New York eHealth Collaborative (NYeC)

New York State Health Information Exchange

Operational Plan

October 26, 2010

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 TABLE OF CONTENTS

Glossary 4

Executive Summary 6

ACHIEVING TECHNOLOGY-ENABLED HEALTH CARE

TRANSFORMATION IN NEW YORK STATE: OPERATIONAL
PLAN FOR HEALTH INFORMATION TECHNOLOGY AND EXCHANGE

1. Background

New York’s Vision of Technology-Enabled Health Care Transformation 13

Overarching Goals for Health IT in New York State

Core Values That Underlie New York’s Approach to Health IT 16

Progress to Date 17

2. Governance 29

Statewide HIE and Health IT Leadership 31

Statewide Collaboration Process 33

Accountability and Oversight 38

Statewide HIE Utility 45

3. Technical Infrastructure 46

Health IT and HIE Gap Assessment and Corrective Strategies 48

HIE Architecture and Approach 54

HIE Standards and Certification 60

4. Business and Technical Operations 62

Statewide HIE Services Approach and Implementation Timeline 62

Broadband Access 67

Technical Assistance Services 68

Adoption Services 68

Standard Operating Procedures 69

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 Identifying and Mitigating Potential Business Risks 70

Monitoring and Evaluation 70

Continuous Improvement 70

5. Legal and Policy Issues 72

Privacy and Security Framework for Statewide HIE 72

6. Finance 77

Financial Model 77

Detailed Cost Estimate and Staffing Plan 81

7. Coordination Among New York’s Health IT Programs 86

Coordination with Medicaid 86

Coordination with REC Programs 88

Coordination with Public Health, Medicare and Federally Funded,

State-Based Programs 89

Coordination with Federal Care Delivery Organizations (VA, DoD, IHS) 93

Coordination with Other New York Policy and Procurement Activities 94

Development of Trust Agreements for Interstate Data Sharing 95

Appendices

Appendix A – New York Regional Health Information Organizations

Appendix B – Minimizing and Managing Risk

Appendix C – Current NYS DOH Electronic Data Systems for Public Health Reporting

Appendix D – Commitment to Fair Information Sharing Principles

Appendix E – Quality Monitoring & Reporting

Appendix F – Letter of Support

Appendix G – NYeC Board Membership

Appendix H – Candidate HIE Services

Appendix I – Project Management Plan

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GLOSSARY
CAC Consumer Advisory Council

CAHPS Consumer Assessment of Healthcare Providers and Systems

CCC Collaborative Care Community

CHITA Community Health Information Technology Adoption Collaborative

CHI2 Child Health Integration Initiative

DOHMH New York City Department of Health and Mental Hygiene

ECLRS Electronic Clinical Laboratory Reporting System

EHR Electronic Health Records

HEAL Health Care Efficiency and Affordability Law for New Yorkers

HIE Health information exchange

HIPSC Health Information Privacy and Security Collaboration

HITEC Health Information Technology Evaluation Collaborative

IIS Immunization Information System

IT Information technology

NHIN Nationwide Health Information Network

NYC New York City

NYeC New York eHealth Collaborative

NYS DOH New York State Department of Health

OHIP Office of Health Insurance Programs (NYS DOH)

OHITT Office of Health IT Transformation (NYS DOH)

PCIP Primary Care Information Project

PCMH Patient-Centered Medical Home

PHI Personal Health Information

PHR Personal Health Records

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POC Policy and Operations Council

NCQA National Center for Quality Assurance

REC Regional Extension Center

RHIO Regional Health Information Organization

SCP Statewide Collaboration Process

SDE State Designated Entity

SHIN-NY Statewide Health Information Network for New York

SPG Statewide Policy Guidance

UPHN Universal Public Health Node

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EXECUTIVE SUMMARY

Since 2004, more than $840 million in Federal, State and private sector funding has
been allocated toward efforts to harness health information technology (IT) and health
information exchange (HIE) to improve the effectiveness and efficiency of health care
delivery in New York State. In support of a technology-enabled health care
transformation, diverse stakeholders have united to forge a strong statewide consensus
for reform. A statewide infrastructure to support HIE has been established and
supported by policies and standards that have enabled early gains in the adoption of
health IT.

These innovations in New York are inspired by a vision of the patient at the center of a
care community that collaborates to address the full array of each individual patient‘s
needs. The State‘s strategic approach to HIE reflects a commitment to privacy and
security, a focus on improved medical outcomes, and an emphasis on continuous
quality improvement, further innovation, and accountability in the public interest. This
emerging technology-enabled health care transformation in New York State will benefit
patients, primary and specialty care providers, hospitals, payers, and governments.

Notwithstanding the strides made in establishing a foundation for widespread HIE,

important gaps remain both in the stakeholders‘ adoption of these promising new
technologies and in the implementation of the policies and procedures needed to
ensure full realization of the State‘s health care vision. New York‘s Operational Plan for
Health Information Technology and Exchange (Operational Plan) aims to continue the
advances achieved to date, to address existing gaps, and to ensure the sustainability of
these efforts.

The Operational Plan outlines specific steps New York will take in the coming months to
expedite progress through the strategic allocation and use of more than $300 million in
grant funds that will be programmed through 2013. Developed in close coordination with
the Office of Health IT Technology (OHITT) and the Office of Health Insurance
Programs (OHIP) in the New York State Department of Health (NYS DOH), the Plan is
submitted by the New York eHealth Collaborative (NYeC), a statewide public-private
partnership that aims to advance health IT.

Governance

Leadership: New York‘s governance infrastructure is led by a collaborative statewide

leadership between NYSDOH and NYeC and is guided by the core value of
accountable HIE governance in the public's interest. Under the guidance of these two
entities, New York developed an open, transparent, collaborative, multi-stakeholder
process for developing health information policies, standards, protocols, and technical
approaches. New York further relies on the implementation and governance of these
policies at the community level.

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Statewide HIE Governance Framework: New York‘s statewide HIE governance
framework aims to accelerate progress towards achievement of the required connected
capabilities for effective HIE. The goals of the governance process include:

 Ensure broad use and access of HIE services by all providers in New York
State
 Support collaborative care model through which multiple stakeholders work
together to measurably improve the quality and efficiency of care and
transform the health of the community
 Accelerate market-driven interoperability
 Create a sustainable marketplace for HIE services that meets public policy
needs
 Strengthen core public health functions, including prevention, service
planning, outcomes research, disease surveillance, and early warning
systems for disease outbreaks
 Advance New York‘s national leadership in statewide HIE

In an effort to maximize effective allocation of resources and strengthen successful local

organizations, New York‘s governance framework has expanded to include two
complementary concepts: a ―Qualified Health IT Entity,‖ which will serve as the technical
on-ramp to HIE services, and a ―Collaborative Care Community (CCC),‖ which will
function as a multi-stakeholder means for improving the quality and efficiency of care
and transforming the health of the community.

Statewide HIE Utility: Examining New York‘s existing statewide HIE infrastructure
revealed that additional opportunities exist to leverage economies of scale, particularly
that of core infrastructure services and other value-added services that could be
procured and managed using a statewide, public utility model. NYS DOH and NYeC
continue to evaluate options for creating a single statewide HIE utility, including the
viability of NYeC serving in this capacity.

Technical Infrastructure

A statewide trend toward adoption of health IT and HIE is evident with respect to e-
prescribing, electronic reporting for public health, electronic lab results delivery, and
patient care summary exchange. Yet considerable gaps remain in the uptake and
utilization of health IT and HIE. To address these gaps, New York will develop and
deploy HIE services aligned with New York State‘s Health Care Efficiency and
Affordability Law for New Yorkers (HEAL NY) health IT strategy, Federal health IT
programs, meaningful use mandates, and developments in the commercial market
related to health information exchange.

Core services: Core services will be made available on a uniform basis to support
connected capabilities statewide. These services may be provided as a single statewide
shared service or by standardizing regional approaches to developing and delivering the
services. In either scenario, NYeC will coordinate activities to ensure that all potential

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state HIE participants have access to them. Below is a list of core services that will be
released in June 2011:
 Provider/HIE Directory – coordinated to function with Message/Record Routing and
Identity Management and Authentication for provider enrollment and other security
features
 Record Locator Service/Master Person Index (Patient Matching) – coordinated to
function with Message/Record Routing, Consent Management and possibly with
Identity Management and Authentication (for patient enrollment and other security
features)
 Message/Record Routing – focused on health information organization (HIO) to HIO
integration, providing access to participants not served by a qualified HIO, and
enabling direct connection by participants and vendors capable of complying with
SHIN-NY policy and standards
 Identity Management and Authentication – a full suite of security features for
participants in statewide HIE, coordinated with RHIO and other qualified HIO
infrastructures and enrollment processes
 Consent Management – coordinated to function across HIO/HIO boundaries and
with all other services in the bundle

Public Health Reporting/Registry: The initial public health reporting/registry services, to

be released in August 2011, will focus on aligning the ongoing HEAL efforts to
implement a Universal Public Health Node (UPHN) with the statewide capabilities and
with requirements for the Public Health Reporting/Registry value-added service.

Value-Added Services: The below value-added services are necessary to support

connected capabilities. These services may be implemented with more variability,
depending on HIE objectives and regional capabilities.

 Medication Management – Collect prescription history for purposes of performing

medication reconciliation, detecting significant changes or overuse of medications,
identifying and notifying patients at risk of adverse events, etc. Data can be de-
identified with a key for re-identification for certain uses as required.
 Personally Controlled Health Record – Populate a patient-centered longitudinal /
lifetime health record from primary data sources. Can be event / rules-driven,
consumer-activated or a combination. Can provide storage and viewing capabilities
or simply route to a consumer-directed service such as Google Health, Indivo, or
Microsoft Health. Also, provide patient / consumer with ability to request and route /
download CCDs and other data to self and other participants. Can be accomplished
through a portal, secure e-mail, IVR, etc. Can be implemented through negotiated
offer of commercial service to consumers.
 Event Notification – Route various notifications of patient status to authorized and
interested parties based on certain triggers. Possible candidates include First
Report of Injury and / or Admission Notification to the patient‘s payer and physicians;
Death Notification to payer, physicians and public health; status changes such as
adoption, protective services, marriage, hospice, PCP change, etc.

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 E-prescribing – Largely delivered through EMR vendor software in combination with
Surescripts‘ national network. A gap analysis will be conducted to determine if
RHIOs and other organizations require assistance to incorporate payer formularies
and pharmacies not available through Surescripts. The goal of this activity is to
increase adoption and volume among NYS providers of e-prescribing to commercial
pharmacies.
 Lab results – Largely already delivered by national lab companies and RHIOs
through existing interfaces. A gap analysis will be conducted to determine required
for delivery of structured lab results uniformly statewide from local hospital, regional
and national labs. Depending on the results of this gap analysis, NYeC may provide
coordination or integration assistance to standardize interfaces or to fill gaps,
especially in delivering results from local hospital labs in some regions.

To support and strengthen the technical infrastructure strategies, New York will develop
and implement user-friendly technical assistance services, including a help desk, to
support and expedite the ability of stakeholders to adopt health IT and HIE strategies.
Working closely with the New York REC programs, New York will provide adoption
support services to all providers, including primary care providers, mental health
providers, long-term care providers, and home health providers to promote and
facilitate the usage and adoption of health IT and HIE.

Legal and Policy Issues

In developing a comprehensive, standardized set of privacy and security policies and

procedures, New York aims to improve health care delivery and health outcomes for all
New Yorkers by achieving the following goals:

 Implement HIE that is secure and protects patient privacy

 Orchestrate levers of state policy to advance Health information Exchange

 Advance state law, policies, and procedures that are aligned with secure health
information exchange within and beyond state borders

 Advance trust agreements that enable parties to share and use data

 Pursue strong oversight and enforcement to ensure compliance with federal and
state laws and policies applicable to HIE.

To ensure a robust and comprehensive legal and policy framework for health IT and
HIE, New York will continue to develop long-term legal and contractual protocols to
maintain the collaborative multi-stakeholder trust that has been nurtured through the
SCP. In addition, investigating strategies to enable interstate data sharing with
neighboring states is underway.

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Consistent with one of the core principles of New York‘s approach to health IT and HIE,
the State will implement a rigorous plan of action to address gaps or shortcomings in
applicable laws and regulations pertaining to privacy and security.

To ensure that NY Policies and Procedures are consistent with evolving Federal and
State laws and regulations, New York will continue to utilize the SCP processes to
update the Policies and Procedures to bring them into alignment with changes in
existing laws and regulations.

Finance

Building upon the financial investments that have enabled New York to achieve the
progress it has made so far, New York will advance strategies to continue, accelerate
and sustain these advances. Given the need for self-sustaining sources of long-term
funding, New York particularly aims to encourage and facilitate market dynamics that
are consistent with Federal policy as well as New York‘s policy objectives.

New York will identify and create incentives to encourage the adoption and
sustainability of health IT. Specific efforts will focus on incentivizing health IT adoption
by key stakeholder groups, including specialty clinicians in ambulatory settings, large
primary care practices, long-term care facilities and nursing homes, home health
agencies, inpatient facilities, hospital emergency departments, mental health providers,
and other segments of the clinical community. A cost-benefit analysis of a shared
services (or ―public utility‖) approach will be undertaken, and Qualified Health IT Entities
and coordinated care projects will be supported to ensure long-term regional
sustainability. Consistent with current practices, NYS DOH and NYeC will implement
and enforce rigorous financing controls and issue detailed financial reports.

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 ACHIEVING TECHNOLOGY-ENABLED HEALTH CARE
TRANSFORMATION IN NEW YORK STATE:

OPERATIONAL PLAN FOR HEALTH INFORMATION

TECHNOLOGY AND EXCHANGE

The New York eHealth Collaborative (NYeC) respectfully submits New York‘s
Operational Plan for Health Information Technology and Exchange (Operational Plan)
for review and approval by the Office of National Coordinator for Health Information
Technology (ONC). This plan operationalizes the strategic directions set forth in New
York‘s Strategic Framework for Health Information Technology and Exchange,
submitted in August 2010 to ONC.

Like the Strategic Framework, the Operational Plan builds on the considerable progress
New York State (NYS) has made to date in advancing its governance and technical
infrastructure for health information exchange (HIE). The Operational Plan specifies
how New York will proceed to achieve technology-enabled health care transformation
statewide, identifying specific activities, timelines, milestones, and responsible parties,
with particular attention to addressing documented gaps in the State‘s efforts.

New York is committed to a single, coherent, well-designed approach to health

information technology and exchange. The Operational Plan takes account of the
substantial Federal, State and private financing that has been mobilized to support
technology-enabled health care transformation in New York. Animated by the vision of a
single statewide system, meeting the needs of the broad array of interested
stakeholders, the Operational Plan aims to reflect and advance both Federal and State
goals with respect to health information technology (health IT).

The Operational Plan provides a framework for aligning statewide health IT strategies
across the private, non-profit and public sectors. The Operational Plan has been
developed in close coordination with the New York State Department of Health (NYS
DOH) Office of Health IT Transformation (OHITT), which oversees New York‘s health IT
programs (including coordination with public health), and the NYS DOH Office of Health
Insurance Programs (OHIP), which oversees New York‘s Medicaid program. The
shared vision and strategic direction outlined in this Operational Plan ensures the joint
pursuit of a common approach to health IT for the benefit the public at large, including
populations served by public insurance programs, in New York State.

The Operational Plan uses a somewhat different format than the Strategic Framework.
Whereas the Strategic Framework described New York‘s goals in six thematic areas,
the Operational Plan focuses on functional categories. Following introductory sections


The Operational Plan sets forth a comprehensive approach that coordinates, aligns and harmonizes investments of State funds
(through the Health Care Efficiency and Affordability Law for New Yorkers), federal funds (through the State Health Information
Exchange Cooperative Agreement Program, or State HIE Program), the Regional Extension Center (REC) programs operated by
NYeC and the Primary Care Information Project, the Beacon Communities grant awarded to HEALTHeLINK in Buffalo, and various
Medicaid initiatives (including enhancement of existing systems and administrative activities supporting implementation of the
meaningful use incentive payments).

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that describe New York‘s overall approach to health IT and identify progress to date, the
Operational Plan sets forth future directions with respect to governance, finance,
technical infrastructure, business and technical operations, and legal and policy matters,
devoting individual chapters to each functional area.

Individual appendixes address risk management, the project management plan,

performance monitoring and reporting, proposed timeline, and relevant statements of
support. Additional appendixes sketch key use cases for New York‘s technology-
enabled health transformation and provide additional information relevant to the
contents of the Operational Plan.

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1. Background
The combined efforts of the Federal and State governments, as well as the private
sector, have already generated important advances in New York State toward health
care transformation through better use of health IT. Gains achieved to date include
progress toward a strong statewide consensus for reform, establishment of an HIE
infrastructure, and early gains in the adoption of technologies that have the potential to
markedly improve the effectiveness and efficiency of health care services.

NYeC is a statewide public-private partnership that seeks to define a strategic roadmap

for New York State to advance health IT and realize the vision of more effective,
collaborative care. Established in 2006 by leaders in the health care field in NYS, NYeC
is a key strategic player in New York‘s efforts to capitalize on the potential of technology
to drive health care transformation in the State. With funding and policy support from
NYS DOH, NYeC is charged with facilitating development of a statewide health
information network, using a multi-stakeholder collaborative process to develop policy
guidance for stakeholders in the health care field. New York State has designated
NYeC to be the State Designated Entity (SDE) for the State HIE program, and
separately awarded NYeC $53 million to pursue complementary initiatives to further
develop statewide health IT policy and enhance the state‘s HIE infrastructure.

NYeC Focus Areas

As a statewide public-private partnership dedicated to the achievement of a technology-enabled health

care transformation in New York State, NYeC has three primary responsibilities. First, NYeC convenes,
educates and engages key constituencies, including health care and health IT leaders across the State.
Second, NYeC facilitates an interoperable health information exchange through the Statewide Health
Information Network for New York (SHIN-NY), supporting the establishment of health information policies,
standards and technical approaches and aiding stakeholders at the regional and local levels to implement
such policies and standards. Third, NYeC partners with organizations across NYS to evaluate the
effectiveness of, and establish accountability measures for, the State‘s health IT strategy.

NYeC and NYS DOH have collaborated to develop this Operational Plan. Within NYS
DOH, OHITT and OHIP have participated in the development of the plan. In addition,
OHITT has consulted other offices within NYS DOH, including leadership of the State‘s
public health programs. This collaborative effort has contributed to a common vision for
using health IT to make measurable improvements in the quality and cost-efficiency of
health care services.

This Operational Plan emerges at a critical juncture for New York State. More than $300
million in State and federal funds will be allocated to accelerate the adoption and
effective use of health IT and HIE in New York over the next three years, and the State
is in the process of significantly realigning incentives in the Medicaid program to
promote improvements in the quality and efficiency of health services. This momentum
for health care reform, aligned with broad health IT adoption in New York, offers an
unprecedented opportunity to accelerate the transformation of health care delivery in
the State – for the benefit of consumers, providers and the State at large.

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New York’s Vision of Technology-Enabled Health Care
Transformation
New York‘s Operational Plan is animated by a vision of the patient at the center of a
care community that collaborates to address the full array of each patient‘s needs. As
the figure below illustrates, reforms currently being implemented will ensure that each
patient is served through a collaborative approach that engages the entire health care
community, including primary and specialty care physicians; pharmacies; health plans
and pharmacy benefit managers; laboratories, radiology clinics, and the like; long-term
care providers; hospitals; public health and other public sector health and social service
agencies; and physical therapy, nutrition and other supportive services.

Pharmacies
Consultant Physicians Health Plans, PBMs

Physical Therapy, Nutrition

Services, Etc.
PATIENT / INDIVIDUAL Labs, X-Rays, etc.

Public Health and Other

Long Term Care
Agencies
Hospitals

The concept of the ―patient-centered medical home,‖ or PCMH, has informed the
thinking reflected in this Operational Plan. PCMH ensures that each patient benefits
from consumer-friendly provider relations and system protocols to facilitate prompt
delivery of the high-quality, coordinated, client-centered services patients need to obtain
optimal health outcomes.

The PCMH vision relies on widespread adoption by diverse providers of interoperable

electronic health records (EHRs), a well-designed system of HIE, and meaningful use
by all providers of these mechanisms, protocols and systems. The health IT
infrastructure that New York has created has catalyzed early adoption of health IT and
will facilitate even more widespread adoption of these protocols and practices. This
Operational Plan sets forth specific directions to further implement this system and to
accelerate its broad adoption and uptake.

Coordination of policy development and implementation support is a central focus for

New York‘s health IT strategy. The policies and practices associated with New York‘s
HIE strategies are intended to promote alignment of diverse stakeholders within the
health system to improve the efficiency and quality of health care service delivery. For
example, the implementation of a well-designed, seamless network of EHRs will
establish the foundation for health care organization and payment models designed to

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encourage more effective and efficient care delivery practices that will optimize health
care outcomes, maximize the impact of health care resources, and promote patient-
friendly cost containment.

Key stakeholders across New York‘s health care system will derive concrete benefits
from the technology-enabled heath care transformation:

 Patients: Consumers of health care services will become active partners in their
health care through better access to information and tools. Over time, they can
expect to receive improved health care services and obtain enhanced medical
outcomes. The transition to a comprehensive, well-regulated system will also
increase patients‘ confidence in the confidentiality and security of their medical
records.

 Primary and Specialty Care Providers: Health care providers will be able to provide
improved care to their patients by accessing and using timely, comprehensive and
accurate information specific to each patient. They will also be able to coordinate
care better due to improved communication channels with other providers and their
patients. Inefficiencies associated with the collection and management of paper
records will be reduced, as will medical errors.

 Hospitals: Facilities responsible for the care of patients, including many admitted
through emergency departments, will be able to access the patient information from
outside sources needed to improve and coordinate care. Health IT systems will
facilitate superior transitions of care among hospitals, private practices and sub-
acute facilities, leading to fewer readmissions and further reductions in medical
errors.

 Payers: A robust statewide health IT infrastructure will enable payers to implement

coverage schemes that incentivize efficiency and intensify systemic focus on patient
outcomes. The technology-enabled health care transformation in New York will
increase payer confidence that they are not paying for wasteful, duplicative or
erroneous services. Payer strategies and activities should be coordinated to ensure
alignment of incentives and reduce administrative complexity for consumers and
providers.

 Governments: As a major payer of health care services, governments will reap the
efficiency and quality benefits to payers generally. In addition, a statewide health IT
infrastructure will advance the public goal of facilitating sound research methods to
answer critical health questions. Public health efforts will be strengthened through
simplified and more comprehensive disease reporting, earlier identification of
potential outbreaks, and enhanced capacity for rapid communication with the entire
community of health care providers.

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Overarching Goals for Health IT in New York State
Through robust, strategic investments in health IT, New York State will continue to focus
on the following overarching goals, which were articulated in the original Strategic Plan
adopted in 2007:

 Improve the Efficiency and Effectiveness of Care: Provide the right information to the
right clinician at the right time – regardless of the venue where the patient receives
care.

 Improve the Quality of Care: Ensure access to clinical information to support

improvements in care coordination and disease management, help reorient the
delivery of care around the patient, and support quality-based reimbursement reform
initiatives.

 Reduce Health Care Costs: Minimize costs associated with medical errors,
duplicative tests and therapies, uncoordinated and fragmented care, and preparing
and transmitting data for public health and hospital reporting.

 Improve Health Care Outcomes: Mobilize health information to evaluate the

effectiveness of health care interventions and monitor quality outcomes.

 Engage New Yorkers in Their Care: Lay the groundwork for New Yorkers to have
access to their health information and communicate electronically with their
providers to improve the quality, affordability and impact of health care services.

Core Values That Underlie New York’s Approach to Health IT

New York‘s strategic approach to HIE is guided by a set of core values. These core
values are consistent with the common set of principles that have shaped efforts in
other states and at the Federal level. They not only point the way toward the specific
strategies which New York is pursuing, but also help define the ways in which these
strategies will be implemented, monitored and sustained.

These core values include the following:

 Support privacy and security: New York has undergone substantial collaborative
efforts to establish a comprehensive set of privacy and security policies and
procedures. It is committed to continually evaluating and updating those policies
and aligning them with similar efforts at the national level.

 Focus on desired outcomes: New York shares the Federal government‘s goal of
enabling more providers to achieve meaningful use of health IT. It is also committed
to continuing to advance efforts to support more complex data exchange necessary
for coordinated care models, and characteristic of future stages of meaningful use
criteria.

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 Support HIE services and adoption for all stakeholder organizations, with particular
emphasis on clinicians and consumers: One of New York‘s key principles is that
New York‘s health IT and HIE infrastructure should be developed according to
various clinical and administrative scenarios or use cases. These and others related
to meaningful use and patient-centered medical homes will drive and inform New
York‘s efforts.

 Build on what is working: New York‘s approach to health IT builds on the State‘s
many achievements to date. By leveraging prior advances and existing health IT and
HIE infrastructure, the State will enhance the feasibility of its strategic approach to
health information.

 Continuously evaluate and adapt: Consistent with the pace of change in the health
care marketplace, New York‘s Operational Plan is designed to be sufficiently flexible
to adapt to emerging health care developments. The collaborative approach used for
development, implementation and monitoring of this Operational Plan will support
continual information feedback to identify new trends and facilitate joint planning to
address emerging challenges and seize new opportunities that arise.

 Foster innovation: New York‘s goal is to develop an HIE infrastructure such that
healthy competition among providers, vendors and payers is based on the
innovative, effective use of information rather than on the control of information. If
New York can succeed in enhancing the exchange of information as a public good,
the State will spur innovation in the marketplace to use that information and improve
care delivery.

 Pursue accountable HIE governance in the public's interest: A successful statewide

HIE network depends on establishing a level playing field and appropriate
safeguards and protections. New York State has developed and fostered consistent
implementation of policies in an open, transparent manner with input from all
stakeholders. It further relies on the implementation and governance of these
policies at the community level.

Progress to Date
New York State is a national leader in health care. The third largest state in terms of
population, New York‘s ―health care community‖ comprises more than 230 hospitals,
more than 60,000 physicians, and 19.5 million consumers of health services. In addition
to serving as home to some of the world‘s leading medical research centers, the State
has the country‘s most expansive Medicaid program. New York has also pioneered
numerous innovations in health care delivery, including insurance market reforms and
regulatory approaches that long predated the country‘s recent adoption of comparable
strategies under comprehensive health care reform.

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Like other states, however, New York has struggled to optimize health care outcomes
and to ensure good value for the money spent on health care services. A major
impediment to the optimization of health care quality and efficiency has been the
fragmented, decentralized, ―low-tech‖ approach to health care delivery in the State. Due
to these weaknesses, health care delivery in New York State has too often been
characterized by waste and duplication, insufficient coordination between key service
providers for individual patients, and approaches that are inadequately patient-centered
and sometimes poorly grounded in evidence of best practices.

In recent years, New York State has taken unprecedented steps to address these and
other related factors, with the aim of improving both the quality and efficiency of health
care delivery. At the same time that the State has made unprecedented investments in
health IT, a broad range of other regional/local and private sector initiatives has arisen
to harness information technology to improve health services.

The remaining portions of this background section review the State‘s environment for
health IT and exchange and summarize the advances that have been achieved through
State leadership and essential Federal support.

New York State’s Health Care Transformation

New York State‘s strategy for health care transformation has been built on a
comprehensive governance, policy and technical infrastructure for statewide HIE. The
key components of this infrastructure are illustrated in the figure below.

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 HITEC NYS Dept of Health NYeC
Create evaluation tools Fund health IT Statewide collaboration process
$ $
Assess sustainability Set Policies ―big P‖ Statewide Policy Guidance
Measure progress Enforce regulations Assist RHIOs/CHITAs
State
Evaluation tools, other Funding and contractual Statewide Policy Guidance
resources obligations Policies & Technical Protocols

Statewide Health Information Network for NY (SHIN-NY)

Region

RHIO RHIO RHIO RHIO RHIO

Local
CHITA CHITA CHITA CHITA CHITA

A governance entity that implements statewide

RHIO: policy guidance and oversees SHIN-NY CHITA: A collaboration supporting EHR adoption;
emphasis on primary care and Medicaid providers
implementation in its region

Figure 1: New York State‘s Health IT and Exchange Infrastructure

Governance and Organizational Infrastructure

Diverse partners collectively work together to drive progress towards technology-

enabled health care transformation in New York State:

NYS DOH: In support of the State‘s health care transformation, NYS DOH in 2007
created OHITT. The Governor has designated the Deputy Health Commissioner who
leads OHITT as the State Health Information Technology Coordinator for purposes of
implementing the State HIE program. OHITT is charged with coordinating health IT
programs and policies across the public and private health care sectors, with the aim of
establishing an infrastructure to support clinicians in quality and population health
improvement, quality-based reimbursement programs, new models of care delivery, and
prevention and wellness initiatives.

NYS DOH also chairs the New York State Health and Human Services CIO Council,
which was established in 2009 to gather and share information to promote adoption of
common policies and standards across health and human services programs and
agencies. Under this umbrella, diverse State agencies have developed a conceptual
model to link their systems, including those related to Medicaid, public health, and
public-sector and private-sector health care settings. One emerging example of
agency-wide coordination of health IT activities is the development of a Public Health
Information Master Plan for HIE.

19
NYeC: As a statewide public-private partnership dedicated to achievement of
technology-enabled health care transformation in New York State, NYeC has three
primary responsibilities. To date, NYeC has focused on facilitating the Statewide
Collaboration Process (SCP), which has led to the development of a comprehensive set
of statewide policies, known as the Statewide Policy Guidance (SPG). Second, NYeC
is leading the next phase of development and implementation of the Statewide Health
Information Network for New York (SHIN-NY), supporting the establishment of health IT
policies, standards and technical approaches and aiding stakeholders at the regional
and local levels to implement such policies and standards. Third, NYeC evaluates and
establishes accountability measures for the State‘s health IT strategy.

Regional Health Information Organizations (RHIOs): RHIOs are independent

governance entities consisting of multiple stakeholders that support secure and
interoperable exchange of health information. Their mission is to govern and provide
health exchange services for the public good in order to support improvements in health
care quality, affordability and outcomes. In that role they participate in the SCP to help
set policies for the state and then oversee implementation of those policies in their
regions. Currently, there are 12 RHIOs that are part of New York‘s governance
structure. A full list of New York‘s RHIOs is provided in Appendix A.

Community Health Information Technology Adoption Collaboratives (CHITAs): CHITAs

provide implementation and wrap-around services to physician practices adopting
EHRs. CHITAs work with providers to ensure proper configuration and implementation
of EHRs and HIE services, as well as effective use of health information to attain quality
and efficiency goals.

Regional Extension Center (REC): The Regional Extension Centers offer statewide
EHR adoption services that will supply providers with the knowledge, training, and
confidence they will need to successfully select and deploy an EHR and use health
information meaningfully. In New York, there are two RECs: The first REC is operated
by NYeC and provides services to practices throughout NYS with the exception of New
York City‘s five boroughs. The other REC, operated by the NYC REACH, supports the
providers of New York City.

Health Information Technology Evaluation Collaborative (HITEC): HITEC is a multi-

institutional, academic collaborative of New York State institutions including Cornell
University, Columbia University, the University of Rochester, and the State University of
New York at Albany, and serves in a research and evaluative role with respect to health
IT initiatives in NYS. HITEC was formed to evaluate and develop evaluation
instruments for HIT initiatives across the State, while integrating a variety of
stakeholders. The State has committed $12 million to HITEC for evaluation and
research activities. These activities include real-time formative generation of results
with rapid feedback to involved stakeholders and policy makers, and longer term
summative generation of results leading to peer reviewed publications. HITEC is an

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important and distinguishing health IT asset in NYS, allowing independent and objective
evaluations of activities.

Legal and Policy Infrastructure

New York State‘s health IT and HIE efforts are guided by a transparent and inclusive
process that includes the following components:

Statewide Collaboration Process (SCP): New York has developed an open, transparent,
multi-stakeholder process for developing health information policies, standards,
protocols, and technical approaches governing the health IT infrastructure. NYeC, in
partnership with the NYS DOH, manages the SCP in order to forge consensus on
requirements in the form of Statewide Policy Guidance (SPG).

Policy and Operations Council (POC): To date, the POC has been composed of the
leaders of the RHIOs and CHITAs that have led the State-funded health IT and HIE
implementation efforts. The POC reviews and approves recommended work group
policies and products for presentation to NYeC and NYS DOH. The POC also reviews
and makes recommendations about the SCP structure and processes and supports
NYS DOH/NYeC leadership in making strategy decisions.

Statewide Policy Guidance: As described above, the SCP is the vehicle for the
development of New York‘s Statewide Policy Guidance. Existing SPG (summarized
below in the Section 2 discussion of governance) is available online at
http://www.nyehealth.org/index.php/resources/nys-policies.

Through the collective efforts of these key stakeholders, the foundation has been
established for momentous changes in New York State‘s approach to health care
delivery. Additional work remains to ensure that new mechanisms, systems, protocols
and procedures are rapidly adopted, fully integrated, and used effectively.

Technical Infrastructure

Under the Health Care Efficiency and Affordability Law for New Yorkers (HEAL) 5
program, NYS DOH outlined a vision and technical strategy for advancing New York‘s
health information infrastructure, the SHIN-NY.1 Built on a ―service-oriented
architecture,‖ SHIN-NY is a network of networks through which regional HIEs and their
participants may share data and services within and across regions using common
standardized protocols. SHIN-NY incorporates and extends Federal standards such as
those adopted by the Nationwide Health Information Network (NHIN)

As part of the HEAL 5 program, NYS DOH engaged NYeC to facilitate the development
of an architecture and a set of technical specifications for SHIN-NY through the SCP.
The various RHIOs awarded HEAL 5 grants were contractually required to implement

1Additional details of the statewide technical strategy advance through HEAL 5 is available online at
http://www.health.state.ny.us/technology/projects/docs/technical_discussion_document.pdf.

21
SHIN-NY specifications in their regional HIEs. To complete their HEAL 5 projects, they
will have to demonstrate successful use of those SHIN-NY specifications. (SHIN-NY
architecture and specifications are available at
http://www.nyehealth.org/index.php/resources/nys-policies

One of the goals of SHIN-NY has been to enable the development of an interoperable
network through which New York can deploy so-called statewide ―shared services‖ in
addition to standardized regional approaches. The development of shared services
provides the opportunity for economies of scale, through the unified development of a
service accessible to all users in the State. Under HEAL 5, New York tested potential
technical approaches to shared services by facilitating a provider‘s query and retrieval
of a test Medicaid medication history data to an EHR system from SHIN-NY.

In addition to this infrastructure and set of technical resources, the State will also
leverage several important operational systems operated by State agencies, including:

 Medicaid “eMedNY” MMIS System: This Medicaid claims processing system allows
Medicaid providers to submit Medicaid claims and claim transactions and receive
payments electronically. eMedNY offers several innovative technical and
architectural features, facilitating the adjudication and payment of claims and
providing extensive support and convenience for its users. Medicaid recently
launched a service that will allow providers to electronically retrieve the medication
history for Medicaid patients into their EHRs. NYeC prototyped delivery of that
service through its SHIN-NY architecture as part of the HEAL 5 program.

 Electronic Public Health Data Exchange: NYS DOH is working with the New York
City Department of Health and Mental Hygiene (NYC DOHMH) on developing and
testing a technical architecture and set of specifications for the ―Universal Public
Health Node‖ (UPHN). UPHN is a collection of services and operational policies
designed to fulfill designated public health reporting and monitoring objectives.
UPHN is narrowly intended to describe the relevant interactions between HIE
partners such as RHIOs and NYS DOH. UPHN transactions support activities and
interactions with other entities, such as local health departments (LHDs) within New
York, other health and human service (HHS) agencies, the Centers for Disease
Control and Prevention (CDC), health care data sources (e.g. hospitals, physician
practices, etc.), and health care consumers. UPHN standards and a working
prototype were developed through the SCP, facilitated with seed funding from CDC
HIE. Three RHIOs are planning to provide this functionality as part of their HEAL 5
projects. In addition, four HEAL 17 projects have committed to facilitate information
exchange through the UPHN, and several more will adopt the service.

 New York State Health Commerce System: This statewide, web-based infrastructure
provides services and support for 24x7, reliable, redundant and secure data
transport and communications between public health and external agencies and a
platform for the successful implementation and deployment of major public health

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 information systems in NYS. This infrastructure provides the current capacity for
secure information exchange activities between NYS DOH and all regulated health
entities in NYS, with more than 100,000 users, including all 58 LHDs, 230 hospitals,
663 nursing homes, 1,481 clinical and environmental labs, 2,259 pharmacies and
more than 50,000 physicians.

 Electronic Clinical Laboratory Reporting System (ECLRS): The Electronic Clinical

Laboratory Reporting System (ECLRS) provides laboratories that serve New York
State with a single electronic system for secure and rapid transmission of reportable
condition information to NYS DOH, LHDs and NYC DOHMH. ECLRS enhances
public health surveillance by providing timely reporting; improving completeness and
accuracy of reports; and generally facilitating the identification of emergent public
health problems by monitoring communicable diseases, lead poisoning, HIV/AIDS,
cancer, and congenital malformations. ECLRS (for lab reporting and ED data)
processes approximately 4.3 million reports per year.

 Immunization Information System: Public Health Law requires health care providers
to report all immunizations administered to persons under 19 years of age, along
with the person's immunization histories, to NYS DOH, using a web-based
immunization information system (NYSIIS) which serves all of NYS outside of New
York City (as NYC has a separate system of its own). NYSIIS provides numerous
benefits to all those involved in the health care of children, contributing to a higher
immunization rate and a healthier population. Immunization reporting is already
underway on the reporting side but has been limited to submission through a portal
or proprietary EHR vendor connections. Once the transition is complete to a
systerm that permits bi-directional data exchange, physicians will be able to submit
immunization information to the NYSIIS through RHIOs and the UPHN and receive
immunization history, recommendations, and guidance from NYSIIS.

 Syndromic Surveillance Systems: All emergency departments in NYS, excluding

NYC, are required to participate in the NYS DOH electronic syndromic surveillance
system. NYS DOH routinely monitors data categorized into eight syndromes:
Respiratory, GI, Fever, Asthma, Neurological, Rash, Carbon Monoxide poisoning,
and Hypothermia. Summary and case-level counts, signals (CuSum analysis
results), short- and long-term trend graphs as well as patient listings are all available
by syndrome, hospital, county, and region. Hospital users may view data for their
hospital and aggregated for their surveillance region, and LHD users may view data
for all hospitals in their county, as well as aggregated data for their county and
region.

Finance Infrastructure

In order to develop and maintain the health IT and HIE foundations needed to support
New York State‘s health care objectives, a two-pronged approach to financing has been
employed. Capital investments in key infrastructural components from Federal, State,

23
and private sector sources have been combined with policy, procurement, and financing
levers to create a path for sustainability.

State and Federal Investments in New York’s Health IT and HIE Infrastructure

Established in 2004, the Health Care Efficiency and Affordability Law for New Yorkers
(HEAL NY) provided capital funding to reform and reconfigure New York State‘s health
care delivery system in order to improve patient outcomes and increase efficiency.

More than 25% of the HEAL NY budget is allocated to health IT, with $398 million in
State funds invested in four rounds of funding by NYS DOH. Through these
investments, an additional $280 million in private sector matching funds have been
leveraged, yielding a total investment to date that exceeds $600 million dollars.

The following table details HEAL investments to date:

Activity Recipients HEAL 1 HEAL 5 HEAL 10 HEAL 17 Total

Community Various $53M $95M $60M $120M $328M
Health IT / HIE
Projects
Statewide NYeC $5M $5.3M $4M $14.3M
Collaboration
Process
Statewide SHIN- NYeC $22.8M $12M $34.8M
NY Infrastructure
Education and NYeC $3.5M $3.5M
Communication
Health IT NYeC $3.4M $3.4M
Adoption
Services
HIE Accreditation NYeC $2M $2M
Evaluation HITEC $5M $5M $2M $12M
Total $53M $105M $100M $140M $398M

Figure 2: HEAL investments to date

HEAL 1 grants provided start-up capital funding for many regional health IT entities
(described below) and other health IT projects. HEAL 5 grants built upon that foundation
and marked the beginning of the development and implementation of the key
organizational, clinical and technical building blocks for New York State‘s health
information infrastructure, also described in more detail below. Acceleration of
momentum stemming from these early State investments in health IT was further
supported by $180 million in additional HEAL 10 and HEAL 17 grants in 2009 and 2010.
These grants were intended to capitalize on initial progress in developing a statewide
health information infrastructure to transition to a new care delivery and reimbursement
model – the patient-centered medical homes.

HEAL NY has provided extensive funding (to be augmented under HEAL 10 and HEAL
17) to NYeC to support policy development, ensure the smooth operation of the

24
processes required to support the envisioned health care transformation, and provide
implementation guidance and support. Through its open and transparent governance
process, NYeC will also oversee the next stage of development of New York‘s HIE
infrastructure, SHIN-NY, described in more detail below.

HEAL NY also supports a collaborative research and evaluation platform, HITEC. An

academic collaborative that includes Cornell University, Columbia University, the
University of Rochester, and the State University of New York at Albany, HITEC
evaluates and develops evaluation instruments for health IT initiatives, including
interoperable health information exchange and EHR adoption across the State.

New York‘s progress to date in reconfiguring its approach to health care has benefited
not only from these unprecedented State investments, but also in the support of private
sector partners. In addition, New York received a $20 million grant from CDC in 2008 to
improve public health surveillance and reporting through the emerging health care
information infrastructure. The State‘s efforts have also been strengthened by a $4.7
million contract that NYeC received from the U.S. Department of Health and Human
Services to support the NHIN Trial Implementations Project, as well as grant support for
policy development from the federally supported Health Information Security and
Privacy Collaboration (HISPC).

The various health IT-related programs funded by the American Recovery and
Reinvestment Act (ARRA) have provided New York with additional opportunities to
advance its initiatives. Under the State HIE program, NYeC was awarded $22 million to
enhance the State‘s HIE infrastructure and ensure the broad availability of options for
providers to meet the HIE requirements of meaningful use. New York has received
funding for two RECs to provide EHR adoption support services to providers, with an
initial focus on "priority" primary care providers working in small practices or treating
underserved populations. The first REC is operated by NYeC and provides services to
practices throughout the entire State with the exception of NYC. The second REC,
operated by the Primary Care Information Project, supports providers in NYC. OHIP will
also receive funding from the Centers for Medicaid & Medicare Services (CMS) to
support the administration of the Medicaid EHR Incentive program.

New York payers have implemented or supported various provider incentive programs
to directly or indirectly reward their use of health IT systems.

 OHIP: NYS DOH has been a leader in advancing new types of reimbursement to
use its purchasing power and reward providers for the use of health IT tools. OHIP
has also implemented various financial incentive programs within the NYS Medicaid
program to encourage providers‘ effective use of health IT systems. Notable
initiatives include:

o e-Prescribing: To encourage the use of electronic prescribing (e-

prescribing), OHIP instituted a program on May 1, 2010, to provide
financial incentives to providers that issue prescriptions electronically and

25
 pharmacies that accept e-prescriptions. Under this program, eligible
providers (including physicians, dentists, nurse practitioners, podiatrists,
optometrists, and licensed midwives) receive incentive payments of $0.80
per dispensed Medicaid e-prescription (including refills), and retail
pharmacies receive incentive payments of $0.20 per dispensed e-
prescription.

o Patient-Centered Medical Homes: Effective July 1, 2010, NYS Medicaid

began to provide incentives to office-based physician and registered nurse
practitioner practices, Federally Qualified Health Centers (FQHCs), and
Diagnostic and Treatment Centers (D&TCs) recognized by NYS Medicaid
and the NCQA as operating a PCMH™. NYS Medicaid has chosen to
adopt medical home standards that are consistent with those of the
National Committee for Quality Assurance‘s (NCQA) Physician Practice
Connections® - Patient-Centered Medical Home Program (PPC-
PCMH™).

 Other Payer Initiatives: Several other initiatives, either sponsored by single-payer or

multi-payer collaboratives, also incentivize providers to implement patient-centered
medical homes. These include:

o Hudson Headwaters: With $7M in funding, the Adirondack Medical Home

Multi-payer Demonstration Program seeks to establish a demonstration
PCMH to serve recipients of public medical assistance, as well as
enrollees and subscribers of commercial managed care plans. In this
endeavor, the Adirondack Health Institute Care Improvement Initiative will
work in tandem with the Adirondack PCMH Pilot to improve and enhance
the provision of healthcare services in the region.

o THINC P4P Medical Home Project: This project is a multi-payer

collaborative pay-for-performance effort involving 237 primary care
physicians with EHRs in the Hudson Valley region of New York. THINC
received a pay-for-performance grant from NYS DOH in 2007, and
broadened it to include a medical home component. Six health plans,
representing 65% of the commercial market, and one major employer
(IBM) pay incentives to practices, based on the PCMH recognition level
received from NCQA, and for meeting HEDIS quality benchmarks.

o Rochester Medical Home Initiative: This pilot, a partnership between

Excellus BlueCross BlueShield and MVP Healthcare, was launched in
March 2009 and involves 20 primary care physicians (PCPs) from 7
practices. It is designed to test how changes in the business practices of
both the health plan and the primary care office can support establishing
Medical Home practices. A central component is changing the
reimbursement model for participating practices to compensate for time

26
 spent in care coordination and to increase PCP income to be more
competitive with medical specialists.

o CDPHP: CDPHP launched a PCMH initiative in 2008 involving three

practices. As part of the initiative, CDPHP tested a new payment model
that paid these providers operating PCMHs additional money for treating
sicker patients. The initiative has proven so successful that it is being
expanded to include 21 new practices.

o EmblemHealth Medical Home High Value Network Project: The

EmblemHealth project includes 38 primary care practices, the majority of
which are solo and small practices, from NYC and the surrounding
counties. The payment structure includes three components: a fee-for-
service payment, a care management payment and a performance-based
payment.

Business and Technical Infrastructure

As the summary above illustrates, NYS has made considerable progress advancing its
health IT and HIE infrastructure. However, it recognizes that significant gaps remain.
To address these gaps, the State will need to continually collect and analyze data to
track its progress. New York recently launched a RHIO dashboard to track individual
RHIOs, and the whole State‘s, performance in advancing adoption and use of HIE tools
and services. Much of the RHIO data included in the following section is gathered from
that dashboard.

Geographic HIE Coverage: According to a recent survey, 59 of New York‘s 62 counties

are currently covered by at least one RHIO. Thus, in terms of geographic breadth,
today‘s infrastructure provides a gateway for local access to the SHIN-NY from every
corner of the state. An overview of the statewide and regional participation levels of
hospitals and physicians in RHIOs is illustrated in the map below. The following table
provides information on the types of key HIE services being provided by the RHIOs.

27
 RHIO Participation by Region
Central New York State
RHIOs: Rochester, STHL, Hospital Access Data: 34% (79/232)
HealtheConnnections Hospital Supply Data: 46% (107/232)
Hospital Access Data: 29% (15/51) Total Provider Users: 10% (6,240/64,818)
Hospital Supply Data: 43% (22/51)
Total Provider Users: 47%

Western
RHIOs: HEALTHeLINK, Rochester Capital
Hospital Access Data: 10% (3/31) RHIOs: HIXNY
Hospital Supply Data: 52% (16/31) Hospital Access Data: 28% (8/29)
Total Provider Users: 29% Hospital Supply Data: 38% (11/29)
(1.041/3,546) Total Provider Users: 10% (365/3,768)

Hudson Valley
RHIOs: THINC
Hospital Access Data: 3% (1/36)
Hospital Supply Data: 3% (1/36)
Total Provider Users: 5% (351/7,388)

New York City Long Island

RHIOs: NYCLIX, BHIX, Bronx, Interboro RHIOs: LIPIX, eHealth Network of LI
Hospital Access Data: 32% (20/62) Hospital Access Data: 65% (15/23)
Hospital Supply Data: 52% (32/62) Hospital Supply Data: 91% (21/23)
Total Provider Users: 2% (636/32365) Total Provider Users: 5% (485/10,160)

Figure 3: RHIO Participation by Region

HealtheConnections
eHealth Network LI

HEALTHeLINK

Rochester
Interboro

NYCLIX
HIXNY

THINC
Bronx

STHL
LIPIX
BHIX

Patient history "pull" queries Y Y Y D Y Y Y Y Y Y Y P

Electronic eligibility and claims N N N D Y P N N N N N N
E-prescribing applications N Y N D Y Y Y D N Y N N
Medication history Y Y Y D Y Y Y D N Y Y N
Electronic lab results delivery (1:1
exchange) N Y D D Y Y N D N Y D Y
Electronic lab orders N N N D N N N N N N N Y
Electronic radiology results delivery
(1:1 exchange) N Y P N Y D N D N Y N N
Electronic transcribed reports
delivery (1:1 exchange) N Y N N Y D N D N Y N N
Record exchange for e-referral / care
coordination (1:1 exchange) N D Y D D D D Y Y D D D
Electronic public health reporting D D N N P N P D N P D D
Quality reporting D D N N P D N D N P D D
Information delivery to/from
personal health records D P D D P D P D D D D P
Clinical decision support D Y N N P N N Y N N N N

Key
Y=Service currently offered P=Service planned within next year
D=Service in development N=Service not offered

Figure 4: HIE Services Offered by RHIOs

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2. Governance
Guided by the core value of accountability in the public's interest, New York‘s
governance infrastructure is built on four key components:

 Effective statewide leadership through two entities, the NYS DOH and NYeC, a
multi-stakeholder public-private partnership.

 A transparent and inclusive Statewide Collaborative Process for policy

development and decision-making.

 Statewide Policy Guidance that provides a common and consistent technical,

privacy, security, and legal framework for participants in HIE.

 Independent and objective evaluation and research of health IT initiatives to

provide formative and summary data to inform activities.

New York‘s governance infrastructure continues to evolve and adapt to the changing
health care landscape. Recent policy developments will drive further evolution in New
York‘s governance approach. At the State level, a new law (Chapter 58, Laws of 2010)
grants the Health Commissioner broad authority to regulate health IT activity, including
the issuance of rules and regulations to implement federal policies, disburse funds, and
promote the development and adoption of SHIN-NY. The statute provides the following:

The commissioner shall make such rules and regulations as may be necessary
to implement federal policies and disburse funds as required by the American
Recovery and Reinvestment Act of 2009 and to promote the development of a
statewide health information network of New York (SHIN-NY) to enable
widespread interoperability among disparate health information systems,
including electronic health records, personal health records and public health
information systems, while protecting privacy and security. Such rules and
regulations shall include, but not be limited to, requirements for organizations
covered by 42 U.S.C. 17938 or any other organizations that exchange health
information through the SHIN-NY.

As part of the collective effort for continuous improvement, NYeC and NYS DOH
assessed the existing statewide health IT and HIE infrastructure, reaching the following
conclusions:

 Provision of Technical and Clinical Functions. As the pace of technology and

transformation of care delivery quickens, it is apparent that providing these
functions requires staff with different expertise, varying levels of capital intensity,
and different relationships with vendors, providers, payers and other
stakeholders.

29
  Value of HIE Utility Models. Procuring HIE services through a utility reduces the
per-unit cost of services and promotes consistency by reducing duplication of
service. This approach has worked successfully at the regional level, where
RHIOs are currently aggregating requirements and collectively providing cost-
effective HIE solutions for participants.

 Costs for Creating and Sustaining Governance Infrastructure. The creation and
maintenance of governance entities and processes requires time and resources
and can be expensive to establish and maintain. Governance infrastructure
should be developed in circumstances and at levels where it is needed and not
redundant.

In light of these findings, NYeC and the NYS DOH began a process in July 2010 to
identify and evaluate options to enhance the statewide HIE governance framework.
Alternative approaches were assessed against the following criteria:

 Protect Public Interest: Core values maintained and protected through

appropriate oversight and accountability.

 Promote Widespread Access to HIE Services: Maximize breadth and depth of

participation in HIE Services.

 Advance Overall System Efficiency: Ensure: (1) governance is not created where
it is not needed; (2) widespread adoption of core services is promoted without
unnecessary duplication of effort/resources.

 Promote Organizational Efficiency: Minimize duplication of roles and avoid

redundant staffing and allocation of resources.

 Encourage Innovation: Ensure capacity to adapt to a rapidly changing technical

and regulatory market.

 Leverage Existing Investments: To the extent they accelerate progress toward

identified goals, existing infrastructure and investments should be built upon as
opposed to disrupted.

 Ensure Data Liquidity: Advances interoperability objectives.

 Promote collaboration in care delivery across institutional boundaries.

 Ensure broad stakeholder involvement in the development of network

management and policy.

 Promote development of financially self sustaining model for operation of the

network.

30
Below are additional detail on each of these governance components, recent
adaptations, and next steps to meet the evolving needs of a dynamic health care
delivery, regulatory, technical and financial environment.

Statewide HIE and Health IT Leadership

New York State‘s HIE and Health IT efforts are led by two entities, the NYS DOH‘s
Office of Health Information Technology Transformation (OHITT) and the New York
eHealth Collaborative (NYeC).

NYS DOH OHITT

As noted in Section 1, the Governor designated the Deputy Health Commissioner who
leads OHITT as the State Health Information Technology Coordinator for purposes of
implementing the State HIE program. OHITT is charged with coordinating health IT
programs and policies across the public and private health care sectors, with the aim of
establishing an infrastructure to support clinicians in quality and population health
improvement, quality-based reimbursement programs, new models of care delivery, and
prevention and wellness initiatives. As also described in Section 1, the NYS DOH-
chaired NYS Health and Human Services CIO Council, established in 2009, has
developed a conceptual model and Public Health Information Master Plan to link the
systems of diverse State agencies and programs.

NYS DOH has begun to develop an agency-wide governance structure for overseeing
health IT adoption and related decision-making across State agencies. This internal
structure will support OHITT‘s multi-disciplinary and cross-office capacity to streamline
health IT policies across all programs, including but not limited to public health. In
moving forward, the emerging internal structure will support all NYS DOH stakeholders
in their efforts to assess their needs, identify priorities, and develop strategic plans for
health IT, including but not limited to meaningful use. Program activities will be
integrated to increase coordination and collaboration within and among NYS DOH
programs, with particular attention to processes that optimize resource allocation. NYS
DOH will launch cross-disciplinary health IT decision-making within the Department to
facilitate priority-setting and coordination. Guidance and assistance on strategic
alignment for funding opportunities will be ensured.

NYS DOH launched the Public HIE Initiative to organize and coordinate public health
HIE activities, with the aim of ensuring alignment with public health goals and
supporting meaningful use requirements. Developed through close collaboration with
Public Health and OHITT, the Initiative adheres to a vision of improved population
health and patient clinical care through public health information system integration and
electronic information exchange with the health care community. The Initiative
coordinates Public Health‘s participation in HIE initiatives to ensure that public health
practice operates effectively and efficiently.

31
Through this Initiative, NYS DOH will integrate program activities to increase
coordination and cooperation with public health programs. A project managers group
will develop a dashboard for current and future public health projects; develop specific
implementation deliverables related to project status, communications, and other
activities; hold weekly meetings to report on project status and review cross-project
coordination issues; and ensure that all initiatives pursue sound project management
techniques and adhere to NYS DOH technology and data standards. A separate project
coordinators group will review and approve implementation approaches proposed by
project managers and hold bi-weekly meetings with project managers to ensure
accelerated progress, coordination and quality control. A third group – the project
sponsors group – will review and ultimately approve implementation approaches
endorsed by project coordinators, hold monthly meetings with project coordinators, and
provide guidance and assistance on strategic alignment for funding opportunities.

In support of further integration of State health and human services programs, top near-
term priorities for data sharing including development of a cross-agency unified privacy
policy, building a unified approach to authentication and access control across State
agencies, development of a State-level client and organization/provider identification
management system, and developed of shared services for both primary care and
mental health, improving the coordination and management of care through a PCMH
model. Having focused to date on information sharing and communication, the group
will place increasing emphasis in moving forward on the advantages of statewide
shared services, determining a formal decision-making process, a resource plan, and
next steps in implementation. A finalized HHS-CIO roster will be agreed, and a
formalized evaluation plan forged.

NYeC

As a statewide public-private partnership dedicated to achievement of technology-

enabled health care transformation in New York State, NYeC has three primary
responsibilities. As described in Section 1, these include facilitation of the Statewide
Collaboration Process, which has produced Statewide Policy Guidance; the
development and implementation of SHIN-NY, supporting the establishment of health
information policies, standards and technical approaches and aiding stakeholders at the
regional and local levels to implement such policies and standards; and evaluates and
establishes accountability measures for the State‘s health IT strategy.

As one of the two RECs in New York, NYeC provides technical assistance, guidance,
and information on best practices to support and accelerate health care providers‘
efforts to become meaningful users of EHRs. A list of NYeC membership is provided in
Appendix G. The Board by-laws is available online at
http://www.nyehealth.org/index.php/about-us/board

32
Statewide Collaboration Process (SCP)
New York‘s governance model aims to accelerate progress toward achievement of the
required connected capabilities and effective HIE. This collaborative governance model
unites key stakeholders, clarifies roles and responsibilities, and provides a fair and
transparent means of reaching key decisions and resolving potential disputes and
bottlenecks.

New York has developed an open, transparent, multi-stakeholder process for

developing health information policies, standards, protocols, and technical approaches.
NYeC, in partnership with the NYS DOH, manages the SCP in order to forge consensus
on requirements that are reflected in Statewide Policy Guidance (SPG).

The SCP is designed to facilitate collaborative and transparent development of common

policies and procedures, standards, technical approaches and services for New York‘s
health information infrastructure. The SCP is largely driven by the efforts of its
collaborative workgroups, which recommend policies and procedures, standards,
technical approaches and services to the NYeC POC, the NYeC Board and NYS DOH.
Recognizing that ongoing input from key stakeholders is critical to success, NYeC will
continue to work collaboratively with SCP workgroups and other key constituents.

To date, workgroups have used the analytical process illustrated below to develop
relevant requirements and policies:

What? How? When

Set Determine Rank Decide Phase

Policy Requirements Requirements Priorities Requirements

Define foundation Distill technological Score requirements Prioritize Map priority ranking to
policy objectives to and process by key prioritization requirements to project phasing
guide projects requirements from dimensions assess phasing:
policy foundation • Importance
• Urgency
• Feasibility

Figure 5: New York‘s Statewide Collaborative Process Workflow

Policy Approval Process

New York‘s governance process provides for four key stages in the development and
approval of any relevant policy:

33
 Policy Development: SCP work groups develop policies by consensus. For major
policies, a public comment period is conducted to ensure maximum public input.

 POC Review: The work groups advance the policies to the POC for consideration,
summarizing the key issues and decisions in a ―decision memo.‖ The POC
considers the policies and votes whether to recommend its passage or not.

 NYeC Board Review: The results of the POC vote are advanced together with the
policy and decision memo to the NYeC Board. The NYeC Board votes whether to
approve the policy.

 NYS DOH Review: Upon approval by the NYeC Board, the policy, including the
decision memo and votes, is advanced to NYS DOH. NYS DOH has final approval.

Policy Amendment Process

The opportunity to regularly review policies based on experience gained during the
implementation process is an important component of New York‘s approach. NYeC has
initiated a semi-annual review process for this purpose. NYeC meetings are open to the
public to seek community participation and input to the SPG. The community has the
opportunity to suggest amendments to the existing SPG. Those requests are then
submitted to the respective work groups, which initiate a similar process to the one
described above for initial development of policies.

Statewide Policy Guidance (SPG)

As noted above, the final component of New York‘s statewide HIE governance
infrastructure is SPG, which provides a common and consistent technical, privacy,
security, and legal framework for participants in HIE.

Through the Statewide Collaborative Process, NYeC and NYS DOH have developed
SPG for the following:2

 RHIO Privacy and Security Policies and Procedures

 EHR Functional Requirements

 Vendor Contract Requirements

 SHIN-NY Technical Specifications

o SHIN-NY Core Services Web Services Implementation Specifications
o SHIN-NY Information Security Architecture and Implementation
Specifications

Statewide Policy Guidance is available online at http://www.nyehealth.org/index.php/resources/nys-policies

2

34
 o SHIN-NY Medicaid Medication Management (MMM) Web Services
Implementation Specifications
o SHIN-NY Universal Public Health Node (UPHN) Web Services
Specifications
o SHIN-NY Quality Reports Implementation Specifications

 RHIO Consent Forms

o Standard RHIO Consent Form
o Level 1 Multi-Provider Consent Form
o Level 1 Payer Consent Form
o Level 2 Payer Consent Form for Payment

In recent months, New York updated its SCP structure to strengthen the SPG and to
refine models and policy issues relating to access to and use of shared services, with
recommendations to be considered in accordance with agreed SCP approval
processes. The updating of the SCP has resulted in clearly defined roles and
responsibilities of all entities involved in governance and technical support, including
finalized criteria for RHIOs and other ―qualified organizations.‖

Consistent with current practice, the SCP will be used to develop statewide policies that
govern HIE in the public interest. Input will be gathered from existing and new HEAL
projects and other stakeholders, and specific efforts will focus on aligning State policies
and requirements with Federal criteria for meaningful use and PCMH. Plans for
deployment of shared services will be analyzed to identify specific policy issues
requiring resolution. Work groups under the SCP umbrella will be convened to develop
recommendations to be advanced through the SCP approval process.

The diagram below illustrates the collaborative governance model.

35
 Figure 6: New York SCP Structure

SHIN-NY Architecture Work Group: The Work Group‘s mission is to

develop strategies, standards and requirements for an enhanced SHIN-NY that
leverages shared services and standardized regional services to enable broad adoption
and use of interoperable HIE tools among providers and consumers across the State
while protecting privacy and security.

Privacy & Security Work Group: The Work Group‘s mission is To ensure that privacy
and security industry standards are employed across all NYS HIE initiatives through the
development of policy recommendations that protect the health information interests of
all users.

Consumer and Provider Engagement Work Group: The Work Group‘s mission is to
provide leadership on the development and implementation of provider and consumer
education and outreach programs/campaigns towards the promotion and utilization of
HIT to achieve health outcomes.

Public Health Work Group: The Work Group‘s mission is to improve population and
public health in NYS through the planning, development, and implementation of a
UPHN infrastructure for HIE utilizing a statewide collaboration process.

36
Collaborative Care Work Group: The Work Group‘s mission is to plan and develop
policies & strategies designed to improve coordination of care through promotion of
clinical care standards, including quality & efficiency, for payment reform

Health IT Strategy Group: The Group‘s mission is to provide leadership and

coordination to the Statewide Collaboration Process (SCP) Work Groups through the
establishment of overall strategies and roadmaps that provide a process for work group
activities.

Policy and Operations Council: The Council‘s mission is to provide guidance and
participate in developing and implementing comprehensive and coordinated
interoperable health information technology policies at the state level to drive
improvements in health care quality, affordability and outcomes.

Next Steps

NYeC and the NYS DOH will advance enhancements to the SCP in accordance with
the following timeline:

Fourth Quarter 2010:

 Establish the Health IT Strategy Council and the POC.
o Recruit and identify council members.
o Draft and adopt council charters and bylaws.
 Establish SCP work groups.
o Recruit and identify work group members.
o Draft and adopt work group charters and bylaws.
 Reconvene NYS SCP.

First Quarter 2011:

 Continue to utilize the SCP to develop statewide policies that govern HIE in the
public interest.
o Gather input from HEAL projects and other stakeholders participating in
SHIN-NY on outstanding issues requiring resolution.
o SCP Work Groups to develop and recommend standards policies.
 Establish clear and measurable goals for the NYS HIE and develop a monitoring
tool.
o Finalize clinical/population health goals and health IT adoption/usage
goals.
o Develop a monitoring plan.
o Develop a communication plan to inform providers of the statewide goals.
 Develop communication tools to educate consumers and providers of the
statewide health IT and HIE strategies and activities.
o Convene the Consumer and Provider Engagement Work Group.
o Research available effective communications and education tools
o Implement identified communication tools.

37
Accountability and Oversight
New York‘s governance model aims to accelerate progress towards achievement of the
required connected capabilities and effective HIE. The goals of the governance process
are multi-faced and include:

 Ensure broad use and access of HIE services by all providers in New York State.

 Support a collaborative care model through which multiple stakeholders work

together to measurably improve the quality and efficiency of care and transform
the health of the community.

 Accelerate market-driven interoperability.

 Create a sustainable marketplace for HIE services that meets public policy
needs.

 Strengthen core public health functions, including prevention, service planning,

outcomes research, disease surveillance, and early warning systems
for disease outbreaks.

 Advance New York‘s national leadership in statewide HIE.

While policies and technical specifications are developed and defined at the statewide
level, New York‘s current governance and technical approach relies on RHIOs and
CHITAs for implementation at the local level. The current alignment of entities, roles and
responsibilities are highlighted in the illustration below.

Figure xx: New York‘s Existing Alignment of Governance Components

Figure 7: Existing Governance Infrastructure in New York

38
In their current form, RHIOs support multiple functions, including the establishment and
maintenance of a collaborative multi-stakeholder mechanism at the local level, the
provision and oversight of technical services for participants in regional exchange, and
enforcement of SPG. State oversight of RHIOs is currently maintained via contracts
through HEAL and other State programs.

With the rapid pace of technical change and the imminent implementation of national
health reform, providers still require assistance at the local level to connect with HIE
services and to navigate new health delivery and financing models. While RHIOs could,
and in some cases do, serve in both these capacities, the skills and resources needed
to support the technical services and the clinical services vary considerably.

To maximize effective allocation of resources and simultaneously strengthen successful

local organizations, New York‘s governance framework has expanded to include two
complementary concepts: a ―Qualified Health IT Entity,‖ which will serve as the technical
on-ramp to HIE services, and a ―Collaborative Care Community,‖ which will function as
a multi-stakeholder means for improving the quality and efficiency of care and
transforming the health of the community.

The diagram below illustrates at a macro-level the roles and relationships between a
Qualified Health IT Entity, a Collaborative Care Community and vendors that provide
HIE services. A detailed discussion follows.

Figure 8: Proposed Relationship between Qualified Health IT Entities, Collaborative Care

Communities and HIE Vendors

39
Qualified Health IT Entities

Qualified Health IT Entities will focus on technical services and the rapid diffusion of
those services consistent with SPG. Ideally, the creation of Qualified Health IT Entities
will increase the supply of on-ramps to HIE services, which, in turn, will address gaps in
technical capabilities; create a flexible, adaptive set of HIE suppliers that can respond to
future policy requirements; and accelerate innovation and reduce costs as Qualified
Health IT Entities compete on the basis of quality of service, functionality, and pricing.

A number of benefits will accrue to Qualified Health IT Entities, including eligibility for
grant funds or contracts for provision of HIE services; access to SHIN-NY and data from
State sources (e.g., public health information, Medicaid data); and the ability to satisfy
Certificate of Need (CON) requirements for health care providers undertaking health IT
projects.

In designing a framework for Qualified Health IT Entities, NYeC and NYS DOH sought
to develop criteria that balanced a free-market model with appropriate regulatory
oversight. Accordingly, organizations seeking designation as Qualified Health IT Entities
must demonstrate their ability to serve as technical on-ramps and also meet a number
of public interest objectives. Criteria currently under consideration include the ability of
an entity to demonstrate proven technical capabilities, the ability to maintain and expand
those technical capabilities, a willingness to comply with SPG and Fair Information
Sharing Principles, a commitment to population and public health, and support of
Collaborative Care Communities.

Because adequate governance mechanisms exist at the statewide level in New York,
Qualified Health IT Entities will not be required to maintain multi-stakeholder
governance for technical implementation. However, as noted above, Qualified Health IT
Entities must agree to participate in the SCP and abide by applicable elements of the
SPG and New York‘s Fair Information Sharing Principles (see Appendix D).

Collaborative Care Communities

While Qualified Health IT Entities will support the development and expansion of HIE
technical services, Collaborative Care Communities (CCCs) will focus on the
coordination of care within a geographic region or a specific population.

The definition of CCCs is based on attributes of a number of State-based and national

initiatives, including:

 New York‘s HEAL 10 and HEAL 17 programs.

 Beacon Communities.

 Medicare Accountable Care Organizations (ACOs).

40
  Patient centered medical home (PCMH) initiatives.

Program elements, as they relate to CCCs, include the following:

 HEAL 10: Organizations receiving funding within the HEAL 10 grant program
focus on supporting and/or accelerating the development and implementation of
New York‘s health IT infrastructure. HEAL 10 Integrates this infrastructure with
PCMH payment incentives and delivery system reforms. In addition, HEAL 10
aims to establish clinical capacity for providers and patients to be prepared and
accountable for models based on quality-based outcomes and care coordination
and management.

 HEAL 17: Initiatives receiving HEAL 17 funds have developed projects to

improve care coordination and management through PCMH components
combined with interoperable health IT infrastructure. This infrastructure includes
the technological building blocks, clinical capacity and policy solutions necessary
to transition to an interconnected health care system encompassing the full
continuum of care at the community level. HEAL 17 projects focus on disease-
specific improvements in chronic conditions and mental health diagnoses.

 Medicare ACOs: Medicare ACOs are accountable for the quality, cost, and
overall care of a defined Medicare FFS population. ACOs must have a formal
legal structure to receive and distribute payments for shared savings, in addition
to both clinical and administrative infrastructure and leadership. ACOs must have
in place defined processes to promote evidenced-based medicine, report quality
and cost measures, coordinate care, and demonstrate patient-centeredness.

 Beacon Community Program: Beacon communities build on an existing

infrastructure of interoperable health IT and standards-based information
exchange to advance specific health improvement goals. Communities strive to
achieve measurable improvements in health care quality, safety, efficiency, and
population health. Most Beacon communities have a disease-specific focus, such
as projects to improve care for patients with diabetes.

 Medicare Advanced Primary Care Practice Demonstration (APCP): APCP is a

multi-payer initiative in a region or state that provides enhanced payment to
medical practices in exchange for providing continuous, comprehensive,
coordinated, and patient-centered health care to the majority of patients. An
APCP must include Medicare, Medicaid, and commercial plans. The APCP is
indicative of the PCMH trend toward regional/state efforts (as compared to
explicitly practice-based activities, such as those receiving recognition by the
National Center on Quality Assurance).

When combined, the elements of each of the above-noted programs will work together
to support provider adoption of health IT; enhance care coordination across and among
settings; improve clinical outcomes and patient experience; support data-driven

41
improvement efforts; rely on both strong and transparent governance; and engage
patients and community stakeholders.

Based on this analysis, the following key attributes will serve as the foundational criteria
for organizations seeking to lead CCCs:

 Multi-stakeholder governance structure, reflecting a broad range of community

stakeholders and strong clinical leadership.

 Defined clinical and efficiency objectives and a commitment to use measures that
reflect these two domains.

 Use of health IT consistent with State and Federal standards and requirements.

 Minimum provider participation requirements such that the majority of providers

within a given geography must participate in the collaborative care community.

 Support from both public and private payers, via payment reform, to support
activities across the majority of a patient population.

Based on these attributes, NYeC proposes the following definition of a collaborative

care community:

A multi-stakeholder initiative through which the majority of providers, plans and

patients work together to measurably improve the quality and efficiency of care and
transform the health of the community. Within this community, providers would:

 Make available to patients a core set of care coordination and patient-

centered services.

 Utilize clinical decision support tools and evidence-based guidelines in clinical

care.

 Advance the use of health IT, such that a significant percentage of providers
within the community have achieved federal meaningful use requirements.

It is also anticipated that, along with efforts to support health IT adoption among
providers, the CCC will be a purchaser of technical services from Qualified Health IT
Entities.

CCCs will be required to use evidence-based measures to advance care and monitor
results in the designated regions and populations they serve. Organizations seeking to
serve as the lead of CCCs will need to demonstrate multi-stakeholder, community
governance; strong clinical participation; and commitment to using data across multi-
institutional boundaries.

42
The following figure illustrates, from the perspective of a health care provider, the roles,
relationships and data flows for CCCs.

Figure 9: Anticipated Relationships and Data Flows from A Provider‘s Perspective

Governance of Qualified HIT Entities and CCCs

Governance of Qualified HIT Entities and CCCs will focus on three core functions: (1)
establishing qualifying criteria; (2) issuing the respective designations, and (3) ongoing
oversight and assurance of compliance. In order to protect the public interest, the
criteria for designation for both Qualified Health IT Entities and CCCs will be informed
by the SCP and formally established by NYS DOH.

The oversight entity responsible for designating such organizations could vary. Given
the State‘s involvement in regulation of care provision and reimbursement, NYS DOH
would likely be in the best position to issue designations to CCCs. While NYS DOH
could delegate issuance of designation of Qualified Health IT Entities to a third party
certification body with staff and expertise in technical services, the State must assess its
statutory obligations with respect to delegation of authority, particularly as it relates to
Medicaid Service Bureaus and the monitoring of Universal Public Health Nodes.

With respect to ongoing monitoring and oversight of Qualified Health IT Entities and
CCCs, a division of labor between NYS DOH and NYeC is currently being agreed on
and will be influenced and informed by the assessment by NYS DOH of statutory
requirements and NYeC‘s potential role vis-à-vis provision of statewide HIE services.
The figure below illustrates the potential oversight construct.

43
 Figure 10: Oversight of Qualified Health IT Entities and Collaborative Care Communities

Next Steps

NYeC and NYS DOH will advance the definition and implementation of Qualified Health
IT Entities and CCCs in accordance with the following timeline:

Fourth Quarter 2010:

 Refine criteria for Qualified Health IT Entities and address the following:
o Development of mechanisms for escalation of issues and dispute
resolution.
o Determine the eligibility of for-profit organizations to serve as qualified
entities.

 Refine criteria for CCCs.

First Quarter 2011:

 Develop accreditation process for Qualified Health IT Entities and CCCs.

44
Statewide HIE Utility

Currently, procurement and deployment of HIE services occurs at the regional and local
levels. Adherence to Statewide Policy Guidance and SHIN-NY protocols and
implementation specifications ensure consistency and cost-efficient deployment.
Review of New York‘s statewide HIE infrastructure (and lessons from other states)
suggest that there are additional opportunities to leverage economies of scale,
particularly for core infrastructure services and other value-added services that could be
procured and managed using a statewide utility model.

As previously noted, procuring HIE services through a single entity reduces per-unit
costs and promotes consistency by avoiding duplication of service. Candidate services
for procurement through a statewide HIE utility are described in the Technical section.

In addition to the procurement of technical services, the statewide HIE utility could also
serve as the entity that contractually binds participants in statewide HIE to the Statewide
Policy Guidance. In this manner, Qualified Health IT Entities accessing core services
through the statewide HIE utility would have reciprocating agreements to abide by
Statewide Policy Guidance.

The NYS DOH and NYeC continue to evaluate options for creating a single statewide
HIE utility, including the viability of NYeC serving in this capacity.

Next Steps

NYeC and the NYS DOH will advance the development of a statewide HIE utility in
accordance with the following timeline:

Fourth Quarter 2010:

 Finalize analysis of options for creation of a statewide HIE utility

First Quarter 2011:

 Implement contracting and governance mechanisms for statewide HIE utility

45
3. Technical Infrastructure
New York‘s strategy for developing the HIE and health IT technical infrastructure is two
fold: (1) accelerate the deployment of cost-effective tools, capacity, and capabilities; and
(2) identify and address gaps in the ability of providers to demonstrate ―meaningful use‖
of health IT. While this effort is directly motivated by the common federal and State
agenda to increase uptake of health IT and HIE, State and federal health reform
agendas are also driving the development and evaluation of coordinated care models.
These models depend on – and provide invaluable opportunities for – HIE services for
providers and patients to share information and collaborate regarding the patient‘s care.

As the previous environmental review explained, New York‘s strategies to advance its
HIE infrastructure build on the significant progress achieved to date through the State
HEAL grant funding programs. HEAL has galvanized the development of a
comprehensive set of standards, protocols and policies for the State‘s HIE
infrastructure, SHIN-NY. These advances have established the foundation for
widespread implementation of coordinated care models to improve the quality, impact
and efficiency of health care.

Despite the considerable progress that has been made, substantial gaps remain in the
adoption of health IT and HIE among key health care stakeholders. This section
describes these gaps and identifies operational plans to further and accelerate the
State‘s progress in health IT and HIE.

As described in this section, New York will implement statewide ―shared services‖
governed and operated by a public utility infrastructure, as well as deployment of
standardized regional approaches that leverage existing infrastructure developed by the
RHIOs. Development of shared services will avert duplication of effort, realize
economies of scale, and expedite access to key HIE services that the market has not
yet effectively provided and is unlikely to provide in the near future.

Taking into account value to participants and alignment with Federal and State policy
priorities, New York has prioritized HIE services, identifying those services that are most
critical as shared services to expedite progress toward technology-enabled health
transformation. Prioritization of HIE services was informed by a mapping and
diagramming exercises of so-called ―Connected Capabilities,‖ which allow visualization
and analysis of the HIE needs of key stakeholders. This section describes the
capabilities required by various stakeholders to optimize health IT and HIE; summarizes
the analytical, evidence-informed process used by NYS to assess potential services;
and identifies the HIE services that the State has identified as operational priorities in
moving forward.

As outlined below, New York‘s operational plans for its technical infrastructure anticipate
the need for considerable flexibility in crafting HIE services. Given the rapidly evolving

46
HIE marketplace, different tactics will be required for the various services planned,
including development of new services, leveraging existing services, and application of
policy and purchasing levers. Some services will need to be delivered statewide, while
in other cases a regional approach will be wisest. Common governance and policies will
enable NYS to meet the challenge of integrating diverse services into a coherent
network, which in turn will spur innovation in the marketplace in response to the routine
exchange of information as a public good.

Taking these and other priority considerations into account, New York envisions an
architecture (illustrated in the figure immediately below) that builds on the SHIN-NY
infrastructure.

Figure 11: Updated SHIN-NY Architecture

The diagram above does not capture all services contemplated by New York (described
in the discussion below), but focuses instead on the highest-priority services. The
architecture enforces standards-based transactions facilitated by the centralized
infrastructure, which will host centralized core services that are fundamental for the
value-added clinical and administrative services desired by stakeholders. Below the
statewide level, other stakeholders, such as RHIOs, may have local networks that
connect communities and offer local network services, as well as serve as a conduit to
the statewide infrastructure and facilitate community sharing of infrastructure.
Consistent with existing SHIN-NY protocols and standards, compliant point-of-care
solutions, like EHRs, or other enterprise systems will be able to connect to the statewide
infrastructure directly to access shared services and communicate with other systems

47
and networks. Multiple transport protocols are supported, as are the prevailing data
standards espoused for meaningful use and dominant security models.

Rather than attempt to replace national networks with ubiquitous connections, SHIN-NY
capitalizes on them to accomplish prioritized use cases. For example, e-prescribing may
be done using interfaces from EHRs connected to Surescripts.

Health IT and HIE Gap Assessment and Corrective Strategies

Built on a commitment to continuous improvement, NYS continues to monitor the
development of the statewide health IT and HIE infrastructure to identify and assess
gaps in deployment and usage, taking corrective action to close these gaps. The
discussion below assesses gaps and identifies corrective action with respect to e-
prescribing, electronic reporting for public health, lab results delivery, and patient care
summary exchange.

E-Prescribing

Between 2007 and 2009, the number of new e-prescriptions in the State increased from
1,571,229 (2% of all prescriptions) to 9,688,675 (9% of all prescriptions) – an increase
of more than 500%.3 The number and percentage of community pharmacies
participating in e-prescribing is also steadily climbing, up to 87% in 2009 from 64% in
2007. Adoption among independent pharmacies is slightly lower at 78%.

Rates of e-prescribing in upstate New York are higher than in NYC. Nearly one in four
(24.3%) physicians in upstate New York e-prescribe, with rates ranging from 18.3% in
the Southern Tier of the State to 27.0% in Western New York. For all forms of providers,
the e-prescribing rate in upstate New York increased from 12% in 2009 to 17% in the
first quarter of 2010.4

The prevalence of e-prescribing is certain to increase even further due to the recent
launch of the State‘s program to provide financial incentives to Medicaid providers that
issue prescriptions electronically and to pharmacies that accept e-prescriptions (e-
prescribing is already up from 5.51% of the overall Medicaid prescription volume in
January 2010 to 8.75% in June 2010.) New York‘s efforts to improve its e-prescribing
rates are also helped by the efforts of four New York RHIOs that are currently offering e-
prescribing tools to their participants. Collectively they serve 260 providers.

Key Gaps

While New York has made strides in recent years, it is still lagging many other states in
certain key adoption metrics, ranking 36th in Surescripts‘ 2009 SafeRx table. The

3
―New York Progress Report on E-Prescribing: E-Prescribing adoption and use statistics for years 2007 –
2009‖ Surescripts
4 ―Trends and benefits of electronic prescribing in upstate New York,‖ Excellus BlueCross BlueShield,

Summer 2010

48
percentage of physicians using e-prescribing and the percentage of prescriptions routed
electronically have been rising steadily but are still low. While New York‘s overall
adoption rate is strong among community pharmacies, there are various regional gaps
that require attention.

Corrective Strategies

New York will leverage widely available EHR options in the market that have
connections to Surescripts. To obtain a clearer understanding of regional gaps, NYeC
will work with Surescripts to obtain more detailed data on pharmacy participation by
geographic areas. Efforts will focus on State agencies and public and private payers to
identify policy and purchasing levers to incentivize small pharmacies to support e-
prescribing and electronic medication management.

Interested public agencies and private sector stakeholders will be convened to update
SPG to leverage Federal rules to allow e-prescribing of controlled substances and
address approaches to complying with ―dispense as written‖ rules. In a further effort to
overcome barriers to prescribing controlled substances, the possible use of provider
authentication services as a potential ―shared service‖ solution will be analyzed.

Goals and Tracking E-Prescribing Progress

Activity Current Goal Goal Goal
State (2011) (2012) (2013)
Percentage of unique patients with at least TBD TBD TBD
one medication in their medication list TBD
seen by providers or admitted to the
hospital's inpatient or emergency
department have at least one medication
order entered using CPOE.

Percentage of all permissible prescriptions 9% TBD TBD TBD

written are transmitted electronically using
certified EHR technology.

Percentage of pharmacies accepting 87% TBD TBD TBD

electronic prescribing and refill requests.

NYeC will work with key stakeholders and the SCP work groups to determine baseline
data on e-prescribing and to develop statewide goals. NYeC will track physician
adoption, volume of e-prescribing transaction, and pharmacy connectivity to e-
prescribing networks. As part of its evaluation plan, NYeC will annually report progress
against these measures.

49
Electronic reporting for public health

Current levels of electronic reporting for public health are described in Appendix C. For
clinical lab reporting, 474 full-service labs are certified to electronically report mandated
lab results, with 193 currently reporting electronically.

New York routinely monitors eight different syndromic categories: Respiratory, GI,
Fever, Asthma, Neurological, Rash, Carbon Monoxide and Hypothermia. Summary and
case-level counts, signals, short-term and long-term trend graphs as well as patient
listings are available by syndrome, hospital, county, and region. Hospital users may
view data for their hospital, as well as aggregated data for their surveillance region, and
LHD users may access data for all hospitals in their county, as well as aggregated data
for their county and region. Currently, 142 out of 144 emergency departments outside of
NYC report to the system, covering more than 98% of the non-NYC population.

With respect to immunizations, NYS DOH supports an electronic immunization

(NYSIIS), with New York City operating a separate system. For NYSIIS, 88% of the over
5000 provider organizations report via a web portal, and 12% report directly from their
EHR. However, 60% of all incoming data comes in from data exchange.

Key Gaps

UPHN architecture and specifications have been developed, but additional work is
needed to develop it into a production-level service capable of supporting bi-directional
exchange of data.

Corrective Strategies

NYS DOH will advance meaningful use of certified EHR technologies and other public
health information functions by leveraging and enhancing UPHN, with the aim of
increasing bi-directional sharing of data and guidance with providers based on the
PCMH model for care coordination. These efforts will build upon draft guidance already
developed for core immunization requirements. Standards-based electronic data
exchange requirements will be defined to meet clinical use case needs, promoting
increased communication and coordination of services among local and state agencies
and providers. Systems requirements will be developed and defined in a streamlined
manner, with input solicited from relevant stakeholders. Roles and responsibilities of
collaborating stakeholders – both within NYS DOH and in RHIOs – will be defined, and
requirements for vendor products will be developed, reviewed and finalized. A
mechanism will be developed for timely delivery of clinical data and guidance (e.g.,
immunization history and guidance, cancer screening eligibility, etc.) from NYS DOH to
provider EHRs via UPHN and RHIOs at point of care. NYS DOH will develop a
repeatable and scalable process for implementing real-time, bi-directional data transfer
within UPHN for strategically prioritized clinical program use cases in public health, with
associated governance requirements. NYS DOH will also develop a communications

50
plan to share and obtain information from stakeholders regarding these innovations, as
well as a training document to inform users of key technical specifications.

NYS DOH will take steps to further develop its bi-directional reporting initiatives relating
to immunization. Providers will be able to receive and respond to queries and make
batch reporting of immunization data via UPHN. Providers will have the ability to make
queries from their EHR via RHIO/SHIN-NY and UPHN in order to receive patient-
specific immunization history. Immunization query results will be available for
retransmission to the provider in a format suitable for uploading in the provider‘s EHR
system. Through further development of bi-directional reporting, NYS DOH will have the
ability to provide immunization-related guidance to health providers, such as
recommendations for needed immunizations for an individual patient. Reporting time
and reporting burdens will be reduced through these advances.

Steps will also be taken to increase utilization of UPHN. NYS DOH will promote
expanded implementation and use of UPHN by RHIOs, HIEs, clinical provider
organizations, and HHS agencies through the development of a compelling value
proposition that identifies potential savings in costs, time and labor. Stakeholder input
will be solicited regarding current UPHN use in order to inform identification of potential
enhancements for public health applications. A number of additional features have
already been identified, including supply data for aggregation and analysis, leveraging
clinicians‘ drive to achieve meaningful use by improving the standardization and
availability of health information for public health, and new methodologies for side
reviews and other auditing procedures in public health. Providers will also benefit from
more timely and effective information regarding priority public health issues. Other
features that have been identified include potential new regulations to support UPHN
objectives, such as new rules requiring providers with in-house labs to provide access
through SHIN-NY using uniform and standardized reporting requirements.

NYS DOH will develop a repeatable and scalable process for implementing real-time,
bi-directional data transfer within UPHN for strategtically prioritized clinical program use
cases in public health, with associated governance requirements. NYS DOH will also
develop a communications plan to share and obtain information from stakeholders
regarding these innovations, as well as a training document to inform users of key
technical specifications.

51
Goals and Tracking Electronic Reporting for Public Health Progress
Activity Current State Goal Goal Goal
(2011) (2012) (2013)
Upstate: 88% TBD TBD TBD
Percentage of providers who submit (via web portal)
immunization data electronically to 12% (batch via
public health agencies EHR vendor)

TBD TBD TBD

Percentage of health departments TBD
electronically receiving immunizations,
syndromic surveillance, and notifiable
laboratory results

Working with NYSDOH, NYeC will track the rate of submission of immunization data
electronically and the percentage of LHDs receiving immunizations, syndromic
surveillance, and notifiable laboratory results. As part of its evaluation plan, NYeC will
annually report progress against these measures.

Electronic lab results delivery

Among the 926 clinical laboratories that have a permit to operate in New York State, 47
hospital-based or commercial labs are currently participating in a RHIO. The total
number of laboratories participating in electronic delivery to EHRs is currently not
known, although NYeC plans to work with NYS DOH‘s Wadsworth Center to conduct
surveys in the near future to obtain better baseline data. Five NYS RHIOs are currently
offering lab results delivery services to their members, and two other RHIOs are
currently developing this service. Together, they facilitate the delivery of 470,000 lab
results each month.

Key Gaps

While New York currently lacks hard data on the number of laboratories currently
supporting the delivery of results in a structured format, it believes that there are
significant gaps in terms of laboratories‘ ability to support electronic delivery of results
as well as providers‘ receipt of them. Adoption is likely especially low among small and
independent labs. While several RHIOs are offering, or planning to offer, a lab results
delivery service, only one currently offers an electronic lab ordering service.

Corrective Strategies

NYeC will partner with the Wadsworth Center of NYS DOH to survey lab companies on
current adoption rates of standardized electronic results delivery as well as challenges
to broader deployment. Available EHR and RHIO options will be leveraged to facilitate
connections to national and regional labs. Through the SCP, RHIOs, providers and lab
companies will be convened to develop a longer-term strategy to address lab

52
connections, with a focus on connecting small and independent stakeholders. Potential
policy and/or purchasing levers will be collaboratively explored to incentivize lab
companies to facilitate electronic results delivery to EHRs. As potential ―shared
services,‖ collaborative efforts will analyze the feasibility of terminology translation for
community exchanges and a future lab network service.

Goals and Tracking Electronic Lab Results Delivery Progress

Activity Current Goal Goal Goal
State (2011) (2012) (2013)
Percentage of clinical lab results received TBD TBD TBD TBD
in a structured format

NYeC will work with key stakeholders and the SCP work groups to determine the
baseline and to develop statewide goals. NYeC will track physician adoption, volume of
e-prescribing transaction, and pharmacy connectivity to e-prescribing networks. As part
of its evaluation plan, NYeC will annually report progress against these measures.

Patient care summary exchange

All 12 RHIOs have plans to offer one-to-one patient care summary exchange services
for e-referral and care coordination purposes. Three (3) currently offer the service,
though only on a pilot basis, while eight (8) are developing the service, and one (1) is in
the planning stage. Two (2) New York organizations are participating in the NHIN Direct
demonstrations.

Furthermore, only eight (8) NY RHIOs have implemented the patient history query
services. Three (3) other RHIOs have the service in development, and one (1) plans to
offer the service within the next two years. Across New York State, an estimated
38,000 such queries for patient information are made each month.

Key Gaps

Few EHRs are presently able to send and receive e-referrals outside of their own
networks, although New York expects the NHIN Direct program to help its efforts to
address that issue. Among the RHIOs developing the service, there are gaps in terms
of full integration of the service with EHR products. In addition, few RHIOs have been
able to fully integrate their patient history query services with end EHR products. For
example, there are still significant gaps in the EHR market for products that can import
clinical information from the RHIOs into their systems.

Corrective Strategies

NYeC will leverage available EHR and RHIO options that currently allow patient care
summary exchange functionality among clients and participants. Options will be
explored to create partnerships and pilot programs with RHIOs and EHR/HIE

53
companies currently deploying NIHN standards-based patient care summary exchange
services for their customers. New York will also explore options to develop provider
directory services as a priority ―shared service‖ solution to facilitate patient care
summary exchange among providers.

Goals and Tracking Patient History Transaction Progress

Activity Current Goal Goal Goal
State (2011) (2012) (2013)
Percentage of hospital discharge TBD TBD TBD TBD
information and care summary to treating
physicians and primary care providers and
other designated providers

Percentage and number of providers who TBD TBD TBD TBD

attest to meeting the MU core definition of
exchanging key clinical information among
providers of care and patient authorized
entities electronically

NYeC will work with key stakeholders and the SCP work groups to determine the
baseline for patient care summary exchange and to develop statewide goals. NYeC will
track physician adoption, volume of e-prescribing transaction, and pharmacy
connectivity to e-prescribing networks. As part of its evaluation plan, NYeC will annually
report progress against these measures.

HIE Architecture and Approach

As part of the planning process for this Operational Plan, a Collaborative Care
Infrastructure Work Group, established by the NYeC Board, worked with stakeholders to
develop a framework to align prior HEAL and SHIN-NY efforts regarding HIE and
interoperability with updated State and Federal policy priorities, market developments
and RHIO capabilities. These deliberations generated a number of key outcomes:

 A list of HIE services, deployable as statewide ―shared services‖ or through

standardized regional approaches, as defined by State and Federal requirements.

 A set of use cases to visualize and explain service requirements, referred to as

“connected capabilities,” encompassing State and Federal HIE priorities.

 Criteria for evaluating and prioritizing how, where and when key HIE services
should be deployed.

 A RHIO inventory and readiness assessment to determine the current capabilities

of the RHIOs and their interest in and capacity to provide or consume standardized
statewide HIE services.

54
Using this framework, NYeC then undertook the following efforts to further refine the
State‘s HIE architecture and technical approach. Specifically, NYeC:

 Validated connected capabilities based on alignment with state / federal policy goals.

 Categorized and prioritized HIE services for development, acquisition and

deployment.

 Created ―SHIN-NY 2.0‖ architecture diagrams to reflect the evolution and future
direction of New York‘s statewide approach to health information exchange.

See Appendix H for a detailed description of the framework components and

evaluation/prioritization methods as critical elements of New York‘s plan for promoting
HIE and making it operational and available statewide.

Summary Services Prioritization

An Operational Plan Work Group met several times in August-September 2010 to

review the work of the Collaborative Care Infrastructure Work Group and finalize an
operational strategy for delivering shared HIE services statewide. The following is a
synthesized and summarized view of candidate HIE services across all dimensions of
analysis, organized into an initial prioritization:

55
 Shared / Standardized Services

Record Locator Service / Master Person Index

Clinical Decision Support / Medication Safety

Identity Management and Authentication

Medical Necessity / Authorization Rules

Personally Controlled Health Record

Quality and Analytics Data Center
Public Health Reporting Registry
Eligibility / Claims Transactions
Medication Data Management

Research Data Aggregation

Message / Record Routing

Provider / HIE Directory

Vocabulary Translation

Imaging Order / Result

Consent Management

Health Record Portal

Disclosure Logging

Lab Order / Result

Event Notification

Patient Education
E-Prescribing
Formulary
Connected Capability
Route visit data to providers and other authorized parties 5 5 5 3 4 3 5 1 3 1 2
Route data in support of care transitions, including referrals 5 5 5 3 4 3 5 2 3 2 4 2 2
Route lab and imaging orders and results 5 5 5 4 4 2 5 5 3 5 3 4 2 2
Query patient history 5 4 5 4 3 5 5 4
4 4 5
Route electronic prescriptions 5 5 3 1 4 4 4 3 5 5
Retrieve medication history for medication reconciliation, other medication mgt. 5 5 5 4 5 5 5 3 4 3 1 2
Route visit and other data for clinical decision support 5 5 5 4 4 2 4
3 3 2 5 4
Route data to patients and enable ownership and management 5 5 5 4 3 5 3
4 2 4 1 5 4
Adjudicate and manage claims and/or patient responsibility 5 5 3 4 4 5 5
Route visit and other data for standardized quality reporting 5 5 4 4 4 3 3 3 2 5
Route visit and other data to disease registry 5 5 5 4 4 4 4 2 5
Route visit and other data for standardized public health reporting 5 5 4 4 4 3 3 4 3 3 5
Factored Result (total score x average score x # of dependencies x .1) 36 35 29 16 14 9 8 7 6 5 5 4 3 3 2 1 1 <1 <1 <1 <1 0
Core Value-Added
Figure 12: Connected Capability Prioritization

56
 Service Value Policy Alignment Business Model C / VA Priority
Message / Record Routing H H U C H
Provider / HIE Directory H H U C H
Lab Order / Result H H C/U VA H
Medication Data Management H H U VA H
E-Prescribing H H C VA H
Quality and Analytics Reporting / Feedback H H U VA H
Public Health Reporting / Registry H H U VA H
Identity Management and Authentication M H C/U C M
Vocabulary Translation H M C/U C M
Record Locator Service / Master Person Index M M U C M
Consent Management L M U C M
Disclosure Logging L M C C M
Event Notification M H U VA M
Imaging Order / Result H M C VA M
Formulary M M C VA M
Eligibility/Claims Transactions M M C VA M
Personally Controlled Health Record L M C/U VA M
Health Record Portal NR M C VA M
Medical Necessity / Authorization Rules M L C/U VA L
Clinical Decision Support / Medication Safety L H U VA L
Patient Education L H U VA L
Research Data Aggregation L L U VA L

Figure 13: Services Prioritization

The Operational Plan Work Group‘s discussions resulted in a few minor changes from
the recommendations generated by the Collaborative Care Infrastructure Work Group.
The previously separate Formulary service was combined into a more complete E-
Prescribing w/Formulary service, and the Clinical Decision Support/Medication Safety
and Patient Education services were elevated in priority based on their strong ties to
New York State HEAL policy objectives. This led to the grouping of services shown
below:

57
 Priority Type Service Notes
Provider / HIE Directory Foundational; no commercial option; delivers economies of scale
Message / Record Routing Foundational; need to guarantee for all participants
Foundational; economies of scale; strategy dependent on approach
Record Locator Service / Master Person Index
Core to patient matching (RLS vs. MPI)
May be economies of scale, with value in statewide solution and tie-
Identity Management and Authentication
in with directory strategy
May be value in state control and tie-in with provider and patient
Consent Management
identification
Strategic for NYS; also perceived high value; leverages current
High Medication Data Management
state program; may be value in state-level Surescripts relationship
Lab Order / Result Critical to ONC; may need to guarantee statewide for all participants
E-Prescribing w/Formulary Critical to ONC; should be provided by EHR vendors,SureScripts
Value- Public Health Reporting / Registry No commercial option; strategic; required for many state objectives
Added Quality and Analytics Reporting / Feedback Value in standardizing statewide; not necessarily in provisioning
Possible enhancement to message routing; no determination on
Event Notification
location
Clinical Decision Support / Medication Safety Strong tie-in with state policy goals; standardize rather than provide
Patient Education Strong tie-in with state policy goals; standardize rather than provide
Perceived high value, but no specific requirement to have this
Vocabulary Translation
Core capability; pilot with normalizing lab results
Disclosure Logging Has value, but does not need to be implemented statewide
Imaging Order / Result Scored high for value, but low in other categories
Medium Explore based on enticement / attractiveness to potential
Value- Eligibility/Claims Transactions
participants and potential tie-in with state payment reform goals
Added Need to explore criticality to policy; low priority otherwise
Personally Controlled Health Record
Health Record Portal Leverage current activities in RHIOs
Medical Necessity / Authorization Rules Value increases if tied to policy or specific state goals
Value-
Low Need to test value proposition and perceptions re: secondary use of
Added Research Data Aggregation
data

Figure 14: Service Prioritization List

Using this framework, Core and Value-Added services are phased and allow for ever-
increasing functionality to be added over time to support expanding State policy goals,
as depicted below:

58
 Later Phase Value-Added
• Research
Data
Aggregation
• Medical Necessity /
Authorization Rules
Next Phase Value-Added

• Imaging Order / Result

• Eligibility/Claims Transactions
• Personally Controlled Health Record Next Phase Core
• Health Record Portal

• Disclosure Logging
High Priority
• Vocabulary Translation
Value-Added,
• Quality and Analytics Reporting / Feedback Guided Statewide
• Patient Education
• Event Notification
• Public •
High Priority
Clinical Decision Support / Medication Safety
Health
• Lab
Value-Added,
Reporting • Message / Record Routing
/ Registry Order Leveraging
•
•Medication
Provider Directory / Result National /
• •
Data Consent Management E-Prescribing Local
w/Formulary
Management • Identity Management and Authentication Solutions
• Record Locator Service / Master Patient Index

High Priority Value-Added, High Priority Core

Provided Statewide
Figure 15: Services Pyramid

As shown at the bottom of the services pyramid, New York State will pursue three
strategies in parallel for shared services over the next 18-24 months:

 High-priority core service development and deployment will be directed by NYeC

statewide.
 High-priority value-added services will be delivered in one of three ways:
o Provided statewide.
o Guided statewide with standards and policy.
o Delivered through local and national solutions, guided by statewide standards
and policy.
 Core services planned for the next phase of implementation will be directed
statewide following effective implementation of high-priority core services.
 Next-phase value-added services will be guided by statewide standards and policy
and are planned to be left to regional delivery at this time.
 Later phase value-added services will be deployed based on a strategy refined over
time.

59
Public Health

NYS DOH will continue working with the SCP Work Groups to define potential
opportunities associated with public health programs, NYS DOH programs, HHS
agencies, and Medicaid. In particular, a number of potential options will be evaluated,
including open-source connectivity to UPHN for public health reporting, laboratory
terminology services as a statewide service, provider identification using the health
commerce system as a statewide service, and trusted and secure clinical messaging
between providers as a shared service. These identified priorities will be categorized by
time frame (e.g., short-term, long-term) and estimated, with pilot testing planned.

HIE Standards and Certification

To ensure adherence to Federal and State policies and mandates, and to promote high
service quality, a comprehensive set of standards will be put in place, along with
processes to ensure proper certification of participants in health IT and HIE. Future
operational plans will build on the considerable progress that has already been made in
the adoption of health IT standards in New York State.

Eligibility for Development, Testing and Implementation of Standards and

Services

New York has used the SCP to convene communities, vendors, State officials, and
other stakeholders to produce the necessary technical specifications and to determine
requirements for network operation. This process was also used to orchestrate
infrastructure testing for HEAL-NY grants, and to facilitate collaborative development
among vendors for specific technical services. There are several work groups that
handle clinical, operational, policy, and technical concerns, and jointly report to a board
of stakeholders that ratify work group decisions on approach. The SCP will be
instrumental in ensuring the development and utilization of testing procedures.

New York will employ a number of mechanisms to ensure appropriate connection of

health care systems to SHIN-NY. An architecture to accommodate all available health
IT systems certified by ONC will be developed, ensuring broad-based applicability to
service providers and stakeholders, avoiding the need for a separate validation
mechanism for NYS, and facilitating the participation of multiple vendors.

New York will develop guidance and documentation that instructs technical
organizations on how to comply with SHIN-NY architecture. This documentation will
leverage mainstream standards, including those endorsed by the Federal government
for the meaningful use of certified EHR technologies, and corresponding implementation
guides. A testing infrastructure specific to SHIN-NY will be constructed for validating
correct implementation of all transactions. UPHN and Medicaid (through the Medicaid
Medication Management Use Case) has begun this process through the development of
test plans, test data, and a certification process for automated public health reporting. In

60
like fashion, all SHIN-NY transactions will have such validations to serve as network-
admittance criteria.

Mechanism for Adoption of HHS and ONC Standards

The statewide HIE services supported through the State HIE Cooperative Agreement
will comply with all national standards as defined in the HITECH Act, including the final
Standards and Certification Criteria used to support the Final Rule on Meaningful Use
for content, vocabulary, privacy and security.

Working in concert with the NYS Health IT Coordinator, NYeC will provide guidance in
establishing statewide standards and requirements. Under the guidance of the SCP,
various key constituents, including RHIOs, EHR vendors, and provider organizations,
participate to develop and implement statewide policies and publish technical
specifications for SHIN-NY. Through this process, SCP work groups will ensure that HIE
services in New York are aligned with national initiatives such as the NHIN and
meaningful use.

Public Health

In coordination with the work groups on governance and sustainability, NYS DOH will
develop and implement a certification process for entities to connect to UPHN,
permitting de-identified list queries for specified public health purposes. This process
will specify policies and technical requirements, data standards and protocols for
certification. A draft of the proposed certification protocol will be shared with
stakeholders, and the process will be pilot tested to assess its effectiveness, with
findings used to refine the certification process. A communications plan will be
developed to share information with RHIOs and other key stakeholders.

61
4. Business and Technical Operations
New York will pursue an energetic plan of action to ensure realization of the connected
capabilities that are central to advancing the State‘s vision of technology-enabled health
transformation. The discussion below outlines a timeline for implementation of the HIE
services that are vital to accelerated progress toward the vision of technology-enabled
health transformation in New York State.

Statewide HIE Services Approach and Implementation Timeline

NYeC will coordinate and manage provision and implementation of uniformly available
statewide HIE services in support of State and Federal interoperability and care delivery
goals. In doing so, NYeC will use the services strategy outlined in this Operational Plan
and focus on:
 Interaction between qualified health information organizations, in a network-to-
network model.

 Providing access to HIE services to participants not served by a RHIO or other

qualified health IT entity.

 Enabling direct connection by participants and vendors capable of complying with

SHIN-NY policy and standards.

 Enabling key value-added services required for high-priority connected capabilities.

Core services will be delivered in progressively advanced releases every six months,
with releases at the end of June and December. Value-added services will be targeted
incrementally, interspersed with releases of core services. Value-added services will be
bundled into annual releases targeted toward consumers, public health and providers,
with three value-added services released each year. Organizing value-added releases
will allow stakeholders to plan annually for new functionalities and enable NYeC to
develop, leverage and retain expertise relevant to specialized customer or stakeholder
segments. All release activities are planned as six-month projects.
The following diagram depicts a summary view of the preliminary timeline:

62
Preliminary Timeline
2011 2012 2013 2014
Planned Releases J FM A M J J A S O N D J FM A M J J A S O N D J FM A M J J A S O N D J FM A M J J A S O N D
Core Service Bundle – R 1.0
•Provider/HIE Directory
•Message / Record Routing
•RLS / MPI (Patient Matching) 9/30/2011
•ID Management and Authentication
•Consent Management
Public Health Bundle #1 – R 1.1
• Public Health Reporting / UPHN
11/30/2011

Provider Bundle #1 – R 1.2

•Medication Data Management / MMM
12/31/2011
•E-Prescribing w/Formulary
•Structured Lab Result Delivery
Core Services Modifications #1 – R 1.3
•Expanded / Refined Functionality 3/31/2012
•Expanded Adoption
Consumer Bundle #1 – R 2.1
•Patient Education 6/30/2012
•Patient Portal
•Event Notification (patient)
Core Services Modifications #2 – R 2.2
•Expanded / Refined Functionality
9/30/2012
•Expanded Adoption
•Vocabulary Translation (Lab Results)
Public Health Bundle #2 – R 2.3
• Enhanced / Refined Med. Data Mgmt. 11/30/2012
and Public Health Reporting
• Event Notification (public health)
Provider Bundle #2 – R 2.4
•Quality Reporting
12/31/2012
•Event Notification (provider)
•Add‘l Service TBD
Core Services Modifications #3 – R 2.5
•Expanded / Refined Functionality 3/31/2013
•Expanded Adoption
Consumer Bundle #3 – R 3.1
•PHR Routing 6/30/2013
•Patient Portal Enhancements
Core Services Modifications #4 – R 3.2
•Expanded / Refined Functionality 9/30/2013
•Expanded Adoption
Provider Bundle #3 – R 3.4
• Features / Functionality TBD 12/31/2014

Consumer Bundle #3– R 4.1

•Features / Functionality TBD 1/31/2014

Figure 16: Services Implementation Preliminary Timeline

Continuing efforts currently underway, NYeC will undertake the following key activities
in the last quarter of calendar year 2010:
 Conduct a comprehensive review of RHIO capabilities and determine RHIO-by-
RHIO interest and capability in providing core or key value-added services.
 Refine initial requirements sufficient to procure one or more service providers for the
first release(s).
 Conduct an RFI / RFP process for one or more procurements:
o Initial provider(s) for Core Services Bundle 1.0 (see below).
o Requirements definition, standards and policy development, coordination and
project management, if needed, for the initial Public Health and Provider Bundles
(see below).

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While release plans are subject to change, the following discussion describes current
plans for releases.

Core Services Bundle 1.0 – September 30, 2011

Core Services Bundle 1.0 will be procured by January 1, 2011 following a period of
analysis and determination of requirements in Q4 2010. This release will deliver a core
set of interrelated foundational services required to provide uniform and standardized
access to SHIN-NY. This release may be delivered by one or more solution providers
or by a single solution provider through a single application platform or using a ―best of
breed‖ approach. In all cases, an integrated set of services will be procured,
coordinated and managed by NYeC and will include:
 Provider/HIE Directory – coordinated to function with Message/Record Routing and
Identity Management and Authentication for provider enrollment and other security
features.

 Record Locator Service/Master Person Index (Patient Matching) – coordinated to

function with Message/Record Routing, Consent Management and possibly with
Identity Management and Authentication (for patient enrollment and other security
features).

 Message/Record Routing – focused on HIO-to-HIO integration, providing access to

participants not served by a qualified HIO, and enabling direct connection by
participants and vendors capable of complying with SHIN-NY policy and standards.

 Identity Management and Authentication – a full suite of security features for

participants in statewide HIE, coordinated with RHIO and other qualified HIO
infrastructures and enrollment processes.

 Consent Management – coordinated to function across RHIO / HIO boundaries and

with all other services in the bundle.
The initial release of core services is likely to be limited in terms of features and
functions and may be limited geographically or by number of participants.

Public Health Bundle #1 – November 30, 2011

The initial public health release will focus on aligning the ongoing HEAL efforts to
implement a UPHN with the statewide capabilities delivered in Core Services Bundle
1.0 and with requirements for the Public Health Reporting/Registry value-added service.
NYeC may procure assistance for requirements definition, standards and policy
development, coordination and project management, if needed, or may undertake these
activities with available staff. NYeC or NYS DOH may also procure assistance and
software, services or infrastructure to enhance UPHN.

Provider Bundle #1 – December 31, 2011

64
The initial provider-oriented release will focus on aligning and expanding the ongoing
HEAL Medicaid Medication Management (MMM) to deploy the Medication Data
Management value-added service identified by the State Collaborative Process, and on
using services deployed in Core Services Bundle 1.0 to help providers implement the
three HIE capabilities identified in ONC‘s Program Information Notice (PIN) dated July
6, 2010 (e.g., e-prescribing, receipt of structured lab results, sharing patient care
summaries across unaffiliated organizations).
The details of this release will be aligned with HEAL policy goals. NYeC may procure
assistance for requirements definition, standards and policy development, coordination
and project management, if needed, or may undertake these activities with available
staff. NYeC may also procure assistance and software, services or infrastructure to
enable certain functions, although it is anticipated at this time that the following
strategies will be pursued:
 E-prescribing – Largely delivered through EMR vendor software in combination with
Surescripts‘ national network. A gap analysis will be conducted to determine if
RHIOs and other organizations require assistance to incorporate payer formularies
and pharmacies not available through Surescripts. The goal of this activity is to
increase adoption and volume among NYS providers of e-prescribing to commercial
pharmacies.

 Lab results – Largely already delivered by national lab companies and RHIOs
through existing interfaces. A gap analysis will be conducted to determine required
for delivery of structured lab results uniformly statewide from local hospital, regional
and national labs. Depending on the results of this gap analysis, NYeC may provide
coordination or integration assistance to standardize interfaces or to fill gaps,
especially in delivering results from local hospital labs in some regions.

 Care summaries – Leverage capabilities delivered as part of the Message / Record

Routing service delivered in Core Services Bundle 1.0.

Core Services Modification #1 – March 31, 2012

Upon deploying the Core Services Bundle 1.0 release at the end of June, the NYeC
team and its vendor(s) will begin work on a first set of modifications to enhance and
refine functionality of the services and to support their expanded adoption statewide.
This release will most likely be a ―patch‖ release to add features and functions partially
implemented in the first core services release and to support requirements of early
value-added services that were not known at the time requirements were defined for the
first release.

Consumer Bundle #1 – June 31, 2012

The initial consumer-oriented release will focus on standardizing and extending simple
consumer/patient features of HEAL. NYeC will explore development of a statewide
patient portal service where patients can manage and access some of their key health
information, including demographic and contact info, ―clipboard‖ information including

65
problems and personal and family medical history, proxy information, as well as consent
preferences. NYeC will also consider funding an event notification service (which could
support provider and consumer alerts), and also provide guidance on patient education
services to promote consumer and patient-centric use of SHIN-NY
As with the other initial releases of value-added services for public health and providers,
NYeC may procure assistance for requirements definition, standards and policy
development, coordination and project management, if needed, or may undertake these
activities with available staff. NYeC may also procure assistance and software, services
or infrastructure to enable certain functions, although it is expected at this time that most
of the services related to patient education will be delivered through RHIOs and other
participants.

Core Services Modification #2 – September 30, 2012

As with the release of Core Services Modification #1, this release will serve to enhance
and refine functionality of the core services and to support their expanded adoption
statewide. Current plans are to explore introducing Vocabulary Translation as a core
service, beginning with providing a service to normalize structured lab data across
multiple sources. This may involve licensing or developing a terminology service for
use centrally or in a uniform and standard fashion regionally, or it may simply involve
providing standards and policy guidance for participants on the use of a standard
nomenclature for labs.

Public Health Bundle #2 – November 30, 2012

This release will add features and functions partially implemented in the first public
health services release related to Medication Data Management and Public Health
Reporting. This release may also support requirements that were not known at the time
requirements were defined for the first release. NYeC also plans to begin
experimenting with Event Notification features in this release.
Since this and subsequent releases are planned for more than 18 months from the
submission of the Operational Plan, the scope and content of this and other future
releases are increasingly subject to change.

Provider Bundle #2 – December 31, 2012

This planned release will add standardized statewide Quality Reporting service
consistent with federal and state policy goals and also introduce Event Notification for
providers. These services/features may be developed and delivered in some form by
NYeC and its vendors, integrated with statewide shared services, or implemented
through standardized regional approaches based on standards and policy guidance
provided by NYeC.

66
Summary
The above releases cover a 24-month planning horizon. Core services releases will
continue on a rolling schedule of every six months (in June and December) to expand
toward the above-described comprehensive services portfolio identified by the SCP.
The consumer-oriented release scheduled for March 2013 is anticipated to focus on
enabling consumers and patients to own and manage their health data via Personal
Health Records and a potential patient-centric Health Record Portal, and to
communicate and exchange information with their providers. Consumer, public health
and provider value-added services releases will continue, with three scheduled releases
per year. Value-added services not addressed in releases described above include:
 Imaging Order / Result.

 Eligibility/Claims Transactions.

 Medical Necessity / Authorization Rules.

 Research Data Aggregation.

In all cases, details of each release will be based on HIE requirements defined
approximately six months before each release date.

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. Through the
Office of Rural Health, NYS DOH develops and deploys rural health initiatives
statewide. Among the initiatives is the FCC Broadband grant program coordinated by
the Office of Rural Health. FCC Broadband grant recipients form an integrated network
across NYS. The projects are encouraged to reach out to and integrate every aspect of
the rural community in their respective service areas. In Western NY the WNY R-AHEC
is providing services to the Seneca Nation. WNY R-AHEC is enabling the Seneca
Nation to take advantage of much needed broadband and IHS stimulus funding to
improve broadband connectivity and care coordination services in rural NY
communities. WNY R-AHEC‘s participation in the SCP will enable coordination with the
broader NYS health IT vision.

Similarly, the Fort Drum Regional Health Planning Organization (FDRHPO) is another
FCC Broadband recipient. Additionally their efforts have been further recognized by
NYS through the HEAL 10 grant program which will advance NYS PCMH goals as well
as facilitate their organizational and technical integration into the SHIN-NY.

The Office of the NYS Chief Information Officer and Office for Technology has mapped
the estimated availability of wired broadband internet access throughout the state.

67
Technical Assistance Services
User-friendly technical assistance services will support and expedite the ability of
stakeholders to adopt health IT and HIE strategies. To inform the development of
technical assistance strategies, the SHIN-NY Infrastructure Work Group will identify
market gaps in standardized technical services. Potential gaps to be addressed by
focused technical assistance services include portal availability for downloading CMS
and VA PHI into beneficiary-designated electronic media, Medicaid fill history and
formulary information, LOINC codes, shared templates and order sets, data aggregation
and dissemination for Healthcare Effectiveness Data and Information Set/Quality
Assurance Reporting Requirements (HEDIS/QARR), public available reviews of
implementation agents and vendors, certification of billers, and recognition technical
assistance relating to NCQA.

Based on the review of market gaps, NYeC will plan and implement a roster of focused
technical assistance services to facilitate the adoption and sustainability of health IT and
HIE. In addition to the above-noted potential gaps to addressed by technical assistance,
NYeC will increase its capacity to allow only portions of Medicaid charts to be shared
with payers. Help Desk services will be developed to assist practices to determine the
source of any health IT problem and to direct the office to appropriate support. NYeC
will also work with the Office of Medicaid Inspector General to publish new guidelines to
promote transparency in audit procedures and regulations, to integrate alerts into EHRs
to inform providers when they are at risk for an audit, to export patient files without
losing data richness, to train and certify auditors, and to convene EHR vendors to
provide audit support.

Adoption Services
New York aims to achieve adoption and usage of HIE and health IT among all health
care providers in NYS. To achieve this goal, NYeC will work closely with NYC REACH
and the NYeC REC to provide adoption support services with an initial focus on
―priority‖ primary care providers working in small practices or treating underserved
populations.

The REC programs currently focus on the following: (1) helping providers without an
EHR, or those whose current systems fail to meet the meaningful use criteria, to select
and successfully implement certified EHRs; and (2) among those providers who already
have a system, providing technical assistance in achieving ―meaningful use‖ status. The
programs‘ service portfolio includes but is not limited to:

 Tailored, personal services to providers

 Consultative services to help providers choose the right EHR software and
hardware to meet their needs
 Discounted pricing and terms for providers to purchase EHRs from preferred
vendors for providers and to ensure implementation is cost effective and meets
their needs

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  Clinical and administrative workflow analysis and redesign to help achieve the
―meaningful use‖ designation
 Highly skilled project management to oversee the whole process
 Training for providers and their staff
 Assist with connectivity and Interoperability
 electronic labs
 e-prescribing
 connecting with other clinicians and hospitals
 A roadmap and support to help providers to qualify for Medicare, Medicaid and
other incentives

Building upon its success, the NYeC REC is in the process of developing a business
plan to broaden its targeted provider groups to include mental health providers, long
term care providers, home health providers, pharmacies and labs to achieve the goal of
100% adoption and usage of health IT and HIE in New York State.

Standard Operating Procedures

NYeC will implement state-of-the-art procedures for achieving maximum results from
the operational activities outlined in this plan.

Program and Vendor Management

NYeC will ensure that EHR and health IT vendors that serve the NYS market align their
efforts with the NYS statewide strategy and adhere to applicable rules and regulations.
In support of this aim, State partners will deploy and refine guiding principles for all
vendors. These principles include the following:

 Vendors will provide connectivity models that do not solely rely on point-to-point
interfaces.

 Vendors will agree to support health information exchange that, in addition to

proprietary networks, will connect to SHIN-NY as well as NHIN Direct and other
national frameworks.

 Vendors will agree to comply with NYS contractual language.

 Vendors will agree to transparency of development cycles.

 Vendors will agree to ensure transparency with respect to version management,

upgrade path, and pricing implications.

 Transparent pricing that leverages efforts by RECs will be practiced.

 Vendors will agree (as a condition to receipt of NYS funding) to comply with the
statewide strategy.

69
 Once EHR vendor has developed an interface to a specific HIE, it must be available
to all other RHIO/HIE within the State as at least a starting point, and the vendor
must refrain from charging subsequent RHIO/HIE for full development costs.

To ensure adherence to State standards, policy and purchasing levers will be

advanced, including Certificate of Need requirements and vendor contract language.

Identifying and Mitigating Potential Business Risks

New York will actively monitor risks and aggressively pursue risk mitigation tactics as
part of its project management activities. An initial set of risks has been identified and is
included in Appendix B.

Monitoring and Evaluation

New York‘s efforts to ensure deployment of health IT will be guided and informed by
ongoing monitoring of the State‘s progress in advancing adoption and use of HIE
services. NYeC will work with HITEC on these activities. They will work together to
enhance the existing RHIO dashboard tool to measure New York‘s progress in
advancing adoption and use of health IT and HIE services, including the use of metrics
identified in ONC-HIT-PIN-001. They will partner with the Wadsworth Center of NYS
DOH and NY Health Plan Association to survey lab companies and payers on current
adoption support of electronic results delivery and electronic eligibility and claims
transactions. Regular progress reports on health IT and HIE will be produced, with such
reports to be made public once the system reaches sufficient maturity. Such ongoing
monitoring efforts will be used to identify gaps in New York‘s progress, investigate gaps
through stakeholder interviews, and inform agreement on corrective action.

Existing survey efforts will be leveraged to provide strategic information on health IT

adoption and use. HITEC has recently completed a physician and a hospital survey.
They have two more rounds of these surveys planned annually over the next two years.
In addition, they are planning two nursing home surveys regarding health IT adoption.
These data can be extracted to provide information on current levels of health IT
adoption. In addition, they are striving to incorporate health IT adoption question into the
NYS Physician Profile, which the NYS Education Department administers at the time of
physician license renewal. Longer-term options include electronic enumeration of
meaningful users based upon State and federal data, monitoring the Master Provider
Index once it is implemented, or querying other professionals to identify additional
surveys that are routinely completed.

Continuous Improvement

New York is dedicated to continuous improvement. Working collaboratively with NYS

DOH and the State Health IT Coordinator, NYeC will monitor the project timeline to
ensure successful and timely implementation and deployment of HIE services. NYeC

70
will also audit the exchange and ensure compliance, and when necessary, determine
appropriate remediation.

71
5. Legal and Policy Issues
Through the Statewide Collaboration Process, NYeC and NYS DOH have developed
Statewide Policy Guidance, which includes a comprehensive set of policies that protect
privacy, strengthen security, and allow clinicians and public health authorities to have
critical access to health information when and where it is needed.

New York continues to develop a long-term legal and contractual framework to maintain
the collaborative multi-stakeholder trust that has been nurtured through the Statewide
Collaborative Process, and has been investigating strategies to enable interstate data
sharing with neighboring states.

New York will continue to work to achieve the following goals to improve health care
delivery and health outcomes for all New Yorkers:

 Implement HIE that is secure and protects patient privacy.

 Orchestrate levers of state policy to advance HIE

 Advance State law, policies, and procedures that are aligned with secure HIE
within and beyond state borders.

 Advance trust agreements that enable parties to share and use data.

 Pursue strong oversight and enforcement to ensure compliance with federal and
state laws and policies applicable to HIE.

Privacy and Security Framework for Statewide HIE

Consistent with one of the core principles of New York‘s approach to health IT and HIE,
the State will implement a rigorous plan of action to address gaps or shortcomings in
applicable laws and regulations pertaining to privacy and security.

Analysis of Existing Federal and State Law

New York State currently has a fragmented legal and regulatory framework for the
exchange of health information. Legal requirements are not organized into a single
regulatory scheme but instead are spread across dozens of statutory and regulatory
provisions. Gaps in legal and regulatory guidance could result in varying interpretations
and consumer consent policies across the State, which would potentially impede
interoperability and prohibit consistent privacy and security protections. The charts
below summarize the legal and regulatory framework governing exchange of health
information in New York.

72
 Federal Law
HIPAA5 Permits Covered Entities to use and disclose Protected Health Information without
patient authorization for treatment, payment and health care operations.
42 CFR Prohibits federally-assisted alcohol or drug abuse treatment facilities or programs from
Part 26 using or disclosing any information about a patient for even treatment, payment or
health care operations unless the patient has consented in writing, except in a medical
emergency.

New York State Law

Law/Rule Entities or Individuals Key Requirements

Governed by Law or Rule
General 10 N.Y.C.R.R. § Hospitals. Records may be released only to
medical 405.10(a)(6) hospital staff involved in treating the
information patient and others ―as permitted by
federal and state laws.‖ Patient
consent required for most TPO
disclosures. Consent may be written
or oral, express or implied.

N.Y. Education Physicians and other Personally identifiable information

Law §6530(23); professions licensed pursuant
may not be revealed without patient
8 N.Y.C.R.R. § consent‖ except as authorized or
to Title 8 of the N.Y. Education
29 Law. required by law. Similar standards
as applicable to hospitals.
Confidential N.Y. P.H.L All health care and social Prohibits disclosure of confidential
HIV-related Article 27-F service providers. HIV-related information without
information special written consent of patient
except in limited circumstances.
Records of N.Y. M.H.L. § Facilities or programs licensed Prohibits disclosure of clinical
facilities 33.13 or funded by the New York records without the patient‘s written
licensed under State Office of Mental Health consent except in limited
the MHL (―OMH‖). circumstances.
Genetic N.Y. Civil Rights All persons or entities holding Prohibits disclosure of genetic
testing Law § 79-l records, findings and results of testing information without the
information any genetic test. written informed consent of the
patient except in very limited
circumstances.
Figure 17: Summary of New York State Law

5
The Health Insurance Portability and Accountability Act (HIPAA) of 1996, Public Law 104-191. Additional
information on HIPAA, including a link to the text of the legislation, may be accessed at
http://www.hhs.gov/ocr/privacy/index.html.
6
Code of Federal Regulations Title 42 Public Health Chapter I – Public Health Service Department of Health and
Human Services, Part 2 – Confidentiality of Alcohol and Drug Abuse Patient Records.
http://www.access.gpo.gov/nara/cfr/waisidx_02/42cfr2_02.html. Additional information specific to the relationship
between 42 CFR Part 2 and health information exchanges may be accessed on the U.S. Department of Health and
Human Services Substance Abuse and Mental Health Services Administration website: www.samhsa.gov.

73
Additional laws also address patient consent for release of personal information,
including Sections 17 and 18 of the New York Public Health Law, as well as NY CPLR §
4504. In addition, 10 NYCRR § 405.7 mandates that hospital staff protect the
confidentiality of patient information.

Given this patchwork of law and regulation, NYeC determined that it was essential to
develop a comprehensive, standardized set of privacy and security policies and
procedures as the foundation upon which a successful HIE network could be
developed. Accordingly, the Privacy and Security Work Group of the SCP developed
the RHIO Privacy and Security Policies and Procedures (the Policies and Procedures),
which protect privacy, strengthen security, ensure affirmative and informed consent, and
support the right of New Yorkers to have greater control over, and access to, their
personal health information.

The Policies and Procedures address the full range of privacy and security policies
necessary for interoperable health information exchange, including privacy (consent),
security (authorization, authentication, access, audit), and breach.

Privacy (Consent)

Consumer consent permits consumers to control the exchange of their health

information through an HIE. The Policies and Procedures include an affirmative written
consent policy and standardized model consent form whereby patients may authorize
provider organizations to access all of their protected health information, including
sensitive health information, through SHIN-NY. To comply with NYS law – which, unlike
HIPAA, does not provide exceptions to consumer consent requirements for treatment,
payment or health care operations – the Policies and Procedures provide that
affirmative consent must be obtained by each provider and payer organization before
accessing health information through SHIN-NY.

A single consent may be obtained to exchange all health information, including sensitive
health information such as HIV, mental health, and genetic information. In addition, the
Policies and Procedures provide that once a provider or payer organization obtains
consumer consent, it may access the information of all data suppliers unless the
Qualified Health IT Entity has voluntarily established additional restrictions on
disclosures. Further, consumers must be able to prevent any or all providers and payer
organizations from accessing their personal health information via SHIN-NY without
risking refusal of treatment or coverage.

Consistent with existing New York law, the Policies and Procedures do not require
providers to obtain consumer consent to upload or convert information to a Qualified
Health IT Entities‘ HIE or SHIN-NY sub-network as long as the Qualified Health IT Entity
does not make the information accessible to other entities without consumer consent.

74
Security

Recognizing that it cannot be successful in gaining and keeping the trust of both
consumers and providers without a systematic and comprehensive approach to data
security, the Policies and Procedures include detailed policies for authorization, access,
authentication, and audit of HIE through SHIN-NY:

 Authorization is the process of determining whether a particular individual has the

right to access health information through SHIN-NY. Qualified Health IT Entities
are required to utilize role-based access standards that take into account an
individual‘s job function and the information necessary for the individual to carry
out that function, and define the purposes for which access may be granted, as
well as the types of information that may be accessed.

 Authentication is the process of verifying that an individual who has been

authorized and is seeking to access health information through SHIN-NY is who
he or she claims to be. Currently, the Policies and Procedures require Qualified
Health IT Entities to use Authentication Assurance Level 2, as established by the
National Institute of Standards and Technology (NIST) for an interim period, with
the goal of transitioning to NIST Level 3 pursuant to a timetable to be established
through the SCP.

 Access controls govern when and how a consumer‘s information may be

accessed. The Policies and Procedures require Qualified Health IT Entities to
implement minimum behavioral controls to ensure that (1) only authorized
individuals access health information through the SHIN-NY and (2) they do so
only in accordance with the requirements set forth in the Policies and
Procedures, including requirements regarding patient consent.

 Audits document all access to health information through SHIN-NY. The Policies
and Procedures require Qualified Health IT Entities to perform periodic audits of
such access. Qualified Health IT Entities must provide their participants with
access to this information. Further, Qualified Health IT Entities are required to
provide (or require their participants to provide) consumers with information on
who has accessed a consumer‘s health information through SHIN-NY.

Breach

The Policies and Procedures acknowledge that the consent, authorization,

authentication, access and audit policies outlined above have little weight if Qualified
Health IT Entities and their participants are not held accountable for violations. Thus,
the Policies and Procedures establish minimum standards Qualified Health IT Entities
and their participants must follow in the event of a breach. Qualified Health IT Entities
and their participants must notify each other of any actual or suspected breaches,
investigate and mitigate any actual breach, and notify affected consumers of such

75
breaches as required by applicable law. Qualified Health IT Entities are also required to
establish sanctions that apply to participants in the event of a breach.

Process for Updating Policies and Procedures

To ensure that the Policies and Procedures are consistent with evolving Federal and
State laws and regulations, and that they reflect implementation experience, NYeC has
established a formal process for considering amendments to the policies. The Privacy
and Security Workgroup will review proposed changes on an as-needed basis, and
make recommendations to the POC and the NYeC Board/NYS DOH, consistent with
existing SCP processes. Updates to the Policies and Procedures will include changes
required to bring them into alignment with changes in existing laws and regulations,
including ongoing implementation of HITECH‘s privacy and security related provisions,
as well as to reflect lessons learned through development and implementation of the
SHIN-NY.

Next Steps

NYeC and the NYS DOH will update the Policies and Procedures in accordance with
the following timeline:

Fourth Quarter 2010:

 Launch ―Health Information Usage Work Group‖ as part of the next phase of the
SCP, serving a similar role as the former Privacy and Security Workgroup.
 Prioritize an initial set of privacy and security topics that need attention and new
policy development. Areas already identified for further work include:
o Substance abuse and behavioral health integration.
o EMR interoperability (consent and audit).
o Minor consent and data segmentation.
o Research issues: (a) clinical trials (b) protocol research studies.
o Patient access and PHRs (community wide).
o Audit reports/findings – standard elements.
o Develop guidelines for sharing information with government oversight
agencies.
o RHIO-RHIO legal agreements and structure.
o Re-disclosure.

First Quarter 2011:

 Develop new policies stemming from the analysis conducted in the prior quarter
on high priority privacy and security topics.
 Conduct next periodic review of existing privacy and security policies and
procedures including an opportunity for public comment; advance
recommendations through review and approval process.
 Continue to track new privacy and security policies being advanced the federal
level and update New York‘s policies accordingly.

76
6. Finance
The development of New York‘s HIE infrastructure has been supported by significant
investments from the public, private, and non-profit sectors. Since 2004, approximately
$840 million in state, local, and federal funds has been allocated to build infrastructure
capacities and extend HIE and health IT capabilities throughout the state.

Although these sums are unprecedented, substantial additional financing will be

required to expand HIE, increase the adoption of health IT, and build and sustain the
infrastructure on which such advances depend. Furthering and accelerating this
transformation will require sufficient long-term support for the technical infrastructure
required for health IT, as well as renewable funding to support maintenance, adaptation
and effective use of HIE by health care stakeholders.

Ensuring the sustainability and further evolution of these reforms will require that the
sources of funding for health IT and HIE be broadened, with particular attention to
identifying reliable and robust sources of ongoing, self-renewing financing. In addition to
accelerating uptake and implementation stemming from the recent infusion of new
funding for health IT and HIE, NYS will work to generate financial dynamics that will
contribute to the sustainability of the State‘s technology-enabled, health care
transformation.

To address long-term financing to support ongoing operations, NYeC is working with

NYS DOH and other stakeholders to develop a comprehensive sustainability model
based on cost forecasts and revenue projections. This section summarizes progress to
date and identifies next steps for completing the financing and sustainability plan.

Financial Model
New York‘s emerging financial model is founded on an understanding of the existing
HIE and health IT infrastructure and scenarios for anticipated rates of adoption and
connectivity.

New York will identify and create incentives to encourage the adoption and
sustainability of health IT. Specific efforts will focus on incentivizing health IT adoption
by key stakeholder groups, including specialty clinicians in ambulatory settings, large
primary care practices, long-term care facilities and nursing homes, home health
agencies, inpatient facilities, hospital emergency departments, mental health providers,
and other segments of the clinical community. The cost model and business plan take
into account these diverse provider types, as well as factors such as respective current
EHR adoption rates, in order to create a viable plan for implementation.

Assessment of New York‘s current capabilities was supported by NYeC‘s ongoing

collection of data from New York‘s RHIOs and additional information from providers,
payers, and the State. The figure below represents a summary view of the healthcare
landscape in New York. These figures and other health IT adoption data served as the

77
baseline for development of the cost model for HIE adoption. They will be further
refined based on future research and outreach to providers.

Provider Type Total Active RHIO Participants Est. Total in State

Private Physician 633 20,000

Practices
FQHCs 12 56
Hospitals 106 236
Home Care Agencies 6 297
Long Term Care Facilities 38 640

Figure 18: Healthcare Landscape

The initial model uses HIE adoption rates reported from the 12 RHIOs. In 2010,
approximately 3% of private physician practices were active RHIO participants, either
assessing or supplying data . Twenty-one percent (21%) of New York‘s FQHCs and
46% of hospitals were actively participating in a RHIO. These figures together with
available EHR adoption information served as the baseline for development of the cost
model for HIE adoption and use.

The figure below depicts the provider connectivity via the 12 existing RHIOs
summarized above as a percentage of total providers in the State over four years.
HIE Connectivity
14 80%

70%
12

60%
10

50%

% Connectivity
8
QOs

40%

6
30%

4
20%

2
10%

0 0%
Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4
Year 1 Year 2 Year 3 Year 4
QEs Private Physician Practices FQHCs Hospitals Home Care Agencies Long Term Care Facilities

Figure 19: HIE Connectivity

78
New York‘s model assumes that by the fourth quarter of Year 2, all 12 existing RHIOs
will become qualified entities offering access to shared services. Projections of growth
in adoption of individual stakeholder groups is shown for private physician practices (in
orange), FQHCs (dark red), hospitals (green), home care agencies (red), and long term
care facilities (blue). This represents 75% of hospitals, 65% of FQHCs, and 20% of
private physician practices.7

Cost Model

New York has estimated the costs of the various bundles of services identified in the
Business and Technical Operations section necessary to serve the projected number of
users identified above. The costs are organized into two categories: (a) costs required
for the build of the service, and (b) ongoing costs required to maintain and operate the
services and oversee the overall utility infrastructure. These cost assumptions were
informed by pricing estimates from commercial HIE vendors, RFIs and RFPs from other
states regarding statewide HIE services and general industry knowledge.

Additional analyses will be undertaken to quantify the required investments to sustain

the utility services, taking into account the potential changes in usage over time. A
framework will be developed for modeling those costs as an input into potential
financing mechanisms, including payment reform initiatives.

Revenue Models

New York expects to support financing of these shared services through a combination
of public and private financing. The public funds will come from the NYeC‘s State HIE
program grant as well as its HEAL 10 and HEAL 17 contracts. Private funds will likely
come from user fees for access to the shared services. Over the life-time of the State
HIE program, New York expects to gradually move to a model that is less dependent on
public financing and instead sustained by user fees.

New York has prepared some initial revenue models for how those utility financing
models might work. It is taking into account the total cost needed to build, operate and
maintain these services, the likely price sensitivity of end users, and the estimated
growth in adoption referenced above. It will enhance and refine these models over time
as it gets a better understanding of the environment.

New York will also identify funding opportunities from the private sector, including
exploration of potential partnerships with medical devices companies, pharmaceutical
and biotech companies, lab companies, insurance entities, medical networks, Medicaid

7
Please note that this is a hypothetical scenario under development that is intended to illustrate
anticipated connectivity to statewide HIE services among the existing RHIOs and their respective provider
coverage. HIE connectivity rates will be revised and updated as this scenario continues to be refined, and
alternative scenarios are developed.

79
FFP, and large employers. NYeC will also identify and pursue opportunities to engage
the philanthropic/non-profit community.

Possible public sector sources of financing will also be explored, including Medicaid
Federal Financial participation, and HEAL grants. Financing opportunities will be
explored with respect to private sector financial institutions (including favorable
financing terms), small-business associations, and federal loan funding.

Financing through Shared Utility

In connection with the planned assessment of shared services (see Section 5), NYeC
will conduct a cost-benefit analysis of a shared services approach in comparison to
leveraging existing RHIO or EHR functionality. Cost estimates and required investments
for transition to a shared services model will be identified and quantified.

Different options for ―utility‖ financing for core SHIN-NY infrastructure and services will
be examined, including those used in other industries. Advantages and disadvantages
of utility financing models will be assessed.

The figure below illustrates potential services and financing flows across key
constituents.

Figure 20: Financing for Provision of HIE Service

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Regional Sustainability

New York will explore strategies to assist RHIOs and coordinated care projects in
establishing robust long-term regional sustainability. Regional stakeholders will be made
aware of emerging value opportunities related to State and national health reform, and
efforts will focus on building the capacity of RHIOs and other stakeholders to take
advantage of these options. NYeC and NYS DOH will work with stakeholders and
coordinated care projects to better understand and document the total investments
required to implement and operate the necessary health IT and HIE services for
effective patient-centered medical homes and other community collaborative care
initiatives.

Detailed Cost Estimates and Staffing Plan

New York has explored various staffing models ranging from a combined employed
staffing and consulting or outsourced services model, to a robust employed staffing
model. In the near term, New York will build a staffing model that employs core staff
with targeted outsourced support for subject matter expertise. Systems integrators and
management agreements will provide the bulk of Statewide HIE‘s capacity in this start-
up phase. In years three and beyond, the Statewide HIE expects to transition toward an
employed staffing model to support the ongoing operations of the exchange. This
strategy will allow the Statewide HIE to engage higher-caliber talent needed during the
critical implementation period, without incurring the long-term expense of those
resources when the HIE reaches sustainability

Controls and Reporting

In cooperation with NYS DOH, NYeC has established internal structures and processes
to ensure reporting for health information governance and operations as well as sound
financial management and controls. This includes general Board oversight and
approval of new contracts, policies and procedures, and budgets and financials. NYeC‘s
Board finance committee meets monthly and reviews and approves budgets and
monthly financial statements. Financials are also submitted to the full Board for
review. NYeC develops and maintains detailed budgets; strong internal processes
related to day-day management of finances; rigorous contract management and
competitive procurement policies for subcontractors; and oversight of its finances
through annual audits.

With a strong track record of driving progress to date in implementation of health IT and
HIE, NYeC and NYS DOH are well-positioned to maintain effective financial
management of the State HIE program . NYeC and NYS DOH will demand strict
accountability from all subcontractors and require regular, detailed progress and
spending reports. NYeC will work with NYS DOH to prepare and submit the required
program reports providing detailed information on progress against goals. NYeC will
also submit all required fiscal reports, ensuring compliance with generally accepted
accounting principles and all relevant OMB circulars. NYeC will also provide a single

81
point of contact between NYS and ONC for the purposes of periodic progress and
spending reports.

The Governor and NYS DOH will require detailed reporting in connection with the
State‘s participation in the grant. Reporting will include a description of the basis and
method of funding distribution and supporting documentation required for payments.
The process will allow for maximum transparency and comply with GAAP and OMB
guidance. Quarterly programmatic and financial reports will be provided and made
available for public review per the process established by OMB and the state. NYS
DOH and NYeC will report quarterly on key elements, including but not limited to:
 Names and locations of the recipients of funds.
 Type of recipient.
 Amount of recovery funds awarded and disbursed.
 Project period and current status.
 Primary performance location.
 Name of project or activity.
 Description of the project or activity.
 Evaluation of completion status.
 Employment impact.
 Rationale for funding.

Marketing

Beginning in January 2011 and continuing throughout the year, NYeC will conduct
aggressive marketing of the newly established statewide HIE and health IT governance
framework, statewide HIE utility, and core and value-added technical services.

NYeC will develop a comprehensive and consistent marketing and communications

approach to effectively brand and promote statewide HIE, establishing the initiative‘s
unique identity in the marketplace. Under the guidance of SCP Consumer and Provider
Engagement Work Group, NYeC will facilitate the creation of a stakeholder outreach,
education and engagement strategy that will outline steps to generate stakeholder
involvement in and understanding of the statewide HIE initiative. As part of this effort,
NYeC will coordinate with Regional Extension Centers (RECs), as well as other
statewide health IT and HIE initiatives, to ensure a unified articulation of the approach
and objectives for statewide HIE. Some of the marketing and education activities NYeC
will undertake include hosting EHR summit series events across the State, inviting
providers to learn about health IT and how the NYeC Regional Extension Center may
assist them. Additionally, NYeC will use methods including but not limited to direct mail,
website development, additional events and advertising in trade magazines, on trade
websites and in other relevant mediums.

With respect to the general population of health consumers in NYS, NYeC will hold
educational events and create and disseminate materials, such as flyers, websites and
online materials, and advertise on radio and television to inform New Yorkers about

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emerging changes and opportunities in the health care environment. These diverse
communications tools will stress that health IT will improve the health care of all New
Yorkers and contribute to cost reduction.

Public Health

NYS DOH will work to ensure sufficient short- and long-term funding to enable
accessible, effective and efficient Statewide HIE, with a particular focus on optimizing
financial support to achieve New York‘s public health goals. To support sound resource
allocation, NYS DOH will identify public health program area priorities, determining
required resources for supporting public health and health IT, including but not limited to
staffing requirements. Market drivers will be identified, emphasized and promoted for
key stakeholders, and program and public health funding opportunities will be
prioritized, with particular efforts to take advantage of the deliberations and learning of
the Public Health Work Group.

NYS DOH will explore ways it can support public health stakeholders with financial,
capital and human resources to implement clinical data exchange. Priorities will be
categorized as short- and long-term investment opportunities. Current public health
program and grant resources will be assessed to determine the feasibility of using
existing funding sources to support New York‘s technology-enabled health
transformation. Particular steps will be taken to support evaluation and implementation
of EHRs, UPHN and SHIN-NY connectivity for counties that offer clinical services of
public health importance (e.g., TB, immunization, well-child clinics, etc.), as well as
other traditional public health roles.

To encourage the adoption and implementation of policies and practices that support
New York‘s public health aims, NYS DOH will adopt communications strategies that
educate key constituencies regarding the benefits of the technology-enabled health
transformation. Stakeholders will be engaged in discussions to answers questions,
solicit feedback and ideas, and inform prioritization for public health information
exchange through RHIOs and UPHN.

Particular steps will be taken to educate stakeholders (e.g., EHR vendors, RHIOs,
health care providers, DOH programs, other HHS agencies, health plans) regarding
UPHN. Educational materials (e.g., presentations, documents) will be created,
demonstrating UPHN‘s values for individual categories of stakeholders, webinars and
phone conferences will be sponsored to each stakeholder about UPHN functionality.
Stakeholder input will be solicited to inform NYS DOH planning, and the State will take
steps to facilitate and/or provide resources for stakeholders to educate their respective
communities on UPHN. NYS DOH will develop a budget to support UPHN-related
communications and generate a plan for roll-out.

Targeted training to potential UPHN users will help ensure that the program reaches its
full potential. Complementary educational efforts will focus on consumers, including
strategies to enable health care providers to share information with patients. Monthly

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meetings of the NYeC Public Health Work Group will serve as a forum for sharing
UPHN best practices, obtaining recommendations, and determining priorities.

Next Steps

The expedited development of this initial financing model and sustainability approach
provides a first step toward generation of a complete and definitive model. The model is
intended to be flexible; assumptions described in the plan may be adjusted to reflect
future conclusions or recommendations. It is expected that the model will involve
several iterations before the final sustainability plan is submitted to ONC in June 2011 in
accordance with NYeC‘s State HIE Cooperative Agreement.

The timeline below describes planned activities to finalize the Sustainability Model and
Business plan:

October 2010:
 Develop initial version of model based on existing data and assumptions. This
initial model will be reviewed with NYeC and its member RHIOs to determine
accuracy of the environmental data and assumptions.

Fourth Quarter 2010:

 Refine expected upfront and ongoing costs to the environment data and adoption
assumptions to develop the expected ―all-in‖ costs for the development and
operations of the Statewide HIE in New York for the next five years.
o Cost estimates will be based on publicly available information from other RFI
and RFP efforts as well as information from experts assisting in the process.
 Upfront funding mechanisms will be identified to offset start-up costs identified in
the previous modeling steps.
o It is expected that these upfront funding mechanisms will not be enough to
support a full build-out and operations of the entire HIE infrastructure being
planned. However, this initial gap will be identified to determine the minimal
additional upfront and ongoing funding necessary for sustainability.
o Ongoing funding mechanisms will be defined based on the generation of
value to various stakeholder groups. Pricing will be applied to these
mechanisms and market tested with members, participants and stakeholders.

First Quarter 2011:

 The cost and funding models will be harmonized into an overall sustainability
model and business plan, reviewed by NYeC, its members and various
stakeholder groups, and iterated based on input.
o It is expected that the model will be iterated 2 to 3 times between the
submission of the Operational Plan and submission of a final plan to ONC.

Second Quarter 2011:

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 The final version of the cost and funding scenarios will be finalized into a
sustainability model and business plan for submission to ONC by the end of Q2
2011.

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7. Coordination Among New York’s Health IT Programs
New York recognizes the importance of coordinating efforts among the State‘s various
health IT programs, including NYS Medicaid‘s various programs, Regional Extension
Center programs, and New York‘s Beacon Communities program. Optimizing collective
results from these endeavors demands policies and protocols that address key points of
intersection and potentiality discontinuity or fragmentation with respect to governance,
policies, technical models and education.

Coordination with Medicaid

Coordination with Medicaid is vitally important to achievement of a coherent, unitary,

statewide approach to health IT and HIE. As described above, OHIP, which administers
Medicaid, already plays a large role in the State‘s health IT efforts, both as a payer
incentivizing providers to use health IT systems, and as a data supplier, providing
access to important medication history information.

OHIP shares New York‘s HIE goals outlined above. Specifically, it has committed to
collaborating on the following aspects of New York‘s HIE program:

Common Priorities: Included in this Strategic Plan are references to several areas
where NYeC, OHITT and OHIP share a business interest and are likely areas of
collaboration. These include:

 PCMH: OHIP has implemented a payment incentive for PCMH based on NCQA
certification criteria. OHITT collaborated with OHIP on the development of the
HEAL 10 and HEAL 17 programs whose focus is application of health IT systems
to support PCMH models.

 E-Prescribing and Medication Management: As previously described, OHIP has

taken a number of steps to improve the adoption and use of e-prescribing and
provide tools for medication management, two priorities shared by New York‘s
State HIE program. Together they will work to advance use of medication
management tools via SHIN-NY and address barriers to e-prescribing.

 Immunization: New York already has a successful infrastructure for the electronic
reporting of pediatric immunizations. In order to reflect this capability and support
existing public health initiatives, OHIP will encourage providers to select the
immunization reporting objective as one of their ―menu set‖ meaningful use
criteria for Stage 1. Implementing bi-directional data transfer for immunization
reporting is a priority focus area for the State HIE program.

 Child Health Information: OHIP is currently engaged in planning activities

regarding interoperability of Medicaid data sources with child health information

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 such as immunization and newborn genetic screening data through the Child
Health Information Integration (CHI2) project. OHIP envisions enabling clinicians
to benefit from a one-stop shopping approach through which they will have
access to comprehensive patient information, including Medicaid history,
newborn screening data, and other information, with a single request.

 Quality Reporting: OHIP collects standardized quality measures from health

plans, and will soon collect Meaningful Use quality measures from hospitals and
eligible providers. OHITT funded several projects under HEAL 5 to develop better
quality reporting within EHRs, and recently issued instructions to those projects
to align their plans with Meaningful Use requirements to the extent possible.

Policy Development and Governance: OHIP will participate in the SCP, with a specific
interest in addressing common policy challenges. In particular, priority will be given to
efforts to:

 Clarify governance roles between NYeC and NYS DOH, and explore
opportunities for State participation in NYeC governance.

 Develop and update statewide policies on issues of mutual interest, including

ongoing alignment of security policies.

 Develop common accountability framework that will govern statewide health

information exchange.

 Amend the current Medicaid requirements to allow RHIOs to be intermediaries

facilitating access to Medicaid medication history data for participating providers.

Technical Infrastructure: As described previously, OHIP already plays an important role

in New York‘s HIE infrastructure, having developed a program to make Medicaid
medication history available to providers. In addition to exploring ways to expand and
enhance this service, OHIP will participate in the analysis of other key HIE services and
plans for development of shared services or standardized regional approaches.

Education: NYeC, OHITT and OHIP, together with New York‘s two REC programs
(operated by NYeC and PCIP NYC REACH) have committed to coordinate outreach to
providers on the Medicaid and Medicare EHR incentive programs and the availability of
REC services to assist priority primary care providers. These organizations have held
two summit series in 2010 on a ―New York EHR Meaningful Use Summit‖ across seven
cities. The organizations will hold additional summits in 2011.

Tracking HIE Progress: NYeC, OHITT and OHIP will work together to identify ways to
track New York‘s progress in advancing adoption and use of health IT and HIE, specific
related metrics related to meaningful use criteria. They will explore opportunities to
leverage the statewide RHIO dashboard NYeC recently launched as well as data OHIP

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gathers as part of its administration of the Medicaid EHR incentive program. Timely
information will help New York to evaluate and improve its performance.

Coordination with REC Programs

New York has received funding for two RECs to provide EHR adoption support services
to providers (see Section 1), with an initial focus on "priority" primary care providers
working in small practices or treating underserved populations. The REC programs offer
statewide EHR adoption services that will supply providers with the knowledge, training,
and confidence they will need to successfully select and deploy an EHR and use health
information meaningfully.

During the planning period, NYeC, NYC REACH, OHITT, and OHIP met to discuss
several areas of collaboration. To maximize coordination, the following items will be
pursued:

Policy Development: New York has long held the principle that its policies need to be
informed by the implementation experiences of those putting them into practice. It is
expected that RECs will help identify any challenges in implementing New York‘s
policies and provide a feedback loop to those developing and updating New York‘s
policies.

Technical Infrastructure: As described above, New York is considering deploying

various shared services to address key HIE functionality. As it designs these services,
it will require input from providers as to their key needs. The clients of REC programs
provide an important potential pool of those providers.

OHIP has expressed interest in key functionalities through integration of Medicaid and
the UPHN. These priority functionalities include a common infrastructure to connect
Medicaid and UPHN, with end users benefiting from batched services that allow for a
one-stop shopping approach. In addition, OHIP aims to ensure that pediatric data under
the State‘s Child Health Integration Initiative is easily accessible. OHIP envisions the
ability of clinicians to access with a single request comprehensive patient information,
including Medicaid history, newborn screening data, and the like.

In July 2010, the Centers for Medicare and Medicaid Services (CMS) released a final
rule on meaningful use. The regulations allow for eligible health care professionals and
hospitals to qualify for Medicare and Medicaid incentive payments when they adopt
certified EHR technology and use it to achieve specified objectives relating to health
care quality, safety and efficiency. Three stages are outline for meaningful use – Stage
1 in 2011, Stage 2 in 2013, and Stage 3 in 2015, with full meaningful use adoption
anticipated by 2015. Each stage will entail the addition of new requirements and
reporting mandates, and each will build on lessons learned in earlier stages.

UPHN/Medicaid integration will provide a means for Medicaid-related data to flow

between public health information systems and Medicaid information systems. Data flow

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will be facilitated by development of bi-directional exchange between UPHN and the
Medicaid Service Center, which will support both HIE advancement and meaningful use
Stage 2 requirements. To ensure effective integration, NYS DOH will define technical
requirements and standards for data quality and completeness. Standard operating
procedures will be established to facilitate usage of the integrated connection.

Education: (see ―Coordination with Medicaid‖ section above).

Coordination with Beacon Communities Program

As part of the Recovery Act Beacon Community Program, the Western New York
Clinical Information Exchange (aka HEALTHeLINK) received $16M to help achieve
meaningful and measurable improvements in health care quality, safety and efficiency
in their communities. Beacon Communities will use health IT resources within their
community as a foundation for bringing doctors, hospitals, community health programs,
federal programs and patients together to design new ways of improving quality and
efficiency to benefit patients and taxpayers. Additionally, Beacon Communities will be
expected to access existing federal programs that are working to promote health
information exchange at the community level.

HEALTHeLINK has also received $15.8M in HEAL grants and has actively participated
in the SCP for several years. Its leadership has committed to continuing to share
experiences from its program with NYeC, NYS DOH and other community members to
help inform development of policies and implementation of more advanced coordinated
care models that leverage health IT and HIE systems.

Coordination with Public Health, Medicare and Federally Funded, State-Based

Programs

There are a broad range of health information programs currently operating and
planned across the landscape of health programs and services in New York.
Coordination of the programs ranges from basic awareness on one end of the spectrum
to formal governance and structured collaboration on the other. New York‘s Strategic
Plan recognizes that greater coordination of State health information programs will
increase the value of the network as more programs are connected and through
resource efficiency.

NYS DOH will lead efforts to coordinate State programs with shared goals regarding
HIE, and promote use of common protocols and standards based on SHIN-NY. Moving
forward, the State will identify opportunities for both new and improved coordination
across a broad range of stakeholders including:
 Medicaid.
 Public health.
 Medicare and Federally Funded, State Based Programs.
 Federal care delivery organizations (VA, DoD, IHS).
 Organizations involved with other ARRA programs.

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Coordination with Public Health: NYS DOH coordinates efforts linking State health
information systems with SHIN-NY, with initial focus on completing implementation of
UPHN and establishing a governance and operational structure for NYS DOH Public
Health Informatics. This includes a process for governance and prioritization of the
development and implementation of NYS DOH program-area specific use cases for
data exchange through the UPHN, including a data validation, certification, and
integration plan. Program area modules currently planned focus on the Child Health
Information Integration (CHI2) Project, infectious disease integration, and integration of
data pertaining to chronic diseases and environmental health. Attention will also be
given to updating NYS DOH and local public health policies and procedures to
incorporate the exchange and use of new data.

Coordination Relating to Long-Term Care Populations and Services to Promote Health

IT: As part of HEAL 5, the Continuum of Care Improvement Through Information
Exchange New York Project (CCITI NY) in NYC is developing a clinical decision support
tool to help manage the care of older and disabled patients in long-term care settings.
As a HEAL 5 awardee and a health IT project in NYS, CCITI NY is part of the larger
SCP. Sharing CCITI‘s commitment to achievement of State and Federal priorities for
long-term care are me, the SCP also facilitates integration CCITI‘s activities into broader
State agency coordination efforts mentioned above. NYS continues to support
innovation in long-term care through separate HEAL NY investments.

New York State Health and Human Services Chief Information Officer Council: As noted
in Sections 1 and 2, NYS DOH chairs the NYS Health and Human Services CIO Council
to disseminate and promote adoption of common policies and standards across health
and human services programs and agencies. These State agencies have developed a
conceptual model for linking their systems to SHIN-NY, and the State will pursue further
design and implementation activities in that direction. The CIO Council is evolving a
governance and operational structure for cross-cutting NYS DOH/Interagency health IT
plans (a ―Policy and Operations Board‖) that will include current as well as new agency
and agency bureau members.

Coordination with CDC on the Epidemiology and Laboratory Capacity Cooperative

Agreement Program: Coordination with CDC is being addressed through the NYS
DOH‘s current plans to develop UPHN based on an earlier grant from CDC. As
described in Section 1, UPHN will allow public health reporting by health care
institutions through SHIN-NY. UPHN will enhance public health functions within NYS
DOH and become more dynamically valuable to health care providers including, but not
limited to, population health and laboratory reporting.

Coordination with HRSA on HIV Care Grant Program Part B States/Territories Formula
and Supplemental Awards/AIDS Drug Assistance Program (ADAP) Formula and
Supplemental Awards: The NYS AIDS Institute within the NYS DOH, Office of Public
Health, is an active participant and contributor to the SCP. Senior representatives from
the Institute are ardent supporters of the NYS health IT strategy and stand ready to

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assist in further enriching the process of developing sound health information standards
and policies. Further, the Institute, on behalf of NYS DOH, has received a Ryan White
Part B Base Supplemental Award, which assists the State in developing and/or
enhancing access to a comprehensive continuum of high-quality, community-based
care for low-income individuals and families living with HIV. Activities under this grant
will be coordinated through the Institute‘s participation in the SCP and will be
incorporated into statewide health IT planning as part of the broader interagency
coordination effort led by OHITT.

Coordination with HRSA on Maternal and Child Health State Systems Development
Initiative Programs: The Division of Family Health within NYS DOH, Office of Public
Health, is responsible for promoting the health of families by assessing needs,
promoting healthy behaviors and providing services to support families. The division's
primary focus is on improving the health of women, children and adolescents. Its
programs touch new mothers, adolescents considering sexual activity, children with
disabilities, rape victims and children with asthma, lead poisoning or lack of access to
dental services. The division receives and administers several HRSA grants on behalf
of the NYS DOH including:
 Maternal and Child Health Services Block Grant.
 Universal Newborn Hearing Screening and Intervention Program which will, among
other goals, develop and enhance the capacity of the UNHS Program to integrate
with other state systems that provide screening, tracking, and surveillance programs
identifying children with special health needs.
 State Systems Development Initiative which will establish or improve the data
linkages between birth records and 1) infant death certificates, 2) Medicaid eligibility
or paid claims files, 3) WIC eligibility files, and 4) newborn screening files.
 Effective Follow-up in Newborn Screening program which will focus on the use of
electronic health information exchange to improve the newborn screening system,
with attention to both short and long-term follow up per the guidance in the
Statement of the Advisory Committee on Heritable Disorders in Newborns and
Children on Long-term Follow-up after diagnosis resulting from newborn screening.
 Children‘s Oral Healthcare Access Program which will strengthen the State's oral
health program infrastructure through collaborative activities and programs with
relevant State and local programs, agencies, organizations and key stakeholders to
improve the oral health of low income infants and children and their families and
reduce oral health disparities.
 Residency training Dental Public Health which supports two or more dentists to be
trained in the practice of dental public health per year.

The Division of Family Health is currently participating in statewide health IT planning as

part of the broader interagency coordination effort lead by OHITT and will incorporate
activities related to its federally funded programs.

Coordination with HRSA on State Offices of Rural Health Policy: The NYS Office of
Rural Health, housed in NYS DOH, has been active in developing telemedicine
initiatives across the state. Efforts are underway to incorporate these initiatives into the

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SCP and the broader interagency coordination effort. NYS has advanced numerous
telemedicine initiatives, including pilot projects, the stroke program, clinical
reimbursement for the use of telemedicine in rural health care settings, and coordinated
efforts to secure telemedicine funding through the FCC. The Western New York Rural
Area Health Education Center (WNY R-AHEC) has been active in coordinating with
local RHIOs and active in the SCP.

Coordination with SAMHSA on State Mental Health Data Infrastructure Grants for
Quality Improvement (DIG): The NYS Office of Mental Health (OMH) operates
psychiatric centers across the State, and also regulates, certifies and oversees more
than 2,500 programs, which are operated by local governments and nonprofit agencies.
OMH is actively working with DIG grant recipients to expand the use of Web-based data
entry for provider and consumer surveys, enabling OMH to collect a greater number of
responses, with lower cost, improved data quality and shorter report preparation time,
integrate descriptions of providers and the services they offer into a master program
directory that is regularly audited against fiscal and survey data systems and used to
generate public reports and collaborate with State and local planners on use of data for
planning and quality improvement and expand the use of administrative data for State
and local reporting of performance measures. OMH is currently participating in
statewide health IT planning as part of the broader interagency coordination effort led by
OHITT and will incorporate activities related to OMH federally funded programs.

Coordination with HRSA on State Offices of Primary Care: The Office of Primary Care
within NYS DOH is responsible for efforts promoting, protecting and preserving NY‘s
―safety net‖ health care facilities which care for the state‘s medically indigent and
underserved populations. The office provides technical assistance to primary care
providers, manages/designates HRSA shortage areas, and manages primary care and
planning grant programs, among other activities. HEAL 6 and 9 provide funding to
primary care settings for the purposes of local health planning, reinforcing the
foundation in primary care necessary to advance NYS PCMH initiatives. The office will
be incorporated into statewide health IT planning as part of the broader interagency
coordination effort led by OHITT.

Coordination with HRSA on Emergency Medical Services (EMS) for Children Program
(SEMSO): The NYS Bureau of EMS within NYS DOH, Office of Health Systems
Management, is responsible for coordinating all EMS activity in NYS. SEMSCO meets
four times a year and advises the Health Commissioner on virtually all aspects of EMS,
including minimum standards for ambulance services, the provision of pre-hospital
emergency care, education and training of providers, and development of a statewide
EMS system. The EMSC Advisory Committee meets quarterly and advises the
Commissioner on all aspects of emergent care for critically ill or injured Children.
Activities under this program will be incorporated into statewide health IT planning as
part of the broader interagency coordination effort led by OHITT.

Coordination with NHIN Trial Implementations Program: NYeC recently completed its
NHIN Trial Implementations program. One of the benefits of this program is that it

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provides a single, standardized, national architecture for federal organizations to
participate in state and regional HIE activities. NYeC expects that it will eventually use
this program as a way to pursue HIE activities with federal delivery organizations and
other federal agencies, including SSA.

Coordination with Workforce Development programs:

Curriculum Development Centers - Columbia University: In April 2010, Columbia
University was one of the five institutions to receive a Curriculum Development Centers.
Under this grant, Columbia will develop curriculum and instructional materials to
enhance workforce training programs primarily at the community college level.

Community College Consortia – Four New York community colleges - Bronx Community
College, Suffolk County Community College, West Virginia Northern Community
College and Westchester Community College – are part of the Community College
Consortia to Educate Health Information Professionals program. These community
colleges will establish intensive, non-degree training programs that can be completed in
six months or less by individuals with appropriate prior education and/or experience.

University-Based Training Program – Columbia University and Cornell University will

jointly offer a certificate program in Health Information Technology. These programs, a
6-month competency-based certificate programs, will provide the practical knowledge
and skills required to use EHRs in health organizations.

New York has held initial meetings with other educational institutions to coordinate
efforts regarding the implementation of health IT workforce programs. New York will
continue to work with institutions above to discuss ways to provide opportunities to their
graduates in NY‘s health IT programs such as the RECs

Coordination with Federal Care Delivery Organizations (VA, DoD, IHS) on

Broadband Access

Coordination with IHS on Tribal Programs: Through the Office of Rural Health, NYS
DOH develops and deploys rural health initiatives statewide. Among the initiatives is the
FCC Broadband grant program coordinated by the Office of Rural Health. FCC
Broadband grant recipients form an integrated network across NYS. The projects are
encouraged to reach out to and integrate every aspect of the rural community in their
respective service areas. In Western NY the WNY R-AHEC is providing services to the
Seneca Nation. WNY R-AHEC is enabling the Seneca Nation to take advantage of
much needed broadband and IHS stimulus funding to improve broadband connectivity
and care coordination services in rural NY communities. WNY R-AHEC‘s participation in
the SCP will enable coordination with the broader NYS health IT vision.

Similarly, the Fort Drum Regional Health Planning Organization (FDRHPO) is another
FCC Broadband recipient. Additionally their efforts have been further recognized by

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NYS through the HEAL 10 grant program which will advance NYS PCMH goals as well
as facilitate their organizational and technical integration into the SHIN-NY.

Coordination with Other New York Policy and Procurement Activities

New York is leveraging a number of policy and procurement levers to advance the
development of robust statewide HIE. This includes building requirements for
compliance with Statewide Policy Guidance into both its health facilities Certificate of
Need (CON) process and its state health IT grant program, provided under the
Healthcare Efficiency and Affordability Law of New York (HEAL-NY).

CON Process

New York utilizes the CON process to ensure that health care services are aligned with
community need. Before health care providers may build new heath care facilities,
renovate existing facilities, or acquire major medical equipment, for example, they must
submit a CON application to NYS DOH or the Public Health Council. As part of this
process, New York requires health care providers proposing to undertake health IT
projects to:

 Connect to SHIN-NY.

 Participate in a RHIO.

 Comply with Statewide Policy Guidance including Vendor Contract

Requirements.

 Develop a health IT adoption and support plan that sets forth how they will
provide health IT implementation services to support clinicians in their adoption
of EHRs and achievement of quality goals.

 Develop a quality measurement and reporting plan that sets forth how they will
report clinical quality and other measures to NYS DOH as appropriate.

Health care providers are also strongly encouraged to participate in the SCP.

State Health IT Grants

New York State has provided over $430 million in grants for health IT projects to New
York health care providers under the HEAL-NY program. Compliance with SPB is
essential to ensuring that these projects result in the adoption of interoperable EHRs
and HIE.

Accordingly, health care organizations receiving funding under HEAL 5, 10 and 17 must
participate in SHIN-NY, abide by SPG, and participate in the SCP. Further, HEAL 5, 10
and 17 grantees must require certain of their health IT vendors to agree that all software

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and/or services provided by the vendor will comply with SPG, including privacy and
security policies, SHIN-NY technical architecture specifications, and EHR functional
requirements contained therein. To ensure this compliance, NYS DOH requires HEAL
5, 10 and 17 grantees to include model contract language, developed through the SCP,
in their vendor contracts.

Next Steps

Fourth Quarter 2010:

 Launch the next phase of the SCP to address outstanding issues related to New
York‘s policies and develop policies specific to the HEAL 10 and 17 programs.
 Meet with OHIP and other state agencies to discuss common policy priorities and
cover those items in the new phase of the SCP. Issues include:
o Clarify governance roles between NYeC and NYS DOH, and explore
opportunities for State participation in NYeC governance.
o Develop and update statewide policies on issues of mutual interest,
including ongoing alignment of security policies.
o Develop common accountability framework that will govern statewide
health information exchange.
o Amend the current Medicaid requirements to allow RHIOs to be
intermediaries facilitating access to Medicaid medication history data for
their participating providers.

First Quarter 2011:

 Review and approve new policies stemming from the analysis conduced in the
prior quarter.
 Set a regular meeting schedule with OHIP and other state agencies to ensure
that everyone is adopting statewide policies and interpreting them in a similar
way.

Development of Trust Agreements for Interstate Data Sharing

New York recognizes the importance of establishing trust or data sharing agreements
with other states for the use and disclosure of an individual‘s protected health
information. NYS DOH has met informally with some of its border states to begin
discussions of sharing information with other states that treat a subset of the same
patient population. Patients from New Jersey and Connecticut often receive care in the
NYC Metropolitan Area because of residential and employment patterns, as well as the
availability of specialized services.

Additionally, because of the lack of tertiary care in certain areas of upstate New York,
New York residents regularly travel to Vermont, Massachusetts and Pennsylvania for
certain types of specialized care. NYeC is also an active participant in the NHIN Trial
Implementations project, which has focused on developing a data use and reciprocal
support agreement for HIEs participating in the NHIN. Under its NHIN Trial
Implementations project, NYeC is continuing to participate in the NHIN Data Use and

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Reciprocal Support Agreement (DURSA) Workgroup and provide its input from New
York‘s perspective and track versions of the DURSA that gets issued.

Next Steps

NYeC and the NY DOH will advance interstate data sharing in accordance with the
following timeline:

Fourth Quarter 2010:

 Continue to meet with other states to explore common HIE business
opportunities.
 Develop common policies and trust agreements in the context of those programs.
 Monitor developments at the federal level on interstate data sharing agreements
such as the NHIN DURSA.

Public Health
To improve public health functions and other health IT and HIE, NYS DOH will use the
expanded regulatory abilities of the Commissioner of Health to develop and enforce
updated or new health IT regulations. In addition, the State will leverage existing laws,
regulations and capacity for regulatory development and enforcement to accelerate
realization of New York State‘s vision of technology-enabled health transformation.

The Commissioner of Health will make all necessary rules and regulations to implement
Federal policies while protecting privacy and security. Regulatory authority will be used
to promote the development of SHIN-NY to enable widespread interoperability among
disparate health information systems. In particular, new rulemaking will focus on
electronic health records, personal health records, public health information systems,
and organizations that exchange health information through SHIN-NY.

NYS DOH will empanel an agency-wide legal work group, leveraging work undertaken
to date by the Child Health Information Integration Initiative (CHI2), the first major effort
within NYS DOH to build bridges across diverse programs. CHI2 has already identified
legal barriers to data exchange, assessed and determined options for allowing data
exchange within current legal and regulatory constraints, defined the need for new
legislation and regulations, and drafted required legislation and regulations.

The new broad-based privacy and security work group will ensure that the public health
HIE initiative complies with guidelines defined by ONC. In addition, the group will ensure
consistency with public health laws, adhering to requirements set forth by HIPAA,
FERPA and State health law. Following the pattern established by CHI2, the privacy and
security work group will identify legal barriers to data exchange between programs and
entities within NYS in addition to those of other states. The work group will develop
necessary policies and regulations for maintaining patient privacy and data security for
public health, using the PCMH model of coordination of care as the basis for decision-
making. Statewide Policy Guidance will be developed to align with new or revised

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regulations, and appropriate representation will be established on SCP work groups and
decision-making bodies to ensure timely attention to legal and policy issues pertinent to
public health practice. Based on collaboratively agreed goals and objectives, regulations
will be forged to enable, promote and mandate bi-directional data exchange and clinical
decision support for collaborative care. Access to State data will be restricted to
organizations that access data through UPHN and comply with Statewide Policy
Guidance, ensuring use of HIE services necessary for public health and Medicaid goals.
NYS DOH will mandate the adoption of UPHN standards and specifications.
Requirements will be enacted to mandate that providers with in-house laboratories
provide access to individual alb results through SHIN-NY and supply data for
aggregation and analysis to the extent required to achieve public health and Medicaid
objectives.

A universal consent form will eliminate redundant consent agreements. Where

indicated, the statewide consent form will be updated to address identified needs. In
addressing consent issues, NYS DOH will facilitate and support each public health
program area to evaluate existing laws and make recommendations for removing
barriers to optimizing consent. Specific consent policies will be developed for minors,
vulnerable populations, and specific levels of use (e.g., treatment, health care
operations, research, population health).

As further support for HIE, NYS DOH will evaluate and develop new methodologies for
site reviews and other auditing procedures in public health to handle the increased used
of health IT and EHRs by health care providers. Regulatory requirements for reviews
and audits will be evaluated and matched to health IT methodologies; for example, HIE
portals may be used to access electronic patient records for site reviews.

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Appendix A – New York Regional Health Information Organizations
Rochester RHIO

HealtheConnections

HEALTHeLINK

Southern Tier HealthLink (STHL)

Brooklyn Health Information Exchange (BHIX)

New York Clinical Information Exchange (NYCLIX)

Interboro RHIO

Bronx RHIO

Healthcare Information Xchange New York (HIXNY)

e-Health Network of Long Island

Taconic Health Information Network and Community (THINC)

Long Island Patient Information Exchange (LIPIX)

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 Appendix B – Minimizing and Managing Risk

Description of Risk Probability Impact Prevention/Mitigation Strategies

Loss of Stakeholder Moderate High Sustaining stakeholder support will be
Support critical to the success of a project as
complex and broad as HIE.

The State of New York will continue to

advance an inclusive and transparent
process of decision-making process
that ensures each stakeholders needs
are identified and considered.

In addition, the statewide HIE program

has and will continue to communicate
directly with stakeholders on the value
and important of participation in the
development of HIE capabilities.
Implementation High High Given limited resources, the NYeC
costs too high engaged in a structured stakeholder-led
process to prioritize services and is also
carefully evaluating cost and value.
NYeC will also establish a competitive
bidding process.
Implementation Moderate High NYeC has adopted an incremental,
delays / Cost phased approach to advancing
overruns statewide HIE. Implementation will be
rigorously and continually evaluated to
identify obstacles and remediate
potential problems, and the NYeC
stakeholders will be continuously
informed of status.
Insufficient funding High Moderate Funding for even basic infrastructure
to ensure future and establishment of a public
sustainability instrumentality exceeds Federal award
and available state funding. Therefore
sustainability model will depend heavily
on outside sources of revenue or
funding. The NYeC will develop
strategies for securing outside funding
sources and contributions and evaluate
revenue generation models to
determine alternate sources of revenue.

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Description of Risk Probability Impact Prevention/Mitigation Strategies
Lack of provider Moderate High The NYeC will develop a plan utilizing
use / lack of stakeholder representatives to educate
provider providers on value proposition and to
participation garner support. As one of two RECs in
New York, NYeC will explore offering a
web-based portal as an alternate
pathway for physicians to connect into
the HIE.
Security breaches Moderate High Security breaches could undermine
consumer and provider confidence and
trust in the HIE. NYeC has developed
extensive privacy and security policies
and technology requirements with
broad stakeholder representation.
Lack of consensus Moderate Moderate New York has adopted an open and
or agreement on transparent, consensus-based
key issues recommendation and decision process.
In cases where consensus cannot be
met, all sides of an issue and the
differing viewpoints are to be clearly laid
out for the NYeC Board of Directors.
Coordination and Moderate High Unforeseen shifts in priorities,
Continuity within leadership changes, budget pressures,
State Government etc. can limit the ability of state
government to participate and support
statewide HIE efforts. To ensure that
HIE and health IT efforts remain a
priority, New York continues to build
these activities into the day-to-day
operations of state departments and
agencies under the leadership of the
OHITT..
Challenge of HIE High Moderate Interstate exchange of health
across state lines information remains a challenge for all
states. New York is participating in two
multi-state collaboratives to share best
practices and facilitate learning and
collaboration. Regional efforts in the
state centered on cross-border medical
trading areas provide another source of
learning and pilot opportunity.

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Description of Risk Probability Impact Prevention/Mitigation Strategies
Unable to get all Moderate High Re-invigorate a strong SCP process
stakeholders with expert leadership
engaged for
uniformity leading
to: uneven adoption
and sub-critical
mass
Vendor distraction Moderate Moderate Align as much as possible with
high due to MU meaningful use; co-opt more states into
leading to: high the same architecture to gain more
vendor-induced bargaining leverage
delays, and high
work-around rate
Requirements are Moderate High Leverage prototyping and iterative
ill-defined and development as a part of requirements
vague leading to: discovery; re-invigorate a strong SCP
Variation in process with expert leadership
individual
implementations
that thwart
interoperability
Privacy policy Moderate High Plan ought to be to incorporate a
variations across flexible privacy management solution as
organizations a service that allows multiple levels of
leading to: policies with configurable restriction
impedance levels
mismatch that
prevents flow of
information, or
shuts out some
participants

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Appendix C – Current NYS DOH Electronic Data Systems for Public
Health Reporting (as listed in the Final Rule EHR for Meaningful Use,
with associated statistics)

1. Electronic Clinical Laboratory Reporting System

NYS DOH had invested more than $10 million over eight years in the statewide
Electronic Clinical Laboratory Reporting System (ECLRS). As an early adopter of Health
Level 7 (HL7), Logical Observation Identifiers Names and Codes (LOINC), and
Systematized Nomenclature of Medicine (SNOMED) standards, ECLRS was developed
to utilize these standards.

What is regulated by NYS DOH:

Clinical labs with NYS DOH permits: 926

Clinical labs with NYS DOH permits pending approval: 62

Limited Service Laboratories (waived testing, or simple procedures): 4,263 testing sites
Solo or primary sites: 2,731/4,263
Ancillary/secondary sites in a multi-site network: 1,532/4,263

Electronic Reporting:

Labs certified to electronically report to NYS DOH: 474

Labs that report s electronically to NYS DOH: 193
Electronic reporting to NYS DOH: 21% (193/926)
Reports processed/year: 4.3 million

Data types reported:

 Blood lead levels

 Communicable diseases
 HIV/AIDS
 Cancer
 Congenital malformations

2. Syndromic Surveillance

NYS DOH has been supported by CDC preparedness funding to establish the capability
in the hospital setting to transmit emergency department (ED) chief complaint data to
NYSDOH. Data is de-identified but includes the patient‘s medical record number should
re-identification be necessary. The estimated state population, excluding NYC, is 11
million. New York routinely monitors data categorized into 8 syndromes: Respiratory,
GI, Fever, Asthma, Neurological, Rash, Carbon Monoxide Poisoning and Hypothermia.
Summary and case-level counts, signals (CuSum analysis results), short-term and long-

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term trend graphs as well as patient listings are available by syndrome, hospital, county,
and region. Hospital users may view data for their hospital and aggregated for their
surveillance region, and LHD users may view data for all hospitals in their county, as
well as aggregated data for their county and region.

Electronic Reporting:

Hospital EDs through ECLRS (outside NYC): 142/144

% of all ED visits captured: ~98%
Number of reports/year: 6.6 million

3. Immunization Registries

The New York State legislature passed the Immunization Registry Law, effective
January 2008, which requires health care providers to report all immunizations
administered to persons less than 19 years of age, along with the previous
immunization history, to the New York State Department of Health using the a web-
based immunization information system (NYSIIS) which serves all of NYS outside of
New York City (which maintains its own Immunization registry system).

New York State Immunization Information System (NYSIIS, areas outside of NYC)
 ‗N‘ Organizations: 5,338
 Organizations via Web portal: 38% (2,023/5,338)
 Organizations - batch via EHR vendor: 12% (664/5,338)
 Users via Web portal:
 Users - batch via EHR vendor:
 EHR vendors: 50

New York City (NYC Immunization Registry (CIR))

 Online registry: 5,305 users @ 2,767 facilities

 Web file repository:
245 individual private providers
44 clinics/health centers within HHC
99 public health centers
110 clinics/health centers within 17 hospitals
15 EHR vendors

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Appendix D – Commitment to Fair Information Sharing Principles
In addition to the Policies and Procedures, Qualified Health IT Entities will be required to
abide by the following fair information sharing principles, which are designed to ensure
robust HIE, and to build trust among patients, health care providers, and other
healthcare organizations participating in SHIN-NY.8

Principle 1 (Participation in the SHIN-NY): Qualified Health IT Entities will

participate in the SHIN-NY.
By facilitating the secure, real-time exchange of health information throughout
New York, SHIN-NY will enable Qualified Health IT Entities and their participants
to enhance medical decision-making and coordination of care, increase system
efficiencies and control costs, and improve healthcare quality and health
outcomes. Participation in the SHIN-NY will also support providers‘ meaningful
use of EHRs by facilitating their achievement of meaningful use objectives and
measures that require HIE.

Principle 2 (Compliance with Rules for Participating in the SHIN-NY):

Qualified Health IT Entities shall, and shall require their participants to,
comply with New York’s Statewide Policy Guidance.
Clear, defined policies are a critical component of the accountability and
transparency that are central to ensuring the success of statewide HIE and
encouraging provider participation. Accordingly, Qualified Health IT Entities shall
sign a participation agreement committing them and their participants to comply
with New York‘s SPG, which sets forth rules for participating in the SHIN-NY. If a
Qualified Health IT Entity ceases to comply with the SPG, its participation in the
SHIN-NY will be terminated.

Principle 3 (Commitment to Information Sharing): Qualified Health IT

Entities shall exchange individually identifiable health information freely
with other health care providers and organizations to coordinate patient
care in accordance with statewide policies.
The potential for EHRs and other health IT tools to improve patient care is
directly proportional to the ability and commitment of health care providers to
exchange information electronically with one another. To overcome historical
barriers to successful HIE, including the proprietary desire to withhold information
for competitive advantage, Qualified Health IT Entities shall commit to
exchanging, without limitation, individually identifiable information about a patient
with all other health care providers involved in the patient‘s care. Qualified Health
IT Entities shall not discriminate or withhold information from exchange.

8
The principles are based on, among other things, the ―Code of Fair Information Practices.‖ Report of the
Secretary‘s Advisory Committee on Automated Personal Data Systems. U.S. Department of Health, Education and
Welfare. 1973 and ―Nationwide Privacy and Security Framework for Electronic Exchange of Individually Identifiable
Health Information. U.S. Department of Health and Human Services. December 15, 2008.

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Principle 4: (Commitment to Population and Public Health): Qualified
Health IT Entities shall exchange identifiable health information in support
of improved population and public health.
EHRs can enable health care providers to engage in electronic public health
reporting to state and federal public health and other agencies, which often offer
immunization registries and other initiatives to improve the quality of health care
at the population-level. Qualified Health IT Entities shall facilitate and otherwise
support health care providers‘ electronic reporting of public and population health
information as required by state and federal law and regulations.

Principle 5 (Openness and Transparency): Qualified Health IT Entities shall

be open and transparent with patients and the public about the policies,
procedures, and technologies that directly affect patients and/or their
individually identifiable health information.
Trust in electronic exchange of individually identifiable health information can
best be established in an open and transparent environment. Qualified Health IT
Entities shall ensure that patients are able to understand what individually
identifiable health information exists about them, how that individually identifiable
health information is collected, used, and disclosed, and whether and how they
can exercise choice over such collections, uses, and disclosures. Notice of
policies, procedures, and technology – including what information will be
provided under what circumstances – shall be provided in a timely manner.

Principle 6 (Individual Access): Qualified Health IT Entities shall facilitate

(either directly or through individual health care providers) the provision of
simple and timely means for patients to access and obtain their individually
identifiable health information in a readable form and format.
Access to information enables individuals to manage their health care and well-
being. Patients should be able to obtain this information easily, consistent with
security needs for authentication of the individual; and such information should
be provided promptly so as to be useful for managing their health. Additionally,
Qualified Health IT Entities shall provide such information in an electronic format
when appropriate. In limited instances, medical or other circumstances may
result in the appropriate denial of individual access to their health information.

Principle 7 (Correction): Qualified Health IT Entities shall provide patients

with a timely means to dispute the accuracy or integrity of their individually
identifiable health information, and to have erroneous information
corrected or to have a dispute documented if their requests are denied.
Electronic exchange of individually identifiable health information may improve
care and reduce adverse events. However, errors or conclusions drawn from
erroneous data may be easily communicated or replicated. For this reason it is
essential for patients to have practical, efficient, and timely means for disputing
the accuracy or integrity of their individually identifiable health information, to
have this information corrected or a dispute documented when their requests are

105
denied, and to have the correction or dispute communicated to others with whom
the underlying information has been shared.

Principle 8 (Individual Choice): Qualified Health IT Entities shall provide

patients a reasonable opportunity and capability to make informed
decisions about the collection, use, and disclosure of their individually
identifiable health information.
The ability of individuals to make choices with respect to HIE is important to
building trust. The degree of choice made available may vary with the type of
information being exchanged, the purpose of the exchange, and the recipient of
the information. Applicable law, population health needs, medical necessity,
ethical principles, and technology, among other factors, may affect options for
expressing choice. Qualified Health IT Entities shall ensure that the process by
which a patient may exercise choice (e.g. provide consent), is fair and not unduly
burdensome.

Principle 9 (Collection, Use, and Disclosure Limitation): Qualified Health IT

Entities shall collect, use, and/or disclose individually identifiable
information only to the extent necessary to accomplish a specified
purpose(s) and never to discriminate inappropriately.
Establishing appropriate limits on the type and amount of information collected,
used, and/or disclosed minimizes potential misuse and abuse. Qualified Health
IT Entities shall take advantage of technological advances to limit data collection,
use, and/or disclosure and shall only obtain individually identifiable information
through lawful and fair means.

Principle 10 (Data Quality and Integrity): Qualified Health IT Entities shall

take reasonable steps to ensure that individually identifiable health
information is complete, accurate, up-to-date to the extent necessary for
the patient’s or Qualified Health IT Entity’s intended purposes and has not
been altered or destroyed.
The completeness and accuracy of an individual‘s health information may affect,
among other things, the quality of care that the individual receives, medical
decisions, and health outcomes. Qualified Health IT Entities shall update or
correct individually identifiable health information and provide timely notice of
these changes to others with whom the underlying information has been shared.
Moreover, they shall develop processes to detect, prevent, and mitigate any
unauthorized changes to, or deletions of, individually identifiable health
information.

Principle 11 (Safeguards): Qualified Health IT Entities shall protect

individually identifiable health information with reasonable administrative,
technical, and physical safeguards to ensure its confidentiality, integrity,
and availability and to prevent unauthorized or inappropriate access, use,
or disclosure.

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Administrative, technical, and physical safeguards help minimize the risks of
unauthorized or inappropriate access, use, or disclosure. Administrative,
technical, and physical safeguards shall be developed after a thorough
assessment to determine any risks or vulnerabilities to individually identifiable
health information and shall be reasonable in scope and balanced with the need
for access to individually identifiable health information.

Principle 12 (Accountability): Qualified Health IT Entities shall ensure that

the principles contained herein are implemented, and adherence assured,
through appropriate monitoring and other means. Qualified Health IT
Entities shall also ensure that methods are in place to report and mitigate
non-adherence and breaches.
At a minimum, mechanisms adopted by Qualified Health IT Entities shall
address: (1) monitoring for internal compliance, including authentication and
authorizations for access to or disclosure of individually identifiable health
information; (2) the ability to receive and act on complaints, including taking
corrective measures; and (3) the provision of reasonable mitigation measures,
including notice to individuals of privacy violations or security breaches that pose
substantial risk of harm to such individuals.

Principle 13 (Remedies): Qualified Health IT Entities shall be subject to

legal and financial remedies to address any security breaches or privacy
violations.
Remedies should be formulated in advance to address situations where
information is breached, used, or disclosed improperly.

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Appendix E – Quality Monitoring & Reporting
In New York, quality reporting and improvement initiatives occur across both the public
and private sectors and at the local, regional, and statewide levels.
In addition to its role shaping health care delivery systems and public health care policy,
New York Medicaid continues to pursue a broad reform agenda and range of quality
improvement initiatives. These improvements include both policy and operational areas.

NY Medicaid‘s Health Reform Agenda includes rationalizing reimbursement; expanding

access to coverage; expanding access to care; pursuing improvements in quality and
outcomes; improving care for enrollees with complex medical needs; making
advancements in Long Term Care; assuring program integrity; and strengthening
information technology systems. New York has made significant strides in achieving
these reform objectives. It has broadened coverage, making it more accessible;
increased investment in ambulatory care to reduce preventable inpatient hospital stays;
and strengthened the commitment to quality through primary care standards,
retrospective review of services, and selective contracting.

Public policy and operational quality improvement initiatives include the following:
Public Policy Improvements
 Reimbursement and Rate Reform – NY Medicaid has taken the initial steps
in developing pay-for-performance initiatives for its Medicaid managed care
program which covers 3.2 million people. These initiatives link compensation
to the quality of outcomes, standardized quality measures, or indicators that
measure the degree to which specific goals are achieved. The State has also
reformed Medicaid rates to encourage care in the proper setting, to ensure
high value in exchange for expenditures; and promote high quality, cost-
effective care.
 Establishment of Patient-Centered Medical Homes – State legislation
incentivizing the creation and use of patient-centered medical homes was
recently implemented, employing National Committee for Quality Assurance
(NCQA) accreditation standards.
Operational Improvements
 e-Prescribing Incentive Program – In May 2010, the State implemented an
e-prescribing incentive program using the National Council for Prescription
Drug Programs (NCPDP) and Medicare Part D standards. This program is
designed to promote e-prescribing and reduce the incidence of adverse drug
effects.
 Medicaid Medication History Exchange Pilot and EHRs – Through the
Medicaid Medication History Exchange pilot project, the use of EHRs has
been promoted. Approximately 180 days of patient prescriptions can now be
shared electronically between Medicaid and selected health care providers
and their patients.

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Hudson Headwaters Health Network

As one of the initiatives funded under HEAL 10, Hudson Headwaters represents
another program developed jointly by NY Medicaid and OHITT. With $7M in funding, the
Adirondack Medical Home Multipayor Demonstration Program seeks to establish a
demonstration PCMH to serve recipients of public medical assistance, as well as
enrollees and subscribers of commercial managed care plans.

In this endeavor, the Adirondack Health Institute Care Improvement Initiative will work in
tandem with the Adirondack PCMH Pilot to improve and enhance the provision of
healthcare services in the region. The Project will leverage the progress and
infrastructure of the PCMH Pilot. PCMH providers will apply population-based,
evidence-based, and patient-centered approaches for diabetes care using EHRs and
care managements tools made available under the Project to facilitate or further
integrate practice improvements to increase the effectiveness of clinical interventions,
with the ultimate goal of improving quality of care (especially at transitions in care).

Telemedicine

Telemedicine systems are interactive audio and video telecommunication system that
allow real-time interactive consultation services to take place between a physician and a
patient at different physical locations. Since 2006, Medicaid has reimbursed
practitioners for clinical consultations performed via telemedicine in the emergency
room and inpatient hospital settings. In order to be eligible for reimbursement, the
consultation must be in a medical specialty not available at the patient‘s location (the
―spoke site‖), and the consultation with the specialist (at the ―hub site‖) must be
conducted via a fully interactive, secure two-way audio and video telecommunication
system that also supports review of diagnostic tests integral to the consultation. As of
July 2010, reimbursement for telemedicine services has now been extended to services
rendered in hospital ambulatory settings.

Recognizing a significant shortage for diagnosis and treatment of stroke caused by the
lack of access to neurologist/stroke specialists in rural communities, NY Medicaid
collaborated with the Office of Health Systems Management (OHSM) and the Office of
Rural Health (ORH) to develop a Telemedicine Stroke Program modeled after a
successful REACH (Remote Evaluation of Acute Ischemic Stroke) program in Georgia.
Currently, four hub hospitals—Basset Hospital in Cooperstown, Millard Fillmore Gates
Circle Hospital in Buffalo, Strong Memorial Hospital at the University of Rochester, and
Upstate University Hospital in Syracuse—are available to remotely examine patients in
rural emergency rooms and inpatient hospitals by reviewing computed tomography (CT)
scans in real time and make recommendations regarding treatment including the
administration of tissue plasminogen activator (tPA) from any broadband-connected
laptop/computer using a HIPAA-compliant web-based system.

Managed Care Plan Performance Reporting

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Managed Care Plans (commercial HMO, commercial PPO, Medicaid and child Health
Plus) in New York are required to report on a set of quality measures. Quality
Assurance Reporting Requirements (QARR) was developed by the NYSDOH to enable
consumers to evaluate the quality of health care services provided by New York State's
managed care plans. QARR measures are largely adopted from the NCQA Healthcare
Effectiveness Data and Information Set (HEDIS) with New York State-specific measures
added to address public health issues of particular importance in New York. When
available, national averages (benchmarks) from NCQA are also included for the
commercial HMO and Medicaid populations. Child Health Plus populations currently
don't have any national benchmarks.

QARR also includes information collected from a national consumer satisfaction survey
program called Consumer Assessment of Healthcare Providers and Systems (CAHPS).
CAHPS is collected every year for commercial adult enrollees. The NYSDOH sponsors
a consumer satisfaction survey for Medicaid enrollees every two years.

Statewide activities

In addition to the activities listed above, additional activities currently underway

throughout the State to encourage HIE and EHR adoption will have an impact on the
success of the Medicaid EHR Incentive Program. Recognizing that the impact of these
activities is not limited to Medicaid participants and providers, NY Medicaid defers to
OHITT for statewide coordination of these activities. To the extent needed and
requested by OHITT, NY Medicaid will participate in statewide activities initiated by
OHITT and provide data to support these activities.

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Appendix F – Letter of Support

111
112
Appendix G – NYeC Board Membership

 Carol Raphael, President and CEO, Visiting Nurse Service of NY (Chair)

 Thomas P. Quinn, President and CEO, Community General Hospital (Vice Chair)

 Pamela Brier, CEO, Maimonides Medical Center (Treasurer)

 Neil Calman, MD, President and CEO, Institute for Family Health (Secretary)

 Dominick A. Bizzarro, CEO, Healthcare Information Xchange of NY

 Jo-Ann Constantino, CEO, The Eddy

 Andrew S. Doniger, MD, Director, Monroe County Department of Public Health

 Eugene Heslin, MD, President/Co-owner, Bridge Street Medical Arts LLC

 David H. Klein, President and CEO, The Lifetime Healthcare Companies

 Arthur A. Levin, Center for Medical Consumers

 Ann F. Monroe, President, Community Health Foundation of Western and Central

New York

 Herbert Pardes, MD, President and CEO, New York-Presbyterian Hospital and New
York-Presbyterian Healthcare System

 Amanda Parsons, MD, Assistant Commissioner, Primary Care Information Project,

NYC DOHMH

 Richard M. Peer, MD, Past President, Medical Society of the State of New York

 Lonny Reisman, MD, Chief Medical Officer, Aetna

 Susan Stuard, Executive Director, THINC

 James R. Tallon, Jr., President, United Hospital Fund

 Dennis Whalen, Executive Vice President for Policy, Healthcare Association of New
York State

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Appendix H – Candidate HIE Services Prioritization
Candidate HIE Services

The HIE candidate services list was designed to be manageably concise yet
comprehensive enough to encompass both federal and state policy and interoperability
requirements. Service identification began based on HEAL policy and proposed
Federal rules for meaningful use, standards and certification and was completed after
the final federal rules were announced and published in the Federal Register. The
group agreed on 21 candidate shared services to guide future direction and discussion:

 Identity Management and Authentication – Authenticate end points (people and

organizations). Leading candidate for implementation is using public key
infrastructure (PKI), with some participant in the health information exchange
sponsoring or acting as certificate authority. Must support e-prescribing of controlled
substances.

 Provider / HIE Directory – Provide demographic, address and routing, and delivery
preference information on providers, facilities, health plans, public health agencies
and other participants in health information exchange. Can be used to find routing
information (street address, e-mail, network address, fax and phone) for an
individual or organization.

 Record Locator Service / Master Person Index – Provide means of person/patient

(subject) matching for the purpose of identifying the location of data regarding the
subject (Record Locator Service, or RLS). Can be implemented through either
probabilistic matching based on demographics, through an agreed standard
algorithm; deterministically, through persistent medical record matching using a
communitywide maintained Master Person Index (MPI); or using an assigned unique
identifier, on a voluntary or mandated basis for each patient / person. Typically, a
combination of these methods is used.

 Consent Management – Track consumer permissions or restrictions to

disclose/release information. Can be opt-in or opt-out, depending on policy and
regulations. Can be global or restricted to named providers/trading partners or by
information type, with increasingly complex implementation and tracking, and
potential safety and accuracy issues depending on granularity of consumer control.
Can be implemented at point of release or point of access. New York currently
supports a policy for ―consent to access‖ which enables data to be shared through
the HIE, but requires attestation of consent for access by any requester.

 Message / Record Routing – Connect and deliver messages among information

exchange participants. Can transmit data without enforcing standards, impose
standards adherence on senders, or include translation / adaptor/transformation,
filtering or de-identification services to assume burden from senders. Should at a
minimum support the following: Transmission services - SMTP, SOAP, REST;

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 Protocol services – CCD/CCR (patient history and encounter/visit summary), HL7
2.x (laboratory and public health), X12 (HIPAA transactions), NCPDP (e-prescribing)
and DICOM (imaging).

 Disclosure Logging – Log disclosures among stakeholders/trading partners for

management purposes and to support providing patients with an accounting of all
disclosures as required. Any centralized infrastructure will log its participation in the
movement of data, but many actual disclosures will be logged by the user-facing
systems that present said data.

 E-Prescribing with Formulary – Deliver new prescription orders and renewals to

retail, facility and mail order pharmacies. Can simplify integration with Surescripts
national pharmacy network and integrate other end points and/or provide features
that enhance, or serve as an alternative to, commercial e-prescribing products (e.g.,
a standalone e-prescribing portal). Must include workflow to provide access to
payer-specific payment, efficacy, safety and cost-effectiveness guidelines
(formularies) on medications. Such data are not uniformly available (i.e., for payers
and PBMs not participating in Surescripts, or in all e-prescribing software solutions).

 Lab Order / Result Delivery – Deliver diagnostic results and reports back to
ordering providers and others designated to receive results. Can be implemented as
a feature of a message routing service or separately. Could be implemented as a
results registry with publish/subscribe/notify or other delivery models. Can also
encompass order delivery, or order delivery can be implemented separately. For
ubiquitous national laboratories, existing channels may be used for these
transactions with the same net effect, such as utilizing direct (non-SHIN-NY)
connections between EHRs and such labs.

 Imaging Order / Result Delivery – Same as for lab services described above, but
limited to diagnostic and treatment-oriented medical imaging. Image delivery can be
separated from report delivery. Can be combined with or kept separate from
message routing and lab order processing.

 Eligibility/Claims Transactions – Deliver messages related to reimbursement

(eligibility, referral authorization and inquiry, claim submission, claim status inquiry,
remittances, etc.). Can include orchestrating portions of the claim-related workflow
and adding functionality beyond what HIPAA mandates. Can be implemented as a
feature of message / record routing (see separate entry) or as defined value added
services.

 Medical Necessity / Authorization Rules – Provide access to payer rules for

ordering certain medical/diagnostic services (used commonly in imaging today) and
governing referrals and hospital admissions. Anticipate a web service that can
respond to a standard structured request and provide a definitive authorized/denied
response, or a request for specific additional information.

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 Clinical Decision Support / Medication Safety – Provide therapeutic guidance for
prescriptions and potentially other orders or treatments, either prospectively (as
initiated by a provider) or retrospectively (based on submitted claim, e-prescribing or
clinical summary data). Can send alerts and recommendations to patients and
providers.

 Event Notification – Route various notifications of patient status to authorized and

interested parties based on certain triggers. Possible candidates include first report
of injury and/or admission notification to the patient‘s payer and physicians; death
notification to payer, physicians and public health; status changes such as adoption,
protective services, marriage, hospice, PCP change, etc.

 Medication Data Management – Collect prescription history for purposes of

performing medication reconciliation, detecting significant changes or overuse of
medications, identifying and notifying patients at risk of adverse events, etc. Data
can be de-identified with a key for re-identification for certain uses as required.

 Vocabulary Translation – Perform or provide access to mapping between LOINC,

SNOMED-CT, ICD-9/10 and RxNorm. Can be implemented through active
translation, a repository and / or negotiated licensing of commercial terminology
services.

 Health Record Portal – Provide a capability to query patient history and view
records and results created elsewhere as structured information and documents
from source systems and entry/upload points. Oriented to provider use, as a front-
end queue/standalone viewer for importing into an EHR; as an aggregation point; or
as an alternative to an EHR (―EHR-lite‖ model). Can also be adapted to patient and
other use.

 Personally Controlled Health Record – Populate a patient-centered

longitudinal/lifetime health record from primary data sources. Can be event/rules-
driven, consumer-activated or a combination. Can provide storage and viewing
capabilities or simply route to a consumer-directed service such as Google Health,
Indivo, or Microsoft Health. Also, provide patient / consumer with ability to request
and route/download CCDs and other data to self and other participants. Can be
accomplished through a portal, secure e-mail, IVR, etc. Can be implemented
through negotiated offer of commercial service to consumers.

 Public Health Reporting / Registry – Collect immunizations, syndromic

surveillance details, reportable lab results and other data for monitoring public health
from primary sources (hospitals, physician offices, diagnostic labs, etc.). Make data
available, with or without filtering and transformation, to multiple state and municipal
agencies. Can also be used to generate immunization reminders for patients or
providers or to analyze data for outbreaks, etc. Can be used to provide physician
alerts and feedback and to drive population health initiatives. Can be made

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 available to providers and others involved in patient‘s care. Data can be de-
identified with a key for re-identification for certain uses as required.

 Quality and Analytics Reporting / Feedback – Collect clinical and administrative

data for analysis and various forms of reporting. Includes data needed to compute
HEDIS, PQRI, and pay for performance measures to CMS, commercial payers and
others. A single organization may offer all services (aggregation, analytics,
reporting and quality data submission) or those tasks might be divided among
multiple organizations. Data from multiple submitters/providers may be aggregated
and de-identified for some reporting. Targeted at cost control, improving efficiency
and influencing patterns of care and payment.

 Research Data Aggregation – Collect clinical data to facilitate the design of

targeted therapies for individual patients and for use in other research-related
activities. Data can be de-identified with a key for re-identification. A single
organization may serve as a data aggregator supporting individual researchers.

 Patient Education – Store education materials and support ordering/routing to

patients/consumers. Access could be voluntary by consumers, by invitation from
providers or information can be pushed based on provider orders/triggers.

In identifying and defining the services list, no effort or determination was made as to
how the services might be developed, acquired or deployed.

Connected Capabilities

The NYeC Infrastructure Work Group developed a set of clinical and operational
scenarios or use cases referred to as ―Connected Capabilities‖ for statewide HIE to
provide context for discussions of HIE services. The Connected Capabilities describe
workflows in which providers and other health care stakeholders, including patients and
consumers, would use an integrated set of HIT/HIE tools to accomplish clinical care and
administrative objectives. In outlining these Connected Capabilities, the Infrastructure
Work Group considered the prior work of New York‘s HEAL and State Collaborative
Process (SCP) efforts, Health Information Technology Standards Panel (HITSP)
specifications and NHIN Direct user stories as input in developing Connected
Capabilities. Connected Capabilities allow a real-life or business-level discussion of HIE
services and priorities, rather than the more technically oriented definitions used in prior
iterations of HEAL and federally-directed NHIN activities.

HEAL Phase 5 established an initial set of six clinical investment priorities for the State
in 2007, with applicants for HEAL funding required to select from among the six in
setting project goals9. RHIOs have been required by the 19 projects awarded HEAL 5
grants to implement these use cases under HEAL 5, but not uniformly or in a completely
standardized approach across the State:

9 http://www.health.state.ny.us/technology/projects/clinical_investment_priorities.htm

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 Connecting New Yorkers and Clinicians – Providing the capacity to connect New
Yorkers to their clinicians and providers to share clinical results, care management
programs and emergency contact information. (Committed to by five awardees.)

 Health Information Exchange for Public Health – Improving situational awareness

and reporting for public health purposes and reducing administrative costs
associated with preparing and transmitting data among providers and public health
officials. This use case incorporates Federal standards emerging from
biosurveillance best practices and the nationwide health information network.
(Committed to by three awardees.)

 Interoperable EHRs for Medicaid – Sharing Medicaid medication history

information with clinicians, with an emphasis on medication management and
electronic prescribing as the initial priority. This includes providing additional sources
of medication history information from pharmacies and pharmacy benefit managers
to enhance clinical decision support capabilities, such as monitoring potential drug-
drug interactions. This use case incorporates Medicare electronic prescribing
standards. (Committed to by 13 awardees.)

 Quality Reporting for Outcomes – Providing quality-based outcome reports based

on clinical information from an interoperable EHR as well as other data sources to all
payers and providers to improve quality and support new payment models. The use
case incorporates Federal standards and NYS priorities and requirements with
respect to quality measures and approaches. (Committed to by four awardees.)

 Clinical Decision Support in a HIE Environment – Providing analytic software to

guide medical decisions and facilitate quality interventions. A Clinical Decision
Support use case must be submitted by each applicant for consideration in the
evaluation process. (Committed to by two awardees.)

 Immunization Reporting via EHRs – Interfacing EHRs with NYS DOH and NYC
DOHMH IIS to enhance their use and improve safety and efficiency. The use case
incorporates NYS Immunization Registry standards, as well as criteria set forth by
CDC and the national Certification Commission for Healthcare Information
Technology (CCHIT). (Committed to by three awardees.)

 Quality Reporting for Prevention via EHRs – Implementing EHRs with embedded
quality metrics for reporting prevention and process measures to support quality
reporting. The use case incorporates the Federal Quality and Lab-EHR use cases
and NYS priorities and requirements with respect to quality measures and
approaches. (Committed to by four awardees.)

HEAL Phase 10, awarded in September 2009 to nine additional regional projects, and
HEAL Phase 17 projects further specified functions and minimum data sets that must be

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supported and provided by awardees and RHIOs in support of New York‘s stated policy
of implementing a PCMH mode of care:

HEAL-10 / 17 Supported Functions

 Access to clinical information, including test ordering and result tracking.

 Referral tracking.
 Communication and exchange of information among providers through a RHIO.
 E-Prescribing and medication management.
 Clinical decision support.
 Care management, patient tracking and registry functions.
 Patient self-management.
 Communication and exchange of information between providers and patients.
 Quality reporting.
 Reimbursement reform (optional).
 Coordination of care during transitions between providers.
 Medication reconciliation across all care settings and clinicians.

HEAL-10 / 17 Minimum Data Set

 Active medications (including name, dose, frequency and route) and medication
allergies.
 Problem / diagnosis list.
 Lab results.
 Radiology and imaging reports.
 Discharge summaries, consults and other clinical documents.
 Other appropriate disease specific diagnostic testing results (e.g., echocardiogram
reports for congestive heart failure) as appropriate for the target patient population
(optional). Active medications (including name, dose, frequency and route) and
medication allergies.

NHIN Direct user stories provide additional useful guidance and were deemed by the
Infrastructure Work Group to best reflect current Federal policy direction on HIE
priorities beyond what is contained in the final rules for Meaningful Use and the recent
State HIE PIN. HITSP specifications were consulted in defining Connected Capabilities,
but were considered too technically oriented and detailed to facilitate business-level
discussions. In addition, while they have influenced ONC standards for meaningful use
and certification, HITSP specifications have not been universally adopted by vendors,
although they have been widely accepted and are undoubtedly guiding vendor
development for certification.

Taking these sources of information, standards and mandates into account, the
Collaborative Care Infrastructure Work Group identified 11 Connected Capabilities to
satisfy NYS and Federal HIE requirements. The Work Group aimed to generate a list
that was concise, yet sufficiently comprehensive to encompass both Federal and State

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policy and interoperability requirements. Variations on these summary Connected
Capabilities can be differentiated (e.g., separating order and result processing, or
detailing different workflows for different types of public health reporting) for more
detailed discussion and to drive future HEAL and statewide HIE planning, development
and operations.
Connected Capability HEAL-NY and SCP
Route visit data to other • Access to clinical information,
providers and authorized including test ordering and
parties result tracking
Route data in support of • Access to clinical information,
care transitions, including including test ordering and
referral tracking result tracking
• Referral tracking
• Communication and exchange
of information among providers
through a RHIO
Route lab and imaging • Access to clinical information,
orders and results including test ordering and
result tracking
• Communication and exchange
of information among providers
through a RHIO
Query patient history • Access to clinical information,
including test ordering and
result tracking
• Referral tracking
• Communication and exchange
of information among providers
through a RHIO
• E-prescribing and medication
management
• Care management, patient
tracking and registry functions
Route electronic • E-prescribing and medication
prescriptions management
Retrieve medication • E-prescribing and medication
history for medication management
reconciliation and other
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Federal NHIN Direct
Use Cases
• Hospital sends discharge
information to referring
provider
• Laboratory sends lab results
to ordering provider
• Hospital sends a clinical
summary at discharge to the
patient
• Primary care provider refers
patient to specialist including
summary care record
• Primary care provider refers
patient to hospital including
summary care record
• Specialist sends summary
care information back to
referring provider
• Laboratory sends lab results
to ordering provider
• No equivalent and explicit
federal ―pull‖ requirement in
NHIN Direct or Stage 1
Meaningful Use
• Pharmacist sends medication
therapy management consult
to primary care provider
• Pharmacist sends medication
therapy management consult
to primary care provider
 Federal NHIN Direct
Connected Capability HEAL-NY and SCP Use Cases
medication management
Route visit and other data • Clinical decision support • Provider sends reminder for
for clinical decision preventive or follow-up care
support to the patient
Route data to patients • Patient self-management • Provider sends patient health
and enable ownership • Communication and exchange information to the patient
and management of information between • Hospital sends patient health
providers and patients information to the patient
• Connecting New Yorkers and • Provider sends a clinical
clinicians summary of an office visit to
the patient
• Hospital sends a clinical
summary at discharge to the
patient
• A patient-designated
caregiver monitors and
coordinates care among
three domains
Adjudicate and manage • Reimbursement reform
claims and/or patient
responsibility
Route visit and other data • Quality reporting • Provider or hospital reports
for standardized quality • Reimbursement reform quality measures to CMS
reporting • Provider or hospital reports
quality measures to State
• Provider or hospital sends
update to regional or national
quality registry
Route visit and other data • Health information exchange for • Primary care provider sends
for standardized public public health patient immunization data to
health reporting • Immunization reporting via public health
EHRs • Laboratory reports test results
• Care management, patient for some specific conditions
tracking and registry functions to public health
• Hospital or provider send
chief complaint data to public
health
• State public health agency
reports public health data to
CDC

Below are visual representations of the 11 Connected Capabilities.

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Route visit data to other providers and authorized parties (hospital example)




Participant Directory
/ Consents /
Disclosure Log 

 

HIE
Service

 

Health
Plan, etc.

1) Patient visits PCP or specialist, establishes a trusted relationship and consents for
release of data.
2) Consents and provider routing preferences are sent to HIE service.
3) As a result of a referral, admission, or emergency, patient registers in hospital.
Trusted relationship and consent for release of data can be established if not
previously established with another provider (steps 1 and 2).
4) Patient receives care and details are noted in hospital medical record.
5) Patient is discharged from hospital.
6) Standard format discharge summary or ER report is transmitted to HIE network
7) HIE service checks consents for release and participant directory for routing
instructions.
8) HIE service routes discharge summary to PCP, specialist or other interested and
trusted party (e.g., health insurance case manager, health record proxy, etc.). HIE
log can store summary or link to allow for tracking and later lookup.

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Route data in support of care transitions, including referral tracking

 

Participant Directory
/ Consents /
Disclosure Log

 
HIE
 Service



Health
Plan, etc.

1) Patient visits PCP or specialist, establishes trusted relationship and consents for
release of data.
2) Consents and provider routing preferences are sent to HIE service.
3) Provider refers patient to a specialist, hospital or other provider for consultation or
service.
4) HIE service submits referral authorization request to payer for approval and referral
number.
5) HIE service checks participant directory for routing instructions and sends referral
request with pertinent patient information, history, diagnosis and service requested
to consulting provider; business rules can be stored in HIE service for elements of
real-time decision support.
6) Patient visits consulting provider, receives services, and details are noted in patient
chart, electronic medical record, or other result is created (e.g., at lab, in laboratory
information system, etc.)
7) Standard format visit summary with consultation notes is transmitted to HIE network.
HIE service routes visit summary to PCP, specialist or other interested and trusted
party (e.g., health insurance case manager). HIE log can store summary or link to
allow for tracking and later lookup. .

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Route lab and imaging orders and results




Participant Directory
/ Consents /
Disclosure Log



HIE 
 Service

Public Health
Reporting Agency

Health
Plan, etc.

1) Patient visits PCP or specialist, establishes trusted relationship and consents for
release of data.
2) Consents and provider routing preferences are sent to HIE service.
3) Provider refers patient to a diagnostic facility (hospital or commercial lab, imaging
center, etc.); support for various diagnostic functions can be implemented separately
(lab, imaging, etc.).
4) If enabled, test order can be sent electronically; order and result delivery can be
decoupled and implemented separately.
5) Specimen is sent or patient visits diagnostic facility; test is performed; results are
noted and forwarded to HIE service in standard structured format
6) Results are routed to authorized providers (referring, PCP, etc.) and other
authorized parties, or stored in a results repository to allow for tracking and later
lookup or download. Alerts can be applied to support clinical decision support.
7) Optional - HIE service can be used for reporting notifiable lab results to public
health, based on business rules (or see separate public health Connected Capability
and services).

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Query patient history

Participant Directory
/ Consents /
Disclosure Log

  Health
Information
Organization,
Portal Vendor or
Provider-Hosted

 Portal

1) Patient visits PCP, specialist, hospital or other provider, establishes trusted

relationship and consents for release of data to named health information
organization.
2) Consents and routing instructions are sent to HIE service.
3) Standard format visit summary and other data generated by visit, diagnostic test or
other healthcare encounter or event is stored by HIE service or proxy to establish
electronic health record or summary based on patient consent and business rules in
HIE service.
4) Providers and authorized parties can access electronic health record through EHR
or portal provided by HIE service.

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Route electronic prescriptions



E-Prescribing
System

 Health
Plan
Participant Directory


/ Consents /
Disclosure Log
 HIE
Service


Pharmacy Intermediary
(SureScripts /
Pharmacy Benefit
Manager)
Mail Order /
Retail
Pharmacy

1) Physician / clinician uses software of his or her choosing to create an electronic

prescription.
2) Electronic prescription is transported to HIE service for submission and tracking.
3) HIE service submits eligibility verification to payer for pharmacy benefit eligibility and
any other available data.
4) HIE service submits electronic prescription / claim to pharmacy processing
aggregator / intermediary or directly to pharmacy benefit manager (PBM) for
formulary compliance, etc.
5) Pharmacy processing aggregator / intermediary sends electronic prescription fill
order to mail order or retail pharmacy.
6) Pharmacy processing aggregator / intermediary sends acknowledgement to HIE
service.
7) HIE service sends acknowledgement and other prescription data back to E-
Prescribing System or directly to prescribing physician / clinician (via e-mail, fax or
standard format message).

126
Retrieve medication history for medication reconciliation and other medication
management


 
Participant Directory
/ Consents /
Disclosure Log 
  HIE
Service

 

1) Patient uses medications dispensed at retail or mail order pharmacy, or purchased

over the counter (OTC).
2) As a result of a referral, admission, or emergency, patient registers in hospital or
visits physician.
3) Medication history request is sent to HIE; HIE retrieves retail and mail order history
from national network and any other available history from other participating
sources (payers, PBMs, other hospitals, etc.) to assemble the patient‘s ―home‖
medication list.
4) Home medication list is validated with patient, incorporating OTC, herbal
supplements, etc.
5) Inpatient prescription orders are created based on treatment plan and home list.
6) If patient is discharged, new discharge prescriptions are written and submitted to
HIE service for routing to external pharmacy for dispensing.
7) If patient is transferred, reconciled medication list is routed to next provider of care
via HIE service.
8) HIE service routes reconciled medication list to interested and trusted parties (e.g.,
PCP).

127
Route visit and other data for clinical decision support

Participant Directory
/ Consents /
Disclosure Log

 


HIE
 Service

Clinical Decision
Support Intermediary

1) Patient visits PCP, specialist, hospital or other provider, establishes trusted

relationship and consents for release of data to a named decision support partner
2) Consents and routing instructions are sent to HIE service
3) Standard format visit summary or batch with data for determining clinical
intervention is sent to decision support partner (community-based, jurisdictional,
commercial vendor, etc.) and processed for intervention by HIE service, based on
patient consent and business rules in HIE service.
4) Clinical intervention is sent back to provider, synchronously (within EHR or as an
alert) or asynchronously (after the fact as an advisory).

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Route data to patients and enable ownership and management

Participant Directory
/ Consents /
Disclosure Log

  Personal
Health Record
Provider /
HIE Host / Proxy
Service


 

1) Patient visits PCP, specialist, hospital or other provider and establishes trusted
relationship and consents for release of data
2) Consents and provider routing preferences are sent to HIE service.
3) Standard format visit summary is sent to patient or to proxy for personal health
record (e.g., Google, Microsoft HealthVault, Dossia, etc.) on patient consent and
business rules in HIE service.
4) HIE service can provide direct patient access to records and other information (lab
results, patient education, alerts, etc.).
5) Patient and authorized parties can access personal health record through PHR
proxy service provider and can maintain certain information (demographics, contacts
/ caretakers, advanced directives, OTC meds, etc.).

129
Adjudicate and manage claims and/or patient responsibility

 
Billing
System

Participant Directory
/ Consents /
 Payer /
Fiduciary /
Clearinghouse
Disclosure Log

 
 HIE
Service

  

Payer /
Fiduciary /
Clearinghouse

1) Patient visit or encounter results in medical claim being created in provider billing
system.
2) Claim is transported to HIE service for submission and tracking.
3) HIE service submits eligibility verification to primary and secondary payers identified
in claim.
4) Claim detail and status available for viewing in HIE service; business users view
and edit claims as necessary to correct insurance and other information, with
original and corrected images of claim stored and clearly identified, allowing edited
claims to be and sorted and grouped according to business rules.
5) HIE service transports claim to responsible party identified via clearinghouse or
other intermediary as specified in business rules or payer address table; secondary
claim created as necessary.
6) HIE service submits claim status inquiry based on business rules.
7) HIE service matches solicited and unsolicited inquiry responses to claim (including
payer scrubber reports), identifying those requiring further editing
8) HIE service collects electronic remittances and matches to claims, on a solicited
and automatic basis.
9) HIE service triggers workflow related to denial management and secondary claim
submission, based on business rules and claim conditions.
10) Business users are able to use HIE service to perform drill-down analysis and
report on claims, claim status and claims management metrics and performance.

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Route visit and other data for standardized quality reporting

Contracted /
Participant Directory Designated
/ Consents / Quality Metrics
Disclosure Log Organization

 
HIE
 Service


Health
Plan,
State,
CMS,
etc.

1) Patient visits PCP, specialist, hospital or other provider, establishes trusted

relationship and consents for release of data to named quality reporting
organization(s).
2) Consents and routing instructions are sent to HIE service.
3) Standard format visit summary or batch with data for determining quality metrics is
sent to payer, government agency or other quality metrics organization based on
patient consent and business rules in HIE service.
4) Computed quality metrics may be reported to other authorized recipients outside of
HIE and / or communicated back to provider and/or patient (via HIE or through
separate messaging or portal).

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Route visit and other data for standardized public health reporting

Primary
Public Health
Participant Directory Reporting Agency
/ Consents / (e.g., state)
Disclosure Log

 
HIE

 Service

Secondary Public Health

Jurisdiction
(e.g., municipal, CDC, etc.)

1) Patient visits PCP, specialist, hospital or other provider, establishes trusted

relationship and consents (if necessary) for release of data for public health
reporting.
2) Consents and routing instructions are sent to HIE service.
3) Standard format visit summary or other standard message is sent to state and
municipal public health agency or to a proxy aggregator , including demographics for
health disparities analysis, chief complaints for syndromic surveillance, immunization
detail or history and lab test results for certain notifiable conditions.
4) Alerts and reports are routed back to providers and other jurisdictions based on
business rules, or are made available by HIE service or agency for query from
portal.

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Service Evaluation and Prioritization Criteria

The Collaborative Care Infrastructure Work Group developed a service evaluation

framework designed to be sufficiently flexible to advance and improve policy while
soliciting comment and input from key stakeholders. Work Group participants
developed a broad set of objective criteria for determining service priorities and delivery
models based on five priority factors:

 Alignment with policy (current HEAL priorities and Meaningful Use) – Does a
service support State policy goals or help close a gap in promoting goals? What
services accelerate health IT adoption or adherence with policy, or correct market
imperfections? Should the State consider regulating, sponsoring or delivering these
services to achieve results? What are the policy or governance implications of
changing the implementation model which today is based on regional organizations?

 Core or value-added – Does this service enable other interoperability services? If

so, how, and does this require or encourage centralization? Is a service
foundational because it is closely coupled to other services? Should services be
bundled or implemented in a granular fashion? (Bundling capabilities together may
result in more complete services offered, while granular and separate services may
preserve flexibility and potentially lower adoption costs.) What is the priority
sequencing of service bundles and core services based on meaningful use
requirements and HEAL specifications?

 Value to participants – What services are valuable, and to whom (e.g., PCP,
hospital, specialist, LTC, home health, payers, consumers, etc.), at present and in
the future? This plays a key role in determining HIE service sustainability, since it is
an indicator of what the market will pay for.

 Statewide shared service or standardized regional approach – Are there clear

technology choices that may be made and agreed upon at a statewide level for this
service? Are there significant economies of scale available if a portion or all of this
service were centralized? Is the service required for, or does it enable, cross-state
coordination or national interoperability? If so, this might argue for centralization of
the service to aid in coordination across states. Are there well-defined and tested
standards that can be used to govern regional standardization? If not, this might
argue for centralization to avoid duplication of definition and testing effort. Are there
existing implementations of the service that should be considered and leveraged? If
there are existing, robust regional implementations, there may be no need for a
centralized service. Will this service require local workflow or technical integration
and training? Is local trust or coordination required for adoption? If so, this might
argue for regional control.

 Public utility or market driven approach – Is a viable national or vendor service

available today or likely to develop naturally without investment or coordination from
NYS? Is it widely available and affordable? Is there justification for ensuring State

133
 control over the service? Is the service critical to the State based on State policy
priorities or timelines?

The Work Group also articulated principles to govern their evaluation and prioritization
efforts:

 NYS goals and policies take precedence over all other evaluation criteria – HIE is a
means to an end in improving health care delivery in the state, not an end in and of
itself.

 Priority should be given to pragmatic projects and results that may be delivered
quickly rather than risking delays as a result or excessive analysis or design or
uncertainties regarding future market or policy developments.

 Use Federal (ONC) direction, the current Program Information Notice and the
framework, and requirements of the Operational Plan to define direction and drive
urgency.

 Use the prior work of HEAL and SHIN-NY as a foundational and unifying element,
and a differentiator for HIE in New York State, rather than as a rigid specification to
which all efforts must adhere.

 Leverage the best of what is already in place in the RHIOs and in the market.

 Consider what the vendor market will do (including what market forces are likely to
do, when anticipated developments are likely to occur, and whether the market will
do it well).

 Recognize that Federal meaningful use, with its more extensive market reach, is a
stronger driver for the vendor market than State-specific requirements.

 Develop sustainability and business models as developments evolve and lessons

are learned, based on cost requirements, which are more easily discerned than
market direction.

 Preserve flexibility in implementation and business models, since HIE is relatively

immature.

State-Level Shared Services and Repositories

This section describes the analytical process resulting from the Work Group‘s
application of above-described criteria and principles, as well as HIE service priorities
identified by the Work Group.

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Connected Capability and HIE Services Alignment

As previously described, the Collaborative Care Infrastructure Work Group identified 11

priority use cases referred to as “Connected Capabilities”, as well as 22 HIE
services, deployable as statewide ―shared services‖ or through standardized regional
approaches.

After validating this framework, the work group further refined the HIE architecture and
technical approach by:

 Cross-referencing HIE services to Connected Capabilities to identify which services

were most critical (―core‖) to enabling capabilities.
 Prioritizing services based on their value to their potential users.
 Relating services to state and federal policy objectives.
 Analyzing HIE / HIT trends relative the services to identify which could be expected
to be reasonably procured from commercial sources as opposed to being provided
through a public utility model promoted by New York State.
 Organizing services into implementation bundles or releases to form the basis of the
Operational Plan.

These activities resulted a prioritized model of shared statewide health information

exchange services to guide the Operational Plan. As the discussion below indicates,
services have been arranged into phases and categorized as either Core or Value-
Added.

• Research Data Aggregation

• Medical Necessity / Authorization Rules
Next Phase • Imaging Order / Result
Value-Added
• Eligibility / Claims Transactions Future
• Personally Controlled (Later Phases)
Health Records
• Quality and Analytics
Reporting / Feedback
• Health Record
• Patient Education Portal

• Event Notification
• Clinical Decision Support / Medication
Safety

High Priority • Public Health Reporting / Registry

Value-Added • E-Prescribing w/Formulary
• Lab Order / Result

• Medication • Record Locator / MPI

Data
• Message / Record Routing
Mgmt. • Vocabulary
• Provider / HIE Directory Translation
• Consent Management • Disclosure
• Identity Management and Authentication Logging

High Priority Next Phase

Core Core

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The framework described here is designed to communicate and coordinate the
development and deployment of HIE services aligned with New York State‘s HEAL
health IT strategy, Federal health IT programs, meaningful use mandates, and
developments in the commercial market related to health information exchange. The
resulting strategy and this Operational Plan for statewide HIE are intended to update the
SHIN-NY architecture to enable providing and accessing shared exchange services
uniformly statewide.

Core vs. Value-Added Services

Members of the Collaborative Care Infrastructure Work Group assessed the relative
importance of standardized statewide HIE services to enabling prioritized Connected
Capabilities. The group applied a scale of 0 to 5 to rate criticality:

0 = Service is not applicable to the Connected Capability.

1 = Service may be useful in enabling a Capability, but Capability can clearly be enabled
without the service.
2 = Service is somewhat useful in enabling a Capability; still not critical, but there is a
recognizable benefit in having the service.
3 = Service enables a Capability; there is a clear benefit to having the service and it is
difficult to see how the Capability could be enabled without the service.
4 = Service is important in enabling a Capability; the value of the Capability would be
severely diminished without the service.
5 = Service is required to enable a Capability; Capability cannot be enabled without the
service.

The results of the analysis were tabulated as follows:

1. The total number of the above dependency / criticality scores were added together.
2. The sum total for each service was averaged for the number of non-zero scores in
support of a Connected Capabilities.
3. The service average was multiplied by the total score and by the number of times it
was identified to determine a meaningful ―factored result‖ that takes into account.
how critical the service is in supporting all Connected Capabilities, how important it
is on average and how many Capabilities it supports.

The table below summarizes tabulated results (with the total factored result rounded to
the nearest one-hundredth for presentation).

136
 Shared / Standardized Services

Record Locator Service / Master Person Index

Clinical Decision Support / Medication Safety

Identity Management and Authentication

Medical Necessity / Authorization Rules

Personally Controlled Health Record

Quality and Analytics Data Center
Public Health Reporting Registry
Eligibility / Claims Transactions
Medication Data Management

Research Data Aggregation

Message / Record Routing

Provider / HIE Directory

Vocabulary Translation

Imaging Order / Result

Consent Management

Health Record Portal

Disclosure Logging

Lab Order / Result

Event Notification

Patient Education
E-Prescribing
Formulary
Connected Capability
Route visit data to providers and other authorized parties 5 5 5 3 4 3 5 1 3 1 2
Route data in support of care transitions, including referrals 5 5 5 3 4 3 5 2 3 2 4 2 2
Route lab and imaging orders and results 5 5 5 4 4 2 5 5 3 5 3 4 2 2
Query patient history 5 4 5 4 3 5 5 4
4 4 5
Route electronic prescriptions 5 5 3 1 4 4 4 3 5 5
Retrieve medication history for medication reconciliation, other medication mgt. 5 5 5 4 5 5 5 3 4 3 1 2
Route visit and other data for clinical decision support 5 5 5 4 4 2 4
3 3 2 5 4
Route data to patients and enable ownership and management 5 5 5 4 3 5 3
4 2 4 1 5 4
Adjudicate and manage claims and/or patient responsibility 5 5 3 4 4 5 5
Route visit and other data for standardized quality reporting 5 5 4 4 4 3 3 3 2 5
Route visit and other data to disease registry 5 5 5 4 4 4 4 2 5
Route visit and other data for standardized public health reporting 5 5 4 4 4 3 3 4 3 3 5
Factored Result (total score x average score x # of dependencies x .1) 36 35 29 16 14 9 8 7 6 5 5 4 3 3 2 1 1 <1 <1 <1 <1 0
Core Value-Added

As the table above reveals, the analysis identified services that are foundational and
critical to a high number of Connected Capabilities. These services have been
designated ―Core Services‖ for New York‘s SHIN-NY HIE architecture, with all other
services designated ―Value-Added‖.

Core services must be made available on a uniform basis to support Connected

Capabilities statewide. These services may be provided as a single statewide shared
service or by standardizing regional approaches to developing and delivering the
services. In either case, NYeC will coordinate activities to ensure that all potential state
HIE participants have access to them. By contrast, value-added services, while
necessary to varying degrees to support Connected Capabilities, may be implemented
with more variability, depending on HIE objectives and regional capabilities.

Value-Based Service Prioritization

A subgroup of the Collaborative Care Infrastructure Work Group asked providers and
other NYS stakeholders to rank services according to how important and valuable the
services would be in meeting their HIE participation requirements. Informants included
hospital executives knowledgeable in HIE, hospital-based physicians (inpatient,
outpatient, emergency department and hospitalists), faculty-based practice leaders,
community-based primary care providers (PCPs) and payer representatives.

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The survey asked participants to consider whether each service was valuable to them
today or would be in the near future. Informants ranked services according the
following:

 Cost savings potential.

 Revenue enhancement potential.
 Ease of adoption.
 Administrative simplification in the back office (simplified billing, etc.).
 Patient satisfaction potential.
 Coordination of care enablement.
 Patient safety and outcome improvement potential.

In tabulating results, the highest and lowest individual rankings of each service were
eliminated to remove any anomalies introduced by a small sample size. The remaining
responses were then averaged across all remaining rankings. The table below
organizes the results into thirds, identified as high, medium and low priorities for service
provisioning.

Ordinal
Service Rank Priority Notes / Evaluation Anomalies
Message / Record Routing 1 H
Lab Order / Result 2 H
Provider / HIE Directory 3 H Ranked much lower by smaller practices
Medication Data Management 4 H
Vocabulary Translation 5 H Ranked much lower by smaller practices
E-Prescribing 6 H Ranked much lower by hospitals
Imaging Order / Result 7 H
Record Locator Service / Master Person Index 8 M Ranked much lower by smaller practices
Formulary 9 M Ranked much lower by hospitals
Event Notification 10 M
Quality and Analytics Reporting / Feedback 11 M May not reflect policy considerations
Public Health Reporting / Registry 12 M Interest high for reporting, low for registry; may not reflect policy need
Identity Management and Authentication 13 M May not have been understood by non-technical reviewers
Medical Necessity / Authorization Rules 14 M
Eligibility/Claims Transactions 15 M
Research Data Aggregation 16 L
Clinical Decision Support / Medication Safety 17 L
Personally Controlled Health Record 18 L May not reflect policy considerations
Consent Management 19 L
Patient Education 20 L May not reflect policy considerations
Disclosure Logging 21 L
Health Record Portal NR NR

This exercise identifies those services that potential HIE users themselves consider
important, as well those with sufficient value to encourage users to adopt them. Users
may be willing to fund these services with fees that could make them self-sustaining in
order to meet their own operational objectives, to participate in State-funded or required
collaborative activities, or to earn federal meaningful use incentives.

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Policy Alignment and Support from Services

The Collaborative Care Infrastructure Work Group also assessed candidate services to
determine how well they help meet State and Federal policy goals related to HIE.
Services were matched to Stage 1 Meaningful Use requirements to assess Federal
alignment, with consideration given to guidance in the Program Information Notice (PIN)
for State HIE released July 6 and for what is expected in Stage 2.

To consider how HIE services would support New York State policy, the Work Group
reviewed the requirements of the HEAL program, specifically phases 5, 10 and 17.
Meaningful Use HEAL-5, 10/17 / PCMH
Service Stage 1 Stage 2/3 Functions Data Sets Alignment Sequencing
Message / Record Routing H H H H H Immediate
E-Prescribing H H H H H Immediate
Lab Order / Result H H H H H Immediate
Clinical Decision Support / Medication Safety H H H H H Immediate
Public Health Reporting / Registry H H H H Immediate
Quality and Analytics Reporting / Feedback H H H H Immediate
Patient Education M H H H H Immediate
Identity Management and Authentication M H H H Immediate
Provider / HIE Directory M H H H Immediate
Event Notification M H H H Immediate
Medication Data Management L M H H H Immediate
Consent Management M M H M Discuss
Personally Controlled Health Record L H H M Discuss
Record Locator Service / Master Person Index L H H M Discuss
Health Record Portal L M H M Discuss
Formulary M M M M Discuss
Disclosure Logging M M M Discuss
Imaging Order / Result L H M M M Discuss
Eligibility/Claims Transactions L H M M Discuss
Vocabulary Translation L H M M Discuss / Defer
Medical Necessity / Authorization Rules L L L Defer
Research Data Aggregation M L Defer

The Work Group then grouped the services into three categories: Those that need to be
addressed immediately; those that required further discussion; and those that might be
deferred at present, with one service (vocabulary translation) considered ―borderline‖
between requiring discussion and being deferred outright.

Market Analysis Related to Services

The Work Group took into consideration how the services would likely be addressed by
the commercial health IT/ HIE vendors and RHIOs over the next two to three years to
determine if service delivery could be left to the market or if a public utility approach to
providing the services is warranted.

139
Work Group members assessed whether each service is either available in the market
today or is likely to develop naturally without investment by the State or coordinated
market effort. For service(s) deemed likely to emerge naturally in the market place, the
Work Group examined whether that service as implemented is imperfect or only partially
supporting New York State‘s vision for HIE. In the event the group identified an
imperfect or partially available service or one that is not available, it assessed whether
there is sufficient market incentive for commercial vendors or RHIOs to develop the
service on their own, putting forward its best informed opinion as to whether those
incentives were strong, weak or to-be-determined. The group also ranked potential
market demand for a service and identified whether or not there were other strategic
factors as to why New York might want to exercise control over operation of the service
or influence how it was developed and delivered. The following table summarizes the
results of the group‘s analysis:

Exists in Market Potential Strategic Commercial

Service
Market Incentive Market Scale Value to NYS Market or Utility
Provider / HIE Directory N S H H U
Public Health Reporting / Registry N W L H U
Quality and Analytics Reporting / Feedback N T M H U
Message / Record Routing P S H H U
Medication Data Management P S H H U
Patient Education P W L H U
Consent Management N W M M U
Clinical Decision Support / Medication Safety N T M M U
Event Notification N T M L U
Research Data Aggregation N T L L U
Personally Controlled Health Record Y T M H C/U
Identity Management and Authentication P S H M C/U
Medical Necessity / Authorization Rules P T M M C/U
Vocabulary Translation P T M M C/U
Lab Order / Result P S M M C/U
Record Locator Service / Master Person Index P S H M C/U
Eligibility/Claims Transactions Y S H M C/U
Formulary P T H M C
Health Record Portal Y S M M C
Disclosure Logging N T L L C
Imaging Order / Result N T L L C
E-Prescribing Y S H L C

The table above identifies services that support New York State‘s policy and public
health goals (―the public good‖) but which neither the commercial marketplace nor
RHIOs are adequately supporting or likely to support. When identifying these services,
the Work Group took into account whether services might be needed in New York
before they would become available without some form of State involvement,
encouragement or management.

140
The last column compiles the analysis detailed in the other columns into a preliminary
recommendation as to whether the service should be delivered by the market or as a
―utility‖ service. Each service was identified as one that could clearly be left to the
commercial market to develop or deliver, one for which a public utility approach guided
by the State may be required, or one that required further discussion and analysis to
determine whether it favored a commercial (―C‖) or utility (―U‖) approach.

Location Analysis Related to Services

As the final step of its analysis, the Work Group analyzed whether individual services
were best developed and deployed statewide (centralized and shared), through
standardized regional approaches (with assistance or leadership from the RHIOs), or by
leveraging national or commercial solutions. The group attempted to answer the
following questions:

 Is a viable service available today or likely to develop naturally, and is it widely

available and affordable?
 Does the State need to ensure control over service development and deployment to
meet policy goals or timelines?
 Is the service a core service, foundational to state HIE, or requiring close
coordination among services?
 Are there potential economies of scale in a centralized service by eliminating
duplicative investments across regions and participants?
 Is the service required for, or does it enable, cross-state coordination or national
interoperability?
 Does the service aid in and increase the likelihood of widespread EHR adoption if
standardized or provided statewide?

The detailed location analysis is shown in the table that follows (―P‖ represents ―partial‖
in some assessment categories):

141
 Viable in State Core / Market Interstate / Local Aids in
Service
Market Control Value-Add Scale National Coordination Adoption
Provider / HIE Directory N H C H H P Y
Message / Record Routing P H C H H P Y
Medication Data Management P H VA H H N Y
Record Locator Service / Master Person Index P M C H H P Y
Quality and Analytics Reporting / Feedback N H VA M M N Y
Consent Management N M C M H Y Y
E-Prescribing w/Formulary Y L VA H H N Y
Lab Order / Result P M VA M M N Y
Imaging Order / Result N L VA L M N Y
Public Health Reporting / Registry N H VA L M N N
Personally Controlled Health Record Y H VA M H N N
Identity Management and Authentication P M C H H Y N
Vocabulary Translation P M C M M N N
Clinical Decision Support / Medication Safety N M VA M M N N
Disclosure Logging N L C L L N Y
Event Notification N L VA M M N N
Eligibility/Claims Transactions Y M VA H H P N
Medical Necessity / Authorization Rules P M VA M M N N
Research Data Aggregation N L VA L L N N
Patient Education P H VA L L P N
Health Record Portal Y M VA M L P N

This analysis suggests that certain characteristics would favor either a centralized
approach or a local/regional control. A single shared service might be implied when:

 The State needs to control development.

 The service is a ―core‖, infrastructural component that is broadly used to enable
other services.
 Potential economies of scale exist.
 Service is required for cross-state coordination or access to national services.
 Centralization aids in widespread adoption of the service itself or of other forms of
health IT critical to state policy objectives.

By contrast, local control may be more strongly warranted when:

 Service is value-added and not as critical to other services or across the State.
 Trust or coordination is required at the local level.
 Tight integration is required with local solutions.

Taking these considerations into account, the Work Group categorized services
according to whether the responsibility for selecting a service should be centralized or
left to regional or local control, or whether a service should be operated centrally or
regionally. In addition, the group highlighted services requiring a higher degree of policy
and standards guidance, either because policies and standards do not exist currently or

142
because they strongly support elements of State policy. Findings are listed in the
following table:

Selection Operation Requires Standards /

Service Statewide Regional Statewide Regional Policy Guidance
Public Health Reporting / Registry   Y
Provider / HIE Directory  
Research Data Aggregation  
Record Locator Service / Master Person Index   (if MPI)  (if RLS)
Quality and Analytics Reporting / Feedback   Y
Identity Management and Authentication Either Either Y
Vocabulary Translation Either Either
Consent Management   Y
Message / Record Routing   Y
Disclosure Logging   Y
Imaging Order / Result   Y
Medical Necessity / Authorization Rules   Y
Event Notification   Y
Patient Education   Y
E-Prescribing w/Formulary  
Lab Order / Result  
Eligibility/Claims Transactions  
Clinical Decision Support / Medication Safety  
Medication Data Management  
Health Record Portal  
Personally Controlled Health Record  

The group recognized that federated hybrids of centralized and regional services are
possible if governed by statewide policy guidance and standards, and that market timing
and cost are important considerations.

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 Appendix I – Project Management Plan

Tasks Start Finish

[Technical] Goal 1: Ensure that all care providers have access to HIE services at point of
use to meet federal Meaningful Use criteria and achieve New York State care delivery
goals in a manner that maximizes use of the SHIN-NY architecture, policies and
standards.
Tactic 1: Ensure availability by 2011 of options for eligible providers to meet meaningful criteria
relative to e-prescribing, receipt of structured lab results into the EHR and exchange of patient
care summaries.

e-prescribing: Leverage the widely available EHR options in 10/1/2010 Ongoing

1.1
the market that have connections to Surescripts
e-prescribing: Convene interested public agencies and private 1/1/2011 6/30/2011
sector stakeholders in a Statewide Collaboration Process work
group to update statewide policy guidance (leveraging federal
rules) to allow e-prescribing of controlled substances (per
1.2 recent law change) and address approaches to complying with
―dispense as written‖ rules
e-prescribing: Work with Surescripts to get more detailed data 10/1/2010 1/31/2011
on the availability of pharmacies supporting e-prescribing by
geographic area to investigate regional gaps
e-prescribing: Work with state agencies and public and private 1/1/2011 6/30/2011
1.3 payers to identify policy and purchasing levers to incentivize
small pharmacies to support e-prescribing
e-prescribing: Analyze options to develop provider 2/1/2011 3/31/2011
1.4 authentication services as a potential ―shared service‖ solution
to overcome barriers to prescribing of controlled substances
Electronic delivery of lab results to provider EHRs: Leverage 10/1/2010 Ongoing
the available EHR and RHIO options in the market that make
1.5 available connections to national and regional labs
Electronic delivery of lab results to provider EHRs: Convene 1/1/2011 6/30/2011
RHIOs, providers, lab companies through the Statewide
Collaboration Process to develop longer-term strategy to
address lab connections, with a focus on connecting small and
1.6 independent labs
Electronic delivery of lab results to provider EHRs: Convene 1/1/2011 6/30/2011
stakeholders, including public and private payers, to explore
potential policy and/or purchasing levers to incentivize lab
1.7 companies to facilitate electronic results delivery to EHRs
Electronic delivery of lab results to provider EHRs: Analyze 1/1/2011 3/31/2011
options to develop terminology translation services as a
potential ―shared service‖ solution to ensure availability of lab
results in community exchanges in a common standardized
1.8 language

144
 Tasks Start Finish
[Technical] Goal 1: Ensure that all care providers have access to HIE services at point of
use to meet federal Meaningful Use criteria and achieve New York State care delivery
goals in a manner that maximizes use of the SHIN-NY architecture, policies and
standards.
Electronic delivery of lab results to provider EHRs: Analyze 1/1/2011 3/31/2011
options for a future lab network service as a potential ―shared
1.9 service‖ solution
Patient care summary exchange: Leverage the available EHR 10/1/2010 Ongoing
and RHIO options in the market that make available patient
care summary exchange functionality among their clients and
1.10 participants
Patient care summary exchange: Explore options to create 1/1/2011 6/30/2011
partnerships and pilot programs with RHIOs and EHR/HIE
companies (per Goal 2 below) that are deploying NHIN
standards-based patient care summary exchange services for
1.11 their customers
Patient care summary exchange: Explore options to develop 1/1/2011 3/31/2011
provider directory services as a potential priority ―shared
service‖ solution to facilitate patient care summary exchange
1.12 among providers as part of transitions of care

[Technical] Goal 2: Update the SHIN-NY technical architecture to support shared

services goals and align with national standards and architectures.
Tactic 1: Review and update the SHIN-NY technical architecture and implementation strategy
based on “shared services” deployed on a statewide and regional basis.
Engage stakeholders and experts to evaluate the current 1/1/2011 3/31/2011
technical architecture and service models, develop options for
1.1 new architecture designs and lead review sessions
Convene Statewide Collaboration Process (SCP) work group 1/1/2011 3/31/2011
1.2 to review potential architecture and service model designs
Update SHIN-NY architecture and service models based on 3/31/2011 6/30/2011
1.3 the outcomes of those sessions

Tactic 2: Update the SHIN-NY specifications to ensure they are aligned with NHIN architecture
and standards and common adoption practices.
Conduct gap analysis of existing SHIN-NY specifications 1/1/2011 3/31/2011
2.1 compared to the latest NHIN specifications
Develop draft plan for incorporating NHIN Direct technical 1/1/2011 3/31/2011
2.2 specifications into SHIN-NY specifications
Convene SCP technical work group to review plans and 1/1/2011 6/30/2011
identify plans to fill any gaps not covered by existing NHIN
2.3 specifications
Update SHIN-NY specifications to align with NHIN 1/1/2011 Ongoing
2.4 specifications

145
 Tasks Start Finish
[Technical] Goal 1: Ensure that all care providers have access to HIE services at point of
use to meet federal Meaningful Use criteria and achieve New York State care delivery
goals in a manner that maximizes use of the SHIN-NY architecture, policies and
standards.

Tactic 3: Develop models for shared services that consolidate key infrastructure components to
reduce service delivery cost (price per transaction), increase adherence to technical standards,
and improve ability to manage statewide policies.

Conduct assessment of the existing health IT and HIE systems 1/1/2011 3/31/2011
in use, including those deployed by state agencies, RHIOs,
3.1 other national and regional HIE networks, providers and payers
Identify gaps in the availability of effective health IT and HIE 1/1/2011 3/31/2011
services including gaps related to functionality, geographic
3.2 penetration and provider adoption
Conduct user focus groups to review the services under 3/31/2011 6/30/2011
consideration, and identify key functional needs and related
3.3 value
Conduct assessment of the right governance and business 1/1/2011 6/30/2011
models for those HIE services, including where the choice of
technology should be made, where it should be deployed and
3.4 maintained, and how it should be integrated into workflow
Simultaneously participate in discussions with other States to 10/1/2010 Ongoing
explore plans for multi-state deployment of services that are of
3.5 mutual interest.
Identify additional levers to advance HIE services, including 1/1/2011 6/30/2011
3.6 policy, purchasing and regulatory actions
Develop a timeline and work plan for building HIE services, 3/31/2011 6/30/2011
3.7 and advancing other policies to ensure their broad deployment

Tactic 4: Measure and evaluate New York’s progress in advancing adoption and use of HIE
services.
Enhance existing RHIO dashboard tool to measure New York‘s 10/1/2010 3/31/2011
progress in advancing adoption and use of health IT and HIE
4.1 services including metrics identified in ONC-HIT-PIN-001
Partner with NYS DOH‘s Wadsworth Center and NY Health 1/1/2011 3/31/2011
Plan Association to survey lab companies and payers on
current adoption support of electronic results delivery and
4.2 electronic eligibility and claims transactions
Publish health IT/HIE progress reports on a regular schedule 10/1/2010 Ongoing
and upon reaching a sufficient level of maturity in the tool make
4.3 the reports public
Use data to identify gaps in New York‘s progress, investigate 10/1/2010 Ongoing
4.4 those gaps further through stakeholder interviews before

146
 Tasks Start Finish
[Technical] Goal 1: Ensure that all care providers have access to HIE services at point of
use to meet federal Meaningful Use criteria and achieve New York State care delivery
goals in a manner that maximizes use of the SHIN-NY architecture, policies and
standards.
determining corrective action

[Technical] Goal 3: Drive broad adoption of the SHIN-NY technical architecture, policies
and standards by certified EHR vendors.
Tactic 1: Develop an inclusive and transparent process to engage EHR vendors in development
of SHIN-NY interoperability requirements and implementation strategies, including interface
pricing.

Collectively agree to collaborate on the development of 1/31/2011 6/30/2011

interface standards that allow EHR/HIE products to utilize state
1.1 services for a selected set of end-user capabilities
Develop a timeline and roadmap for pilot development and 6/30/2011 9/30/2011
1.2 implementation
Evaluate the results and identify obstacles to broader, TBD TBD
1.3 ―production-level‖ deployment
Determine how policy and incentives can be leveraged to 1/1/2011 Ongoing
promote and ensure broad adoption of EHR-HIE
1.4 interoperability

147
[Governance] Goal 1: Advance a governance structure for the SHIN-NY, including
roles and responsibilities for NYS DOH, NYeC, RHIOs and other “qualified
organizations,” providers, data suppliers, and other stakeholders.
Start End
Tactic 1: Define roles and responsibilities of all entities involved in governance funding and
technical support to oversee and operate the SHIN-NY, including Qualified HIT Entities and
Collaborative Care Communities (CCCs)

Refine criteria for Qualified Health IT Entities and address 10/1/2010 3/31/2011
the following:
 Development of mechanisms for escalation of
1.1
issues and dispute resolution.
 Determine the eligibility of for-profit organizations
to serve as qualified entities.
1.2 Refine criteria for CCCs. 10/1/2010 3/31/2011
Develop accreditation process for Qualified Health IT 1/1/2011 3/31/2011
1.3
Entities and CCCs.
Explore ways to strengthen and make permanent the 10/1/2010 6/30/2011
relationship between NYS DOH and NYeC. Options
include:
 Participation of State officials on NYeC Board
1.4
 Right of State to approve certain NYeC by-law
changes
 Long-term contractual relationship relating to
participation by NY Medicaid program in SHIN-NY

Tactic 2: Develop governance, organizational and business models for operation and
oversight of the SHIN-NY, including “public utility” and community supported services.
Use outputs of above analysis to prepare different 10/1/2010 6/30/2011
organizational models for operating and overseeing all
components of the SHIN-NY technical architecture and
2.1 services
Convene SCP work group to refine models and prepare 6/30/2011 12/31/2011
recommendations to be considered through the SCP
2.2 approval process

Tactic 3: Determine the legal and regulatory models to support the models identified in
Tactic 2 and oversee and enforce compliance with Statewide Policy Guidance.
Prepare potential legal and regulatory structures for 6/30/2011 9/30/2011
binding participants to Statewide Policy Guidance,
3.1 including certification process for those entities providing
access to shared services and overseeing community
governance
Gather input through SCP work group and advance 9/30/2011 12/31/2011
3.2 recommendations to NYS DOH

148
[Policy/Legal] Goal 1: Enhance and strengthen Statewide Policy Guidance through
the Statewide Collaboration Process.

Tactic 1: Update SCP to include new HEAL projects, other stakeholders and key State
Agencies.
Identify common policy, operational, and business 10/1/2010 Ongoing
priorities with other State Agencies and involve them in
1.1 SCP work groups addressing those issues
Update the composition of POC based on the range of 10/1/2010 1/31/2011
organizations participating in the HEAL 10 and 17
1.2 programs
Establish the Health IT Strategy Council 10/1/2010 1/31/2011
 Identify and recruit council members
1.3  Draft and adopt council charter and bylaws

Tactic 2: Reconvene the SCP to develop statewide policies that govern health information
exchange in the public’s interest.
Gather input from HEAL projects and other stakeholders 10/1/2010 Ongoing
participating in the SHIN-NY on outstanding issues
2.1 requiring resolution
Identify ways to align state policies and requirements with 10/1/2010 Ongoing
federal criteria for meaningful use and patient-centered
2.2 medical homes
Analyze plans for deployment of shared services to 10/1/2010 Ongoing
identify specific policy issues requiring resolution for their
2.3 successful implementation
Reconvene SCP work groups 10/1/2010 1/31/2011
 Draft work group charters
 Identify and recruit chairs
2.4  Recruit work group members
Convene SCP Work Groups to develop and recommend 1/1/2011 6/30/2011
2.65 standards and policies.
Establish clear and measurable goals for the NYS HIE 1/1/2011 3/31/2011
and develop a monitoring tool.
 Finalize clinical/population health goals and health
IT adoption/usage goals.
 Develop a monitoring plan.
 Develop a communication plan to inform providers
2.6 of the statewide goals.
Develop communication tools to educate consumers and 1/1/2011 3/31/2011
providers of the statewide health IT and HIE strategies
and activities.
 Convene the Consumer and Provider Engagement
2.7 Work Group.

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  Research available effective communications and
education tools
 Implement identified communication tools.

Tactic 3: Refine New York’s privacy and security policies and procedures
Reconvene Privacy and Security Work Group to work on 1/31/2011 Ongoing
set of priority topics that need attention and new policy
3.1 development.
3.2 Develop and approve new policies on priority topics. 1/31/2011 6/30/2011
Conduct next periodic review of existing privacy and TBD TBD
security policies and procedures including an opportunity
for public comment; advance recommendations through
3.3 review and approval process.
Continue to track new privacy and security policies being 10/1/2010 Ongoing
advanced the federal level and update New York‘s
policies accordingly.
3.4

[Finance] Goal 1: Identify sustainable revenue paths for maintaining the SHIN-NY,
including New York’s statewide and regional HIE infrastructure.
Tactic 1: Develop business model for the public utility infrastructure
Refine business model including likely costs to develop 10/1/2010 3/31/2011
and operate the utility and revenues based on adoption
1.1 assumptions and potential user fee structures
Finalize cost and revenue models into an overall 3/31/11 6/30/2011
sustainability model and business plan ready for
1.2 submission to ONC

Tactic 2: As part of assessment of potential shared services outlined in “Collaborative Care”

section, conduct cost-benefit analysis of moving to shared services compared to leveraging
existing RHIO or EHR functionality.
Develop cost estimates for the development and 1/1/2011 3/31/2011
maintenance of candidate SHIN-NY shared services
2.1 (including both central and regional dimensions)
Conduct analysis to identify required investments to 3/31/2011 6/30/2011
2.2 leverage other models, including existing RHIO services
Complete cost-benefit analysis for inclusion in ―shared 6/30/2011 9/30/2011
2.3 services‖ analysis

Tactic 2: Based on the governance, technical and business models developed through the
SCP, analyze different options for “utility” financing models for core SHIN-NY infrastructure
and services, as well as community-level infrastructure and services.
Identify potential utility financing models including those 1/1/2011 9/30/2011
used in other industries and review advantages and
2.1 disadvantages of different models for sustaining SHIN-NY

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 services
Test potential pricing models with potential end users, 9/30/2011 12/31/2011
taking into account end users‘ total cost of ownership, as
well as RHIOs and EHR/HIE vendors that might leverage
2.2 the service as part of their applications
Conduct other analysis to identify the required 6/30/2011 9/30/2011
investments to sustain the utility services, taking into
2.3 account the potential changes in usage over time
2.4 Incorporate revenue models into the business model 9/1/2011 9/30/2011

Tactic 3: Assist RHIOs and coordinated care projects in establishing robust long-term
regional sustainability. (Shared with Payment Reform Work Group).
Help ensure regional efforts are aware and capable of 10/1/2010 Ongoing
supporting emerging value opportunities related to state
3.1 and national health reform
Work with RHIOs and coordinated care projects to better 10/1/2010 Ongoing
understand and document the total investments required
to implement and operate the necessary health IT and
HIE services for effective patient-centered medical homes
3.2 and other community collaborative care initiatives
Develop a framework for modeling those costs as an 10/1/2010 Ongoing
input into potential financing mechanisms, including
payment reform initiatives, and develop recommendations
3.3 on policies to implement this financing

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[Public Health] Goal 1: Monitor health status.
Tactic 1: Facilitate public health reporting and enhanced data collection for surveillance.
Identify, describe and address reporting challenges and 10/1/2010 11/1/2010
1.1 barriers for providers and county health departments
Support development and implementation to increase use 10/1/2010 3/1/2012
of the SHIN-NY and RHIOs connected to the UPHN for
providers to meet new reporting requirements rather than
using older methods (i.e. for new maternal fetal health
1.2 requirements for newborn screening etc.)
Continue to support older electronic reporting systems but 10/1/2010 Ongoing
transition to UPHN model connecting to the SHIN-NY to
1.3 help decrease duplicative reporting and other burdens
Using Immunization as a model, develop a repeatable 1/1/2011 1/1/2012
and scalable process for implementing bidirectional data
transfer connections between NYS DOH systems and the
1.4 UPHN
Build on the model developed for Immunization and
implement connections to the UPHN for Newborn
1.5 Screening

Tactic 2: Implement bi-directional data transfer for Immunization reporting.

Enable providers to be able to submit the queries from 1/1/2011 1/1/2012
their EHR via RHIO connection to the SHINY-NY and the
UPHN to NYSIIS to search for individual's immunization
2.1 history
Enable the immunization results for the query submitted 10/1/10 12/1/2010
by the provider to be provided back to the provider via a
RHIO in a format that can allow the information to be
2.2 uploaded to the provider EHR system
Enable providers to be able to receive guidance from 1/1/2011 1/1/2012
NYSIIS on recommendations for an individual's needed
2.3 immunization in their EHRs
Enable providers to be able to receive and respond to the 10/1/2010 12/1/2010
queries and batch reporting of data on immunizations
given from their EHR systems to NYSIIS via the UPHN
2.4 and have a RHIO act as an intermediary

[Public Health] Goal 2: Diagnose and investigate health problems.

Tactic 1: Facilitate public health investigation.
In coordination with Governance and Sustainability Work 11/1/2010 2/1/2011
Group efforts, complete development and implementation
of certification process for RHIOs and HIEs to connect to
the UPHN to provide services for de-identified line list
1.1 queries for specified public health issues.
1.2 Implement identified patient specific queries for CCD with 4/1/2011 12/1/2011

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 specified clinical content for public health investigation
needs.

Tactic 2: Provide earlier identification of disease trends and gaps for disease prevention and
intervention.
Access reporting of clinical information via subscription 1/1/2011 3/1/2011
query services that may be hosted at the RHIO or SHIN-
NY level more directly with provider EHR systems to
2.1 result in decreased time to reporting

[Public Health] Goal 3: Inform and educate about health issues.

Tactic 1: Improve ability for public health to communicate with clinical providers.
Define technical architecture including data standards and 11/1/2010 6/1/2011
protocols for bi-directional exchange with provider EHRs
of public health related data and clinical guidance and
require EHRs to include this functionality through
1.1 Statewide Policy Guidance
Promote the PCMH in order to center the patient and the
1.2 primary care practice for coordination of care

Tactic 2: Improve ability for public health to communicate with targeted patient populations.
Provide data for improved clinical decision support, 2/1/2012 6/1/2012
enabling providers to better inform and share information
with patients about their care and align their care with
2.1 prevention and other population health priorities

[Public Health] Goal 4: Mobilize community partnerships.

Tactic 1: Define requirements for standards-based electronic data exchange, promoting
increased communication and coordination of services among local and state agencies and
providers.
Collaborate with stakeholders to assess existing systems 10/1/2010 3/1/2011
and streamline standards implementation for new and
1.1 existing systems.

Tactic 2: Increase collaborative health IT planning with other HHS agencies in NYS.
Continue to gather and evaluate summary 10/1/2010 Ongoing
2.1 recommendations from HHS CIO work group.

Tactic 3: Provide clinicians with public health prevention and control recommendations,
guidelines, alerts, and advisories to improve identification and management of diseases and
conditions of public health importance.
Improve access for the clinical community to disease 3/1/2011 7/1/2011
screening, medical management, or care coordination
recommendations and guidelines from NYS DOH (e.g.
3.1 cancer screening eligibility, asthma treatment guidelines)

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 via the web (general information) or web services through
the UPHN or the health commerce system (patient
specific targeted information)

Tactic 4: Collaborate with Collaborative Care Infrastructure Work Group to evaluate the
potential to provide statewide “shared services” through expansion of current NYS DOH
systems.
Evaluate potential options for the following services: 12/1/2010 12/1/2011
 Open source connectivity to the UPHN for public
health reporting and consuming public health
guidelines directly from and directly into a provider
EHRs
 Laboratory terminology services as a state wide
service
 Provider identification using the health commerce
system as a state wide service
 Trusted and secure clinical messaging between
providers as a shared service provided in the health
4.1 commerce system linked to provider EHRs

Tactic 5: Enable greater levels of communication and collaboration with local health
departments.
Enable ability for local health departments to access 11/1/2010 2/1/2011
5.1 physician contact information and identity
Enable local health department access to a CCD or other 4/1/2011 12/1/2011
5.2 clinical summary
Enable local health department notification regarding 10/1/2011 1/1/2012
5.3 ordering of lab tests for specific syndromic diseases
Provide local health departments with aggregate data about 1/1/2011 4/1/2011
5.4 chronic disease by county
Promote the PCMH model for interaction with public health 10/1/2010 Ongoing
through coordination of care by the primary care physician
practice and facilitate communication through data
5.5 exchange
Enhance current public health applications on the health 10/1/2010 Ongoing
5.6 commerce system

Tactic 6: Support local health departments who provide direct patient services.
Assist local health departments with technology decisions 6/1/2011 12/1/2011
and implementation (including connectivity for data
exchange) of EHRs where those departments provide
direct services for health care such as immunization, TB
6.1 and well child clinics etc.

[Public Health] Goal 5: Develop policies and plans.

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Tactic 1: Develop general policies to address patient consent and specifically minor
consent, consent for vulnerable populations and consent for levels of use (e.g. treatment,
health care operations, research, and population health).
Assess existing policies and laws, existing Statewide Policy 10/1/2010 3/1/2011
Guidance for Privacy and Security, identify information
1.1 sharing goals and objectives collaboratively

Tactic 2: Enact requirements for providers with in-house laboratories to provide access to
individual lab results through the SHIN-NY and supply data for aggregation and analysis to
the extent required to achieve public health and Medicaid objectives.
Work with providers to identify value opportunities for 10/1/2010 6/1/2011
2.1 information sharing, draft regulations to support the solution

Tactic 3: Establish regulations that enable, promote, and mandate bi-directional data
exchange and clinical decision support with all health care providers based on the PCMH
model and investigate the need for mandated reporting through certified EHRs.
Restrict access to state data to occur through the UPHN 10/1/2010 2/1/2011
based on compliance with Statewide Policy Guidance. This
will ensure the use of HIE services necessary for public
health and Medicaid agendas. It will also encourage
participation in statewide registries and compliance with
interoperability/connectivity aggregation requirements by all
3.1 RHIOs or otherwise qualified entities.
Organize data exchange and public health related clinical 10/1/2010 9/1/2011
guidance to occur through the PCMH model of coordination
3.2 of care

Tactic 4: Effectively integrate public health participation in statewide health IT Action Item
and policy development through participation in NYeC.
Establish representation on SCP work groups and decision-
4.1 making bodies

Tactic 5: Work with border states and border state coalitions for public health (New Jersey,
North East States Coalition, Mid Atlantic States Coalition).
Pursue opportunities for leveraging best practices in health 10/1/2010 Ongoing
IT, and information sharing across state lines where
5.1 appropriate

Tactic 6: Design and implement a NYS DOH agency-wide governance structure for health
IT decision-making.
Support OHITT‘s multi-disciplinary and cross-Office 10/1/2010 Ongoing
governance initiative to streamline health IT policies across
6.1 all programs including, but not limited to, Public Health
Operationalize the Public Health Information Master Plan 10/1/2010 11/1/2010
6.2 (PHIM) and Health Information Exchange Initiative
6.3 Build on successes related to implementation of the PHIM 11/1/2010 1/1/2011

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 and PH-HIE initiative to develop a model framework that
will enable cross-discipline health IT decision-making within
NYS DOH that enables priority setting and coordination
between programs with health IT components
Ensure collaboration takes place within the department and 10/1/2010 Ongoing
with outside partners. The ultimate goals of this process are
to facilitate public health-wide governance, planning and
priority setting, integrate public health programs and
leverage and provide core guidance and assistance on
6.4 strategic alignment for funding opportunities.
Focus areas for meaningful use, prioritize immunization and 10/1/2010 11/1/2010
public health surveillance databases will be initial
6.5 candidates for this coordinated approach

Tactic 7: Facilitate partnerships between clinicians and public health practitioners in ways
that address the needs of both clinical care and public health.
Leverage clinicians‘ drive to achieve meaningful use by 11/1/2010 5/1/2011
improving the standardization and availability of health
7.1 information for public health
Create working relationship with technical staff to develop 10/1/2010 12/1/2010
technical and data testing and certification plans focused on
7.2 a specific use data/program use case

Tactic 8: Connect the UPHN to Medicaid systems.

Provide mechanism for data sharing between Medicaid 11/1/2010 5/1/2012
8.1 information systems and public health

[Public Health] Goal 6: Enforce laws and regulations.

Tactic 1: Utilize the expanded regulatory abilities of the Commissioner of Health role.
1.1 Develop and enforce updated or new health IT regulations 10/1/2010 12/1/2011
Leverage the SCP and existing capacity for regulatory 11/1/2011 Ongoing
1.2 development and enforcement

Tactic 2: Ensure production level implementation of the UPHN to facilitate mandated

reporting and provide public health guidance. (see Goal 1)

Tactic 3: Accomplish meaningful use and other public health information needs by
leveraging and enhancing the UPHN.
Support optional Meaningful Use Public Health 10/1/2010 1/1/2011
Requirements for all providers in 2011 through submission
of immunization reports via direct connection of EHRs to
Immunization registry OR data exchange to registry via
3.1 UPHN and RHIOs
Support optional reporting of MU public health 1/1/2011 12/1/2011
requirements for all providers in 2011 for submission of
3.2 syndromic surveillance either through ECLRS and PHIN

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 MS or UPHN and RHIOs
Expand use of UPHN for bidirectional data exchange to 1/1/2011 12/1/2012
support Public health MU requirements for both
Immunization and syndromic surveillance through RHIOs
3.3 and the SHIN-NY
Support reporting of patient registries for quality 4/1/2011 11/1/2011
3.4 improvement and public reporting through the UPHN
Support 2015 MU objectives through further expansion of 10/1/2010 Ongoing
UPHN connectivity to providers through RHIOs and the
3.5 SHIN-NY

Tactic 4: Evaluate and develop new methodologies for site reviews and other auditing
procedures in public health to handle the increased use of health IT and EHRs by health
care providers.
Evaluate regulatory requirements for reviews and audits 6/1/2012 9/1/2012
and match these requirements to health IT methodologies
such as using HIE portals to access electronic patient
records for site reviews and possible development of a
4.1 public health review clinical view

[Public Health] Goal 7: Link people to needed health services.

Tactic 1: Further promotion and support of the medical home model to coordinate care and
services.
Coordination of services through HIE - promote RHIO/HIEs 1/1/2011 5/1/2011
providing collective data on services to providers and
referral functions to multiple different agency supportive
1.1 services
Identify and support ways for patients to take more direct 4/1/2011 5/1/2011
1.2 control and responsibility for their own medical care
Support and further the efforts to implement the CHI2 10/1/2010 Ongoing
project, as a major first step in integrating NYS DOH child
1.3 health data into the medical home model

Tactic 2: Improve ability for providers to only have to enter patient information once and
have it used for multiple different public health reporting requirements from different
programs.
Increase bi-directional sharing of data and guidance with 12/1/2010 Ongoing
2.1 providers based on the PCMH model for care coordination
Support and further the efforts to implement the CHI2 10/1/2010 Ongoing
project. Multiple siloed maternal and child health data
systems exist within NYS DOH, requiring providers to
access multiple systems and enter redundant data related
2.2 to reporting of child health data.

Tactic 3: Ensure sufficient short and long-term funding to enable accessible, effective and

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efficient statewide health information exchange.
Identify required resources for supporting public health and 10/1/2010 1/1/2011
3.1 health IT
3.2 Identify Public Health funding priorities 10/1/2010 3/1/2011
3.3 Promote and emphasize market drivers: 10/1/2010 Ongoing
Determine feasibility of using current public health program 11/1/2010 1/1/2011
3.4 funds to support strategic imperatives

Tactic 4: Ensure feasibility and necessary support among public health users for
implementation and adoption of statewide health information exchange.
Engage public health stakeholders in frank and honest 10/1/2010 5/1/2011
discussion of the concerns, challenges and desired future
4.1 outcomes relative to their vision and fears for HIE
Develop a specific action plan based on stakeholder input 10/1/2010 6/1/2011
and designed to identify a 3 year phasing of initiatives
4.2 developed to address their concerns
Identify specific ways NYS DOH can support public health 10/1/2010 Ongoing
stakeholders with the necessary financial, capital and
4.3 human resources necessary for HIE implementation
[Public Health] Goal 8: Assure a competent personal and public health work force.
Tactic 1: Ensure that clinical users of state data systems and external clinical systems which
are connected to the UPHN are willing, able and have the capability to provide required
reportable data.
Assess existing system use to determine extent of actual 12/1/2010 3/1/2011
reporting, particularly where existing EHR systems are
1.1 used in a bidirectional reporting mode.
Provide targeted training to system users to ensure 1/1/2011 5/1/2011
1.2 understanding and ability to report data effectively
Assess existing EHR systems for alignment with public 12/1/2010 3/1/2011
1.3 health and NYS DOH reporting needs
6/1/2012 9/1/2012
Evaluate and develop new methodologies for site reviews
1.4 and other auditing procedures in public health
Promote efforts to include education on the use of health 1/1/2011 5/1/2011
information systems in all levels of health care education
including public health work force training programs. This
would include the advantages, challenges and changes in
approach to reporting, and also auditing and review
1.5 processes.

Tactic 2: Ensure that patients and all NYS citizens understand, value, and support public
health information exchange leveraging the state wide health information exchange and the
PCMH.
2.1 Implement public relations outreach programs 10/1/2010 6/1/2011
[Public Health] Goal 9: Evaluate personal and population based services.

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Tactic 1: Improve data accuracy, timeliness and consistency
through implementation of standardized data formats and transport
specifications.
1.1 Integrate EHRs through the SHIN-NY 3/1/2011 12/1/2011

Tactic 2: Identify and implement ways to reduce duplicate and

mandated reporting.
Move towards unified single reporting structure with 7/1/2011 6/1/2012
outside providers communicating through UPHN for
mandated reporting resulting in decreased duplication and
resource requirements (Including but not limited to
2.1 validating transaction metrics and data quality).

Tactic 3: Develop mechanisms for data reporting and data

exchange with ambulatory providers through the PCMH model.
Enact uniform requirements for providers with in-house 9/1/2011 12/1/2011
laboratories to provide access to individual lab results
through the SHIN-NY and supply data for aggregation and
analysis to the extent required to achieve public health and
3.1 Medicaid objectives.

Tactic 4: Provide unified connectivity across internal NYS DOH systems while maintaining
support for individual program needs.
Further develop the integration engine side of the UPHN to 12/1/2010 9/1/2011
4.1 allow program systems to share data

Tactic 5: Support public health stakeholders in allocating their resources and outreach
based on regional needs.
Support public health stakeholders in their efforts to 1/1/2011 6/1/2011
assess their needs, identify priorities, and develop
5.1 strategic plans
Provide timely and effective data to public health 10/1/2010 Ongoing
5.2 stakeholders regarding priority public health problems.

Tactic 6: Support local public health researchers and policy makers in monitoring public
health status.
Support local public health stakeholders in their efforts 1/1/2011 9/1/2012
related to syndromic and communicable disease
6.1 surveillance
6.2 Assist in identifying suspected cases of outbreak. 10/1/2010 Ongoing
Investigate ways to enable diagnosis by chief complaint 1/1/2011 6/1/2011
6.3 while limiting false positives.
Enable customization and integration of stakeholder- 1/1/2011 Ongoing
6.4 independent needs and priorities.
6.5 Enable cross-functional, customized, timely and targeted 1/1/2012 9/1/2012

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 alerts and reporting for local public health stakeholders.

[Public Health] Goal 10: Conduct research.

Tactic 1: Improve ability to share survey and other research data between programs and
between programs and NYC etc. by connecting data between systems that may inform
choice and prioritization of public health questions.
Identify current processes and targeted areas of 11/1/2010 2/1/2011
improvement related to data sharing, with specific regard
1.1 to accessibility, timeliness and quality of data.
Identify and address regulatory or legal issues which may 10/1/2010 1/1/2011
1.2 limit sharing of data.

Tactic 2: Increase coordination, cooperation and communication

between and among public health program areas and promote
collaboration in support of achieving common goals.
Leverage the public health and agency-wide governance 10/1/2010 12/1/2010
2.1 process to integrate program activities

Tactic 3: Increase access to clinical data to better answer questions and target services.
Identify ways to enable the free flow of knowledge and 11/1/2010 2/1/2011
3.1 research information among public health stakeholders
Identify collaborative technology tools or other approaches 11/1/2010 3/1/2011
3.2 which could support these efforts.

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