North Carolina Statewide HIE STRATEGIC PLAN

Transcription

1 North Carolina Statewide HIE STRATEGIC PLAN UPDATED Version 2.0

2 TABLE OF CONTENTS NC HIE STRATEGIC PLAN Page INDEX OF FIGURES AND ILLUSTRATIONS... iii LIST OF COMMONLY USED ACRONYMS... iv S.1. BACKGROUND Statewide Cooperative Agreement North Carolina Health Information Exchange (NC HIE) Timeline Vision...4 S.2. HEALTH IT AND HIE LANDSCAPE Health IT Adoption Statewide and Regional Health Information Exchange...9 S.3. COORDINATION Overview State HIT Coordinator Medicaid & Public Health ARRA Programs Federal Care Delivery Networks Other States...52 S.4. GOVERNANCE Overview State-Level Infrastructure Development NC HIE Governance Structure Accountability and Transparency...56 S.5. TECHNICAL INFRASTRUCTURE Overview Clinical and Technical Principles Participation in the NC HIE Qualified Organizations Technical Approach Interoperability Approach to Implementing Standards and Certification...65 S.6. BUSINESS AND TECHNICAL OPERATIONS Meaningful Use Requirements...67 Statewide HIE Strategic Plan i

3 S Leveraging Existing HIE Capacity, Statewide Shared Services and Directories...67 LEGAL AND POLICY Overview Consent Approach for Statewide HIE Privacy and Security State Laws Policies and Procedures Trust Agreements Oversight...74 S.8. FINANCE Overview Financing Model & Approach to Sustainability...76 S.9. APPENDICES Definition of Key Terms Legal and Policy Workgroup Briefing Paper: Developing a Statewide Consumer Consent Policy for Electronic HIE in North Carolina, December Statewide HIE Strategic Plan ii

4 INDEX OF FIGURES AND ILLUSTRATIONS Figure 1: Data Link s Geographic Footprint and Hospital Members...15 Figure 2: Interactions between Practices and e-prescribing Facilitators in the North Carolina e-prescribing Adoption Initiative...19 Figure 3: E-Prescribing Volume...20 Figure 4: Broadband Distribution...42 Figure 5: Office of Health Information Technology...45 Figure 6: NC HIE Governance Structure...55 Figure 7: Approaches to Statewide HIE...59 Figure 8: Attributes of a Qualified Organization and Regional HIE Approach...60 Figure 9: Qualified Organization Model...63 Figure 10: Illustration of Statewide Core Services and Targeted Meaningful Use HIE Transactions for Figure 11: Proposed Core Services & Phased Implementation of Value-Added Services...68 Statewide HIE Strategic Plan iii

5 LIST OF COMMONLY USED ACRONYMS ACO AHEC Accountable Care Organization North Carolina Area Health Education Centers (NC REC) ARRA American Recovery and Reinvestment Act of 2009 BCBSNC CAH CCD CCNC CCNC CCR CIA CLIA CMS CPT CVX DMA DURSA EHR EP FOA FQHC GAAP Health IT HHS Blue Cross Blue Shield of North Carolina Critical Access Hospital Continuity of Care Document Community Care of North Carolina Community Care of North Carolina Continuity of Care Record Confidentiality, Integrity and Availability Clinical Laboratory Improvement Amendments Centers for Medicare and Medicaid Services Current Procedural Terminology Codes for Vaccine Administered North Carolina Division of Medical Assistance Data Use and Reciprocal Support Agreement Electronic Health Record Eligible Provider Funding Opportunity Announcement released by ONC for Statewide HIE Cooperative Agreement Program Federally Qualified Health Center Generally Accepted Accounting Principles Health Information Technology U. S. Department of Health and Human Services Statewide HIE Strategic Plan iv

6 HIE HIO Health Information Exchange Health Information Organization HIPAA Health Insurance Portability and Accountability Act of 1996 HITECH HITSP HL7 HWTF ICD IDN IHE LOINC MH/DD/SAS MITA MMIS NC DHHS NC HIE NCCCN NHIN NIST OERI ONC PCMH Health Information Technology for Economic and Clinical Health Act (part of ARRA) Healthcare Information Technology Standards Panel Health Level Seven (not-for-profit, ANSI-accredited standards developing organization) North Carolina Health and Wellness Trust Fund International Statistical Classification of Diseases and Related Health Problems (classification code set) Integrated Delivery Network Integrating the Healthcare Enterprise Logical Observation Identifiers Names and Codes (a database and universal standard for identifying medical laboratory observations) North Carolina Division of Mental Health, Developmental Disabilities and Substance Abuse Services Medicaid Information Technology Architecture Medicaid Management Information System North Carolina Department of Health and Human Services North Carolina Health Information Exchange North Carolina Community Care Network National Health Information Network National Institute of Standards and Technology North Carolina Office of Economic Recovery and Investment Office of the National Coordinator for Health Information Technology Patient Centered Medical Home Statewide HIE Strategic Plan v

7 PIN QO REC RFI RFP RHC RHIO RxNorm SAMHSA SCHIP SDE SNOMED-CT SPCCP VistA Program Information Notice, additional guidance requirements for Statewide HIE Strategic and Operational Plans released by ONC in July 2010 Qualified Organization Health Information Technology Regional Extension Center Request for Information Request for Proposal Rural Health Center Regional Health Information Organization RxNorm (a standardized nomenclature for clinical drugs and drug delivery devices, is produced by the National Library of Medicine) Substance Abuse and Mental Health Services Administration (an agency of HHS) State Children s Health Insurance Program State Designated Entity Systematized Nomenclature of Medicine--Clinical Terms Southern Piedmont Community Care Plan (Beacon Community) Veterans Health Information Systems and Technology Architecture Statewide HIE Strategic Plan vi

8 S.1 BACKGROUND The American Recovery and Reinvestment Act (ARRA) of 2009 authorized new funding opportunities and resources for health information technology (IT) and health information exchange (HIE). The Health Information Technology and Clinical Health Act (HITECH) within ARRA provides for: New incentives for Medicaid and Medicare providers to adopt and meaningfully use electronic health records (EHRs) Appropriations for health IT in the form of loans, grants, and technical assistance Appropriations for HIE planning and implementations allocated to each state and territory Grants to support the continuing development of broadband and telehealth Workforce training grants to support the development of a skilled health IT and HIE workforce Following the passage of the HITECH Act, North Carolina Governor Perdue signed Executive Order 19, naming the North Carolina Health and Wellness Trust Fund (HWTF) Commission as the State Designated Entity (SDE) for North Carolina. 1 The HWTF Commission subsequently established the North Carolina HIT Collaborative (HIT Collaborative) to provide guidance and oversight as the HWTF Commission prepared its application for health IT funding under the State HIE Cooperative Agreement Program. Under the guidance of the HIT Collaborative, the HWTF Commission completed and successfully submitted its application to the Office of the National Coordinator for Health IT (ONC), receiving notice of award for $12.9 million on February 8, The State HIE Cooperative Agreement Program is one of several programs North Carolina is pursuing under the HITECH Act. An inventory of ARRA-funded health IT projects in the state is below. To date North Carolina and its stakeholders have received notice for approximately $203 million in funding to support health IT and HIE adoption. ARRA Program Awardee Amount State HIE Cooperative North Carolina HIE $12.9 million Agreement Program State Medicaid Planning State Medicaid Agency $ 2.3 million Regional Extension Center North Carolina Area Health $13.9 million Cooperative Agreement Program Education Centers Program (at UNC Chapel Hill) Beacon Community Southern Piedmont Community $15.9 million Care Plan Health IT Workforce Community College Consortia Program Pitt Community College $10.9 million 1 Under HITECH only States or State Designated Entities (SDEs) may access funds through the State HIE Cooperative Agreement Program; an SDE must be named by the Governor. Statewide HIE Strategic Plan 1

9 ARRA Program Awardee Amount Health IT Curriculum Duke University $ 1.8 million Development University-level Health IT Duke University $ 2.1 million Workforce Training Broadband BTOP Round 1 MCNC/North Carolina Research $28.8 million and Education Network (NCREN) Broadband BTOP Round 2 MCNC, City of Charlotte, Olive Hill $115 million Community Economic Development, WinstonNet, Yadkin Valley Telephone Membership Corporation Total funding to date $203.6 million 1.1. State HIE Cooperative Agreement Program Under the State HIE Cooperative Agreement Program, states or SDEs are required to complete and submit HIE Strategic and Operational Plans to ONC; guidance as to the structure and requirements for these plans was originally published in the Statewide HIE Cooperative Agreement Funding Opportunity Announcement (FOA) in August ONC has subsequently provided further guidance through a Program Information Notice (PIN) published on July 6, The submission and approval of the North Carolina HIE Strategic and Operational Plan is a critical milestone that will trigger the flow of funding from ONC to North Carolina. Under the cooperative nature of the program, North Carolina and its leadership will continue to work with ONC following the approval of its plan to provide regular updates and report on specific measures ONC has identified (e.g. receipt of structured lab results, electronic prescribing, and clinical summary exchange). After receiving notification that North Carolina had been awarded $12.9 million for statewide HIE planning and implementation in February 2010, governance and planning responsibilities shifted from the HIT Collaborative to the North Carolina Health Information Exchange (NC HIE). NC HIE was created as a new non-profit, public-private partnership organization responsible for the execution and oversight of North Carolina s HIE strategy, including the completion and submission of North Carolina s HIE Strategic and Operational Plans. The NC HIE Board of Directors is a diverse group of CEO-level representatives of key health care constituencies in North Carolina. The HIE Strategic and Operational Plans are organized into five domains that NC HIE is required to address in detail: Governance; Finance; Business and Technical Operations; Technical Infrastructure; and Legal and Policy. At the recommendation of its Board, NC HIE convened four workgroups to assist with strategic planning for each of their respective areas. The Workgroups are described in greater detail below in Section 1.4. Statewide HIE Strategic Plan 2

10 1.2. North Carolina Health Information Exchange (NC HIE) Timeline To date, the North Carolina market has been characterized by multiple uncoordinated HIE initiatives, most of which are in early stages of development. These initiatives are attempting to address specific regional needs or the needs of a specific health system and have resulted in valuable lessons learned. However, a coordinated statewide governance approach is required to meet North Carolina s vision and goals for HIE, to take advantage of significant federal investment in health IT, and to create a policy infrastructure that allows North Carolina s providers to meet the goals of meaningful use including the ability to exchange health information. In early 2009, the North Carolina Health Information Technology Strategic Planning Task Force (HIT Task Force) was established to forge a new vision of how health and healthcare can be improved by enhancing the use of health IT. On behalf of Governor Bev Purdue, the Director of the Office of Economic Recovery & Investment (OERI) charged the HIT Task Force to engage stakeholders to develop a set of strategic guidelines by which North Carolina could apply for, and most effectively use, resources made available through ARRA. The HIT Task Force was composed of 17 members; however, more than 65 subject matter experts, staff, and members of the public were invited to participate in the seven open meetings that were held from April through June June 24, 2009: The HIT Task Force releases a report titled Improving Health and Healthcare in North Carolina by Leveraging Federal Health IT Stimulus Funds that outlines recommendations around the critical components of a successful health IT infrastructure and operations for a statewide HIE. July 16, 2009: Governor Purdue signs Executive Order 19, charging the NC HWTF Commission with the responsibility for coordinating North Carolina's Health IT efforts and creating the North Carolina HIT Collaborative to make recommendations to the Commission regarding the development of the NC HIE Action Plan. August 20, 2009: ONC announces the Funding Opportunity Announcement (FOA) for State HIE Cooperative Agreement Program. September 11, 2009: HWTF submits Letter of Intent to seek Cooperative Agreement funds on behalf of North Carolina. October 16, 2009: HWTF submits Cooperative Agreement Application and NC HIE Strategic Plan. December 9, 2009: NC HIT Collaborative Privacy Workgroup releases a report titled Briefing Paper: Developing a Statewide Consent Policy for Electronic HIE in North Carolina addressing issues and making recommendations for next steps. February 12, 2010: HWTF receives Notice of Grant Award from ONC to fund HIE planning and implementation activities through 2014 and notification of approval of North Carolina State HIE Strategic Plan Version 1. April 2010: A public-private partnership model to govern statewide HIE in North Carolina is recommended and approved and the NC HIE not-for-profit organization is incorporated. Statewide HIE Strategic Plan 3

11 May 14, 2010: The first board meeting of the new nonprofit, public-private partnership governance entity for NC HIE is held. The NC HIE Board of Directors is comprised of 21 CEOlevel executives plus ex officio members from the state. The Board is co-chaired by the NC Department of Health and Human Services (DHHS) Secretary Lanier Cansler and past CEO and Chairman of Glaxo, Inc., former CEO of Massachusetts General Hospital and internationally renowned health care advocate, Dr. Charlie Sanders. Late May 2010: NC HIE appoints multi-stakeholder Workgroups and drafts Workgroup Charters. June 2010: NC HIE Workgroups begin developing consensus-based recommendations to inform the Statewide HIE Operational Plan and to update the Statewide HIE Strategic Plan. : The NC HIE and HWTF submit an updated Statewide HIE Strategic Plan and Operational Plan to ONC Vision The NC HIE, a public/private collaboration, will provide a secure, sustainable technology infrastructure to support the real time exchange of health information to improve medical decision-making and the coordination of care to improve health outcomes and control health care costs for all residents of North Carolina. Statewide HIE Strategic Plan 4

12 S.2. HEALTH IT AND HIE LANDSCAPE In North Carolina, the health information infrastructure consists of various organizations operating at the enterprise, local, regional and state levels. Operating as a system of systems, North Carolina s health information infrastructure includes: HIOs that serve multi-stakeholder entities and enable the movement of health-related data as hubs of natural information markets; Health systems, affiliated providers, and ancillary services; Specialized participants that operate for specific purposes, including but not limited to laboratory services, radiology, public health, research, and quality assessment; Information and service providers that operate in vertical markets such as e- Prescribing, State registries, Medicaid and Medicare; Care coordination organizations; and Private payers and clearinghouses that transmit administrative data for claims purposes and for pay for performance. Credential Service Providers (CSP) and Identity Service Providers (IDP) that provide identity credentials and identity management services to the healthcare industry. Many of these organizations have their own health IT systems and networks. At any point in time the networks will be in different stages of their life cycles, will be built on many different technologies, and will have differing priorities regarding the data they collect and transmit. The evolving statewide health information infrastructure in North Carolina is intended to complement and integrate, not supplant, these networks. Reflecting the geographic and demographic diversity and economic complexity of North Carolina are a number of other overlapping influences on the development of healthcare delivery and policy. It is expected that communities across the state will continue to extend collaborative relationships between community leaders, healthcare providers, and public health officials. As a means for tracking the progress of the expansion of health exchange in North Carolina, NC HIE has catalogued the current exchange capabilities across the transactions identified in the ONC State HIE Cooperative Agreement Program and those necessary to support eligible providers meet stage 1 meaningful use requirements Health IT Adoption The success of HIE depends upon many factors, not the least of which is the extent to which providers, practices, clinics, and hospitals acquire, implement and certified EHR technologies. Below are findings from the studies of EHR adoption in North Carolina conducted over the last four years. The North Carolina HIE, North Carolina DHHS, and the North Carolina REC will continue to track adoption of certified EHR technology. Statewide HIE Strategic Plan 5

13 Physician Adoption of EHRs North Carolina s experience with adopting electronic health records (EHRs) appears similar to the findings documented by national and other state-level studies. A survey conducted by the North Carolina Academy of Family Physicians (NCAFP) on behalf of the Carolinas Center for Medical Excellence found that as of January 2006, 22% of North Carolina physicians had adopted EHRs and another 30% were actively considering implementing an EHR system. 2 A study by Rosenthal and Layman of information technology utilization by physicians in eastern North Carolina published in 2008 found (consistent with national survey findings) that smaller practices were less likely to use EHRs and other health information technologies. 3 In order to provide budget estimates to CMS, the Medicaid health IT team completed a preliminary estimate and analysis of an EHR survey submitted by North Carolina providers as part of a North Carolina Medicaid reenrollment process. The table below provides the results of the 885 respondents analyzed by the Office of MMIS Services as of July 27, Percent of Count Respondents Respondents that Currently Use EHR % Respondents that Plan to Purchase Within 12 Months % Clinic Adoption of EHRs In 2009, 32% of both state-funded rural health clinics and federally funded community health centers had implemented EHRs. This is the equivalent of eight out of the 25 state-funded rural health clinics and nine of the 28 federally-funded community health centers. Hospital Adoption of EHRs In 2009, the North Carolina DHHS conducted a survey of the current landscape on hospital adoption of EHR. Of the 125 hospitals that responded to the survey, 15% (19 hospitals) are using electronic health records exclusively 49% (61 hospitals) are using both paper and electronic records 21% (26 hospitals) are not using electronic health records 15% (19 hospitals) had no response or did not know One major barrier commonly noted was the amount of capital needed to adopt EHRs. Fifty-nine (59) percent of respondents indicated that this was an issue of major significance 2 NC Academy of Family Physicians, Inc. EHR Survey Results Overview Final. January Rosenthal DA, Layman EJ. Utilization of information technology in eastern North Carolina physician practices: determining the existence of a digital divide. Perspectives in Health Information Management. 2008;5(3). 4 The Office of MMIS Services continues to input responses into a database for tabulation. Statewide HIE Strategic Plan 6

14 Other major barriers to adoption include: Finding an EHR that meets providers needs (38% of respondents indicated it as an issue) Resistance to adoption by physicians (33%) Capacity to select, install and implement an EHR (28%) State Agency Adoption of EHRs The North Carolina DHHS Division of Mental Health is implementing a Community Electronic Health Record - Web Infrastructure for Treatment Services (WITS) project to advance EHR adoption amongst its stakeholders. The Community EHR project has just been approved to move forward. This initiative will result in better coordination of services for consumers, improved data quality, standardization, data availability, and improved administrative efficiencies across the system. The objective of this initiative is to develop a community electronic health record system that will ensure continuity of care for MH/DD/SAS consumers across all types and levels of care by providing standardized data collection and interoperability among community service providers, Local Management Entities (LMEs), and state operated MH/DD/SAS facilities. For this initiative, the North Carolina Division of Mental Health has selected the Web Infrastructure for Treatment Services system as the solution for managing care in community settings. It is primarily for community providers' planning and delivery of services, and secondarily for LMEs' management and oversight of services. The North Carolina DHHS is also developing plans to support the implementation of VistA (Veterans Health Information Systems and Technology Architecture) as an EHR for the 15 state-operated facilities. With the VistA system, the state operated facilities would have access to CPOE; data from labs, pharmacies, and radiology; physician and nurse assessments, progress notes, consult reports and discharge summaries. Pending the availability of funds, deployment of VistA would begin at two acute care hospitals. Support for EHR Adoption North Carolina Regional Extension Center The NC Area Health Education Centers (AHEC) Program at the University of North Carolina, Chapel Hill received a notice of grant award dated February 8th, 2010 to perform the function of the North Carolina Regional Extension Center (NC REC) for health information technology. The award was for $13.6 million dollars over two years which will allow NC AHEC to reach at least 3,465 priority primary care physicians and assist with practice assessment, workflow redesign, selection and implementation of EHR to achieve meaningful use of the technology and improve health outcomes throughout the state of North Carolina. NC AHEC will expand its consulting workforce throughout the nine regions of the state to help practices implement technology and/or use previously existing technology to meet the federal standards of meaningful use to achieve incentive payments from the Centers for Medicare & Medicaid Services between 2011 and Statewide HIE Strategic Plan 7

15 The NC REC has hired 27 well-trained personnel with experience in EHR implementation and technical expertise to assist primary care practices across the state, and plans to hire an additional professionals. A training mechanism for these new staff members has been built with assistance from the REC subcontractors at the Carolinas Center for Medical Excellence (CCME), the North Carolina Medical Society Foundation and the Institute of Public Health. Additionally a website and tracking tool has been developed by CCME to enable the NC REC to provide tools and resources while tracking the progress of each practice through the necessary steps of readying for, selecting and implementing an EHR. To date, over 1,000 providers have submitted information and been entered into the web-based system. NC AHEC has worked with the Carolinas Center for Medical Excellence, the North Carolina Medical Society Foundation, Community Care of North Carolina (CCNC) and the NC Institute for Public Health to build a detailed training program including over 40 hours of instruction and interactive learning for newly hired personnel within the nine regional AHECs across the state. These new personnel will engage with primary care providers across the state to help them implement and use electronic health records to achieve the incentive payments and improve care for their patients. Additionally, NC AHEC has developed a plan to identify a REC-supported EHR vendor list to guide primary care providers across the state in their selection of certified EHR products. This process includes the development of a detailed request for information (RFI) that will be sent to EHR vendors across the country. NC AHEC has also identified a committee of physicians, practice managers and an expert in HIPAA and security to score the responses to this RFI. Those EHR systems that demonstrate a high enough score will be invited to demo their product for the committee to ensure that the product performs to the meaningful use standards. Once the demos have been completed the systems that the committee deem appropriate will be listed on a REC-supported vendor list. At that time, all RFI responses and the scores that they received will be made available to providers across the state to use in their process of selecting EHR systems. Community Care of North Carolina (CCNC) Provider Portal CCNC s Informatics Center is currently upgrading its capacity to host a secure web portal for direct provider access to Medicaid patient information, include care team contacts, medical and pharmacy claims history, medication adherence and clinical care gap alerts. North Carolina Electronic Health Record Loan Fund Pilot Program In August 2010, the HWTF announced the creation of the North Carolina Electronic Health Record Loan Fund Pilot Program. The pilot will provide financial assistance to healthcare providers in Tier 1 counties seeking to create or upgrade EHR systems required for Medicare and Medicaid reimbursements beginning in A grant of $127,461 was awarded to the North Carolina Medical Society Foundation to provide technical assistance for and evaluation of the EHR loan fund pilot program over a five-year period beginning July 1, The Center for Community Self-Help (Self-Help), a Durhambased nonprofit, will manage the $750,000 loan fund and underwrite prospective borrowers. Self-Help will work in partnership with the North Carolina Medical Society Foundation and the North Carolina Area Health Education Centers to identify eligible providers and help them transition to advanced EHR systems. Statewide HIE Strategic Plan 8

16 The revolving loan fund is designed as a pilot program to expend its initial capital within the first year of operation. Individual loans are expected to range in size from $40,000 to $60,000 and may be used to: Purchase a certified EHR technology or upgrade an existing EHR to meet certification criteria; Train personnel in the use of such technology; and/or Improve the secure electronic exchange of health information. Loans will vary in pricing based on the borrower s credit/collateral profile and will feature flexible repayment terms to better serve the needs of a wider variety of practices Statewide and Regional Health Information Exchange The statewide HIE that will be overseen and managed by NC HIE will leverage and support existing and emerging information exchange efforts across the state. In North Carolina, several health information organizations (HIOs) have formed or are forming to offer providers direct access to a range of HIE services. It is envisioned that many of these HIOs could eventually serve as Qualified Organizations and provide gateways to the shared services that would be offered at a statewide level or offer to host services for other participants in statewide HIE. Currently, one HIO, Western North Carolina Health Network (WNCHN) Data Link, is operational within the state and a second effort, the North Carolina Healthcare Exchange (NCHEX) launched pilot projects in August Five other HIE efforts are in advanced planning stages. These initiatives are more fully described below. In addition to those described here, North Carolina has a significant number of enterprise-level private networks and emerging collaborations throughout the state that could support and be enhanced by participation in the NC HIE. HIE Initiatives Coastal Connect Health Information Exchange In 2007, the Coastal Connect Health Information Exchange (Coastal Connect) initiative was first conceptualized by a committee of Chief Information Officers from member hospitals of Coastal Carolinas Health Alliance in Wilmington, NC. The Alliance currently represents nonprofit hospitals in nine counties, seven of which are located in North Carolina and two in South Carolina, serving approximately one million residents. In 2010, CCHIE was officially incorporated and corporate bylaws approved for submission for the organization to receive its 501(c) (3) status. For Phase I of the initiative, Coastal Connect is targeting at least ten counties including: Bladen, Brunswick, Columbus, Duplin, New Hanover, Pender, Pitt (associated counties within the system to be identified), Robeson, Sampson, and Scotland. New Hanover County and Pitt County are the home of two major health systems (New Hanover Regional Medical Center and University Health System, respectively) that will be integral in creating the HIE. In addition to large, urban hospitals, both of these systems also encompass rural-based providers and practices. Statewide HIE Strategic Plan 9

17 With the help of Computer Sciences Corporation (CSC), Coastal Connect has completed a survey assessment to determine providers needs in the community related to health IT and HIE and is using the information to help select a vendor for implementing the exchange. The organization plans to launch a pilot in late 2010 to demonstrate the value of the exchange to Coastal Connect members. The demonstration project will include 5 hospitals and as many as 100 affiliated physician practices (in five counties) as participating partners, and will seek to achieve the following goals and objectives: Improve access to care in underserved and uninsured areas Create a resource for clinicians to access, exchange and manage meaningful patient data Improve quality of care Provide electronic collection of 646 chronic disease measures to improve patient health outcomes Develop policy or guidelines for data collection and publication Improve coordination of care Implement use of clinical summary document to facilitate care delivery at care transitions Improve efficiency of data flow through real-time applications minimizing time spent completing paperwork and patient registration Provide laboratory results data Coastal Connect expects to utilize a hybrid-federated HIE data model which will extract data from source systems and store the information in federated repositories, all operated by a centralized information management system. With this hybrid model, CCHIE expects full push/pull capabilities through clinical messaging and master patient index (MPI)/record locator service (RLS) technologies. Coastal Connect also expects standardized interoperability capability between providers and anticipates interoperability on the state and national levels. Finally, Coastal Connect submitted a grant proposal to HRSA in 2009 and received $50,000 in grant funding which was used to develop a sustainability model for the exchange. Additional achievements include the creation of a Data Usage and Reciprocal Support Agreement (DURSA) and a standard Patient Consent Form based on an opt-out model with restrictions, both of which have been sent to the organization s legal team for final approval. North Carolina Healthcare Exchange (NCHEX) Currently in development at two pilot sites, the North Carolina Healthcare Exchange (NCHEX) is a voluntary HIE of hospitals and physician practices sponsored by the North Carolina Hospital Association (NCHA) and the North Carolina Medical Society (NCMS). NCHEX services will enable providers to share clinical data to meet Meaningful Use exchange requirements. NCHEX builds on the experience and technology of the North Carolina Hospital Surveillance System (NCHESS), created in 2004 as a public-private partnership between NCHA and the North Carolina Division of Public Health (NCDPH) to provide critical data from 114 emergency Statewide HIE Strategic Plan 10

18 departments to enable the state to recognize and respond to acts of bioterrorism, disease outbreaks, emerging infections, and other public health emergencies. 5 NCHEX allows caregivers to access HIE data via their native EHR interface or a secure Web browser to view summary and detailed information about a patient over time and across providers through a Virtual Single Patient Record viewer, including: ADT/Registration Labs Dictation Pharmacy (if available) By using a hybrid model that combines certain aspects of the centralized and federated HIE models, NCHEX seeks to facilitate speed, security and scalability. NCHEX allows caregivers to access HIE data via their native EHR interface or a secure Web browser to view summary and detailed information about a patient over time and across providers, including: problem history medication history provider history procedure history allergies top 300 labs inpatient summary for previous 36 hours detailed clinical notes and reports, including discharge summaries In addition to the HIE requirements of Meaningful Use, NCHEX can also provide the following capabilities: electronic prescribing hosted EHR 'lite' for small practices or free clinics public health reporting immunization registry reporting 5 Please see Section 3.3i for a full description of NCHESS. Statewide HIE Strategic Plan 11

19 CCD generation for use with external providers and HIEs NHIN connectivity capability patient inquiry through the Continuity of Care Viewer by community physicians and case managers medication reconciliation clinical alerts (surveillance) never event management NCHEX is in pilot phase with the Moses Cone and WakeMed health systems and includes seven hospitals, three free-standing emergency departments and 57 hospital-owned physician practices. NCMS is working to identify several independent physician practices to join the pilot. NCHEX also seeks to provide clinical insight to additional stakeholders such as the NC Department of Public Health, emergency medical services, CCNC and safety net providers. Sandhills Community Care Network Health Information Exchange (SCCN) The Sandhills Community Care Network is a regional component of the NC Community Care system which provides case management services to the Carolina Access Medicaid recipients in Harnett, Hoke, Lee, Montgomery, Moore, Richmond and Scotland counties. SCCN has proposed to build on this existing foundation to establish a community health information exchange. The SCCN network consists of multiple entities of varying size with disparate IT capabilities with providers that have multiple stand-alone product-centric applications. As such, SCCN faces inefficiencies stemming from these silos of irretrievable information. SCCN is committed to eliminating these barriers by 1) partnering with the South Regional- Area Health Education Center (SR-AHEC) to research available EHRs and produce a slate of choices selected to meet the needs of SCCN providers based on cost, capabilities, support and ability to exchange information, and 2) working with network hospitals, practices and other partners who already have significant IT integration to select a best of breed HIE service for the entire region. SCCN utilizes an HIE Committee comprised of both Board members and SCCN staff. SCCN has invested $180,000 over the last two years working with consultants to ascertain present needs and capabilities and future objectives. The SCCN HIE Committee, working in a facilitative role with SR-AHEC, has interviewed several cost-effective, web based, CCHIT certified electronic medical record vendors and is in the process of vetting a preferred list. The SCCN HIE Committee is seeking to initiate, develop and sustain a Health Information Exchange that allows appropriate, privacy-protected access to data in a common format. Several leading HIE consulting firms have been interviewed. In a recently repeated survey, SCCN approximates that 50% of network practices already have EHRs in place highlighting the anticipated reality of data exchange. In addition, one hospital and several large practices have implemented advanced IT systems and early collaborative efforts have been successful. Moving forward, the goal of SCCN is to encourage Network providers to obtain a low-cost, certified, Web-based EHR while concurrently building a health information exchange to allow communication across practices, hospitals and other members of the community. SCCN Statewide HIE Strategic Plan 12

20 anticipates working on two parallel tracks to facilitate regional HIE development: 1) an on-going commitment to the implementation of EHRs within the Network and 2) simultaneously appending to an existing HIE project with a local hospital and a few large group practices. SCCN s focus is to assist SR-AHEC who has an additional 30 practices within the SCCN network at various stages of EHR implementation currently. SCCN s desire to align with ONC initiatives is strengthened by developments in two areas: 1) approximately 40% of Network providers utilize e-prescribing (an additional 14 practices utilize standalone e-prescription modules) and 2) aggressive marketing of the newly established Provider Portal of the NC Community Care Informatics Center to stimulate data exchange of information related to Medicaid recipients. SCCN has hired a full-time information technology specialist to help facilitate HIE development in the network. Southern Piedmont Community Care Plan Health Information Exchange The Southern Piedmont Community Care Plan (SPCCP) was selected by the ONC Beacon Community Program as one of the 15 Beacon Community award recipients and will receive more than $15 million to build and strengthen health IT infrastructure and health information exchange capabilities in its area of operation to enhance quality of patient care and cost efficiency. SPCCP will incorporate health IT to advance community level care coordination in areas including hypertension, diabetes, blood pressure control, asthma, medication reconciliation, non-emergent ED visits and preventable readmissions. SPCCP collaborated with nearly 400 health care providers within the community to establish priorities as a Beacon Community. The group considered priorities identified by recent public community health assessments for the three participant counties (Cabarrus, Rowan, and Stanly), the goals of the North Carolina Community Care Network s (NCCCN) Medicare Modernization Act 646 program, other SPCCP initiatives such as asthma management, alignment with HHS meaningful use objectives, and alignment with the State HIE and regional extension center plans. High level objectives of the project include: 1. Enhance HIT Infrastructure and Exchange Increase EHR penetration by implementing EHRs in free clinics, public health departments, FQHCs, and small practices. Increase provider and patient access to health data to facilitate management of personal health data. Reduce rates of performing duplicate imaging tests by enabling the sharing of imaging study reports and results. Reduce rates of readmission for chronic disease and ED utilization for ambulatory care sensitive conditions with a care transition notification system for hospitalization and ED use. 2. Care Quality Improve chronic disease care for patients with hypertension, diabetes, congestive heart failure, and asthma. For example, reduce high blood pressure levels, improve hemoglobin A1c levels, and decrease the number of ED visits due to asthma attacks. Increase patient quality related to pharmacotherapy. Statewide HIE Strategic Plan 13

21 A central focus of the Southern Piedmont Beacon Community is to improve health outcomes and learn from the early health IT adoption experiences and share the related lessons-learned with other, later EHR/HIE adopters. Health outcomes will focus on the evaluation of quality measures in high-risk populations (diabetics, asthmatics, patients with congestive heart failure, and hospitalized patients with complicated problems who are transitioning to their medical homes) and be conducted with support from experienced healthcare researchers at the Duke and UNC-CH Schools of Medicine and the UNC-CH Sheps Center for Health Services Research. The evaluation will assess the impact of the Southern Piedmont Beacon Community interventions on care process and outcome measures and on the cost of care. Southern Piedmont Health Information Exchange (SoPHIE) In mid 2008, the Southern Piedmont Partnership for Public Health (SPPPH) started a planning process for a person-oriented health information exchange called SoPHIE the Southern Piedmont Health Information Exchange. The planning was carried out by a group including representatives from local public health agencies, the NC Division of Medical Assistance (Medicaid), the NC Institute for Public Health (the outreach arm of the UNC Gillings School of Public Health), private clinics, informatics experts, medical researchers, security and privacy experts, and consumer advocates. This planning process was supported by the Robert Wood Johnson Foundation s Common Ground Project. SoPHIE planning focused on using health information exchange to support NC public health agencies objectives -- as key providers of clinical services across the state, as population health entities, as health promotion agents, and as connective agents for health in their communities working with all other clinical and health-related community services. This focus led to SPPPH s development of a set of principles about HIE that in aggregate are called person-oriented. Following these person-oriented principles will result in an HIE that has an associated store of longitudinal data per patient/consumer (though not necessarily all patients in the same store) and can engage in exchanges without storage. This is generally considered to be a hybrid HIE model. The planning process involved creating value propositions for using SoPHIE, prioritizing and sequencing those value propositions, developing business plan outlines for the top value propositions, developing key business process descriptions for these business activities, and creating an architecture that explored how the technical, governance, and business needs of SoPHIE might be met. Since June 2009, the work has focused on determining how to pilot/demonstrate SoPHIE. With support from an additional grant, we intend to complete the tactical planning for such a demonstration. By March 2011, we expect to have done an RFI and created an RFP for the demonstration. This demonstration project is viewed as a potential first step towards a more general deployment of an HIE based on SoPHIE principles. The SoPHIE demonstration project will seek to involve several public health agencies, non-public health care providers, payers (one private payer and one public payer, preferably Medicaid), consumers and medical/health services researchers. WNC Data Link of the WNC Health Network The 16 far-western counties of North Carolina, with a combined population of 750,000, are predominantly rural and mountainous, characterized by isolated communities and pockets of extreme poverty in which patients often travel substantial distances to obtain needed care. This often results in patients medical histories being disbursed across a number of providers. To address this, in 2002, the 16 hospitals serving these counties collaborated to identify options for the purpose of securely and efficiently exchanging electronic patient medical information. In Statewide HIE Strategic Plan 14

22 February 2006, Data Link went into production to provide authorized providers and clinicians access to a virtually integrated view of a patient s electronic records from across all WNC hospital systems. Data Link s goal is to allow every WNC resident to have a longitudinal electronic medical record that can be accessed and updated in real time by any authorized provider. Data Link s current geographic footprint map can be seen in the figure below. Figure 1. Data Link s Geographic Footprint and Hospital Members Through a detailed request for proposal process, the WNC hospitals chose MEDSEEK for the provision of software and interfaces. Hosting services are currently provided by Peak 10 Data Center Solutions. Currently, upon provider request, WNC Data Link searches all of the WNCHN hospitals information systems for a patient s records and collates them in a standardized format in real time. Clinicians can access the records through any internet connected device. Patientcentric data available through Data Link includes: admission/discharge information, lab results, microbiology reports, radiology reports, medications, allergies, discharge summaries, history & physicals, Emergency Department notes, progress notes and other transcribed reports. Lab results available inside the EHRs connected to Data Link are accessible for exchange in Data Link today and an evaluation is being conducted to assess whether a need to connect to other lab vendors exists and, if so, how to negotiate that connectivity on behalf of regional providers. Also, all hospital radiology providers within the region have their results available within Data Link and technical scoping is underway with the largest regional privately-owned radiology provider for connectivity. Data Link has begun focusing on making medical images and outpatient medication history available through the exchange. Medical images will include radiology, nuclear medicine, tomography and ultrasound images, as well as images of medical mappings such as EEGs, EKGs, or ECGs. Access to outpatient medication history will be added to facilitate medication reconciliation, as well as e-prescribing tools, via a link to a retail pharmacy database. E- prescribing tools will also be available with this developed link to Surescripts. Planning is also ongoing to have a patient portal available on Data Link within the next year. Statewide HIE Strategic Plan 15

23 Technical scoping is underway to connect the regional Cerner Healthe Hub, E-Clinical Works regional hub, and other vendor regional hubs to Data Link. Additionally, a point-to-point interface is being developed to connect the EHR of the Hot Springs Health Program of Madison County, a full service (physician office, home health, hospice, and urgent care center) Federally Qualified Health Center (FQHC), and a second to connect the EHR of the largest regional home health and hospice program managed by CarePartners (which currently covers seven of the 16 counties). Finally, Data Link is currently implementing the ability to accept and produce CDA Release 2 Level 2 CCD C32 Patient Summary Records. In the initial phase, the C32 record includes: demographic information, allergies, problem lists, medications, and information source. Those documents will be accessible technically to federal partner(s) via the NHIN Gateway by October 2010 pending the on-boarding process. To date, there are an average of 450 providers using Data Link on a monthly basis, with over 20,000 hits in Data Link each quarter. Data Link averages 13,300 lab transactions, 1,550 microbiology transactions, 1,600 inpatient pharmacy transactions, 12,500 radiology transactions and 35,800 transcription transactions per month, and over 2.6 million medical records are available to be accessed via Data Link. Statewide HIE Strategic Plan 16

24 A table summarizing key components of these initiatives is provided below: HIE (Lead Org(s)) CCHIE (Coastal Carolinas Health Alliance) NCHEX (North Carolina Hospital Association) Sandhills HIE (Sandhills Community Care Plan) Year Established Region Range of Participants Technical Approach 2010 Pilot includes 5 5 hospitals Hybrid counties in Eastern Up to 100 physicians North Carolina (including New Hanover and Pitt) 2010 Pilot involves multiple sites TBD Seven Counties in south of the state (Harnett County, Hoke County, Lee County, Montgomery County, Moore County, Richmond County, Scotland County) 7 Hospitals 8 Emergency Departments 57+ Physician Practices 6 Hospitals 1 CAH 250 providers (92 practice sites) 4 labs 1 FQHC 29 SNFs Hybrid Hybrid Data Exchanged as of August 2010 Planning to exchange: CCD erx (Will commence in October 2010) All data available in EMR/EHR systems including ADT, labs, Rx, care summary, immunization data, etc. Transitional Care Summaries E-Prescription Lab results Diagnostic images (data types currently being electronically exchanged within Sandhills region) Clinical Priorities Provide tools to enhance delivery of care Facilitate effective coordination of care across clinicians Provide tools to enhance delivery of care Facilitate effective coordination of care across clinicians Financing/Sustainability Model Participant Financing (membership fees) Leveraging NCHESS footprint. Participant financing (membership fees) Seeking additional funds to support state-wide expansion. Participants funding (membership fees, subscription fees & marketing) Grant financing (discretionary funds from cost savings for 646 Medicare Demonstration Project Southern Piedmont Community Care Plan HIE (Southern Piedmont Community Care Plan) 2010 Three counties in western central North Carolina (Cabarrus, Rowan, and Stanly) 1 FQHC (two sites) 3 local health departments 3 local hospitals 4 community free clinics 1 VA Med Ctr 796 providers (physicians, PAs, NPs) Hybrid Planning to exchange: Transitional Care Summaries Public Health Data Medication History Medical Images Facilitate effective coordination of care across clinicians Provide tools to enhance delivery of care Grant financing (Beacon Community Grant) Statewide HIE Strategic Plan 17

25 HIE (Lead Org(s)) Southern Piedmont Health Information Exchange (SoPHIE) (Southern Piedmont Partnership for Public Health) WNCHN Data Link (WNC Health Network, Asheville, NC) Year Established Region Range of Participants Technical Approach Data Exchanged as of August 2010 Clinical Priorities Financing/Sustainability Model 2008 Eleven counties in Planning to include: Hybrid TBD TBD Grant financing (Robert western/central Local and state public Wood Johnson North Carolina health departments Foundation s Common (Alexander, Providers Ground Project) Cabarrus, Catawba, Payers Cleveland, Gaston, Consumers Iredell, Lincoln, Medical/Health Services Mecklenburg, Researchers Rowan, Stanly, and Union) 2006 Sixteen counties in western North Carolina ( Buncombe, Cherokee, Clay, Graham, Haywood, Henderson, Jackson, Macon, Madison, McDowell, Mitchell, Rutherford, Transylvania, and Rutherford) 16 hospitals 1270 physicians Federated moving toward hybrid Demographics Lab Results Radiology Reports Inpatient Rx List Admission Info Microbiology Allergies Transcriptions including ED reports, Consultative notes, Progress Notes, History and Physical, and Discharge Summaries. Provide tools to enhance delivery of care and moving toward facilitate effective clinical coordination of care across clinicians For development, grant funding was used from HRSA and the Duke Endowment. For sustainability, participant financing are subscription based fees and participant pro rata fees. Statewide HIE Strategic Plan 18

26 2.2.b. e-prescribing E-prescribing is the use of health IT to improve prescription accuracy, increase patient safety and reduce costs, as well as enable secure, bi-directional, electronic connectivity between physician practices and pharmacies. Physicians Use of E-Prescribing Tools North Carolina has demonstrated leadership in health IT adoption gains. One measure of the increase in e-prescribing adoption is the percentage of physicians who route their prescriptions electronically. The percentages of North Carolina providers routing e-prescribing at year end were: 9 percent in 2007, 23 percent in 2008; and 24 percent in The figure below represents the number and type of interactions between practices and e- prescribing facilitators participating in the BCBS/CCNC/NC Medicaid e-prescribing adoption program (July 2008-present). It demonstrates the depth and intensity with which North Carolina is able to deploy health IT-centric initiatives statewide and across stakeholders. This health IT adoption program acted as the precursor to the Regional Extension Center effort. Figure 2. Interactions between Practices and e-prescribing Facilitators in the North Carolina e- Prescribing Adoption Initiative Sponsored by BCBSNC/CCNC/NCDMA 6 Surescripts. State Progress Report on Electronic Prescribing. Data as of June Statewide HIE Strategic Plan 19

27 Routing of Scripts According to data compiled by Surescripts, there were over 9 million electronic prescriptions in North Carolina in Figure 3. E-prescribing Volume Pharmacy Access to E-Prescribing In North Carolina, there are 2,461 in-state pharmacies of which 1,119 are retail chain pharmacies, 622 are independent, and 180 are hospital based. Of the 12,526 active pharmacists licensed in North Carolina: 3,286 work at retail chain pharmacies 2,117 work at hospital pharmacies 1,407 work at retail independent pharmacies In 2009, Surescripts reported that 1,777 out of 1850 or 96% of community pharmacies have the ability to receive electronic prescriptions and refill requests. 7 Based on this data, we believe there are robust capabilities among pharmacies within North Carolina for accepting electronic prescribing and refill requests. 2.2.c. Electronic Delivery of Laboratory Results The electronic delivery of laboratory results is a multi-step process that begins with the creation of an order for a laboratory test. The test results can be sent directly to the clinician s EHR system or another clinical data system in support of the provisioning of historical results and results for non-ordering, providers of care. Providers of care may receive test results in the 7 Surescripts. State Progress Report on Electronic Prescribing. Data as of June Statewide HIE Strategic Plan 20

28 EHR system or another clinical data system or receive notification of the results (for later retrieval). According to the Clinical Laboratory Improvement Amendments (CLIA) laboratory demographics file, North Carolina s distribution of laboratory facilities is as follows: Hospital labs 154 Independent labs 101 Ancillary test sites 58 County public health labs 1 State Laboratory of Public Health The 154 independent labs sites represent 72 laboratories. The table below illustrates the top 10 labs with more than one site. Lab Corp, Spectrum Lab and Carilion Lab make up 71% of all independent lab sites in the top 10 labs. Facility Name Total Percent of Labs Labcorp Labs 30 19% Spectrum Labs 20 13% Carilion Labs 16 10% Select Diagnosis 5 3% Pathologists 5 3% Celligent Diagnosis 5 3% Quest Diagnostics 3 2% Piedmont Health 3 2% Raleigh Radiology 2 1% Coastal Carolina 2 1% Carolina Med 2 1% Ascertaining the state of structured lab results activities currently taking place in North Carolina requires an understanding of the: Percent of labs able to produce and deliver structured lab results Percent of labs able to receive orders electronically Percent of lab results currently being delivered electronically Percent of providers receiving structured lab results Using the list of unique organizations based on license numbers, the NC HIE will conduct a survey of laboratories that seeks information on their current ability and plans to (1) produce and 8 CDC Oscar database. Accessed on August 3, Statewide HIE Strategic Plan 21

29 deliver structured lab results electronically and (2) the data content and transmission standards deployed. 2.2.d. Care Summary Exchange The ability to create, transmit, receive and interpret patient care summaries can enhance a wide range of health services, including continuity of care, accurate diagnosis and treatment, and patient and care giver engagement. As the patient centered medical home model becomes a more accepted method of practice for primary care physicians, the desire to exchange summary records will underscore the need for availability of electronic data from all possible healthcare sources. The extent exchange of patient care summaries can be measured by assessing volume of transactions at multiple levels. Across the state, one fully operational HIE in North Carolina, WNC Data Link, currently facilitates the exchange of patient care summaries. In addition, the NCHEX project has launched pilot projects that present summary care records to clinicians. At the provider level, the NC HIE will work with Medicaid and NC REC to develop a survey that assesses the current level of adoption of EHR technology capable of producing and receiving summary care records. 2.2.e. Medicaid Within the North Carolina Department of Health and Human Services (DHHS), the Division of Medical Assistance (DMA) oversees the State s Medicaid and Health Choice programs. North Carolina Medicaid is the single largest payer of health services within North Carolina. In , North Carolina Medicaid served approximately 1.7 million children, aged, blind and/or disabled individuals. The budget for the Medicaid program was $11.3 billion which is supported by $8.4 billion in revenue (predominately federal Medicaid funds) and $2.9 billion in state appropriations. North Carolina s Health Choice for Children (NCHC) is a free or reduced price comprehensive health care program for children. NCHC provides funding to extend health care coverage to roughly 115,000 children each month whose family income exceeds Medicaid financial eligibility criteria. The budget for NCHC was $226.8 million of which $167.4 million was supported by federal funds and $59.4 million in state appropriations. Inter-agency Coordination North Carolina DHHS has established a committee (DHHS HIT Workgroup) to direct the health IT and HIE activities of Medicaid and all associated DHHS agencies including Public Health, Mental Health, and Rural Health. While many states vary widely in the extent of their coordination of mental health, substance abuse, and Medicaid agencies with external behavioral health entities, North Carolina has all of these programs under a single umbrella, the Department of Health and Human Services (DHHS). In an effort to narrow coordination and data consistency gaps among these services, Statewide HIE Strategic Plan 22

30 the Centers for Medicare & Medicaid Services (CMS) and the Substance Abuse and Mental Health Services Administration (SAMHSA) have entered into a national joint project to adapt Medicaid Information Technology Architecture (MITA) planning tools and processes for behavioral health services. North Carolina has the unique advantage in this initiative to have already centralized behavioral health activities to facilitate greater coordination, cooperation, and interoperability among agencies, programs, and systems at the State level. In NC approximately 16 percent of all claim reimbursements in the Replacement MMIS multipayer systems will be related to the behavioral health spectrum of treatment. While there are many safeguards around data specifically related to Behavioral Health services, the adoption of national behavioral health-mita standards increases the potential for inclusion of these services within an EHR. Community Care of North Carolina (CCNC) The Medicaid program has worked closely with various organizations across the state on the implementation of various health IT initiatives. CCNC operates a medical home based patient care model, and currently has the single largest Medicaid provider group in North Carolina, with more than 3,000 participating primary care physicians in more than 1,400 practices across North Carolina, serving approximately 1 million Medicaid and North Carolina Health Choice for Children enrollees. CCNC utilizes Medicaid claims data for multiple purposes, including identification of patients in need of high-risk case management, disease management, or care coordination; facilitation of practice-based quality improvement; monitoring of cost and utilization outcomes; and monitoring of quality of care with performance feedback at the network, practice, and patient level. North Carolina Medicaid Management Information System (MMIS) The Department established the Office of MMIS Services (OMMISS) as a Program Management Office (PMO) to oversee the various health information technology projects associated with the replacement of the State s MMIS system. The replacement system is as a multi-payer initiative with Medicaid, State Children s Health Insurance Program (SCHIP), Public Health, Rural Health and Mental Health, Developmental Disabilities and Substance Abuse Services. The projects that are a part of this effort include the MMIS Replacement, decision support and health informatics, surveillance and utility review and the MITA State Self- Assessment. North Carolina Department of Health and Human Services project for Design, Development, and Implementation (DDI) of a new MMIS that is aligned with the CMS defined Medicaid Information Technology Architecture (MITA) is underway. MITA is setting the standard for MMIS systems of the future and provides the basic infrastructure and framework for healthcare modernization of state public welfare systems amid the implications of evolving health information exchanges, electronic health records, emerging national standards, ever-changing federal and state directives, and the critical need for immediate and better access to health data for all providers, consumers and administrative entities within the healthcare delivery system. The replacement MMIS system will utilize service-oriented architecture and with the ongoing development of federal HIE standards will be able to support EHR protocols such as CCD. The first phase of the MMIS modernization includes a service-oriented architecture to enable connectivity of disparate systems, a Workflow component, a master file transfer protocol, and Statewide HIE Strategic Plan 23

31 integrates with NCID, the official North Carolina Identity Management Service. Upon implementation, the system will support new e-prescribing technology using NCPDP and Medicare Part D standards. These new HIE capabilities will ultimately improve care by consolidating and making all current prescription information available to providers and pharmacists to work in partnership for the patient to reduce the incidence of adverse drug effects. For the Department, the Replacement MMIS will be a key component of North Carolina s HIE infrastructure. Patient claims data will continue to be available to CCNC regional care coordination networks and Medicaid providers via a data repository download to the centralized CCNC Informatics Center. In addition, the improved MMIS type HIE services will supply claims to support creation of a CCD standard record that will be available to providers as a part of their new EHR systems. All components of the NC Replacement MMIS Project are being developed with HIE capability and aligned with MITA. The Reporting and Analytics Project replaces the current Medicaid decision support data warehouse with a more robust centralized informatics reporting solution capable of storing all NC public healthcare program claims data, including Medicaid, Children s Health Insurance Program, Public Health, Behavioral Health, and Migrant and Rural Health data. Future plans include the option for further expansion to claims data from the State Employees Health Plan. North Carolina s Administration of Meaningful Use Incentive Program The Division of Medical Assistance has established a timeline for creation of a written State Medicaid HIT Plan to be submitted to CMS as part of their responsibility for enabling the utilization of EHRs by providers and monitoring Meaningful Use by Medicaid providers in North Carolina. The Planning Advanced Planning Document (PAPD), the initial funding document required from North Carolina by CMS, was resubmitted to CMS on January 29, 2010 and approved by CMS effective February 4, The approved document meets the requirements outlined in Section 4201 of the Recovery Act and the guidance found in the State Medicaid Director s letter, /ARRA HIT#1, dated September 1, Approved FFP is $2,288,648 with $255,512 in state matching funds. On April 30, 2010, CMS provided a more comprehensive plan detailing interface requirements between a National Level Repository (NLR), other federal computer systems and state incentive payment management systems. The project team completed an alternative analysis to identify options for meeting these new requirements and has contracted with CSC to build the North Carolina Medicaid Incentive Payment System (NCMIPS). North Carolina is the first state to test interfaces with the NLR. Currently, CMS has a dedicated technical team working with the NCMIPS team, which provides a unique opportunity for NC to be at the forefront of developing the interfaces required in order to launch the EHR Incentive Payment program. The NLR interfaces represent one component of NCMIPS that must be designed, built and configured before NC will be able to begin making incentive payments. Work on NCMIPS is underway and NCMIPS is expected to be integrated with the replacement MMIS. Initially, prior to full MMIS integration, NCMIPS will interface with the Enrollment, Verification and Credentialing (EVC) system and be accessed via NCTracks. Statewide HIE Strategic Plan 24

32 2.2.f. Quality Reporting and Improvement The exchange of information in support of quality reporting involves the documentation, collection and transmission of patient information relevant to the calculation of an established quality measure for clinician quality, where a specific clinician can be identified as responsible for ensuring adherence to best practices. Examples include measurement of clinician performance in both inpatient and outpatient settings, including but not limited to physician offices, emergency departments, and surgical settings. In North Carolina, quality reporting and improvement initiatives occur across both the public and private sectors and at the local, regional, and statewide levels. North Carolina Healthcare Quality Alliance (NCHQA) NCHQA is a Section 501c3 non-profit organization with the goal of dramatically improving the quality of care across the state of North Carolina. NCHQA is a collaboration of virtually all the leaders in the delivery of medical care in North Carolina. The Board of Directors consists of members appointed by the Governor and other public officials, various medical societies, insurers, the state hospital association, the Foundation for Advanced Health Programs, and Community Care of NC. It also includes representatives of academic medical centers, business, consumers, and other key players dedicated to improving care. NCHQA was initially organized under the auspices of the Governor, and now operates as an independent non-profit organization. NCHQA works with physician practices to improve the quality of care delivered to patients with chronic diseases. NCHQA s quality improvement activities are administered by the NC Area Health Education Center (NC AHEC), a federally designated Regional Extension Center (REC). To accomplish its goal of improving the quality of care in primary care settings, the NCHQA (1) develops nationally recognized quality measures for the treatment of chronic diseases, (2) ensures that those measures are supported by all insurers, (3) recruits primary care practices willing to adopt those measures and improve their delivery of chronic disease care, (4) provides training, support and tools to assist those practices in improving the quality of care, and (5) provides feedback to practices regarding their performance in meeting quality standards. NCHQA has selected five common chronic diseases diabetes, asthma, hypertension, congestive heart failure, and post-mi care as the first diseases to include in the initiative. Selection of measures for these conditions was guided by the following principles: Measures used in the NCHQA are based on nationally recognized evidence-based standards such as those developed by the National Committee for Quality Assurance (NCQA) and endorsed by the National Quality Forum (NQF) and which have been widely accepted in the North Carolina provider community. Whenever possible, NCHQA measures will build on existing reporting systems, particularly Community Care of North Carolina (CCNC) measures, to assess quality. Building on existing systems will reduce burden and ensure the most comparable results across time. Assessment in progress regarding quality of care will be regularly conducted and will include critical review of the measures being used and the need to adjust them. Changes in measures will be linked to the release of new national standards and improvements in the measurement process suggested by evidence-based practice. Statewide HIE Strategic Plan 25

33 Expansion of NCHQA to measures for other conditions and across the continuum of care is a long-term goal. Data to calculate measures will be obtained both through claims data and chart audits. Collection of data will consider the privacy concerns of providers and patients and every effort will be made to reduce the cost and administrative burden on practitioners of additional data collection activities. Other NCHQA activities to assist practices in improving quality will provide support for provider-based data collection for short-term assessment of improvement. North Carolina Division of Medical Assistance Managed Care North Carolina s Division of Medical Assistance (DMA) is responsible for required reporting to CMS on the following EPSDT components annually: Total individuals eligible for EPSDT State Periodicity Schedule Number of Years in Age Group Annualized State Periodicity Schedule Total Months of Eligibility Average Period of Eligibility Expected Number of Screenings per Eligible Expected Number of Screenings Total Screens Received Screening Ratio Total Eligibles Who Should Receive at Least One Initial or Periodic Screen Total Eligibles Receiving at One Initial or Periodic Screen Participant Ratio Total Eligibles Referred for Corrective Treatment Total Eligibles Receiving Any Dental Services Total Eligibles Receiving Preventive Dental Services Total Eligibles Receiving Dental Treatment Services Total Eligibles Enrolled in Managed Care Total Number of Screening Blood Lead Tests Statewide HIE Strategic Plan 26

34 The DMA s quality evaluation and health outcomes unit reports HEDIS data broken out by Medicaid and the Managed care programs. The reported data consists of: Breast cancer screening Cervical cancer screening Diabetes related services Appropriate medication for asthma Access and utilization of ambulatory care for adults and children Prenatal care Childhood immunization status North Carolina Quality, Evaluation & Health Outcomes Unit The Quality, Evaluation and Health Outcomes Unit (QEHO) of the North Carolina Division of Medical Assistance: Identifies opportunities for strategic improvement in Medicaid program operations; Monitors the performance and effectiveness of Medicaid programs; and Analyzes information to identify patterns of utilization, trends in performance, and opportunities for improvement in delivering care to the populations served by Medicaid in North Carolina. In its annual county-specific reports, QEHIO reports some high-level quality and overall health measures for each of North Carolina s 100 counties in comparison to a state average: Percent Women with no Prenatal Care in 1st Trimester Infant Mortality per 1000 Medicaid births Percent of live births with low birth weight Adult Cardiovascular Risks: Tobacco Use (from Behavioral Risk Factor Surveillance System) Obesity (also BRFSS) Hypertension incidence Diabetes incidence AHRQ Quality Indicators: Diabetes short-term complication admission rate Diabetes long-term complication admission rate Chronic obstructive pulmonary disease admission rate Congestive heart failure admission rate Statewide HIE Strategic Plan 27

35 Adult asthma admission rate Pediatric asthma admission Quality Measurement and Feedback for Community Care of North Carolina Since its inception in 1998, CCNC has used performance measurement and feedback to help meet its goals of improving the quality of care for Medicaid recipients while controlling costs. Quality measurement is intended to stimulate or facilitate quality improvement efforts in CCNC practices and local networks, and to evaluate the performance of the program as a whole. Under the direction of the Clinical Directors, CCNC s measurement and feedback process has evolved over time to meet the changing needs of the program. Several factors necessitate a continuing need to evolve, such as 1) expansion of Community Care s enrolled population and increasing focus on aged, blind, and disabled patients with multiple chronic conditions, 2) practice participation in other quality initiatives (such as PQRI, NCQA HSRP and DPRP, Bridges to Excellence, NCHQA), and desire that measures be aligned as much as possible, and 3) changes to evidence-based clinical practice guidelines over time. A Quality Measurement and Performance workgroup, with representation from all fourteen networks, meets periodically to review performance measures. Goals are to identify measures with: 1) clinical importance (based on disease prevalence and impact, and potential for improvement), 2) scientific soundness (strength of evidence underlying the clinical practice recommendation; evidence that the measure itself improves care; and the reliability, validity, and comprehensibility of the measure), and 3) implementation feasibility. Workgroup recommendations are presented to the CCNC network leaders, and final measures are chosen by vote of the Clinical Directors. As of January 2009, patients are eligible for chart review on the basis of asthma, diabetes, ischemic vascular disease, and heart failure. Chart review measures pertain to: appropriate asthma management; diabetes glycemic control and foot care; management of blood pressure, cholesterol, and tobacco use; appropriate aspirin use; and assessment of LV function in heart failure. Community Care has contracted with Area Health Education Centers (AHECs) to perform independent randomized chart reviews for >26,000 recipients in >1325 CCNC practices, with an electronic data abstraction tool. Practice-level results with patient-level detail are available to the networks by secure Internet reporting services on a next-day basis. Program-level results are reported annually. An additional set of quality of care measures are derived from Medicaid claims data, pertaining to: medication therapy for asthma, heart failure, and post-mi patients; adult preventive services (breast, cervical, and colorectal cancer screening); and pediatric preventive services (dental care and well child exams). Claims measures are reported quarterly at the practice, county and network level. A care alert system to readily identify patients in default of recommended services is set to be released in Fall of Practices and networks receive monthly, quarterly, or annual feedback on process, cost, utilization, and quality metrics. A critical element to Community Care s success centers on the ability of the networks to locally implement system changes needed to improve quality in practices. The network Clinical Directors are instrumental in engaging community providers to implement the quality initiatives. Providing credible and provider friendly reports are powerful tools, particularly when accompanied with benchmarks and comparisons to peers, helping to motivate providers to improve processes that will enable them to provide best care. The focus is on implementing evidence-based best practices in the medical home. Statewide HIE Strategic Plan 28

36 In addition CCNC reports monthly on utilization measures designed to monitor quality initiatives such as e-prescribing, transitional care and ED diversion. Community Care of North Carolina Informatics Center The CCCN s Informatics Center is an electronic data exchange infrastructure maintained in connection with health care quality initiatives for the State of North Carolina sponsored by the Department of Health and Human Services Division of Medical Assistance, Office of Rural Health and Community Care, and the United States Department of Health and Human Services Centers for Medicare & Medicaid Services. Currently, the Informatics Center contains health care claims data provided by Medicaid, as well as health information about program participants obtained directly from health care providers and care managers and/ or the primary care medical record. Additional data sources will be integrated into the Informatics Center in 2010, to include: Medicare claims and Surescripts pharmacy data for dual eligibles, Labcorps (laboratory results), and real-time hospital admission/discharge/transfer data from 48 large NC hospitals. Information is accessed by the Community Care networks to identify patients in need of care coordination; to facilitate disease management, population management, and pharmacy management initiatives; to enable communication of key health information across settings of care; to monitor cost and utilization outcomes; and to monitor quality of care and provide performance feedback at the patient, practice, and network level. Informatics Center applications include: Case Management Information System (CMIS): CMIS is a user-built, patientcentric, electronic record of care management activities used by CCNC care managers since 2001, with over 1,000 active users statewide. CMIS contains demographic data and claims data on over 2 million Medicaid recipients, over 1 million of whom are currently enrolled with a practice in a CCNC network. CMIS also contains enrollment, eligibility and case management services for HealthNet projects across the state, which are regional collaboratives for the care of the uninsured, currently serving 12,500 enrolled individuals. Patients enrolled in Medicaid, Health Choice and HealthNet all reap the benefits of the continuity of care provided by CMIS, which maintains a health record and single care plan that stays with the patient as he or she moves from one area of the state to another, or across eligibility programs. CMIS contains standardized health assessment and screening tools, disease management and health coaching modules, and workflow management features. and health coaching modules, and workflow management features. Pharmacy Home. The Pharmacy Home Project was created to address the need for aggregating information on drug use and translating it to the network pharmacist, case manager and primary care provider in a manner best suiting their care delivery needs. To accomplish this charge, the system was set up to provide both: 1) a patient level profile and medication history for point-of-care activities as well as 2) a population-based reports system to identify patients that may benefit from pharmaceutical care delivery via pharmacists, case managers and PCPs in the medical home. The Pharmacy Home drug use information database is used both prospectively (for identification of care gaps and problem alerts, targeting of at-risk patients, and development of the pharmaceutical care plan) and retrospectively (for continuous quality improvement and program evaluation). Statewide HIE Strategic Plan 29

37 Quality Measurement and Feedback chart audit system: NCCCN conducts over 26,000 medical record reviews in over 1250 primary care practices statewide on an annual basis, to abstract medical record data pertaining to quality of care measures for asthma, diabetes, hypertension, heart failure, and ischemic vascular disease. Medicaid claims data is used to generate a random sample of eligible patients, and to pre-populate audit tool elements according to an individual s identified chronic conditions. Secure client-server software allows users to work offline when Internet access is not available in the clinic location. When access to Internet is available, the system automatically synchronizes data with the server. Data is fully encrypted offline and in transit. Data sent to the server automatically updates a variety of process, progress, and analysis reports. Practices and CCNC networks have immediate access to chart review results, with local, state, and national comparative benchmarks, through a secure web portal. Informatics Center Reports Site: NCCCN creates patient-, practice-, county-, and network-level reports related to population management, case management/case identification and quality of care/performance measurement through a secure web portal and report distribution system. Provider Portal: NCCCN released a Provider Portal in August 2010, which allows secure web-based query access to the health record of NC Medicaid recipients, by treating providers involved in CCNC quality initiatives. The portal provides medical home and care team contact information, medication fill history and current med regimen (with indication of adherence and therapy gaps); clinical care alerts for point-of-care decision support; and visit history including inpatient, ED, office visits, imaging, DME supplies. Medical home providers have direct access to cost, utilization, and quality, and care gap reporting for their patient population to assist with population management. The portal also provides access to a comprehensive resource of low-literacy patient education materials and multilingual medication counseling tools. North Carolina Medicare 646 Waiver In 2003, Congress established the Medicare Health Care Quality Demonstration Program (Section 646 of the Medicare Prescription Drug, Improvement, and Modernization Act of 2003). The program has become known as the 646 Demonstration. The goal of the 646 Demonstration is to improve the quality of care and services delivered to Medicare beneficiaries through system redesign that fosters best practice. A competitive process was used to select health care organizations (physician group practices, integrated delivery systems, and regional coalitions of physician group practices and integrated delivery systems) to participate in this five-year demonstration. Under the 646 Demonstration, CCNC will carry out an intervention that combines a physiciandirected care management approach with the use of health IT to connect providers, support care management and delivery, measure performance, and implement pay-for-performance financial incentives. CCNC will extend its medical home and community based care management system to dual-eligible and Medicare-only populations. During years one and two, CCNC will manage approximately 44,000 dual eligible beneficiaries who receive care from 165 Community Care practices in 26 counties. At the beginning of year three, an estimated 170,000 Medicare-only beneficiaries, who receive care from those 165 practices, will be added to the demonstration. From years three to five, Community Care will Statewide HIE Strategic Plan 30

38 manage approximately 214,000 Medicare-only and dual eligible beneficiaries. As part of the demonstration there will also be a comparison group, which will be composed of the beneficiaries who receive their care from approximately 200 practices in 32 North Carolina control counties. 2.2.g. Public Health Reporting North Carolina Public Health collaborates with local health departments, hospitals, community health centers, practitioners, and community agencies throughout the state and nation to promote and contribute to the highest possible level of health for the people of North Carolina. NC Public Health has a dual role in health IT, as public health includes both individual care level services and population health services. North Carolina Public Health Information Network (NC PHIN) NC Public Health, including state and local health departments, organizes health IT and HIE under the concept of the Public Health Information Network (PHIN) according to National Health Information Network (NHIN) standards. NC PHIN was initially built through the use of Federal Public Health Preparedness funds that came to states following the events of September 11, The NC PHIN infrastructure provides 24/7/365 secure operations with high availability for applications that support the CDC Preparedness Goals. NC PHIN supports the national standards and objectives that are critical elements of a new statewide HIE such as open source development, interoperability, HIE, and certified standardsbased messaging. Listed below are additional details on some of the NC PHIN public health services provided. North Carolina Health Alert Network (NC HAN) NC HAN is a secure web-based alerting/communication system within NC PHIN designed to automatically and immediately alert appropriate users to health and bioterrorism threats. The service provides an effective method of ensuring that all appropriate personnel within the NC Division of Public Health, local health departments, hospitals, laboratories and other community partners are notified via , pager and/or fax according to PHIN PCA requirements. Syndromic Surveillance North Carolina has several systems in place to facilitate syndromic surveillance. In North Carolina, 100% of local health departments have access to syndromic surveillance information from emergency departments via the NC DETECT system. NC Disease Event Tracking and Epidemiological Collection Tool (NC DETECT) NC DETECT is the web-based early event detection and timely public health surveillance system in the NC PHIN. NC DETECT provides services for situational awareness, case finding, contact tracing and timely surveillance related to injuries, chronic diseases, environmental exposures and other public health concerns. NC DETECT receives data on at least a daily basis from four data sources: emergency departments (via a system called the North Carolina Hospital Emergency Surveillance System, or NCHESS, more fully described below); the statewide EMS data collection system (called the Pre-Hospital Medical Information System, or PreMIS, also more fully described below); Statewide HIE Strategic Plan 31

39 the statewide poison center; and a regional wildlife center. Data from select urgent care centers and three laboratories from the NC State College of Veterinary Medicine are in pilot testing. North Carolina Hospital Emergency Surveillance System (NCHESS) NCHESS was developed in 2004 by the North Carolina Hospital Association (NCHA) and the NC Department of Public Health using funding provide by the U.S. Department of Homeland Security through the Centers for Disease Control (CDC). NCHESS is a statewide clinical data surveillance program that captures real-time clinical data from hospital information systems and analyzes that data to quickly and accurately identify public health emergencies at specific hospitals, in certain geographic locations, or across the state. The NCHESS Emergency Department Data Interface (EDDI) is in place at 114 hospital emergency departments statewide, and collects 23 discrete data elements and provides syndromic surveillance, situational awareness, and clinical information of public health interest. In addition to the surveillance function, NCHESS Investigative Monitoring Capability (IMC) is in place at 45 of 114 hospitals, will 11 more capable of enabling this feature. Utilizing technology created by Thomson-Reuters, the IMC monitors all hospital clinical data in real time for patterns suggestive of public health threats and alerts hospital and public health officials accordingly. The IMC allows epidemiologists at DPH and at hospitals the ability to electronically reachback into hospital data systems to access electronic data on individual patients as needed to further investigate specific public health concerns. Over its lifespan, NCHESS has collected and reported on over 19 million unique patient records and over 115 million individual records. The data from 114 NCHESS hospitals comprise 93% of the data monitored by NC DETECT for public health surveillance in North Carolina. This represents approximately 25% of all the hospital data contributed to the CDC s BioSense surveillance system. NCHESS anticipates adding approximately 9 new emergency departments to the program by the end of Pre-Hospital Medical Information System (PreMIS) PreMIS is primarily an Emergency Medical Service (EMS) electronic medical records system that is also used as a mandated statewide system for collecting and analyzing EMS data from the over 1.4 million EMS events that occur in North Carolina every year. North Carolina regulations require that an electronic patient care report be completed on each EMS patient contact. EMS Agencies are required by regulation to complete an electronic patient care report and submit it into the PreMIS system within 24 hours of the event. EMS Agencies can meet this electronic data submission requirement by using the free PreMIS web-based data entry tool or through a commercial EMS data system which has been certified as a National EMS Information System (NEMSIS) Gold Compliant vendor. NC DETECT downloads daily files from the PreMIS and analyzes the EMS data for particular syndromes based on standardized pick lists for dispatch complaint and primary symptom. The North Carolina Office of Emergency Medical Services (NC OEMS), the state regulatory agency for EMS, established the EMS Improvement Center (EMSPIC) at the University of North Carolina-Chapel Hill to provide technical support and assistance to North Carolina s 540 EMS Agencies and 100 county-based EMS Systems in the use of EMS data. PreMIS is maintained through a contractual agreement by the EMSPIC. The PreMIS system is based on the National Statewide HIE Strategic Plan 32

40 EMS Data System standard adopted by all 56 US states and territories. Currently there are 26 different commercial EMS software packages active within North Carolina. Additionally, the Duke Endowment recently funded the EMSPIC s development of 5 EMS Performance Improvement Toolkits based on the NC EMS Data Systems. The Toolkits address key patient types or EMS events including EMS Response Time, Acute Trauma Care, Acute Cardiac Care (STEMI), Acute Pediatric Care, and Cardiac Arrest Care. The Centers for Disease Control and Prevention has also funded the development of an Acute Stroke Care Toolkit. All 6 EMS Performance Improvement Toolkits are now active within all 100 EMS Systems. Finally, this past year, the NC OEMS and the EMSPIC have focused on the linkage of EMS data with other existing North Carolina data sources. The purpose of the linkage is to better describe, evaluate, plan, and improve the healthcare provided to the citizens of North Carolina. At this time, NC OEMS and EMSPIC are linking PreMIS data and Trauma Registry data and have been granted approval by NC DHHS to obtain North Carolina Emergency Department, and Stroke Registry Data for linkage. NC OEMS is also seeking other ways to make EMS data available for HIE initiatives, including working on an initiative to make copies of EMS patient care reports retrievable by hospitals from the PreMIS system. Notifiable Results North Carolina has created a system to facilitate notifiable lab results reporting. In North Carolina, 100% of local health departments have electronic access to reportable lab results via the North Carolina Electronic Disease Surveillance System. Electronic lab reporting has been implemented with two laboratories, the State Laboratory of Public Health and LabCorp (both major sources of lab data for communicable disease surveillance). NC Electronic Disease Surveillance System (NC EDSS) NC EDSS is a statewide disease surveillance, outbreak/case management and early detection system. NC EDSS is utilized by public health users to receive, manage and analyze electronic data from public health entities, clinics, laboratories, hospitals and health care providers. NC EDSS replaced several communicable disease databases that had previously existed in the state, including TIMS (tuberculosis), NETSS (general communicable diseases and vaccinepreventable diseases), STD*MIS (STDs), HARS (HIV) and the Perinatal Hepatitis B Database. NC EDSS services include support for required case or suspect case reporting of reportable diseases, electronic lab reporting, outbreak management, emergency situational awareness and GIS mapping capabilities. Immunization Reporting North Carolina has created a system to facilitate statewide access to immunization data. In North Carolina, 100% of local health departments have electronic access to immunization information via the North Carolina Immunization Registry (NCIR). The state is evaluating ways to provide an interface that will enable EHRs to send as well as receive immunization information. North Carolina Immunization Registry (NCIR) NCIR is a secure, web-based clinical tool which is the official source for North Carolina immunization information. The NCIR takes the place of handwritten charting of immunizations administered in the state. Immunization providers may access all recorded childhood Statewide HIE Strategic Plan 33

41 immunizations administered in North Carolina, regardless of where the immunizations were given. The primary purposes of the NCIR are: To give patients, parents, health care providers, schools and child care facilities timely access to complete, accurate and relevant immunization data; To assist in the evaluation of a child's immunization status and identify children who need (or are past due for) immunizations; To assist communities in assessing their immunization coverage and identifying areas of under-immunization; and To fulfill federal and state immunization reporting needs. Statewide Registries In North Carolina, various statewide databases exist and may be made accessible to authorized users through statewide HIE services. These registries include: North Carolina Central Cancer Registry (CCR) The North Carolina CCR collects, processes, and analyzes data on all cancer cases diagnosed among North Carolina residents. All health care providers are required by law to report cases to the CCR, but the primary data source is the hospitals of the state. The CCR supplements hospital data with reports from physicians who diagnose cases that are not seen in a hospital. Death certificates and pathology laboratory reports are used to help identify cases that are missed in the routine reporting. Duplicate reports are consolidated in the data editing process. This is primarily a cancer surveillance activity, monitoring the incidence of cancer among the various populations of the state. The data are used by: State and county health departments to target resources for health education and screening services, Researchers for investigations into the causes and treatment of cancers, Public health advocates for focusing attention on the risk of cancer, The CCR staff to educate the public and provide evaluations of geographic and behavioral risk. Summary data are published on the internet and in several periodic publications. National organizations (CDC and NAACCR) that pool the data for national estimates of cancer incidence. These data submissions are also used to evaluate the quality of the CCR data. North Carolina Collaborative Acute Stroke Registry The North Carolina Stroke Care Collaborative (NCSCC) is part of a national effort to reduce the incidence of death and disability caused by stroke. The NCSCC assesses the use of best Statewide HIE Strategic Plan 34

42 practice guidelines for stroke treatment by conducting real-time data collection on stroke treatment within North Carolina hospitals. Using these data, hospitals are able to measure and improve the quality of patient care. In February, 2007, Congress passed a bill to appropriate $390,000 annual recurring funds to the North Carolina Collaborative Acute Stroke Registry. The NCSCC is currently in its 3 rd year of the current funding, with a total of 53 hospitals participating. Since 2006, the number of NCSCC participating hospitals has grown from 35 to 53. The NCSCC is the only program in NC in which data is collected prospectively; concurrent with care, and allows participating hospitals to measure their performance on an ongoing basis. This process will improve the quality of stroke care by continually promoting compliance with best practice guidelines. In addition, the registry's performance measures include the Stroke Measure Set utilized by the Joint Commission on Accreditation of Healthcare Organizations for awarding the Certification of Primary Stroke Center. The mission of the North Carolina Stroke Care Collaborative is: To measure, track, and improve the quality of acute stroke care To decrease the death and disability from acute stroke through secondary prevention. To increase public awareness of stroke treatment and prevention. To reduce the disparities in acute stroke care through increased access to quality acute stroke care. North Carolina Trauma Registry (NCTR) The North Carolina Trauma Registry collects data from 15 hospitals in the state, eleven of which are designated as Level I, II, or III trauma centers. State designated trauma centers are required to submit data to the NCTR which is maintained by the Office of Emergency Medical Services. The overall mission of the registry is to collect information on injured patients in North Carolina for the purposes of performance improvement, outcomes measurement, resource utilization, injury prevention, and clinical research. North Carolina Birth Defects Monitoring Program (NCBDMP) NCBDMP is part of the State Center for Health Statistics in the North Carolina Division of Public Health and was formally established by the State General Assembly in However, the NCBDMP has been collecting information about birth defects since NCBDMP is a team of public health professionals dedicated to providing information about birth defects in our state and working toward reducing the occurrence of birth defects everywhere. The NCBDMP gathers information on infants who are born with serious birth defects (also called congenital anomalies) that are diagnosed within the first year of life and also collect information about affected pregnancies from stillbirths and elective terminations. The NCBDMP is an active, population-based surveillance system. This means that it actively collects information about all medically diagnosed cases of birth defects across the entire state. Data are collected by a team of trained field staff who systematically review and abstract (summarize) medical records. These data are combined with other information from Statewide HIE Strategic Plan 35

43 administrative health databases such as hospital discharge records, birth certificates and newborn screening records. The NCBDMP performs several other services, such as: Maintaining a central registry with information about birth defect cases in NC. As required by state law, all personal identifying information in the registry is confidential. Responding to inquiries from health departments, health care professionals, legislators and the public about the occurrence of birth defects in our communities. Conducting epidemiologic studies of birth defects in North Carolina. We often work with other state agencies, advocacy groups, local universities and other research organizations with the common goal of identifying new ways to prevent birth defects. Improving the delivery of services to children with special needs through identification and referral to appropriate services. Vital Statistics The Vital Statistics team is located within the Statistical Services Unit of the State Center for Health Statistics (SCHS). The team is responsible for the processing and dissemination of vital statistics data. The Vital Statistics team is comprised of two main work groups, although these groups often work together to achieve common goals. Quality Control: This group is charged with developing and implementing thorough quality control initiatives to improve the accuracy of vital records data. The Quality Control group works closely with staff in the Vital Records Office to investigate data quality issues and work toward reasonable solutions. Each year, this group processes and finalizes the following data files: Deaths Births Fetal Deaths Matched Birth/Infant Deaths Marriages, and Divorces. An annual Infant Mortality Report is also generated by this group. In addition, the members of this group perform infant death/live birth matching, code vital events that occur out-of-state, and contribute to other annual publications based on Vital Statistics data. Data Dissemination: This group produces and disseminates statistical information to the public. These statisticians respond to requests from citizens, health departments, students, the media, private corporations, hospitals, universities, and legislators. They work with researchers and government agencies on special projects involving vital statistics data. The Data Dissemination group creates the Population, Abortion, and Communicable Disease data files. This group also assists with the production of SCHS reports and publications, such as the County Health Statewide HIE Strategic Plan 36

44 Data book for Community Assessment, North Carolina Reported Pregnancies, and the Pocket Guide. Health Services Analysis Team (HSAT) The Health Services Analysis Team (HSAT) is located within the Statistical Services Unit of the State Center for Health Statistics. Statisticians in the HSAT work in partnership with North Carolina health agencies to provide program managers with timely statistical information that will be used to inform decisions about the health management of populations, cost effectiveness of programs, quality of care, and cost management and accountability. The goal is to improve health programs in North Carolina, resulting in better health for our citizens. One important use of health services data facilitated by the HSAT is to identify emerging morbidity and mortality patterns. Often, this process is facilitated by combining a program's health service data with birth, death, or other health records, to get a broader understanding of the health status of North Carolina populations. The HSAT also provides researchers in other agencies and university settings with assistance in research design and with data files for public health evaluation and research projects. Clients regularly served by the HSAT include: Many agencies of the Division of Public Health North Carolina Supplemental Food and Nutrition Program for Women, Infants, and Children (WIC) Division of Medical Assistance North Carolina's Community Care Program: Carolina Access and Access II and III Children's Environmental Health Branch, Division of Environmental Health Local Health Departments of North Carolina School of Public Health, University of North Carolina, Chapel Hill Cecil B. Sheps Center for Health Services Research, University of North Carolina, Chapel Hill North Carolina Healthy Start Foundation Wake Forest School of Medicine Citizens of North Carolina Specific areas of focus of the HSAT s work include: Quality assurance for health care programs Assessment of cost-effectiveness of health programs Inter-agency health database development Statewide HIE Strategic Plan 37

45 Data support for medical record audits Demographic profiling of health program populations Medicaid systems of care evaluations and comparisons Description of and analysis of hospitalization patterns in North Carolina Annual reports & special requests generated from North Carolina Medical Examiner's data Annual child fatality reports North Carolina Health Care Personnel Registry The NC Health Care Personnel Registry Section operates under state and federal laws for unlicensed health care workers and their employers. The Personnel Registry s scope includes review and approval of Nurse Aide I education programs and of Nurse Aide I and Medication Aide testing programs. The Personnel Registry maintains competency based registries for Nurse Aide I and Medication Aides. The Health Care Personnel Registry Section also investigates abuse, neglect, and other allegations against unlicensed health care workers and lists allegations and substantiated findings on the Registry. Information from the registries is used by health care providers in their hiring process. Additional Public Health IT Systems Health Information System for NC Public Health Agencies (HIS) This new system is essentially a centrally provided Electronic Medical Record system that provides an automated means of capturing, monitoring, reporting and billing services provided in local health departments, children s developmental services agencies (CDSA) and the state lab. The rollout of this system will be completed by the middle of September The HIS is designed to provide better client service at lower cost and to provide higher quality health care services through better availability and integrity of relevant patient information. The centrally served architecture of HIS requires that each public health clinic user s workstation have an active session with the central servers (in Raleigh NC) whenever the system is being used. NC Comprehensive Assessment for Tracking Community Health (NC-CATCH) The State Center for Public Health Statistics houses an innovative data warehouse known as NC-CATCH (Comprehensive Assessment for Tracking Community Health.) NC-CATCH is a collaborative effort between state and local public health agencies in the state to provide community and county health profiles with easy assembly of a wide array of demographic and community health data, along with comparisons with peer counties and the state. This information is used to establish community public health priorities which in turn inform public health interventions and decisions. Secondary data from a number of sources is compiled and organized for access by public health agencies. Statewide HIE Strategic Plan 38

46 2.2.h. Telehealth and Telemedicine North Carolina Telehealth Network (NCTN) The North Carolina Telehealth Network (NCTN) is a collaboration of NC healthcare providers, both public and private that organized prior to ARRA for the purpose of responding to federal funding opportunities with the FCC. NCTN includes collaborators from e-nc (a state authority devoted to broadband adoption), the NC Association of Local Health Directors, the state Division of Public Health, the NC Association of Free Clinics, the NC Hospital Association, NC Medical Society, the Southwestern Commission, Albemarle Health, and University Health Systems of Eastern NC. The overall goal is to create a dedicated broadband network for health in NC. The project set leverages $12.1M in broadband discounts from the FCC s Rural Health Care Pilot Program. The NCTN is now three projects. The NCTN-Public Health Phase (NCTN-PH) supports a broadband network for public health agencies and free clinics in NC. The NCTN-H is a similar (and connected) broadband network for hospitals in NC; NCTN-H is currently in an RFP phase and is expected to be active in the fall of The NCTN-AMB is devoted to developing a broadband network component for private ambulatory practices in NC that interconnects with the NCTN-PH and NCTN-H, and is currently in a planning stage. MCNC MCNC is a non-profit organization incubated by the State of North Carolina General Assembly in One of MCNCs main activities is to operate the North Carolina Research and Education Network (NCREN). NCREN provides broadband communications technology services and support to all 115 K-12 school districts, 20 of 58 North Carolina Community Colleges, all University of North Carolina system institutions, 24 of 36 of North Carolina s Private Colleges and Universities and public health facilities across the state. In January 2010 and as described more fully below, MCNC received federal funding to expand their middle mile network into 37 counties in the west and southeastern portion of the State. In addition, MCNC has applied for federal recovery funds to build middle mile fiber and direct fiber to select community anchor institutions in 69 rural counties. This will likely meet the last mile needs of several major non-profit and university hospitals. Both the North Carolina Office of Information Technology Services (ITS) and MCNC have a long history of working with providers in procuring last mile services to education facilities and has offered to help with this aspect for healthcare facilities and, if needed, physician offices. ITS and MCNC recently collaborated on and won a bid to connect County Health Agencies and County Free Clinics to the ITS and MCNC backbones. These backbones peer seamlessly and serve as resilient back-up to one another. The two entities are planning on another cooperative bid to provide backbone networks services to the non-profit and university hospitals in the State. 2.2.i. Broadband In order for HIE related applications and services to perform with proper speed and reliability, a robust fiber optic based broadband infrastructure is required. This fiber infrastructure should interconnect all elements of the health care ecosystem within North Carolina to an intranet infrastructure and then provide, through this intranet infrastructure, connections to the commercial Internet, advanced research networks and federal information repositories. The Statewide HIE Strategic Plan 39

47 health care ecosystem includes all places where care is provided, information stored, reimbursement offered, or medication disbursed: 1) All in-state facilities that host repositories of healthcare information 2) DHHS 3) State and County public health facilities 4) Free clinics (county, local, non-profit) 5) Federal health facilities located in North Carolina 6) Hospitals - University, non-profit, publicly owned, privately owned 7) Practice offices 8) Insurance providers 9) Pharmacies Private sector and public sector networking technology providers must work together in order for such an infrastructure to be provided. North Carolina has been aggressive and successful in pursuing federal broadband recovery funds through both the Department of Commerce's BTOP and Department of Agriculture BIP funding. Through two rounds of funding, North Carolina has received the following infrastructure awards that have great potential to assist in building a core HIE network infrastructure. Broadband Technologies Opportunity Program Round 1 Award Through ARRA $7.2B in funding was allocated to the US Department of Commerce and the US Department of Agriculture to promote the deployment and use of broadband technologies to underserved and unserved populations in the United States. Commerce administers $4.5B of this broadband recovery funding through the National Telecommunications and Information Administration s (NTIA) Broadband Technologies Opportunities Program (BTOP), the majority of which is for deploying last mile and middle mile broadband infrastructure to unserved and underserved consumers and to Community Anchor Institutions (Schools, Libraries, Health Care facilities, other facilities of public importance). In January 2010, the NTIA announced that MCNC had been awarded $28.2M in middle mile broadband recovery funds. MCNC s funded proposal includes the construction of 500 new miles of fiber in 37 counties in the rural southeastern and western part of the state. Counties traversed by the initial build include: Eastern North Carolina Beaufort Bladen Carteret Columbus Craven Cumberland Edgecombe Greene Harnett Johnson Nash New Hanover Onslow Western North Carolina Alexander Buncombe Burke Caldwell Catawba Cleveland Davidson Davie Gaston Haywood Henderson Iredell Jackson Statewide HIE Strategic Plan 40

48 Eastern North Carolina Western North Carolina Pender Lincoln Pitt McDowell Robeson Mecklenburg Wake Polk Wilson Rutherford --- Transylvania In May 2010, MCNC chose ONUG Communications from among 17 bidders for the engineering contract. In early June 2010, MCNC received responses from potential vendors for an earlierissued RFI related to provision of fiber, conduit and couplers, and in the same month issued an RFI for optical equipment that will light the fiber. MCNC s goal is to start building BTOP Round 1 by the end of summer BTOP Round 2 Award On August 18, 2010, Governor Purdue announced that North Carolina received an additional $115 million through five federal recovery grants to extend broadband connectivity in North Carolina: MCNC $75,757,289 This approximately $75.8 million award will allow MCNC to offer affordable middle-mile broadband service in 69 of the most economically disadvantaged rural counties along the northern and southern borders of North Carolina. The project plans to directly connect 170 community institutions to broadband. As many as 5.1 million stand to benefit as do 160,000 businesses. Yadkin Valley Telephone Membership Corporation $21,668,232 This approximately $21 million award, will allow Yadkin Valley Telephone Membership Corporation to offer a diverse Fiber-To-The-Home (FTTH) network to areas of six counties in the Piedmont area of western North Carolina. Approximately 12,803 people stand to benefit, as do roughly 606 businesses and 56 community institutions. City of Charlotte $16,702,490 This approximately $16.7 million award will allow public safety entities in the city to deploy an interoperable wireless public safety broadband network in the Charlotte/Mecklenburg County area. The project plans to construct 24 new wireless towers to complement six existing towers on the network, and bring over 11,000 public safety end users onto the system. As many as 890,000 people stand to benefit from this project. Olive Hill Community Economic Development $448,742 This nearly $450,000 award will allow the Olive Hill Community Economic Development Corporation to expand access to broadband in the greater western region of North Carolina by establishing a public computer center and providing community training and support, with a focus on helping disadvantaged local businesses, the unemployed, and individuals seeking higher education opportunities. WinstonNet Inc. $926,537 This approximately $926,000 award, with $696,000 in matching contributions, will allow WinstonNet to improve broadband access for communities with the greatest need in Forsyth County, North Carolina. Statewide HIE Strategic Plan 41

49 North Carolina Health Information Exchange The following is a map showing the existing and BTOP Round 1 and BTOP Round 2 fiber routes: Figure 4. Broadband Distribution 2.2.j. Health Plan Support of Electronic Eligibility and Claims Transactions North Carolina's Medicaid program supports electronic eligibility checking and submission of claims. In North Carolina, Medicaid requires that all claims be submitted electronically. Due to a few provider and medical service exceptions, approximately 2 percent of providers claims submitted to Medicaid remain in paper form. Providers can submit claims via one of three methods: (1) North Carolina Electronic Claims Submission/Recipient Eligibility Verification Web Tool, an Internet-based portal, (2) through Value-Added Networks (VANs) which support real-time and batch 270/271 transactions; and (3) an automated voice response system. Medicaid estimates that approximately 15 million claims are submitted electronically every month, 93.5 percent through VANs and 6.0 percent through the Web Tool. The NC HIE and the State Health IT Coordinator are working with the North Carolina Department of Insurance to determine the number of commercial health plans supporting electronic eligibility and claims transactions. Statewide HIE Strategic Plan 42