NHIN Direct Face to Face Meeting
State HIEs Panel
Panelists: Tim Andrews, Claudia Williams, Gary Christensen, Will Ross
August 17, 2010
Gary (Rhode Island)
· Will engage those not plugged into the larger HIOs.
· Most advanced practices willing to jump into a Beacon community.
· His organization is an SDE, REC, and also a Beacon program. They all approach NHIN Direct as one project.
· Committed and happy at prospect of being able to solve MU goals for small HIE and centralized state HIE goals through NHIN Direct.
· If the NHIN Direct tool works, can solve Meaningful Use issues around small HIEs. It can be rolled out through the REC, so it never has to touch the capital HIE.
· Most advanced practices are willing to participate, be part of the Beacon program.
Will Ross (Redwood MedNet)
· Redwood MedNet is not a state HIE and has no Beacon program.
· California is under no illusions about the uniqueness of every state and how every state has to go about putting pieces together. He is a participant in the process questions from the perspective of the small /rural/small public health department so he brings this table a set of questions capital HIE without a budget. In other words, when down in the trenches with no resources, how do we get people engaged?
· Redwood MedNet has looked at creating an option for providers in the trenches to actually get something accomplished.
· Between Cal-eConnect and participation of Redwood they have found a way to experiment, understand.
· Gives them the opportunity to understand areas where NHIN Direct is not yet relevant, or identify some of the questions NHIN Direct has not yet looked into enough.
o How the pilot project fits into the state HIEs, how state HIEs look at NHIN Direct?
· There is still no obvious answer, no single enterprise, until we provide something that is more coherent than a fax.
Tim Andrews
· Works with many states.
· Issue: provider addresses.
· EHRs will hold most of the data.
· Other big thing: at the end of the day, EHRs and their ability to exchange data is important but real grinding is getting data in and out of EHRs.
· They have been working on plan for general push messaging for Meaningful Use.
· Challenge: finding marketplace solutions and knowing a timeline for when they can be taken advantage of, in order to meet Meaningful Use guidelines.
· Get involved, build stakeholder consensus.
Arien Malec summarizes on behalf of Joel Ryba (HIXN)
· HIO/HIE maturity model: direct exchange and registry lookup exchange seem like competitors in early maturity model HIOs, especially when there are limited resources.
o Directed exchange or a registry lookup exchange.
· He is hearing from states:
o they need to solve provider’s issue for Meaningful Use (quality issue based on provider).
o wider scale issues about health records and whether this leads to a central registry (quality concerns on a centralized registry).
· Quality HIO needs to both
o get labs into EHR.
o and produce longitudinal records.
· Question for all three panelists: From an operational and quality perspective, how do you address this?
Gary Christensen
· See this as a separate activity stream, and joining them would be misleading.
· Don’t want to mix up EHRs with lab reports.
· In essence, they are not the same. Consent laws are strict in RI, so anytime capital HIE is involved, needs to be done with consent from patients. This limits capital HIE activities.
· So they are thinking of them as separate.
· Supports policy group’s findings regarding consent.
Will Ross
· In California these are unresolved issues about consent and privilege, intertwined for the purpose of understanding what we know and don’t know and how to move forward.
· Not sure if California’s project will work a practical level.
Tim Andrews
· Need to focus efforts on getting strong policy in place to be able to implement.
· Before consent issues, there are questions about the infrastructure.
· Getting consent policy in place is a very different issue.
· Policy issues have many layers.
· No PHI exposure not an issue for them.
· Interested to see who has those issues.

Claudia Williams
· Progress against MU goals in the near term, and how we might sequence the different activities to meet the ends we are aiming for.
· Those in the trenches know how hard it will be to create EHRS and get info out of EHRS.
· Direct focus on complexity and nuances of getting info into EHRs.
· Not every state will go this route but she would be interested in talking to Gary offline.
· Don’t need to be in conflict, just support one another.

Questions to the panel
David McCallie
· In the Tiger Team discussions, even in a model when data was copied in registry and pushed to the provider, the idea of falling back to direct exchange (not copying in registry) came up because info was sensitive to the customer or because it was not available.
· Is it true direct exchange may still be relevant in registry models?
Gary Christensen
· Does not see it as a fallback. What is the utility, what is the value add of the data flowing through the centralized HIE? If Doctor A needs to get info to Doctor B, why does it need to be copied to the registry?
· The central HIE wants that data but for other purposes rather than continuity of quality care.
· Not adding any real value to the transaction.
Arien Malec
· Hears a fear that if they do the direct path, they won’t want to do the centralized non-direct path.
Gary Christensen
· Depends on the state’s business goal.
· If longitudinal view is not helpful to a doctor, then you don’t need the centralized HIE.
Claudia Williams
· Starting with complexity doesn’t lead to rapid process.
· So if the state doesn’t have a goal of centralized registry, could we make the pitch they’d be able to get there over time?
· Thinking of standards discussions with Aneesh Chopra.

Tim Andrews
· Does not think the concern is about centralized registries. Thinks there is a concern about business models.
· Need to establish baseline models.
· Direct was supposed to be a catalyst.
· What if a network doesn’t have staying power?
· States with existing infrastructure v. states that do not have infrastructure.
· Unification of data overtime is tough.
Gary Christensen
· Same risk occurs within accountable care organizations (ACOs), silos of information.
David McCallie
· HIEs challenged in this way specifically.
· Those organizations outside of HIPAA that can share data in aggressive ways are springing up everywhere.
Arien Malec
· Conflict between ACO and HITECH.
o ACO – medical homes and ACO policies.
· Has seen IDNs use direct as a way to back out of state obligations.
· Business model problem more than a tech problem.

Claudia Williams
· Interesting challenge for policy work for State HIEs and health reform:
o Recognition that there are multiple networks, there will not be one network in our lifetimes.
o Policy issue: positioning future world where there are multiple networks,
Tim Andrews
· We are all by definition inter-network, bad idea to have multiple networks at the grand level.
· Does not think it will be easy to unify, and they have no desire to.
· Should model after the Internet, with millions of local networks.
Doug Arnold
· Issue of ACOs: even though health reform talks about pilots starting in 2010, CMS is already talking about turning physician groups into ACOs.
Arien Malec
· Sees ACOS as vehicles of reduced cost and increased quality.
· Multiple exchanges can be cross-connected by design.
· A lot depends on trust.
David McCallie
· Patient sharing information.
· Consistent with Direct, inconsistent with state HIEs.
· Alternate: patient’s entry which is not inconsistent with state ACOs or Direct, just with state HIEs.
Gary Christensen
· And is inconsistent with behavior of people.