Workgroup CALL June 9, 2010 & June 16, 2010 (same agenda – two date options for participants) 4:00 pm – 5:00 pm Dial-in:1-866-922-3257; Participant Code.

Workgroup CALLJune 9, 2010 & June 16, 2010 (same agenda – two date options for

participants) 4:00 pm – 5:00 pm

Dial-in:1-866-922-3257; Participant Code 654 032 36#

North Carolina Health Information Exchange

Finance Workgroup

22

Agenda

Discussion Document – Not for Distribution2

Topic Leads Time

Welcome & Introductions Co-Chairs 4:00 PM - 4:05 PM

Project Background & Approach Co-Chairs & Manatt

4:05 PM - 4:15 PM

Review Charter & Project Plan Co-Chairs & Manatt

4:15 PM - 4:25 PM

Introduction to Modeling Approach and Discussion of Data Collection Requirements

Co-Chairs & Manatt

4:25 PM - 4:55 PM

Next Steps Co-Chairs & Manatt

4:55 PM – 5:00 PM

3

Welcome and Introductions Co-Chairs, Facilitators, and Members

Facilitators• Joseph Ray, Manatt• Brenda Pawlak, Manatt• Allison Garcimonde, Manatt

Members• Mark Bell, NC Hospital Association• Greg Gombar, Carolinas Health Care

System• Brian Harris, Rural Health Group• Yvonne Hughes, Coastal Connect HIE• John Minnich, CSC

Co-Chairs• Maureen O’Connor, BCBSNC• Dr. Dave Tayloe, American Academy of

Pediatrics

• Steve Owens, NC Medicaid• Phred Pilkington, Cabarrus

County Health Dept.• Devdutta Sangvai, MD, Duke

University Medical Center• Beat Steiner, Community Care

of NC at UNC

44

Meeting Objectives – Key Decisions

• Confirm Workgroup charter

• Review project plan and revise based on Workgroup discussion

• Review modeling approach

• Understand data collection requirements and identify next steps/ points of contact


5

Orientation and Overview

66

Project Background & Approach


• HITECH Act funding opportunities and incentives have significantly anticipated the HIE financing landscape– To date, no single financing strategy for HIE efforts has emerged

as the clear path to viability

• The state of North Carolina is eligible to receive up to $12.9 million in Federal funds under the State HIE Cooperative Agreement Program– The Finance Workgroup will review and update the proposed

project budget to ensure it reflects the decisions of the NCHIE collaborative process

• The Statewide HIE will be responsible for establishing a sustainability model to ensure that the HIE is viable

7Discussion Document – Not for Distribution

7 7

Definitions – ARRA & HITECH

HITECH ActHealth Information Technology for Economic & Clinical

Health Act

Title XIII and Title IV of the ARRA, the section of the stimulus package focused on supporting the more widespread adoption of health

information technology.

ARRAAmerican Recovery & Reinvestment Act

$787 Billion federal stimulus package passed by Congress and signed by President Obama in February 2009.


8

$1.2 B for loans, grants & technical assistance for:

Regional Extension Centers ($640M)

Workforce Training ($80M)

Research and Demonstrations

Medicare & Medicaid incentives for HIT adoption

~$19.1 to $29.8 B total in expected outlays (revised estimate)

$564 M for Statewide HIE Development

States receive between $4M & $40M

$220 M for “Beacon” Community Program

15 HIEs receiving between $10-$20M

$4.3 B for broadband & $2.5 B for distance learning/ telehealth grants

$1.5 B in grants through HRSA for construction, renovation and

equipment, including acquisition of HIT systems

New Incentives for Adoption Funding for Health IT

Funding for HIE

Broadband and Telehealth

Community Health Centers

HITECH FundingHIT & HIE infrastructure


9

North Carolina Health IT Awards

ARRA:

•State HIE Cooperative Agreement: $12.9 million

•Medicaid Meaningful Use Planning: $2.29 million

•Regional Extension Center: $13.9 million NC AHEC (North Carolina Area Health Education Centers Program @ UNC Chapel Hill)

•Beacon Community: $15.9 million Southern Piedmont Community Care Plan

•Health IT Workforce Community College Consortia Program (non degree programs): $10.9 million Pitt Community College

•Health IT Curriculum Development: $1.8 million Duke University

•University-level Health IT Workforce Training (degree programs): $2.1 million Duke University

•Broadband: $28.8 million MCNC / North Carolina Research and Education Network (NCREN)

•CHIPRA (non-ARRA): $9.2 million (one of 10 state awards)

–Testing medical home for children with special health care needs through three provider-led community-based models

–Implementing a model electronic health record format for children

10

Overview of Workgroup Process and Tasks

11

State HIE Cooperative AgreementGoals and Planning Requirements

Domains toAddress

Domains toAddress

RequiredPlans

RequiredPlans

Goal: Plan and develop the HIE infrastructure to ensure• Widespread interoperability across entire state• Providers and hospitals can achieve meaningful use

Goal: Plan and develop the HIE infrastructure to ensure• Widespread interoperability across entire state• Providers and hospitals can achieve meaningful use

- Strategic Plan: State’s vision, goals, objectives and strategies for statewide HIE; including plans to support

provider adoption( Submitted to ONC Oct. 09 , to be

verified via Operational Plan process)

- Operational Plan: Detailed explanation, targets, dates for

execution of strategic plan

-Governance-Finance-Technical infrastructure-Business & Technical Ops-Legal and Policy

Types of Exchange

Types of Exchange

– Eligibility & claims transactions

– eRx & refill requests– Lab ordering & results

delivery– Public health reporting– Quality reporting– Rx fill status/med fill Hx– Clinical sum for care

coordination & patient engagement


Workgroup Deliverables for Operational Plan

Workgroup Deliverables

Governance • Recommendation on public-private partnership structure and functions of the governing body• Recommendation on bylaw-related issues for governing body• Recommendation on approach to statewide HIE• Recommendations to ensure alignment with Medicaid and state programs• Recommendations to ensure alignment with ARRA funded HIT and HIE activities in North Carolina• Components of a consumer engagement and outreach plan

Finance • Environmental data collection / provider landscape • 2-3 financial model scenarios• Payment flow models• Finance section of NC HIE Operational Plan• Workplan for ongoing sustainability effort

Clinical & Technical Operations

• Landscape survey of relevant health IT assets across key stakeholders• Clinical opportunity analysis as relates to NC HIE meaningful use and operational goals• Selected use cases• Straw technical architecture and approach based upon use cases• Description of how the technical architecture will align with NHIN core services and specifications

Legal/Policy • Recommendation on statewide policy framework that protects the privacy and security of health information and that allows for incremental development of polices over time.

• Process to harmonize federal and state legal and policy requirements to support HIE.• Recommendations on operational processes to support privacy and security policies and ensure

implementation and evaluation of policies• Process to develop a consumer and stakeholder outreach, education and engagement plan.• NC state law scan


13

Work Group MethodologyIntegration of Key Deliverables

Clinical & Tech Operations Work Group

Clinical & Tech Operations Work Group

Legal &Policy

Work Group

Legal &Policy

Work Group

Finance Work Group

Finance Work Group

•Identify clinical/business objectives

•Define architecture•Identify services•Detail functions, options•Develop high-level costs

•Identify privacy issues•Define options•Identify policy/tech requirements

•Collect relevant environment data

•Define revenue sources •Identify funding constraints and timing considerations

Implementation Requirements

•Technical specifications•Implementation sequencing

•Detailed cost estimates•Detailed, 4 yr budget•Evaluation strategy

Governance Work GroupGovernance Work Group

•Define roles, decision making authority

•Identify goals•Define measures

1414

Finance Workgroup Charter

Co-Chairs •Maureen O’Connor•Dave Tayloe

Staff •Joseph Ray•Brenda Pawlak•Allison Garcimonde

Members See Member List.

Charge Make recommendations to the Board of NC HIE regarding:• Budget to support implementation of NC HIE Strategic Plan• Analysis of costs and ongoing funding streams (existing and potential)

associated with statewide HIE• Value and business case/return on investment (ROI) of investments at the

state, regional, and institutional levels• Financing strategies to support adoption of HIE

Deliverables •Environmental data collection/provider landscape•2 – 3 financial model scenarios•Payment flow models•Finance section of NC HIE Operational Plan•Workplan for ongoing sustainability effort

1515

Finance Workgroup Project Plan

WG Meeting

Action Items & Key Workgroup Deliverables Reach Agreement On

June 9th

Initial Workgroup Meeting Option 1• Review and adopt Workgroup charter and Project Plan • Initiate collection of relevant environmental data necessary for the

calculations of cost and revenue

• Workgroup charter• Project plan • Data collection needs, assignments and expected

sources

June 16th

Initial Workgroup Meeting Option 2 – Same Agenda as 6/9 Mtg. (See Above)

Board Meeting – June 15, 2010 – Finance Workgroup to present:• Key assumptions of financial modeling approach• Environmental data collection process

See above.

June 23rd

Workgroup Meeting 2• Review HIE financial modeling approach, key assumptions, and drivers• Discuss characteristics specific to North Carolina that may impact modeling

• Financial model approach summary• Financial model key assumptions and drivers• North Carolina characteristics that impact modeling

Week of June 28th

No Workgroup Meeting N/A

July 8h

Workgroup Meeting 3• Review initial draft of financial model components and adoption

assumptions• Review sources, guiding principles, and approach for ongoing revenue

• Provider environment assumptions and next steps• Next steps and adjustments to financial model and

adoption assumption components • Ongoing revenue guiding principles, prioritized sources

and approach for modeling

1616

Finance Workgroup Project Plan

WG Meeting

Action Items & Key Workgroup Deliverables Reach Agreement On

Week of July 12th

No Workgroup MeetingBoard Meeting – July 13, 2010 – Finance Workgroup to present• Findings of environmental data scan• Recommended financial model components

N/A

July 22nd

Workgroup Meeting 4• Harmonize financial model with operational planning activities,

assumptions, and key decisions of other Workgroups• Initiate development of payment flow models• Initiate finalization of financial models for inclusion in Operational Plan

Draft

• Updates to financial model• Payment model flows draft for Operational Plan• Determination of financial models to be included in

Operational Plan

Week of July 26th

No Workgroup Meeting N/A

Aug 4th

Workgroup Meeting 5• Review and finalize recommended financial models for inclusion in draft

Operational Plan • Develop work plan for ongoing sustainability effort

• Operational Plan input• Recommend financial models• Initial payment flow models• Work plan for ongoing sustainability effort post-

Operational Plan submission

Week of Aug 9th

No Workgroup Meeting – Workgroup calls to be scheduled as necessary • Ongoing review of Draft Operational Plan

N/A

Week of Aug 16th

Full Workgroup Conference Call - to be scheduled as necessary • Ongoing revisions to Draft Operational Plan

N/A

1717

Introduction to Modeling Approach


18

Progress in North CarolinaFinancing

Considerations Status Discussion, Remaining Questions to Address

Environmental data

In January of 2009, significant initial work was completed by NCHICA as part of their NHIN Trial Implementation Contract to develop a sustainability and business plan for North Carolina.

Additional work required to update inventory of revenue resources and mechanisms including providers, payers, population, boarder states, existing HIOs, etc.

Cost modelDevelop total cost of ownership model (over four year period) based on selected HIE services.

Revenue modelDevelop revenue models for the state based on environmental data and high-level assumptions.

Updated budget Update ONC State HIE Cooperative Agreement budget.

Issues and risk mitigation strategies

Develop as required by ONC State HIE FOA.

Controls and reporting Develop as required by ONC State HIE FOA.

1919

Financing Approach and Key Assumptions


Refinement Cycle

Refinement Cycle

Up Front Financing

Value Added Services

Participants, Connectivity and Use Cases

Core Services

Governance and Operations

Ongoing Connectivity

Core Services / MU Use Cases

Value Added Services

Fees or Assessments

6 YR

Model

Cos

t Inp

uts

Revenue Inputs

Key

Sou

rces

and

Driv

ers

of

Cos

t

Sources and D

rivers of

Up Front Financing &

Ongoing R

evenue

Key

Sou

rces

and

Driv

ers

of

Cos

t

Sources and D

rivers of

Up Front Financing &

Ongoing R

evenueFinancing

Model

Framework

2020

HIE Model Approach Steps

Step 1: HIE Modeling Approach and Key Assumptions

Review HIE modeling approach, key assumptions and drivers with Finance Workgroup and modeling sub committee. Update key assumptions and drivers as required to customize the model for North Carolina.

Step 2: Environment Data Collection

Collect relevant environment data necessary for the calculations of cost and revenue. Data includes: providers, payers, population, boarder states, existing HIEs, etc.

Step 3: Initial Cost and Revenue Models

Develop initial draft of overall costs and revenue for the state based on environmental data and high-level assumptions.

Step 4: Harmonize Model with Strategic Plan and Operational Plan Draft

Harmonize the assumptions with the Strategic Plan and initial draft of the Operational Plan. Perform additional data collection as20 required to produce a second draft of the model.

Step 5: Iterate Model with Operational Planning Activities

Continue to iterate versions of the model to incorporate operational planning activities, assumptions and decisions. This step will ultimately lead to a final version of the model.

21 21For discussion purposes only - Not for distribution

NHIN

MiHIN Backbone

CommunityHIE

CommunityHIE

OtherCommunityProviders

PhysicianOffices

ExternalData Source

ExternalData Consumer

ReferenceLabs

Hospital

SecurityServices

PublicHealth

ReportingService


PhysicianOffices

Hospital

PrivateHIE

PhysicianOffices

PhysicianOffices

PhysicianOffices

Personal HealthRecord System

Private HIE (Hosp)

PhysicianOffices

Hospital OtherCommunityProviders

MiHIN Conceptual Architecture

Query forDocuments

Service

StandardProtocols

LocalProtocols Local

Protocols

EMPI/RLS StandardProtocols

StandardProtocols

(Paid Connection)

StandardProtocols

(Paid Connection)StandardProtocols

StandardProtocols

StandardProtocols

(Paid Connection)

DataWarehouse

MiHIN Backbone Provides:Infrastructure ServicesSecurity ServicesData ServicesTransactional Services

Standard Protocols Include:Level 4: Transaction PackagesLevel 3: Nomenclature StandardsLevel 2: Message StandardsLevel 1: Security Standards

MessagingGateway

Public ServiceRegistry

Payers

ProviderIndex

MedicationManagementPharmacies

Medicaid

Other State Agencies

EHR/CIS Implementers and Remediators

NHIN

MiHIN Backbone

CommunityHIE

CommunityHIE


PhysicianOffices

ExternalData Source


ReferenceLabs

Hospital

SecurityServices

PublicHealth

ReportingService


PhysicianOffices

Hospital

PrivateHIE

PhysicianOffices

PhysicianOffices

PhysicianOffices


Private HIE (Hosp)

PhysicianOffices



Query forDocuments

Service

StandardProtocols


Protocols


StandardProtocols

(Paid Connection)

StandardProtocols


StandardProtocols

StandardProtocols

(Paid Connection)

DataWarehouse



MessagingGateway


Payers

ProviderIndex


NHIN

MiHIN Backbone

CommunityHIE

CommunityHIE


PhysicianOffices

ExternalData Source


ReferenceLabs

Hospital

SecurityServices

PublicHealth

ReportingService


PhysicianOffices

Hospital

PrivateHIE

PhysicianOffices

PhysicianOffices

PhysicianOffices


Private HIE (Hosp)

PhysicianOffices



Query forDocuments

Service

StandardProtocols


Protocols


StandardProtocols

(Paid Connection)

StandardProtocols


StandardProtocols

StandardProtocols

(Paid Connection)

DataWarehouse



MessagingGateway


Payers

ProviderIndex


NHIN

MiHIN Backbone

CommunityHIE

CommunityHIE


PhysicianOffices

ExternalData Source


ReferenceLabs

Hospital

SecurityServices

PublicHealth

ReportingService


PhysicianOffices

Hospital

PrivateHIE

PhysicianOffices

PhysicianOffices

PhysicianOffices


Private HIE (Hosp)

PhysicianOffices



Query forDocuments

Service

StandardProtocols


Protocols


StandardProtocols

(Paid Connection)

StandardProtocols


StandardProtocols

StandardProtocols

(Paid Connection)

DataWarehouse



MessagingGateway


Payers

ProviderIndex


NHIN

MiHIN Backbone

CommunityHIE

CommunityHIE


PhysicianOffices

ExternalData Source


ReferenceLabs

Hospital

SecurityServices

PublicHealth

ReportingService


PhysicianOffices

Hospital

PrivateHIE

PhysicianOffices

PhysicianOffices

PhysicianOffices


Private HIE (Hosp)

PhysicianOffices



Query forDocuments

Service

StandardProtocols


Protocols


StandardProtocols

(Paid Connection)

StandardProtocols


StandardProtocols

StandardProtocols

(Paid Connection)

DataWarehouse



MessagingGateway


Payers

ProviderIndex


NHIN

MiHIN Backbone

CommunityHIE

CommunityHIE


PhysicianOffices

ExternalData Source


ReferenceLabs

Hospital

SecurityServices

PublicHealth

ReportingService


PhysicianOffices

Hospital

PrivateHIE

PhysicianOffices

PhysicianOffices

PhysicianOffices


Private HIE (Hosp)

PhysicianOffices



Query forDocuments

Service

StandardProtocols


Protocols


StandardProtocols

(Paid Connection)

StandardProtocols


StandardProtocols

StandardProtocols

(Paid Connection)

DataWarehouse



MessagingGateway


Payers

ProviderIndex


EHR LiteConsumersNHIN

MiHIN Backbone

CommunityHIE

CommunityHIE


PhysicianOffices

ExternalData Source


ReferenceLabs

Hospital

SecurityServices

PublicHealth

ReportingService


PhysicianOffices

Hospital

PrivateHIE

PhysicianOffices

PhysicianOffices

PhysicianOffices


Private HIE (Hosp)

PhysicianOffices



Query forDocuments

Service

StandardProtocols


Protocols


StandardProtocols

(Paid Connection)

StandardProtocols


StandardProtocols

StandardProtocols

(Paid Connection)

DataWarehouse



MessagingGateway


Payers

ProviderIndex


NHIN

MiHIN Backbone

CommunityHIE

CommunityHIE


PhysicianOffices

ExternalData Source


ReferenceLabs

Hospital

SecurityServices

PublicHealth

ReportingService


PhysicianOffices

Hospital

PrivateHIE

PhysicianOffices

PhysicianOffices

PhysicianOffices


Private HIE (Hosp)

PhysicianOffices



Query forDocuments

Service

StandardProtocols


Protocols


StandardProtocols

(Paid Connection)

StandardProtocols


StandardProtocols

StandardProtocols

(Paid Connection)

DataWarehouse



MessagingGateway


Payers

ProviderIndex


PrivateHIE

NHIN

MiHIN Backbone

CommunityHIE

CommunityHIE


PhysicianOffices

ExternalData Source


ReferenceLabs

Hospital

SecurityServices

PublicHealth

ReportingService


PhysicianOffices

Hospital

PrivateHIE

PhysicianOffices

PhysicianOffices

PhysicianOffices


Private HIE (Hosp)

PhysicianOffices



Query forDocuments

Service

StandardProtocols


Protocols


StandardProtocols

(Paid Connection)

StandardProtocols


StandardProtocols

StandardProtocols

(Paid Connection)

DataWarehouse



MessagingGateway


Payers

ProviderIndex


State HIE

NHIN

MiHIN Backbone

CommunityHIE

CommunityHIE


PhysicianOffices

ExternalData Source


ReferenceLabs

Hospital

SecurityServices

PublicHealth

ReportingService


PhysicianOffices

Hospital

PrivateHIE

PhysicianOffices

PhysicianOffices

PhysicianOffices


Private HIE (Hosp)

PhysicianOffices



Query forDocuments

Service

StandardProtocols


Protocols


StandardProtocols

(Paid Connection)

StandardProtocols


StandardProtocols

StandardProtocols

(Paid Connection)

DataWarehouse



MessagingGateway


Payers

ProviderIndex


Community HIE

EHR/CIS Implementation and Remediation Boundaries

2222

Financing Approach and Key Assumptions


1. Governance and operations costs will focus on the statewide HIO, not the individual governance and operations of any regional or local HIOs.

2. The cost of participants’ connectivity to the HIE will be based on adoption estimates that may vary by participant type (e.g. solo provider, critical access hospital, FQHC).

3. The cost for participants to implement new EHRs or remediate existing clinical information systems (CIS) is not included in the cost of statewide HIE, with the exceptions of: Medicaid system implementation or remediation required for

statewide HIE; and Estimated costs and revenues generated by providers that

connect to the statewide HIE using an HIE-provided EHR lite.4. Value-added HIE products and services that can help providers

meet meaningful use requirements and generate revenue to support sustainable HIE will be identified, including any potential added costs for incremental development and/or delivery of such products and services.

5. The finance and revenue model does not include a return on investment (ROI) calculator; only direct sources of revenue are included in the model (ROI and cost avoidance are not included).

2323

Environment Data Collection

Category Statistic(s) Potential Source(s) Complete

General Information

• Residents• Medicaid Enrollment• Medicaid status • Public health departments• Other state agencies• Border States

• Kaiser Family Foundation• Census Data• Medicaid Agency

Physicians • Primary care physicians• % PCP practicing• Nurse practitioners• Physician assistants• % eligible professional (EPs) for Medicaid

and Medicare incentives • EHR adoption among small, medium,

large practices

• Kaiser Family Foundation• Medical Society/Association• Academy of Family

Physicians• Licensing Board

Hospitals • Total hospitals• State/local government owned hospitals• Not-profit hospitals• For-profit hospitals• EHR adoption among small, medium, and

large hospitals• Large hospital system demographics

• Hospital Association

2424



Federally Qualified Health Centers (FQHCs)

• Total FQHCs• Size breakdown (small, medium, and

large)• EHR adoption among small, medium, and

large practices

• Primary Care Association

Rural Health Clinics (RHCs)

• Total RHCs• Size breakdown (small, medium, and

large)• EHR adoption among small, medium, and

large practices

• Rural Health Clinic Association

Payers • Total – Self-insured– Employer-based– Medicare– Medicaid/S-CHIP– Uninsured/Charity care– Cash

• Claims (by payer)• Associated PBMs (by payer)• Surescripts connectivity (by payer)

• Medicaid Agency • Payers • Department of Insurance

2525



Pharmacies • Total pharmacies• Chain v. independent pharmacies• Surescripts connectivity • Pharmacy benefit mangers

• Pharmacy Association• Medicaid Agency• Surescripts

Labs • Total labs• Hospital-based labs• Independent labs • Labs affiliated with large chains

• Medicaid Agency• LabCorp• Quest

Radiology Centers

• Total radiology centers• Hospital-based centers• Independent centers

Regional HIOs

• Demographic data • Technology model• Business/sustainability model• Complexity of connectivity

• NC HIE Strategic Plan

Border States

• Medical trading areas • Expected complexity • Data/services to coordinate

(South Carolina, Georgia, Tennessee, Virginia)

2626

Next Steps

• Initiate data collection and report on progress• Develop provider environment assumptions to inform

financial model• Discuss approach to develop initial cost and revenue

models

Upcoming Meetings– Board of Directors– June 15th – Finance Workgroup Kick-Off Call – June 16th

o Same agenda as 6/9 call for those not able to attend– Finance Workgroup – June 21st

Questions or Comments? Contact [email protected].

Discussion Document – Not for Distribution

26

Workgroup CALL June 9, 2010 & June 16, 2010 (same agenda – two date options for participants) 4:00 pm – 5:00 pm Dial-in:1-866-922-3257; Participant Code.

Documents

pm slide

pm introduction

pm dial

stepscochairs manatt

agenda discussion document

unc slide

overview slide

viable slide