Florida HIE Plan Overview -- Issues and Selected Comments 1. RHIO funding FAR believes that continued support for and use of Florida's RHIOs should be a priority objective of the proposed HIT/HIE Plan.... Participation by leaders of the Florida RHIOs in developing the Florida HIT/HIE Plan is essential to get statewide impact, and this inclusion will demonstrate Florida s compliance with the legislative intent clearly stated in ARRA regarding utilization of local and regional entities to build the national health information infrastructure. (Florida Association of RHIOs) We hope AHCA will issue a revised version of the Florida Plan which includes a more active and responsible role for RHIOs/HIEs in communities across the state. This can be accomplished by: expanding and rotating membership of the Health Information Coordinating Committee (HIECC) to include more representation from the Florida RHIOs and other organizations working to expand HIE activity in Florida; reinstating the FHIN grant program or similar funding opportunity... (Northwest Florida RHIO) 2. State level HIE and relationship to RHIOs; viability of RHIOs with state level HIE We believe the RHIOs and their HIEs have been, and should remain, the centerpiece of the Florida Health Information Network infrastructure. If a "State-level health information exchange" partner is to be created at all, its scope should be limited to supporting providers and patients who are not located in areas served by a local RHIO. To maintain a consistent level of service statewide, data made available to the new "State-Level health information exchange," such as Medicaid data, payer data, etc., must be made available to the local RHIOs to support access by participating providers and patients. The cost to the Florida RHIOs for this data should be no greater than what the "State-Level health information exchange" pays for the data on an enrolled patient or provider basis, as applicable An important key to a RHIO s sustainability is minimizing costs. Covering the high operating cost of a State-Level HIE, could result in fees charged to RHIOs that could make them unsustainable. For example, these fees could easily overwhelm the total annual operating budget for Healthy Ocala s HIE and PHRs (less than $150,000 for this year and about $250,000 for subsequent years). (Healthy Ocala) 3. Functionality of state level HIE services, technical feasibility, scalability etc. The federal interoperability standards could provide the opportunity for a less expensive means of exchanging data yet the Plan does not seem to recognize that as a possibility. (Florida Hospital Association)
There are many challenges to successfully implementing and operating these kinds of systems, minimizing and resolving the issues that surface, and taking steps to deliver solutions that gain wide acceptance by the physicians and clinical staff. These challenges include: - Supporting large master patient indices and clinical data repositories - Dealing with real life data integrity and data security issues, which is critical to maintaining the confidence of care givers and patients, not to mention being a requirement for patient safety - Implementing solutions in such a way that the systems are intuitive and have sufficient usability such that front line care givers, who are operating in busy settings such as an emergency room, will be willing to take the time to use the tools during the care delivery process - And importantly, recognizing when a proposed IT strategy and/or a solution is not likely to lead to a good outcome. (Mike Smith, Lee Memorial Health System) 4. Concerns about clinical data access by payers FMA further believes that insurance companies and other third party payers should not be in possession of clinical data that relates to patients that are not insured by that company or payer, and further that the entity controlling the medical data in any exchange program should not be an insurance company or third party payer nor be significantly influenced by such company or payer. (Florida Medical Association) The technical description appears to be payer-centric. Paragraph 2 in section A states that the multi-payer HIE will have a bidirectional connection with the State-Level HIE to facilitate the exchange of pertinent patient records held by the government, payer, provider and laboratory... This seems to imply that clinical data will flow freely from providers to the payers. If so, adoption by providers as well as consumers could be problematic as consumers, in general, are wary of payers having access to their clinical information. (Mosaica Partners) 5. Recognition of payer-based and provider based PHRs AHCA should not promote or recognize any particular PHR product, particularly since there are few guidelines and regulations in place... (Northwest Florida RHIO) The draft plan appears to only endorse use of electronic Personal Health Records (PHRs) of payers and providers. In our experience, neither patients nor health care providers are comfortable with clinical records being provided to (insurance) payers for incorporation into a PHR. Patient portals that provide access to physician Electronic Health Record (HER) systems do not include the robust technical capabilities available in state-of-the art Personal Health Record systems. One of the centerpieces of Healthy Ocala is our operational Personal Health Record (PHR) with a state-of-the-art Personal Health Record Management System provided by WorldDoc (Healthy Ocala) 6. Governance structure of HIE
[The Plan] proposes an organizational structure that may not necessarily meet the long term needs of the consumers (Florida Hospital Association) As other states have long surpassed the Governance Structure milestone, it is imperative that Florida act quickly in order to effectively compete for available federal stimulus funding. (Harris Corporation) The governance structure during the early stages will be very different than the governance structure required during steady state operations. (Accenture) 7. Concerns about claims data The Tampa Bay RHIO is concerned that claims based data would be perceived as an EHR or clinical data Using claims data as clinical data may compromise patient safety because it isn t always timely and does not always accurately reflect the patient s clinical information. (Tampa Bay RHIO).there is wide spread concern that the Plan as written is more reflective of an exchange of claims data not clinical data. (Florida Hospital Association) The use of the hospital encounter data in the statewide health information exchange for coordination of care does not appear consistent with the federal goal of sharing clinical not administrative data. (Florida Hospital Association) 8. Negotiating preferred prices with vendors One way to maximize resources and expand local/regional HIE activity would be for the State to select one or two preferred vendors offering a range of products that meet local HIE needs and enable access to the state portal, and negotiate group pricing for Florida customers. (Northwest Florida RHIO) 9. Funding for non-traditional EHR including social services, program tracking systems etc. and how will connect (e.g. Ryan White CareWare, Northwest Florida Community Health Information Network) For community-based HIEs targeting poor and uninsured patients, AHCA should consider a waiver for entities using non-certified software systems if meaningful use can be demonstrated and audited. (Northwest Florida RHIO) There are currently other electronic medical record systems in place such as the Ryan White CAREware system that is being implemented through contract with the Federal and state government and particular counties/lead agencies. How will these required systems and those providers fit into the overall picture? (Treasure Coast Health Council, Inc.) 10. More stakeholder engagement (various comments) We strongly urge the Agency and the Policy Center to workshop this plan with the HIECC. (Florida Hospital Association)
Given the importance of this HIE work to the future of Florida health care, I would like to respectfully suggest that AHCA consider a much deeper level of engagement with the Florida healthcare CIO community in the leadership of these State HIE planning activities. (Michael Smith, Lee Memorial Health System) 11. More emphasis on State role in adoption outreach, role of Regional Extension Centers This model does not include the necessary facets that would promote adoption. Action items such as training, consumer outreach and education are missing. (Tampa Bay RHIO) a collective cooperative organization of significant healthcare organizations should apply to become a Regional Extension Center and that such application should be in conjunction with an existing, functional Regional Health Information Organization. (Florida Medical Association) 12. Data integrity (De-duplication, errors, time lag or other data quality issues) There is no mention in this document of two important technical challenges: data security and privacy, and de-duplication. If solutions to these challenges are documented elsewhere, this document should address them. How will we assure that information about multiple people is not mixed together in what is supposed to be a single person s record, and that information about a single real person is not scattered across records with several different IDs? (Richard Hopkins, MD, Florida Department of Health) 13. Other providers (pharmacies, emergency responders) need to be explicitly included When discussing Certified and Qualified Provider EHRs with Interfaces to the HIE we feel it is important to include EMS data, Independent Pharmacies, and other additional Health care Providers. (Wuesthoff Health System, Inc.) 14. Cost of uninsured data collection to hospitals The Governor s Office, Senate and House Leadership have all indicated a commitment to matching cost verses benefit when applying new regulations or revising current regulations on hospitals. We are concerned that the cost of expanding the data collection and/or changing the reporting timeframes for hospital discharge data will increase hospital cost without providing real value in the delivery of meaning health information exchange. However, per our discussion we look forward to discussing this objective when the Policy Center has a clear understanding of its goals. (Florida Hospital Association) 15. Need to address privacy and security (authentication, etc.) The draft paper does not touch on the need for privacy or information security at all. Consideration must be made to how access will be granted to those looking to access the exchange, who will manage the access and who will take the legal responsibility for the information once it reaches the exchange. (Health First) 16. Need to address consumer access
There should be a venue for consumers or patients to access or add to their records within the HIE without being part of, or attached to, a payer/provider. (Execdata, LLC) 17. Need to address use of clinical decision support tools Reed Elsevier recommends leveraging clinical decision support tools to ensure quality and cost savings from the HIE. Integration of evidence-based content and clinical support tools will help enhance the quality of care of patients across the state (Reed Elsevier Inc.) 18. Need to address public health access and design issues It is important that public health be involved in the design of this system from the beginning, so that we can help assure that the correct data are collected and that they are exchanged and presented using the correct coding systems, not just to have a plan for accessing the data. (Richard Hopkins, MD, Department of Health) 19. Need to address prevention of fraud and abuse EHR platform systems are a great tool for reducing and controlling cost and dealing with fraud issues. Failing to address the cost issue will jeopardize the sustainability of the HIE plan in the long run and underutilize the technology. (Vermis) 20. More emphasis on patient care and how health information exchange will improve outcomes This is probably one of the largest transformational changes that the State will undertake, impacting the citizens and businesses of Florida. Looking at it from this perspective we advocate clearly defining desired health outcomes from the start, then developing a roadmap of how to get there, with defined measures and a process for actively managing and refining the approach and plan. (Accenture) 21. Need more background, explanation, clarity of proposal my initial observation is that this HIE Plan seems broad but very general in nature, and it raises a number of conceptual questions, making it hard for me to make specific comments. (Mike Smith, Lee Memorial Health System)