care providers. Georgia Strategic Local Implementation Process (GSLIP) may become sponsoring / convening organization.

11. Hawaii

The Hawaii Health Information Corporation (HHIC), a collaborative including over sixty organizations ranging from hospitals, health plans, state government, laboratories, physician groups and associations among its membership. Primary activity is data archive. Responded to ONCHIT request for information on RHIOs.

9. Florida

On May 4, 2004, Governor Bush issued Executive Order Number 04-93 creating the Governor's Health Information Infrastructure Advisory Board. The Board was established to advise the Agency for Health Care Administration as it develops and implements a strategy for the adoption and use of electronic health records. Since the appointment of Board members in June, the Board has actively sought to educate itself and the Agency through workshops and public forums. The Board has facilitated an intensive planning process and provided an opportunity for physicians, nurses, pharmacists, dentists, hospital administrators, health insurers, community groups, and many others to contribute their expertise (www.fdhc.state.fl.us/dhit/index.shtml).

12. Idaho

Legislative Action ­ In March, 2006, both houses passed and the Governor signed into law HB 738, which establishes the Health Quality Planning Commission to perform a study on HIT in Idaho and assist in the implementation of a final plan for the creation of an HIT System.

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13. Illinois

State bill 2345 passed both houses May 28, 2005. This bill created the Electronic Medical Records Taskforce with the intent to create a plan for the development and utilization of electronic medical records in the state. Also Northern Illinois Physicians For Connectivity aims to foster both a secure network for healthcare data exchange and a consortium for purchasing computer hardware, software, and IT consulting services. NIPFC incorporated in December 2005 and pursuing non-profit status (www.niphysiciansforconnectivity.org/about.htm).

15. Iowa

Iowa has two bills being reviewed by committees. The bills would establish an HIT Advisory Committee and provide for the incremental implementation of an electronic health records system.

16. Kansas

Kansas Health Care Cost Containment Commission (H4C) created by Executive Order 04-14. This commission has undertaken development of a statewide roadmap for health information exchange to be completed by fall 2006. As the convening group, the H4C has engaged stakeholders from across Kansas in a shared vision for HIE.

14. Indiana

Indiana Health Information Exchange (IHIE). The company's first service is a community-wide clinical messaging service, which provides physicians with a single source for clinical results including laboratory/ pathology , radiology, and electrocardiogram reports, transcriptions, and ED and hospital encounter information from all participating central Indiana hospitals. IHIE's clinical messaging service delivers clinical reports to the responsible providers electronically reducing costs for the health care data provider and improving efficiency and usability for the recipient. The health care data providers send clinical reports electronically; the clinical messaging software converts them into a consistent, easy to use report format and delivers them to the responsible provider (www.ihie.com).

17. Kentucky

Kentucky e-Health Network. The network was created by legislation known as the "e-Health bill" (Senate Bill 2) passed by the 2005 General Assembly and signed into law by Governor Fletcher. Senate Bill 2 focuses on the need to develop a secure electronic network that will allow health care providers to share medical information about patients through a paperless system, without reducing patient privacy. The network would allow faster and more accurate information sharing to reduce mistakes, inefficiencies and administrative costs ­ all resulting in better patient care (http://chfs.ky.gov/ehealth/)

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18. Louisiana

Louisiana is participating in several statewide initiatives during 2006. As a product of the hurricane season in 2005, Louisiana is the lead state in a multi-state effort to assess and plan for HIT and HIE adoption across the Gulf States. Additionally, Louisiana has been designated as a separate test case for the implementation of a demonstration National Health Information Infrastructure (NHIN). Within Louisiana, strong leadership is being provided by the Governor's office and the Louisiana Department of Health and Hospitals.

19. Maine

The Maine Health Information Network Technology (MHINT) project is a statewide system being designed to: 1) Improve patient safety and the quality of clinical care by providing clinicians with timely, accurate and secure patient-specific information at point-of-care; 2) Create a virtual electronic health record of critical information accessible to all participating clinicians and consumers; and, 3) Assure that clinicians caring for patients who may not have a single-source medical record, e.g. uninsured or underinsured patients who may not have a primary care provider, will have access to clinical information necessary for appropriate treatment planning. This highly coordinated, statewide electronic clinical information-sharing system is being developed so that it can be fully integrated with efforts by individual providers and hospitals in Maine to develop electronic medical records (EMRs). The MHINT system is intended to dovetail with the emerging national health information system infrastructure (www.mhint.org/). In spring 2006, the organization assumed its separate identity as HealthInfoNet (http://www.hinfonet.org/), governed by a board of nineteen healthcare leaders from the public and private fields.

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20. Maryland

The Maryland / D.C. Collaborative is a non-profit 501(c)(3) corporation, whose specific mission is: "To work collaboratively with Maryland and Washington, D.C. healthcare providers and organizations to improve quality of care, patient safety, and efficiency through healthcare information technology." The partnership now includes community hospitals, CareFirst Blue Cross Blue Shield and the region's major academic healthcare systems ­ Johns Hopkins Medicine, University of Maryland Medicine, and MedStar Health ­ and seeks to involve patients, payers, employers, ancillary centers, and the Federal and State Government in planning, design and implementation of a secure, HIPAA-compliant, regional healthcare information infrastructure (RHIO). The Collaborative's primary objective is the establishment a RHIO infrastructure linking all components in the Maryland/D.C. healthcare delivery chain ­ physician offices, hospitals, clinics, labs, imaging centers, nursing homes, payers and patients ­ to secure, and appropriate, exchanges of health information. This interoperable environment will enhance communication of patient information, quality of care, patient safety, disease management capabilities, patient and provider satisfaction, clinical and administrative cost reductions, and bio-surveillance/early detection preparedness. (www. collaborativeforhit.org/)

21. Massachusetts

Massachusetts-SHARE (Simplifying Healthcare Among Regional Entities) is a regional collaborative initiative operated by the Massachusetts Health Data Consortium. MA-SHARE seeks to promote the interorganizational exchange of healthcare data using information technology, standards and administrative simplification, in order to make accurate clinical health information available wherever needed in an efficient, cost-effective and safe manner. MA-SHARE seeks to foster improvements in community clinical connectivity, allowing appropriate sharing of inter-organizational healthcare data among the various participants in the healthcare system ­ including patients, doctors and other practitioners, hospitals, government, insurers, HMOs and other payers. The MA-SHARE operating model is generally conceived as that of a facilitator and incubator, in which projects exploring healthcare data connectivity will be undertaken in order to develop, pilot, and demonstrate new healthcare information technologies across communities and enterprises. The MA-SHARE clinical connectivity vision is to design technology solutions that assemble, organize, and distribute a variety of up-to-date clinical information to a broad range of clinical settings; all accomplished in a secure, confidential manner. (www.mahealthdata.org/ma-share/)

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22. Michigan

Statewide planning sponsored by Michigan Department of Community Health.

24. Mississippi

Mississippi is in the early stages of HIT adoption with "islands of connectivity" primarily between hospitals and their medical staffs. Mississippi is represented on the Southern Governor's Associations Gulf Coast Task Force for HIT grant from RWJ and HHS. The MS QIO, Information & Quality Healthcare(IQH) is the designated contractor for the HISPIC proposal via RTI, INC. Mississippi efforts are part of Gulf Coast response. Funded by Federal contracts.

23. Minnesota

Legislative initiation of HIE activity included: HF139: The commissioner shall establish a Health Information Technology and Infrastructure Advisory Committee governed by section 15.059 to advise the commissioner on the following matters: (1) assessment of the use of health information technology by the state, licensed health care providers and facilities, and local public health agencies; (2) recommendations for implementing a statewide interoperable health information infrastructure, to include estimates of necessary resources, and for determining standards for administrative data exchange, clinical support programs, patient privacy requirements, and maintenance of the security and confidentiality of individual patient data; and (3) other related issues. SF107: Identical to HF139. Subsequently the Minnesota Department of Health has assumed a convening role for statewide HIE activity. A statewide strategic plan for HIE is to be issued in 2006. (www.health.state.mn.us/ehealth/index.html)

25. Missouri

Gov. Matt Blunt introduced the Missouri Healthcare Information Technology Task Force in his State of the State Address and signed Executive Order 06-03 in early 2006 to officially create the task force. Blunt created the task force to ensure that healthcare information can be readily available to health care providers, consumers, and public health agencies in order to make the best healthcare decisions and to improve patient safety by reducing medical errors. The task force's preliminary recommendations will be due July 1 and the final report will be due on September 1 of this year. The task force will expire on Dec. 31, 2006.

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26. Montana

2005 - Unsuccessful application for NHIN contract other activity undetermined.

28. Nevada

Southern Nevada RHIO was established by the Southern Nevada Medical Industry Coalition (SNMIC) and expects the transition to an interoperable exchange to be a 10-year process. The Southern Nevada RHIO is currently working with major employer groups, insurance companies and health professionals, including the culinary union, Sierra Health Services, Fremont Medical, Clark County Health District and Health Insight. The Southern Nevada RHIO Phase I, linking transactions through a newly created hub, hopes to be operational by early 2007. (http://www.snmic.com/)

27. Nebraska

NeHII, or the Nebraska Health Information Initiative, (inclusive of the Nebraska Biomedical Informatics Project and the Nebraska Telehealth Project), chose HealthAlliant to lead a visioning exercise which coalesced disparate stakeholders statewide. This agreement paved the way for creation of the business model for the nation's first statewide RHIO. Among the participants are the University of Nebraska Medical Center, the Nebraska Hospital Association, the Nebraska Medical Association, a variety of health systems, and Blue Cross and Blue Shield of Nebraska. Notably, the effort is aimed at bringing together existing, successful programs such as a rural healthcare access initiative, disease-specific programs, electronic medical records efforts and quality and safety improvement programs.

29. New Hampshire

Statewide HIE strategic planning program established under the direction of the Governor in 2006. This effort convened under the authority of the existing NH Citizens Health Initiative which includes 150 stakeholders in various workstreams including HIE. Assessment to be competed in summer 2006. (www.steppingupnh.org/ hhsonline/nhchi/about.asp)

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Texas Assessment

30. New Jersey

Historical activity included the establishment of the Healthcare Information Networks and Technologies group under a legislative act, commonly known as "HINT," which required the Commissioner of the Department of Banking and Insurance (DOBI), in consultation with the Commissioner of the Department of Health and Senior Services (DHSS), to: Establish by regulation timeframes for payment of "clean" insurance claims by health insurance carriers. These are the so-called "prompt pay" provisions of the HINT law. In addition, the HINT law called for the establishment of a timetable by the Commissioner of DOBI, tied to the federal Department of Health and Human Services' adoption of rules establishing electronic standards for health care administrative transactions. HINT requires DOBI to specify one set of standard health care enrollment and claims forms in paper and electronic formats to be used by each carrier and third party administrator (TPA) in all health care transactions completed within the State, with the electronic formats conforming to the federal standards. In April 2003 the HINT group issued a report identifying the short and long term needs to advance HIT and HIE in NJ. Subsequent activity has been led from both private and public entities, and appears poised for a state-wide scope again in 2006. (http://www.state.nj.us/dobi/hint.htm)

31. New Mexico

New Mexico Healthcare Information Collaborative. A community-wide effort to build a health information exchange whose objective is: to allow the sharing of timely and privacy protected health care information among health systems and plans. This is a 3-year project; $1.5 million AHRQ grant plus $1.5 community match; initiated October 2004. (http://www.nmhic.org )

32. New York

New York State Department of Health is sponsoring statewide activity through the Health Care Efficiency and Affordability Law (HEAL) to 1) Identify and support development and investment in HIT Initiatives on a regional basis and 2) to identify and support the funding of restructuring plans undertaken in regional health care service delivery areas that result in improved stability, efficiency, and quality of health care in the region. (www. health.state.ny.us/funding/rfa/0508190240/index.htm)

33. North Carolina

Governor chartered North Carolina Healthcare Information and Communication Alliance (NCHICA) to accelerate adoption of Healthcare Information Technology in NC. This non-profit established in 1994. Ongoing coordination of local and regional projects. (www.nchica.org)

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34. North Dakota

The North Dakota General Assembly has not introduced any HIT legislation; however U.S. Senator Kent Conrad hosted the 2006 North Dakota HIT Summitt (April 18, 2006) to bring to light the importance of implementing a statewide HIE- hopefully this will result in new statewide legislation.

37. Oregon

The Oregon Health Care Quality Corporation is working collaboratively to make Oregonians' health record information available to them and their providers anytime and anywhere that it is needed, while assuring that records are confidential and secure at all times. The Oregon Health Information Infrastructure (OHII) project is a collaborative catalyst effort with many partners that will lead to a regional, sustainable organization to manage health information exchange. (www.q-corp.org/default.asp?id=13)

35. Ohio

Statewide discussions of the potential for HIE convened by the Health Policy Institute of Ohio. Project titled Ohio Health Information Technology (OHHIT) includes broad stakeholder participation. Assessment completed in 2005. (www.healthpolicyohio.org/publications/HIT.html)

38. Pennsylvania

The Pennsylvania eHealth Initiative is a collaboration of over 40 health care-related organizations that plan to create an electronic patient data network that will ultimately tie into a national system allowing patients and doctors to securely access medical records throughout the country. The initiative will work with providers, health insurers, businesses, and government to facilitate the use of information technology to improve the quality, efficiency, and safety of health care for all Pennsylvanians. (www.paehi.org/)

36. Oklahoma

Considering state sponsorship of HIE activity through OU. Waiting for NGA grant. HB 2842, known as the "Oklahoma Medicaid Reform Act of 2006", passed both houses and was signed into law by the Governor in June 2006. Section 4 calls for the Oklahoma Health Care Authority to conduct a needs analysis to design a webbased database of clinical utilization information or EMRs for Medicaid providers. A report is due by January 1, 2008. The Authority shall also design and implement an e-prescribing pilot program.

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Texas Assessment

39. Puerto Rico

Convening group being created led by PRHIN

41. South Carolina

Introduced legislative action includes statutes establishing teams to develop HIE plans: SB305: The Director of the Office of Information Technology of the State Budget and Control Board shall convene an Information Technology Planning Team to develop plans for the efficient and effective use of information technologies by health and human service agencies. The Director must include an equal number of private sector information technology professionals on the team. The purpose of the advisory committee is to benefit the public agencies with the expertise of the private sector in designing and managing health and human service agency information systems. HB4034: The Department of Health and Human Services shall convene an interagency team of information technology professionals to develop plans for the efficient and effective use of information technologies by health and human service agencies.

40. Rhode Island

The Rhode Island Health Improvement Initiative (RIHII or "the Initiative") will demonstrate that appropriate, science-based, cost-effective care can be delivered consistently across an entire medical community, resulting in better quality and significantly lower costs. This will be accomplished by reorganizing the delivery of health care: more specifically, by implementing a full suite of clinical information systems and process improvements across the entire community of physicians; interconnecting the physicians, hospitals, labs, imaging systems, and other providers within the community; encouraging adoption of best practice innovations with economic and non-economic incentives; and creating a local governance structure. RIHII will measure the improvements in health care quality and cost savings and use these achievements to attract investment into the initiative from the State's health care purchasers. (www.riqi.org/projects.htm)

42. South Dakota

South Dakota has not yet introduced any legislation related to HIT, HIE, or electronic medical records.

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43. Tennessee

Governor Phil Bredesen announced in early 2006 establishment of a statewide council to guide the ongoing development of eHealth initiatives across the state. Since Bredesen's State of the State address in 2002 where he pledged resources to build Tennessee's health information infrastructure to both help Tennesseans and be a model for the nation, a portfolio of eHealth initiatives have launched across the state. The Council will guide ongoing eHealth initiatives in Tennessee to ensure interoperability, facilitate the definition of uniform standards, eliminate duplication of effort and reduce competition for resources.

45. Utah

The Utah Health Information Network (UHIN) is a broadbased coalition of health care insurers, providers, and other interested parties, including the State government. UHIN participants have come together for the common goal of reducing health care administrative costs through data standardization of administrative health data and electronic commerce (EC). UHIN has a centralized health data transaction system. UHIN is the hub for this system. UHIN is a State not-for-profit company so it only charges enough to cover the costs of running the network. UHIN began operations in 1994. (www.uhin.com/)

44. Texas

The Texas Statewide Health Coordinating Council (SHCC) has named an advisory committee to develop a long-range plan for the use of health care information technology in Texas. The Health Information Technology Advisory Committee was mandated by Senate Bill 45, passed during the 79th Regular Session of the Texas Legislature (2005). The health care information technology plan will cover use of electronic medical records, computerized clinical support systems, computerized physician order entry, regional data sharing and other methods of incorporating information technology to improve patient outcomes and cost effectiveness. (www.dshs.state.tx.us/chs/shcc/)

46. Virginia

Secretary of Health and the Secretary of Technology are working together to form a government course on HIE. Privately founded MedVirginia, created to organize, coordinate and serve provider interests in health care information technology by providing a system for community-wide clinical data and information exchange that enables and supports improved business and clinical transactions. MedVirginia, established in 2000, is a Virginia Limited Liability Company. Initial investors in MedVirginia are CenVaNet, a leading hospital and physician owned network based in Richmond, VA, and MedAtlantic, an affiliate of the Virginia Urology Center. (www.medvirginia.net/)

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Texas Assessment

47. Vermont

The Vermont Information Technology Leaders (VITL) is a multi-stakeholder corporation formed by the Vermont Association of Hospitals and Health Systems (VAHHS) and a broad base of providers, payers, employers, patients, state agencies, information technology vendors and other business leaders. The group has created a health information technology strategy for Vermont in collaboration with the federal Office of the National Coordinator for Health Information Technology (ONCHIT) and the eHealth Initiative. The VITL organization is working to implement health information infrastructure for data sharing. VITL's efforts facilitate communication among Vermont's health information technology experts and lay the foundation for further HIT collaboration. (www.vitl.net)

48. Washington

Recently passed bills included statutes establishing teams to develop HIE plans: SB5064: The Washington state health care authority, in collaboration with the advisory board, shall develop a strategy for the adoption and use of electronic medical records and health information technologies that are consistent with emerging national standards and promote interoperability of health information systems.

49. Wisconsin

Wisconsin Governor Doyle issued Executive Order 129 on November 2, 2005, creating an eHealth Care Quality and Patient Safety Board, which will be charged with developing a plan to automate all health care information systems in Wisconsin. The Wisconsin eHealth Action Plan for Health Care Quality and Patient Safety will articulate a path to improve the quality and reduce the cost of healthcare in Wisconsin through fostering a statewide health information infrastructure. Workgroups meeting during summer / fall 2006 with a final report by year end 2006. (http://ehealthboard.dhfs.wisconsin.gov/)

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50. West Virginia

The West Virginia eHealth Initiative (WVeHI) is a coalition of representatives from health care, business and state government. Its purpose is to promote the broad adoption, use and coordination of information technology in health care. The WVeHI works with providers, health insurers, businesses, and government to facilitate the use of information technology to improve the quality, efficiency, and safety of health care for all West Virginians. The WVeHI works toward the goals of the Office of the National Coordinator for Health Information Technology to fulfill West Virginia Governor Joe Manchin's pledge "to put critical health care information in the hands of doctors and caregivers at the time they need it most ­ when care is delivered," putting special emphasis on encouraging the use of technology in rural areas. (http://www.wvehi.org/)

51. Wyoming

Wyoming Heathcare Commission was created in 2004 to address a range of health care issues. It issued a report in 2005 calling for an initial $41 million investment in health information technology in Wyoming. In 2006 the Wyoming Senate stopped legislation that would have made Wyoming the first state in the country to create an electronic health records network, the Casper Tribune reports (Nordby, Caper Tribune, 2/24). Opponents of the bill questioned whether the multimillion-dollar system would actually be launched. State Sen. Phillip Nicholas (R) said he had "grave concern as to whether the plan [would] ever work," the Associated Press reports. Critics of the bill also cited privacy concerns. The bill's supporters argued that the proposed EHR network would reduce health care costs and improve care (Associated Press, 2/24). (www.wyominghealthcarecommission. org/reports.html)

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Texas Assessment

Appendix C: Senate Bill 45 ­ Establishment of the Health Information Technology Advisory Committee

An ACT relating to the establishment of an advisory committee on health care information technology. BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:

Section 1.

Subchapter B, Chapter 104, Health and Safety Code, is amended by adding Section 104.0156 to read as follows: Sec. 104.0156. Health Care Information Technology Advisory Committee. (a) The statewide health coordinating council shall form an advisory committee on health care information technology. The committee must include representatives of interested groups, including the academic community, health plans, pharmacies, and associations of physicians, hospitals, and nurses. The committee must also include at least one member with at least 10 years of experience in the health care information technology industry.

(b) The advisory committee shall develop a longrange plan for health care information technology, including the use of electronic medical records, computerized clinical support systems, computerized physician order entry, regional data sharing interchanges for health care information, and other methods of incorporating information technology in pursuit of greater cost-effectiveness and better patient outcomes in health care. In developing the longrange plan, the advisory committee shall study the effect of health care information technology on price disparities in insurance coverage for residents of this state. (c) The advisory committee shall elect a presiding officer. (d) Members of the advisory committee serve without compensation but are entitled to reimbursement for the members' travel expenses as provided by Chapter 660, Government Code, and the General Appropriations Act. (e) Chapter 2110, Government Code, does not apply to the size, composition, or duration of the advisory committee. (f) Meetings of the advisory committee under this section are subject to Chapter 551, Government Code.

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Section 2.

Subsections (e) and (f), Section 104.022, Health and Safety Code, are amended to read as follows: (e) The state health plan shall be developed and used in accordance with applicable state and federal law. The plan must identify: (1) major statewide health concerns; (2) the availability and use of current health resources of the state, including resources associated with information technology and state-supported institutions of higher education; and (3) future health service, information technology,and facility needs of the state. (f) The state health plan must: (1) propose strategies for the correction of major deficiencies in the service delivery system; (2) propose strategies for incorporating information technology in the service delivery system;

(3) propose strategies for involving statesupported institutions of higher education in providing health services and for coordinating those efforts with health and human services agencies in order to close gaps in services; and (4) provide direction for the state's legislative and executive decision-making processes to implement the strategies proposed by the plan.

Section 3.

This Act takes effect September 1, 2005. President of the Senate Speaker of the House I hereby certify that S.B. No. 45 passed the Senate on April 14, 2005, by the following vote: Yeas 31, Nays 0; and that the Senate concurred in House amendments on May 27, 2005, by the following vote: Yeas 29, Nays 0. Secretary of the Senate I hereby certify that S.B. No. 45 passed the House, with amendments, on May 25, 2005, by a non-record vote. Chief Clerk of the House

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Texas Assessment

Appendix D: Health Information Technlogy Advisory Committee Membership List

Tim Turner, B.B.A.

Tim Turner & Associates, LLC Consulting Firm

Susan McBride, Ph.D., R.N.

Vice President DFWHC Data Initiative

W. Michael Brimberry, R.Ph.

Network Pharmacy IS Manager Seton Healthcare Network

David S. Muntz, M.B.A.

Senior Vice President of Information Services and CIO Texas Health Resources

Brooke Brownlow

Vice President Human Resources Strategy and Design H-E-B Grocery Company

Patti J. Patterson, M.D., M.P.H.

Vice President for Rural & Comm. Health Texas Tech Univ. Health Science Center

Brian E. Reynolds Christopher C. Crow, M.D., M.B.A.

Family Medical Specialists of Texas, LLP Associations of Physicians Healthlink, an IBM Company Business Consulting Services

Manfred Sternberg, J.D. Raymond J. Harrison, M.D.

Internal Medicine and Assoc. Director Dept. of Medical Informatics Scott and White Clinic Entrepreneur and Attorney

William J. Taylor, M.D., M.P.H.

Medical Director, Midwest Region BC BS of Texas

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Texas Assessment

Appendix E: Catalogue of Texas Health Information Technology and Health Information Exchange Initiatives

DISCLAIMER: This section attempts to capture information as to existing HIT or HIE projects in the State of Texas discovered during the interview and research process for this assessment. At this point, it is not complete. This catalogue is "a starter representation" and should be updated as appropriate. Please submit any existing initiatives to Emily Welebob at [email protected] ehealthinitiative.org for inclusion.

Participants: · 29 physicians in six clinics · Digestive Health Specialists of Tyler · Family Healthcare of East Texas · Laura J. Haygood, M.D. P.A. · Pulmonary Associates of East Texas · Tyler Internal Medicine Associates

1. Access Medica

Location: Tyler, Texas; Additional Information: www.accessmedica.org Contacts: · Ken Haygood, MD, Chief Executive Officer; Brenda Shepherd, Executive Director

Access Medica was founded in 2005 to provide healthcare IT services to physicians, hospitals, and patients of east Texas. The nonprofit RHIO includes members of the Physicians Contracting Organization of Texas and other independent practices. The result will be dramatically improved quality of care, countless lives saved, and reduced healthcare costs for the businesses and families of East Texas. Access Medica is deploying an Electronic Health Record systems from Allscripts to 29 physicians in six clinics during the first phase of the rollout, with an additional 50 to 60 physicians expected on board by mid2006.

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Access Medica, technologically, will serve the community in two ways, first by hosting and coordinating the deployment of the EMR solution chosen by a consensus of independent physicians for their practices (Allscripts' Touchworks), which will allow them to crosscommunicate directly over the Access Medica network, and second by providing the broader Continuity of Care Record from HealthVision to allow Allscripts, NextGen, Centricity, and other EMR users to interact over a seamless community health information network by providing the interfaces that will allow sharing of information.

Phase II

Around 150 additional independent physicians have expressed interest in joining the second phase of EMR installations, continuing through 2007, and this number continues to grow.

Phase III ­ Integration of Hospital Clinics and Systems

Laboratory, diagnostic, and transcription data from regional hospitals will flow through the Access Medica network as the Continuity of Care Record (CCR) components and its necessary interfaces are deployed. ETMC is currently evaluating Allscripts and NextGen EMR systems for their 200 physicians. Both are supported by the HealthVision CCR and used together in the Taconic IPA's RHIO in New York. The Trinity Clinic's Centricity EMR system can also be integrated by HealthVision to join the Access Medica network. Other regional clinics as well as a large home health agency based in Dallas (Action Home Health) have expressed the desire to join through similar interfaces. The UTHC at Tyler has been developing their own EMR system, and efforts are underway to coordinate their activities with the community.

Phases of EMR and CCR Implementation

Phase I

Fifteen clinics with a total of 132 providers are anticipated to participate in Phase I implementation, which itself will be staged. The first 29 providers, in six independent clinics, will begin deployment of the Touchworks EMR in January 2006, and the remaining 103 will begin implementation during 2006. Seamless bi-directional interfaces with eight practice management systems, four regional laboratories, and direct electronic links to pharmacies will accompany each installation. These clinics will begin to communicate and share information with one another across the Access Medica network as they come online.

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Texas Assessment

2. Access to Care for the Uninsured ­ San Antonio

Location: Bexar County South-Central Texas Additional Information: www.acu-sa.org Contact: Dewey Biscotto, Executive Director Participants: · 2 Federally Qualified Health Centers · local public health department · 3 private hospital systems · 2 faith-based non-profit organizations · public hospital system with a high low-income utilization rate

2. Develop an Internet-based, interface database application that allows health care providers to share patient medical information.

The objectives of the ACU Information System are to allow consortium members to access common patient information that helps to: 1. Improve customer service to the uninsured 2. Increase access to appropriate care and reduce duplication of services 3. Reduce inappropriate emergency room utilization 4. Improve system access to primary care thus reducing the potential for delayed care and associated hospitalization 5. Improve overall patient care through timely exchange of information.

The purpose of this project is to develop a shared patient database called ACU Information System that will significantly integrate and coordinate health care for the uninsured. The system will enable providers to share results of laboratory and other tests and help monitor diseases. Eventually, the system will allow authorized users to view a patient's medical record improving patient care and health provider coordination. Finally, the system will improve analysis of uninsured patients' use of the health care system.

3. Blue Cross Blue Shield of Texas - Personal Health Record

Location: Texas Additional Information: www.bcbstx.com/hs/pdf/benefitmemos/PHMflyer.pdf www.bcbstx.com/member/products/blueedge/# Participants: Blue Cross Blue Shield Blue Cross and Blue Shield of Texas provides the online Personal Health Manager, a personal health record (PHR), to plan members to help manage their health care and their health care benefits. The personal health record helps patients keep track of and manage their family's health information. As a Web-based resource, consumers can access their personal health information through the Internet.

The primary goals of the ACU Information System are to: 1. Develop a common eligibility program to screen uninsured patients for third party payer or reduced cost health care programs and to assign patients to an appropriate provider based on eligibility requirements of each organization

4. City of Corpus Christi ­ Health e-Cities Enablement Project

Location: Austin, Texas Participants: Christus Health and the City of Corpus Christi The City of Corpus Christi is developing a citywide WiFi network and is partnering with Christus Health to explore a range of home, community, record-keeping, and emergency response medical applications to be deployed across this broadband-wireless network. Christus Health is the largest healthcare provider in Corpus Christi with three hospitals in the city and three hospitals in the surrounding rural areas. The partnership is considering four phases, as follows: Phase 1: Emergency Response: Plan is to create a linkage between the hospital's database and the paramedics in the field who can access individuals' information from the scene of an incident. Christus is early in the phases of the project. Nine ambulances in Corpus Christi have an EKG machine, and the wireless network will be used to transmit the EKG readings from the ambulance to the cardiologists. Phase 2: Personal Health Record: Under discussion is a plan to develop a Personal Health Record that goes beyond the hospital database--a separate database linked to the city's CAD system to serve everyone in the city. Privacy and confidentiality are very important, and creation of the Personal Health Record would be on a voluntary basis. Individuals will be able to create their own personal health information and input the data with their permission from the hospital database.

Phase 3: Home Health: To service the home bound patient, consideration is being given to having nurses equipped with a laptop or PDA device in which to access the person's record via the wireless network. Medical equipment and monitoring machines placed in the home will have the data delivered to providers using the wireless network. Phase 4: The Healthy Community: Plans include using kiosks to distribute access to healthcare across the entire community. Entry into the network will be authenticated through use of a smart card.

5. Criticalconnection

Location: Austin, Texas Additional Information: www.criticalconnection.com Contacts: · Marlene Smitherman ­ CEO, CriticalConnection · Earl Maxwell - chairs CriticalConnection's community advisory group · Dr. Paul LeBourgeois, CriticalConnection's community medical director Participants: Composed of 50 Austin medical and business leaders who are intent on finding an affordable way to share patient information electronically.

Texas Assessment

CriticalConnection is a pilot program in South Austin that focuses on developing a community-accessible medical information database and providing an electronic link between patients, providers and payers. Their goal is to provide a community solution that creates a collaborative environment of secure, electronically shared healthcare information between patients, physicians, hospitals, other caregivers and payors. With support from key community stakeholders and the Texas Healthcare Quality Collaborative, the program objectives include: · Implementing an e-connectivity infrastructure that meets the needs of patients, physicians, hospitals, other providers of care and those who pay for care · Establishing a community accessible medical information repository (Universal Patient Record) · Creating an environment of collaboration among healthcare stakeholders · Generating multiple value measurements to support a transparent, sustainable economic model for community-level electronic connectivity and data exchange.

An early step in the South Austin initiative was the creation of an advisory group representing the community and state-level stakeholders. This group began as 20 and has grown to over 50 participants. The geographic reach of the advisory group has expanded to include representatives from other Texas communities including Houston and Dallas-Ft. Worth. The group includes representatives from major health insurance companies (BlueCross, Humana and United HealthCare), major employers (AISD, state agencies and Applied Materials), the Medicaid program (HHSC), key physicians, the CEO of the Travis County Medical Society, hospital representatives and consumers.

6. Dallas-fort Worth Hospital Council Data Initiative

Location: Dallas, Texas Additional Information: www.dfwhc.org Dallas-Fort Worth Hospital Council (DFWHC) Data Initiative (DI) is a not-for-profit Education and Research Foundation established in 1997 to answer the growing need in the health care community for high quality, standardized data which could be used to measure value, facilitate evaluation of health care quality and promote quality improvements. Projects: · Texas Health Care Information Collection (THCIC) Center for Health Statistics · Data Quality Analysis Software (DQA)

The goal is not to create a regional health information organization (RHIO) but to demonstrate a connectivity model that successfully brings physicians into electronic collaboration on patient care. As the initiator of more than 80% of all patient care, an electronically connected physician community is a critical building block for the eventual establishment of a RHIO that includes all stakeholders.

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· Regional Hospital Discharge Data Warehouse · Hospital Discharge Data Exchange · Community and Provider Comparative Reports · Healthcare Value initiative (HVI) · Rural Hospital Grant Collaborative · CMS/TMF Partnership on Quality Improvement · UTSW Reynolds Foundation Grant

8. Indigent Care Collaboration (ICC)

Location: Travis, Hays and Williamson Counties; Central Texas Additional Information: www.icc-centex.org/index. cfm Contact: Ann Kitchen Participants: · Austin/Travis County Health And Human Services Department · Austin Travis County Mental Health Mental Retardation Center (Atcmhmr) · Austin Women's Hospital · Central Texas Medical Center · City Of Austin Community Care Services Department · El Buen Samaritano The ICC is an alliance of healthcare safety net providers that work together to increase access, improve quality, and impact financing solutions to provide care to the region's medically indigent. The goal of the system is to have an impact on obtaining "one-stop" health care for the patient and to better coordinate the needs of the medically under-served in Hays, Williamson, and Travis counties by improving continuity of care, reducing duplicate procedures and reducing the time spent in seeking health care services.

7. Houston-Harris County Health Care Alliance

Recognizing the need for better coordination between public and private health care providers, the Greater Houston Partnership's Board of Directors has adopted a resolution in support of the Houston Harris County Alliance (Alliance). The Alliance will facilitate public and private providers in Harris County working together to create and sustain a comprehensive care delivery model, coordinate health care delivery system by enhancing existing health care assets, developing additional assets and working with other organizations interested in advancing the Alliance's mission.

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Texas Assessment

Since its inception, the ICC has worked to develop a system of care in central Texas, and to invest in strategies to accomplish this. Most noteworthy among these strategies are: · MPI/CDR, also known as I-Care A Master Patient Index/Clinical Data Repository through which safety net providers build shared longitudinal electronic health records for uninsured and other low income patients to improve care continuity and delivery. · Medicaider/Case Tracker A common eligibility program through which uninsured central Texas residents are screened for eligibility for medical assistance and charitable programs. · Pharmacy Pharmacy strategies, through which lower cost and free drugs are made available for low-income patients.

9. Medicaid Integrity Project

Location: Tarrant County, Texas Contact: Office of Eligibility Services, Texas Health and Human Services Commission Participants: · Office of Eligibility Services, Texas Health and Human Services Commission · Atos Origin

Tarrant County and Atos Origin, an international information technology services provider, are launching a program issuing 30,000 smart cards to Medicaid recipients seeking services with 150 health care providers. The goal of the pilot program is to facilitate a transition to a technology-based means of preventing Medicaid fraud & establish a platform that will permit the consolidation of state program eligibility credentials onto a single ID card.

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10. Midland Memorial

Location: Midland, Texas Additional Information: www.midland-memorial. com/ Contact: Lawrence Wilson, MD, FACEP, Medical Director of Emergency Medicine Participants: · Midland Memorial Hospital · Midland County Hospital District · Allscripts

11. North Texas RHIO Project

Location: North Texas Participants: · Dallas-Fort Worth Hospital Council (DFWHC) · Tarrant County Medical Society (TCMS) · Dallas County Medical Society (DCMS)

Midland Memorial Hospital is a 371-licensed-bed hospital, operating on three campuses in Midland, Texas. MMH will implement the HealthMatics® ED Emergency Department Information System to automate its emergency services. The Allscripts solution will enhance patient safety, improve clinical documentation, and optimize provider access to patient information in the hospital's Emergency Department and beyond.

The goal of the North Texas RHIO is to continually improve the quality and safety of medical care through the sharing of accurate patient information. The DallasFort Worth Hospital Council, Tarrant County Medical Society, and the Dallas County Medical Society agreed to create the North Texas RHIO Steering Committee. This Committee will oversee the governance and development of processes required to deliver accurate and secure patient information to participating North Texas RHIO members. The discussion of Regional Health Information Organization (RHIO) for North Texas began in late 2004. Under the leadership of Congressman Pete Sessions and Dr. John Gill, these discussions continued through the summer of 2005. On November 9, 2005, leaders from the Dallas-Fort Worth Hospital Council (DFWHC), Tarrant County Medical Society (TCMS), and the Dallas County Medical Society (DCMS) met to discuss progress and developments to date.

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Texas Assessment

As a result of this meeting, the leadership from participating organizations agreed to continue the important work initiated by Congressman Sessions and Dr. Gill. The North Texas RHIO Steering Committee shall: 1. Define and prioritize specific needs, goals, and expected outcomes of the North TX RHIO Steering Committee; and 2. Utilize a regional approach taking into consideration the needs of patients, physicians, public & private health care systems, employers and consumers, payors, and government. 3. Consider as one of its first priorities the accurate identification of patients. 4. Recognize its responsibility and accountability for the confidentiality of patient information and implement a consumer awareness campaign to secure public confidence. 5. Seek to establish the use of shared technology to assure the broadest participation amongst physicians, hospitals, and other health care providers. 6. Establish appropriate rules, should vendors be used as consultants to the committee. 7. Require the preparation and approval of business plans for all major initiatives.

8. Report annually to DFWHC, TCMS, and DCMS on its efforts, outcomes, and plans for the future. 9. Consider the need to create a non-profit corporation to conduct the business of the RHIO. 10. Establish a technical subcommittee including hospital Chief Information Officers and other appropriate non-vendor professionals to assure the broadest participation. A Clinical Standards Subcommittee will be established including Chief Medical Information officers, or the equivalent. The Steering Committee shall appoint one of its members to serve as Chair of the Subcommittee.

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12. PSI Network: National Data Source Connectivity

Location: Plano, Texas Additional Information: www.ptsafety.org Contact: Johnny Walker, CEO; 555 Republic Drive, Suite 200 Plano, Texas 75074 Participants: Patient Safety Institute, Inc. Funding: Supported by funding from associations and private foundations, Patient Safety Institute (PSI) is a national, non-profit, patient-centric 501(c)(3) open membership organization that is dedicated to supporting communities across the nation in their development of clinical information sharing networks. The Patient Safety Institute was formed in 2001 to apply the "trusted third party governance" philosophy to the patient safety and clinical information sharing problems facing the healthcare industry. PSI aims to be the overseeing organization to facilitate access, delivery and exchange of patient information (with consent) via a national network. Through a proposed project, PSI will link 3 national data sources (RxHub, LabCorp and Quest) to the PSI network, bringing the total number of constituency groups to 5 (adding PBMs and Laboratories) and providing a more comprehensive data set to providers.

13. Regional Syndromic Surveillance Reporting Network

Location: North Texas Additional Information: www.dfwhc.org www.texasapc.net Partners: · Dallas-Fort Worth Hospital Council · Southwest Center for Advanced Public Health Practice Participants: 32 hospitals in North Central Texas · Arlington Memorial · Baylor All Saints Medical Center at Fort Worth · Baylor Institute for Rehabilitation · Baylor Medical Center at Garland · Baylor Regional Medical Center at Grapevine · Baylor Medical Center at Irving · Baylor Jack & Jane Hamilton Heart & Vascular Hospital · Baylor Regional Medical Center at Plano

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Texas Assessment

· Baylor Medical Center at Southwest Fort Worth · Baylor Medical Center at Waxahachie · Baylor Specialty Hospital · Baylor University Medical Center at Dallas · Cook Children's Medical Center · Harris Methodist Erath County · Harris Methodist Fort Worth · Harris Methodist HEB · Harris Methodist Northwest · Harris Methodist Southwest · Harris Methodist Walls Regional · John Peter Smith (JPS) Hospital · Medical Center of Mesquite · Mesquite Community Hospital · Methodist Charlton Medical Center · Methodist Dallas Medical Center · Our Children's House at Baylor · Presbyterian Allen · Presbyterian Dallas · Presbyterian Kaufman

· Presbyterian Plano · Presbyterian Winnsboro · USMD Hospital at Arlington · UT Southwestern Medical Center

The Dallas-Fort Worth Hospital Council and the Southwest Center for Advanced Public Health Practice have formed a regional surveillance reporting network. The 32-hospital network will focus on syndromic surveillance ­ the timely collection, analysis and investigation of health data before a disease spreads. The data is analyzed frequently and alerts are provided to epidemiologists if the volume of cases for specific syndromes exceeds thresholds for a given ZIP code, county or the region. Work on the network began in September 2004, but just recently has been translated to an official network with participating hospitals.

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14. Rural Hospital Collaboration for Excellence Using IT

Location: Mineral Wells, Texas Additional Information: http://www.rchitexas.org/ hit Co-Project Directors: · Josie R. Williams, MD, MMM · David J. Ballard, MD, MSPH, PhD, FACP Partners: · Texas A&M University System Health Science Center's Rural Community Health Institute (RCHI) · Palo Pinto General Hospital · Baylor Health Care System · Dallas/Fort Worth Hospital Council · Texas Medical Foundation

The Texas A&M University Health Science Center's Rural Community Health Institute (RCHI) is participating in a three-year project that began in October 2004. The objective of this project is to implement advanced information technology and standards of care in rural and small community hospitals to increase patient safety and quality of care. Rural and small community hospitals are defined as acute care hospitals and located in a county with a population of less than 100,000. In addition, all Texas Critial Access Hospitals are included. Specific project aims include implementation of webbased business intelligence tools, internet connectivity, and standardized national measures of patient safety and quality to improve delivery of care; implementation of advanced technology with an enriching educational intervention to support a committed patient safety and quality culture; and conducting a randomized trial to evaluate technology and the incremental effects of an educational intervention on patient safety and quality.

Funding: $1.5 million project, funded by the National Institutes of Health (NIH)'s Agency for Health Research and Quality (AHRQ) RFA- HS-04-011

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Texas Assessment

15. Texas Health Intitiute (THI) - Shared Vision for Health Care Project

Location: Texas Additional Information: www.healthpolicyinstitute.org www.healthpolicyinstitute.org/sharedvision Contact: Camille Miller, CEO Participants: Texas Health Institute Funding: Self-funded (Supported by funding from associations, private foundations and individuals) As a nonpartisan, nonprofit 501(c)(3) organization, the Texas Health Institute takes a broad view of health care issues and their impact on people and their communities. The Institute has experience with activities as the neutral convener, facilitating balanced health care dialogue, and creating a vision of improved health care of Texans and their communities. The Texas Health Institute, through their Shared Vision Project is attempting to produce a vision for health care in Texas. The Project is grounded on three premises. First, there is no model for delivery of health care services nor vision for what a model should be in Texas. Second, all stakeholders are dissatisfied, to varying degrees, with the current "system" of health care delivery. Third, the pervasive "sense of urgency" makes this the right time for significant change.

To create this vision, the Institute has established a forum for dialogue among the leaders of Texas' health care providers, payers, and consumers. This collaborative effort is a statewide effort that brings stakeholders together to provide leadership in developing innovative products, ideas, and demonstration projects to improve the state's access, effectiveness, and efficiency of health care. In the first meeting of the Institute's Shared Vision Panel, project panel members identified five elements that a shared vision for health care must possess to address the urgent health care issues in our state. The five elements of a shared vision for health care are Regional Solutions, Access for All, Incentives for Personal Responsibilities, Sound Use of Resources, and Education About Consequences. In addition to the vision process, the Shared Vision Panel will be producing recommendations for short and long term policy options based on evidence-based research, and working with community collaborative, to implement pilot demonstration projects.

16. South East Texas Health System

Location: South East Texas Contact: Shannon Calhoun, Executive Director for Southeast Texas Hospital System Participants: · Southeast Texas Hospital System (STHS) · HealthMeans, Inc. (HMI)

This will allow for the development of a baseline of measurable quality, which will ultimately lead to pathways for measurable improved outcomes. It is essential that the providers can work collectively in order to share the volume of health information effectively and uniformly. The Smart Card and the standards supported by HealthMeans provide those components. STHS has engineered the initiatives to build the infrastructure components and HealthMeans supplies the technology so that the collaboration can be deployed region-wide and eventually nationwide. The STHS Project scope includes installation of STHS kiosk patient registration and check-in software, distribution of Smart Cards to patients in the region, and on-line registration at each participating facility accessed from a central data center located in Austin, Texas. The project will also include STHS's private patient personal health record and registration web portal for access by physicians practices in the STHS network. The project will be expanded to include 12 rural hospitals that will have access to the smart card data center utilized by STHS. The network will be running live at 6 facilities by the end of August 2006. This is the first live RHIO completely relying on smart card technology as the RHIO backbone. It will be the 2nd largest live healthcare smart card project in the country to date.

Southeast Texas Hospital System is an organization consisting of 8 hospitals with associated referring physicians, clinics and other rural health facilities that is committed to improving patient access, quality of care, and cost efficiencies among the healthcare providers in the middle Gulf Coast region. This will be the first step towards building a virtually integrated Regional Health Information Organization and is specifically designed to deploy a set of clinically integrated pathways that provide a structured process for identifying and defining quality care, as well as providing a step-by-step guide to measurable positive outcomes. Work on the project has been going on for several years - acquiring the appropriate grants and private funding to achieve the overall goals for the health system. The goal of this project is to use the data gathered and shared by utilizing the secure HealthMeans (HMI) eNvision Smart Card solutions throughout STHS' facilities as the basis for empirical data.

Texas Assessment

17. Texas Children's Hospital - Integrated Clinical Information System

Location: Houston, Texas Additional Information: www.texaschildrenshospital. org Contact: David Finn, VP Information Services Participants: · Baylor College of Medicine · Texas Children's Pediatric Associates · TCPA; Texas Children's Health Centers · Texas Children's Health Plan, TCHP

18. Texas Health Resources (THR) - Electronic Health Record (EHR) & Personal Health Record (PHR)

Location: Arlington, Texas Additional Information: www.texashealth.org Participants: · Arlington Memorial Hospital · Harris Methodist Hospitals · Presbyterian Healthcare System Texas Health Resources is implementing an electronic health record (EHR) that will provide real-time access to comprehensive health information supporting patient care and evidence-based medicine for the system's 13 hospitals. This multiyear, multimillion dollar investment in information technology will help THR improve the quality of care in its family of hospitals. Additionally, Texas Health Resources provides consumer personal health record system to registered users of their IQHealth system. Patients can access their private personal clinical information through secure Internet access. THR has worked with multi-entity, interdisciplinary groups in this collaborative effort to further its mission to improve the health of the people in the communities it serves. Plans call for implementing the EHR at Presbyterian Hospital of Plano in 2006 with a subsequent phased rollout at all other THR facilities.

Texas Children's Hospital (TCH) is launching a major initiative to transform multiple, disparate information systems into an integrated pediatric information management portal to support its commitment to quality pediatric patient care, education, and research. TCH is commited to promoting quality patient care, research, and education by building a culture that expects integrated clinical information systems, electronic healthcare information exchange, and pervasive access to digital information.

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19. Texas Medical Foundation

Additional Information: www.doqit-tx.org/index. html Contact: Tara Frease Participants: State partners · Texas Academy of Family Physicians · Texas Academy of Internal Medicine · Texas Medical Association · Texas Osteopathic Medical Association Local partners · Dallas County Medical Society · Harris County Medical Society

Texas Medical Foundation, under contract with the Centers for Medicare & Medicaid Services, is providing support for a limited time to small and medium-sized primary care practices in implementing an EHR system through an initiative called Doctor's Office Quality Information Technology (DOQ-IT). By educating physician offices on EHR system solutions and alternatives, as well as providing implementation and quality improvement assistance, DOQ-IT mission is to assist physician offices in migrating easily from paperbased health records to EHR systems that suit the needs of their office. DOQ-IT does not endorse any particular vendor product or service

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Texas Assessment

20. University Health System HIE (UHS HIE)

Location: Bexar County, San Antonio, Texas Additional Information: www.universityhealthsystem. com/Default.htm Contact: Tim Geryk Participants: · Texas Diabetes Institute (TDI) · Centro Med (a Federally qualified health center) · Community Medicine Associates (CMA) The project is a web based patient health indicator database that includes a diabetes specific curriculum developed by: certified diabetes educators, dietician, fitness specialist, PharmD, IS & patient focus groups. Fifty patients will participate in the interactive bilingual, culturally sensitive health information exchange system. Modules regarding specific health indicators will be established with interactive activities and data will be entered into a SQL database from a web browser by the patient (from their residence) on a regular basis. This HIE will provide for the collection and exchange of patient-monitored health indicators and the sharing of these indicators with assigned clinicians.

21. University of Texas Center of Excellence for Patient Safety - Measuring the Value of Remote ICU Monitoring

Location: Houston, Texas Additional Information: www.uth.tmc.edu/schools/ med/imed/patient_safety/index.htm Contact: Eric Thomas Participants: University of Texas (Houston) Funding: AHRQ (R01 HS15234)

In September of 2001 the U.S. Agency for Healthcare Research and Quality awarded a five-year, $7 million grant to The UT Houston Medical School to establish The University of Texas Center of Excellence for Patient Safety. AHRQ grant (R01 HS15234) was awarded to examine the effect of tele-ICU monitoring on mortality, complications, length of stay, cost effectiveness, provider attitudes, and human factors issues in the intensive care units of a tertiary care hospital and seven community hospitals.

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22. Valley Baptist Health System

Location: South Texas - Harlingen - Brownsville Participants: Valley Baptist Health System Valley Baptist Health System, one of the largest in South Texas, is a not-for-profit health system with more than 800 beds. They are currently updating core clinical applications with GE Healthcare's Carecast Solution to: provide greater access to patients and physician offices and to provide clinicians more information in a timely and efficient manner.

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Texas Assessment

Appendix F: Interview Contributors

Shannon Calhoun

Executive Director Southeast Texas Health Center

Raymond J. Harrison, M.D.

Associate Director Department of Medical Informatics Scott and White Clinic

Christopher C. Crow, M.D., M.B.A.

Physician Family Medical Specialists of Texas

Ken Haygood, M.D.

Chief Executive Officer Access Medica

Michael Darrouzet

Executive Vice President, Chief Executive Officer Dallas County Medical Association

Lori Hooks, M.S.H.P.

Director of Training and Technology Texas Association of Community Health Centers

Kim Dunn, M.D., Ph.D.

Associate Dean School of Health Information Sciences The University of Texas Health Science Center at Houston

Jenifer Jarriel

Vice President of Information Technology Baylor College of Medicine

Hank Fanberg

Manager, Research & Development/Information Management CHRISTUS Health

Kirk Kirksey

Vice President of Human Resources University of Texas Southwestern

Ann Kitchen

Executive Director Indigent Care Collaboration

Eric W. Ford, M.P.H., Ph.D.

Director Center for Healthcare Innovation, Education, and Research Texas Tech University

Bridget McPhillips

Director, Division of Membership Development and Physician Services Texas Medical Association

John C. Gavras

President Dallas/Ft. Worth Hospital Council

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Ann Mausser

Manager of Ambulatory Medical Records Texas Children's Hospital

Kathleen Mechler

Director of Medical Services Rural Community Health Institute

J. Darren Rodgers

Divisional Senior Vice President Health Care Management & Public Affairs Blue Cross Blue Shield of Texas

Marlene Smitherman

Chief Executive Officer Critical Connections

Joseph H. Schneider, M.D., M.B.A.

Chief Medical Information Officer Children's Medical Center of Dallas Clinical Assistant Professor University of Texas Southwestern Medical Center at Dallas

Tim Tindle

Chief Information Officer Harris County Hospital District

Starr West

Director of Health Care Quality Texas Hospital Association

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Texas Assessment

Appendix G: Glossary

Agency for Healthcare Research and Quality (AHRQ)

A national entity whose goal is to support, conduct, and disseminate research that improves access to care and the outcomes, quality, cost, and utilization of health care services. This mission is fulfilled through establishing a broad base of scientific research and promoting improvements in clinical and health system practices, including the prevention of diseases and other health conditions.

Centers for Medicare and Medicaid Services

The Centers for Medicare and Medicaid Services (Health and Human Services Administration). CMS seeks to protect and improve beneficiary health and satisfaction; foster appropriate and predictable payments and high quality care; promote understanding of CMS programs among beneficiaries, the healthcare community, and the public; promote the fiscal integrity of CMS programs and be an accountable steward of public funds; foster excellence in the design and administration of CMS programs and provide leadership in the broader healthcare marketplace to improve health.

Anti-Trust Laws

These prohibit agreements in restraint of trade, monopolization and attempted monopolization, anticompetitive mergers and tie-in schemes, and, in some circumstances, price discrimination in the sale of commodities.

Computerized Physician Order Entry

CPOE is a process whereby the instructions of physicians regarding the treatment of patients under their care are entered electronically by the physician and communicated directly to the responsible party. This process is being increasingly encouraged as an important solution to the challenge of medical error reduction.

Certification Commission for Healthcare Information Technology (CCHIT)

The mission of CCHIT is to accelerate the adoption of robust, interoperable HIT throughout the US healthcare system, by creating an efficient, credible, sustainable mechanism for the certification of HIT products.

Dallas County Medical Society

A professional organization of over 6,000 physicians that provides local community health services. They work with the state government to influence legislation as it pertains to the quality of care delivered to patients. Furthermore, they inform physicians of clinical advancements and other issues pertinent to the medical office.

Chronic Care Management

Process used to administer care for high-cost beneficiaries in order to control costs.

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Dallas/Ft. Worth Hospital Council (DFWHC)

A non-profit trade association for hospitals in the DFW area committed to the continuous improvement of healthcare in the metroplex. The group is governed by area hospital Chief Executive Officers and Chief Operating Officers.

Electronic Health Record (EHR)

Generic term for all electronic patient care systems. It is a real-time patient health record with access to evidencebased decision support tools that can be used to aid clinicians in decision-making. The EHR can automate and streamline a clinician's workflow, ensuring that all clinical information is communicated. It can also prevent delays in response that result in gaps in care. The EHR can also support the collection of data for uses other than clinical care, such as billing, quality management, outcome reporting, and public health disease surveillance and reporting.

Disease Management

A system of coordinated healthcare interventions and communications for populations with conditions in which patient self-care efforts are significant. Disease management supports the physician or practitioner/ patient relationship and plan of care, emphasizes prevention of exacerbations and complications utilizing evidence-based practice guidelines and patient empowerment strategies and evaluates clinical, humanistic, and economic outcomes on an on-going basis with the goal of improving overall health.

Electronic Medical Record (EMR)

Electronic record with full interoperability within an enterprise (hospital, clinic, practice).

E-prescribing

A type of computer technology whereby physicians use handheld or personal computer devices to review drug and formulary coverage and to transmit prescriptions to a printer or to a local pharmacy. E-prescribing software can be integrated into existing clinical information systems to allow physician access to patient-specific information to screen for drug interactions and allergies.

Doctor's Office Quality Information Technology (DOQ-IT)

Promotes the adoption of electronic health record (EHR) systems and information technology (IT) in small-tomedium sized physician offices with a vision of enhancing access to patient information, decision support, and reference data, as well as improving patient-clinician communications.

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Texas Assessment

Health Information Exchange (HIE)

The mobilization of healthcare information electronically across organizations within a region or community. HIE provides the capability to electronically move clinical information between disparate healthcare information systems, while maintaining the meaning of the information being exchanged. The goal of HIE is to facilitate access to and retrieval of clinical data to provide safer, more timely, efficient, effective, equitable, patientcentered care.

Healthcare Information and Management Systems Society (HIMSS)

The healthcare industry's membership organization exclusively focused on providing leadership for the optimal use of healthcare information technology and management systems for the betterment of human health.

Health Insurance Portability and Accountability Act (HIPAA)

Enacted by the U.S. Congress in 1996 . According to the Centers for Medicare and Medicaid Services , Title I of HIPAA protects health insurance coverage for workers and their families when they change or lose their jobs. Title II of HIPAA, the Administrative Simplification provisions, requires the establishment of national standards for electronic healthcare transactions and national identifiers for providers, health insurance plans, and employers.

Health Information Technology (HIT)

The application of information processing involving both computer hardware and software that deals with the storage, retrieval, sharing, and use of healthcare information, data, and knowledge for communication and decision making.

Health Information Technology Advisory Committee (HITAC)

An assembly of health care stakeholders within Texas that reports to the SHCC. The group, represented by consumers, payors, purchasers, and providers, assesses potential strategies and barriers to the advancement of health information technology within the state from technological, procedural, and interpersonal standpoints.

ICD- (International Classification of Disease, th Revision)

The 1972 revision of the international disease classification system developed by the World Health Organization. The International Statistical Classification of Diseases and Related Health Problems (commonly known by the abbreviation ICD) is a detailed description of known diseases and injuries. It is published by the World Health Organization and is used world-wide for morbidity and mortality statistics, reimbursement systems and automated decision support in medicine. The ICD is a core classification of the WHO Family of International Classifications.

10

Institute of Medicine (IOM)

A nonprofit organization specifically created for this purpose as well as an honorific membership organization, the IOM was chartered in 1970 as a component of the National Academy of Sciences. The IOM's mission is to serve as advisor to the nation to improve health. The Institute provides unbiased, evidence-based, and authoritative information and advice concerning health and science policy to policy-makers, professionals, leaders in every sector of society, and the public at large.

Patient Record Locator

An electronic health record locator that would help patients and their clinicians locate test results, medical history, and prescription data from a variety of sources. For example, a physician could use the locator to find out which other physicians have information on a patient he is seeing. A record locator would act as a secure health information search tool.

Personal Health Record (PHR)

An electronic application through which individuals can maintain and manage their health information (and that of others for whom they are authorized) in a private, secure, and confidential environment.

Master Patient Index (MPI)

A software database program that collects a patient's various hospital identification numbers, perhaps from the blood lab, radiology, admission and so on, and keeps them under a single, enterprise-wide identification number.

Practice Management System (PMS)

Part of the medical office record. It carries the financial, demographic and non-medical information about patients. This information frequently includes: patient's name, patient's federal identification number, date of birth, telephone numbers, emergency contact person, alternate names for the patient, insurance company or entities financially responsible for payment, subscriber information for an insurance company, employer information, information to verify insurance eligibility, information to qualify for lower fees based on family size and income, and provider numbers to process medical claims.

Office of the National Coordinator for Health Information Technology (ONC) ­ (Department of Health and Human Services)

Provides leadership for the development and nationwide implementation of an interoperable health information technology infrastructure to improve the quality and efficiency of healthcare and the ability of consumers to manage their care and safety.

Pandemic

An epidemic (an outbreak of an infectious disease) that spreads worldwide or at least across a large region.

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Texas Assessment

Quality Improvement Organization (QIO)

Medicare QIOs work with consumers, physicians, hospitals, and other caregivers to refine care delivery systems to make sure patients get the right care at the right time, particularly among underserved populations. The program also safeguards the integrity of the Medicare trust fund by ensuring payment is made only for medically necessary services, and investigates beneficiary complaints about quality of care. Under the direction of the Centers for Medicare & Medicaid Services (CMS), the program consists of a national network of fifty-three QIOs responsible for each U.S. state, territory, and the District of Columbia.

Request for Proposal (RFP)

An invitation for suppliers, through a tender process, to bid on a specific product or service. An RFP typically involves more than the price. Other requested information may include basic corporate information and history, financial information (can the company deliver without risk of bankruptcy), technical capability (used on major procurements of services, where the item has not previously been made or where the requirement could be met by varying technical means), product information such as stock availability and estimated completion period, and customer references that can be checked to determine a company's suitability.

Results Delivery Service

A service that delivers clinical results from labs to the ordering clinician in the formats that they require. Examples of results could include blood tests, immunology, pathology reports, X-ray, CAT scan, mammography, transcribed reports, etc. The service will deliver those results to the ordering physicians and to anyone else requiring a copy of those results.

Regional Health Information Organization (RHIO)

Multi-stakeholder organizations expected to be responsible for motivating and causing integration and information exchange in the nation's revamped healthcare system. Generally these stakeholders are developing a RHIO to improve the safety, quality, and efficiency of healthcare as well as access to healthcare as the result of health information technology.

Southern Governors' Association

A group that supports the work of Southern governors by providing bipartisan, regional forums to help shape and implement national policy and to solve state and regional problems.

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STARK Laws

These laws govern against physician self-referrals due to the inherent conflict of interest given the physician's position to benefit from the referral. This conflict of interest can result in the over-utilization of services which, in turn, drives up health care costs.

Texas Department of State Health Services

The DSHS promotes optimal health for individuals and communities, while providing effective health, mental health, and substance abuse services to Texans.

Texas Health Care Policy Council

A new entity within the Office of the Governor. The council's responsibilities include: ensuring effective collaboration among state agencies, promoting and facilitating the use of technology in health care, and maintaining a clearinghouse of information on the needs of local health care systems.

Statewide Health Coordinating Council (SHCC)

A 17-member, primarily governor-appointed council ensuring that health care services and facilities are available to all Texans through health planning activities. The council then makes recommendations to the governor and the legislature through the Texas State Health Plan.

SureScripts

Founded in 2001 by the National Association of Chain Drug Stores (NACDS) and the National Community Pharmacists Association (NCPA) to improve the quality, safety, and efficiency of the overall prescribing process. The SureScripts Electronic Prescribing Network is the largest network to link electronic communications between pharmacies and physicians, allowing the electronic exchange of prescription information.

Texas Health Institute

A nonpartisan, nonprofit organization providing leadership in the development of health care solutions. The Institute is a think tank ­ providing innovative, collaboratively developed options to improve the health of Texans.

Texas Medical Association (TMA)

A group of more than 40,000 physician and medical student members providing Texas physicians with distinctive solutions to the challenges they encounter in patient care. TMA priorities include making health care affordable and accessible to all Texans, protecting patient safety, and promoting the wise and effective use of health information technology.

Tarrant County Medical Society

A group of over 2,700 physicians, residents, and medical students who work together to provide a supportive practice environment for all physicians and foster quality health care for the people of Tarrant County since 1903.

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Produced by Booz Allen Hamilton www.boozallen.com Copyright 2006 eHealth Initiative www.ehealthinitiative.org For more information on this Report contact: eHealth Initiative, Foundation for eHealth Initiative 1 Connecticut Avenue, NW Suite 500 Washington D.C, 20006 [email protected]

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