Building Health Information Exchanges To Support ACOs and Medical Homes: Delaware's Experience

Building Health Information Exchanges To Support ACOs and Medical Homes: Delaware's Experience

Event Date: 
Wednesday, June 5, 2013

On June 5, 2013, the Innovations Exchange held a Web event titled Building Health Information Exchanges To Support ACOs and Medical Homes: Delaware's Experience.

This was the third Web event in a three-part series designed to share novel experiences and lessons learned in putting accountable care organization (ACO) and patient-centered medical home (PCMH) principles into practice.

    Participants

    Host:
    Judi Consalvo, Program Analyst at AHRQ Center for Outcomes and Evidence

     


    Presenter:
    Jan Lee, MD, Executive Director, Delaware Health Information Network

    Dr. Lee is the Executive Director of the Delaware Health Information Network (DHIN). Previously, she was Vice President of Knowledgebase and Content for NextGen Healthcare, a vendor of health information technology (HIT) products and services, where she was responsible for the development of clinical content in 26 medical specialty areas for the NextGen electronic health record (EHR). She transitioned to NextGen from a 23-year career in the United States Air Force, where she had worldwide assignments in clinical settings from outpatient clinics to medical centers, and several academic appointments. Dr. Lee led the EHR implementation in 75 facilities throughout the Air Force for the Department of Defense. Her specific areas of interest are health policy and the use of HIT to improve clinical practice and population health. Dr. Lee was recognized in “Guide to America’s Top Family Doctors” and “Who’s Who in America” and selected by “Cambridge Who’s Who” as Executive of the Year.

    Respondent:
    Jennifer Fritz, MPH, Deputy Director, Health Information Exchange, Office of Health Information Technology, Minnesota Department of Health

    Jennifer Fritz is Deputy Director of the Office of Health Information Technology at the Minnesota Department of Health. Ms. Fritz is responsible for the direction of Minnesota e-Health programs, including the Minnesota e-Health Initiative, Minnesota’s Health Information Exchange Oversight Program, Minnesota’s State Health Information Exchange Cooperative Agreement, and activities related to privacy and security, health informatics and data standards. Prior to serving as Deputy Director, she served as project manager on the state’s health information exchange activities with responsibilities for developing and implementing Minnesota’s strategic plan for health information exchange. Ms. Fritz also worked on a variety of public health informatics projects aiming to improve the development and use of public health information systems.

    Moderator:
    Gerry Fairbrother, PhD, Senior Scholar, AcademyHealth

    Dr. Fairbrother is a Senior Scholar at AcademyHealth, an Adjunct Professor of Health Policy at the George Washington University, and Adjunct Professor of Pediatrics at the University of New Mexico and the University of Cincinnati. Dr. Fairbrother is an experienced health services researcher and evaluator, whose work has emphasized measurement of quality of care, policy research and evaluation, and health information technology and its effects on quality of care. She serves on the Centers for Medicare and Medicaid Services (CMS) Technical Expert Panel on National Impact Assessment of CMS Quality Measures and on the National Policy Advisory Committee of the National Institute of Children’s Healthcare Quality. She received the “Best Ohio Health Policy Award for Independent Scholar or Practitioner” from the Health Policy Institute of Ohio.

    Additional Information

    Panel Slides

    Download PowerPoint Presentation Slides (PPT, 2.84 MB). (PowerPoint Viewer )

    Slide 1



    Building Health Information Exchanges To Support ACOs and Medical Homes: Delaware's Experience

    Web Seminar
    June 5, 2013
    Follow this event on Twitter Hashtag: #AHRQIX

    Slide 2



    Using the Webcast Console and Submitting Questions

    Image of attendee console with an arrow pointing to the box to type in questions and another arrow pointing to the Q&A widget.

    Slide 3



    Accessing Presentations

    Image of attendee console with arrow pointing to the Download Slides widget.

    Slide 4



    What is the Health CareInnovations Exchange?

    • Publicly accessible, searchable database of health policy and service delivery innovations
    • Searchable QualityTools
    • Successes and attempts
    • Innovators’ stories and lessons learned
    • Expert commentaries
    • Learning and networking opportunities
    • New content posted to the Web site every two weeks

    Sign up at http://www.innovations.ahrq.gov under “Stay Connected”

    Slide 5



    Innovations Exchange Web Event Series

    • Archived Event Materials
    • Available within two weeks under Events & Podcasts http://www.innovations.ahrq.gov
    • Next Events
      Tuesday, June 18 at noon ET
      Chats on Change: Home Base Program for Veterans with PTSD

    Slide 6



    Today’s Event Moderator

    Gerry Fairbrother, PhD
    Senior Scholar
    AcademyHealth

    Slide 7



    HITECH* Spurred Dramatic Growth in Technology

    • Increase in electronic health records adoption
    • Meaningful Use provisions to promulgate standards and promote quality
    • Community-wide technology (Beacon Communities Program)
    • Health Information Exchanges (HIE) at state and regional level

    *Health Information Technology for Economic and Clinical Health

    Slide 8



    Growth in Technology

    Graph showing the percentage of office-based physicians with EMR/EHR systems in the United States from 2001-2010 and preliminary data for 2011-2012. X axis shows the years 2001 through 2012. Y axis shows the percent of physicians. The data points show a linear increase from 2001 with 18.2% having any EMR/EHR systems up to 71.8% in 2012. A second line shows a similar pattern beginning in 2006 with 10.5% of physicians having a basic system up to 39.6% in 2012.

    Slide 9



    Beacon Communities

    Image of the United States highlighting the Beacon Communities which include: Inland Northwest Health Services in Spokane, WA; Mayo Clinic Center in Rochester, MN; Western NY Clinical Information Exchange in Buffalo, NY; Eastern Maine Healthcare Systems in Brewer, ME; Rhode Island Quality Institute in Providence, RI; Southeastern Michigan Health Association in Detroit, MI; Geisinger Clinic in Danville, PA; Indiana HIE in Indianapolis, IN; Rocky Mountain HMO in Grand Junction, CO; HealthInsight in Salt Lake City, UT; The Regents of the University of California in San Diego, CA; University of Hawaii at Hilo; Community Services Council of Tulsa in Tulsa, OK; Louisiana Public Health Institute in New Orleans, LA; Delta Health Alliance in Stoneville, MS; Southern Piedmont Community Care Plan in Concord, NC; and HealthBridge in Cincinatti, OH.

    Slide 10



    HIEs are Key

    “…Health information exchange (HIE) is a key driver of efficiency gains…

    …Therefore, the success of HITECH hinges, in part, on whether we can jump-start HIEs.”

    Adler-Milstein J, DesRoches CM, and Jha AK. Health information exchanges among US hospitals. Am J Manag Care. 2011 Nov;17(11):761-8.

    Slide 11



    Coverage and Locus

    • Coverage and locus of Health Information Exchanges (HIEs) vary
    • State (Delaware – linked to other states)
    • Local and regional (Cincinnati, Ohio; Buffalo, New York; Indiana)
    • Market-based (Minnesota, Arizona)

    Slide 12



    Growth of Accountable Care Organizations and HIE

    • Accountable Care Organizations (ACOs) need population management at system level (data warehouse, registry function)
    • Move data from different electronic health record systems to point of care
    • Some HIEs have adjusted to become connectors between ACOs

    Slide 13



    Important Functionality of HIE

    • Technology to improve quality (data exchange, alerts, population management)

    • Beyond technology: Need to make business case and need for strong governance structure

    Slide 14



    More than Technology

    “HIE is dependent on government to change the way care is paid for…

    …Things not related to technology need to happen.”

    Blumenthal, David. Interview by Ravi Parikh for Medgadget. September 10, 2012.

    Slide 15



    Now We Will Hear From

    • Representatives of two different HIEs
    • How they are organized
    • Challenges and lessons learned

    Slide 16



    Presenter

    Jan Lee, MD
    Executive Director
    Delaware Health Information Network

    Slide 17



    Delaware Health Information Network (DHIN)

    Timeline for the Delaware Health Information Network (DHIN) beginning in 1997 through 2012. In 1997, Legislation established DHIN under Delaware Healthcare Commission; In 2005, awarded AHRQ Implementation contract ($4.7M); in 2007, operational with results delivery (May 2007), data senders (3 hospitals and Lab Corp), data receivers (5 physician practices); in 2010, enabling legislation amended, DHIN is an “independent, not-for-profit public instrumentality”; in 2011, new board, new management team; in 2012, explosive growth in participation and functionality and financial sustainability achieved.

    Slide 18



    Getting Started

    • Governance, many stakeholders
    • Policies and procedures
    • Security and Trust Framework
    • Consent model: opt-in versus opt-out
    • Data model: federated versus consolidated or hybrid
    • Environmental scan: electronic health records versus paper, statewide availability of broadband
    • Market survey: what exchange services would providers value and actually use?

    Slide 19



    Community Health Record

    • Delaware Health Information Network (DHIN)’s core service
    • Federated Data Repository Architecture
    • Clinical data sent into DHIN hosting center from many sources: labs, pathology, radiology, hospital admission, discharge and transfer (ADTs), transcribed reports, medication history (subscription service)
    • DHIN delivers results to ordering provider…and aggregates into a longitudinal Community Health Record

    Slide 20



    Community Health Record

    Information accessed in several ways:

    • Directly populate a practice electronic medical record through interface
    • Auto-print for inclusion in a paper record system
    • View over a web portal (ProAccess)
    • Incorporate into a patient-controlled personal health record

    Slide 21



    Provider Adoption of DHIN

    Graph showing the provider adoption as a percent of Delaware healthcare ordering providers (December 2012). X axis shows the years 2007 through 2012. Y axis shows the percentage. Bar charts for each year show an increase from 2007 with 1% of provider adoption of Delaware Health Information Network (DHIN) up to 98% in 2012.

    Slide 22



    Current Membership in DHIN

    As of May 2013

    • Acute care hospitals and Federally Qualified Health Centers (100%)
    • Providers (98%)
    • Skilled nursing (100%); assisted living (77%)
    • Labs (99%) and radiology groups (97%)
    • Health home, hospice and pharmacy
    • Division of Public Health, health plans, other HIEs

    Slide 23



    Benefits

    • Hospitals, labs and other data senders: Over $2 million cost saving from results delivery
    • Providers/practices with electronic health records
    • Payers/health plans: Estimated 30-33% reduction in redundant ordering of high cost labs and radiology studies over 2 years
    • Public health: Real world outbreak of swine flu detected in near real time
    • Patients: Many “stories” but no metrics

    Slide 24



    What’s Next?

    Current Services

    • Results delivery
    • Discovery tools: record locator service (RLS), common master person index (CMPI)
    • Public health reporting: syndromic surveillance, reportable labs, immunization update
    • Electronic health records (EHR) interfaces

    Slide 25



    Under Development/Planning

    • Event notification service
    • Immunization query
    • Image viewing
    • Consumer engagement
    • Connect with other HIEs, federal exchange partners via eHealth Exchange
    • Integrate newborn screening
    • Connect with Delaware prescription monitoring program
    • Incorporate continuity of care documents into the community health record

    Slide 26



    …and Next?

    New data types for the Community Health Record

    • Ambulatory
    • Medical Device
    • Medication History
    • Claims

    Analytic Tools

    • Clinical Quality Measures
    • Business Intelligence
    • Population Health

    Slide 27



    Lessons Learned

    • Consensus building is slow but essential
    • Begin with the willing
    • Find out what your market values and will use; do that extremely well
    • Use a small number of highly valued services to drive adoption and utilization
    • Provide value for everyone; not just the technology elite
    • Measure, measure, measure! Know the business case for participation
    • Success begets success

    Slide 28



    Overcoming Barriers

    • Technology
    • Trust
    • Natural reluctance to change
    • Late adopters versus early adopters
    • Meet them where they are; not where you wish they were
    • Business model for an HIE whose members are business competitors

    If it were easy, anyone could do it!

    Slide 29



    Respondent

    Jennifer Fritz, MPH
    Deputy Director, Health Information Exchange
    Office of Health Information Technology
    Minnesota Department of Health

    Slide 30



    Minnesota (MN) History

    Policy Levers encouraging HIE*

    • MN e-Health Initiative (2004)
    • MN Health Records Act (privacy law) re-codified to enable HIE, still stricter than most states

    *Before Health Information Technology for Economic and Clinical Health (HITECH)

    Slide 31



    HIE Governance Structure

    Post-HITECH

    • HIE Oversight Law (2010)
    • MN e-Prescribing mandate (2011)
    • State-Certified HIE Service Providers (4 as of May 2013)
    • Interoperable electronic health record mandate (2015)

    Slide 32



    State Certification and Oversight

    • Establishes oversight by Commissioner of Health to protect the public interest on matters pertaining to health information exchange
    • Requires State Certificate of Authority to operate Health Information Organizations (HIO) and Health Data Intermediaries (HDI)
    • Allows market-based approach for provision of HIE services; multiple HIE service providers (HIO/HDI) may be certified and operate in the state

    Slide 33



    Minnesota Approach: One HIE

    Diagram showing eHealth Exchange and other eHealth Exchange Nodes connected to Statewide Health Information Exchange and one HIO with an arrow pointing to private practices, hospitals, and other settings.

    Slide 34



    Minnesota Approach: Two HIEs

    Diagram showing eHealth Exchange and other eHealth Exchange Nodes connected to Statewide Health Information Exchange and two HIOs with arrows pointing to private practices, hospitals, and other settings.

    Slide 35



    Minnesota Approach: Multiple HIEs

    Diagram showing eHealth Exchange and other eHealth Exchange Nodes connected to Statewide Health Information Exchange and two HIOs with arrows pointing to private practices, hospitals, and other settings. The HIOs also have arrows pointing to Health Data Intermediaries and then another arrow from that to the private practices, hospitals, and other settings. The Statewide Health Information Exchange is also connected to Direct Exchange through Shared HIE services: directory services and consumer preference management.

    Slide 36



    Market-Based Approach Versus Single HIE

    Pros

    • Allows for private sector investments and innovation
    • More adaptable to changes in technology trends or requirements (e.g., meaningful use)
    • Gives providers multiple options for HIE services

    Cons

    • Can create confusion in the marketplace
    • Interoperability requirements
    • Many aspects to monitor (technology, policy/legal, changes in national trends)

    Slide 37



    Accountable Care and HIE

    • Adult day services
    • Behavioral health
    • Birth centers
    • Chiropractic offices
    • Clinics: primary care and specialty care
    • Complementary/ integrative care
    • Dental practices
    • Surgical centers
    • Government agencies (state, county, city)
    • Habilitation therapy
    • Home care
    • Hospice
    • Hospitals
    • Laboratories
    • Long-term care
    • Pharmacies

    Slide 38



    Future of HIE in Minnesota

    • Interoperability: Need for shared services and agreements between multiple entities, including common standards
    • Continued certification of entities providing HIE services and monitoring of HIE marketplace
    • Potential updates in laws pertaining to HIE

    Slide 39



    Future of HIE in Minnesota

    • Provider education and technical assistance on HIE options
    • Privacy and security to increase provider adoption of HIE
    • Interstate/national connectivity
    • Movement from basic HIE (e.g., direct secure messaging) towards advanced HIE (e.g., analytics, greater automation, and population management)

    Slide 40



    Reflections on Delaware’s Lessons Learned

    • Consensus: Difficult but essential for sustainability
    • Start small with those motivated and those that have a specific use case that can be met by HIE
    • Provide a range of HIE options for different HIE needs (basic to advanced)
    • Demonstrating Return on Investment (ROI) and Value on Investment (VOI) is critical; harder to do when there are multiple HIE options available

    Slide 41



    Reflections on Delaware’s Barriers

    • Monitoring and adapting technology according to changes in medical practice
    • Scalable trust is emerging as a need for HIE sustainability
    • Natural reluctance to change: Importance of HIE solutions that are in the provider workflow at the point of care

    Slide 42



    Reflections on Delaware’s Barriers

    • Early adopters can be champions to others
    • Meet them where they are, not where you wish they were
    • Business model for an HIE whose members are business competitors: Need to overcome for accountable care

    Slide 43



    Final Observations

    • Many type of entities provide HIE services; interoperability is a challenge
    • Sustainability requires a sound business model and identification of value added services
    • Low provider adoption is linked to low meaningful use requirements
    • Don’t underestimate non-traditional settings
    • Accountable care requires easily sharing clinical data; HIE need to adapt to shifts in market demands

    Slide 44



    Questions

    Image of attendee console with an arrow point to the Q&A widget.

    Slide 45



    The Innovations Exchange

    Visit our Web site:
    http://www.innovations.ahrq.gov/

    Learn more about Delaware Health Information Network
    Follow us on Twitter: @AHRQIX

    Send us email: info@innovations.ahrq.gov

    Transcript

    Judi Consalvo:  Good afternoon, and perhaps for some of you it's good morning.  On behalf of
    the Agency for Healthcare Research and Quality, I'd like to welcome you to our web event
    entitled, “Building Health Information Exchanges to Support Accountable Care Organizations
    and Medical Homes: Delaware's Experience.”  I'm Judi Consalvo with AHRQ's Center for
    Outcomes and Evidence.  We're very excited about today's topic and glad to see that you share
    our enthusiasm.  We have over 700 registered for this event today.

    Before we begin, I would like to introduce you to our webcast console.  The console can be
    resized to fit your entire browser window.  All the components on the console can be resized,
    moved and minimized into the menu doc at the bottom of the console.  If the slides are too small,
    click on the lower right-hand corner of the slide window and drag your mouse down to make it
    larger.

    Twitter functionality is available in the console for today's webcast.  Feel free to participate
    using the Hashtag #AHRQIX.  We are pleased to offer closed captioning on the web seminar.  
    To access the closed captioning, please click on the link called Closed Captioning.  That is on the
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    I would also like to remind you that if you experience any technical problems, you may click on
    the question mark button at the bottom of the screen to access the Help Guide, or click on the
    Q&A button at the bottom of your screen to contact us with your question.  Our technical staff
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    The last 10 minutes of this web seminar is reserved for a discussion based on questions that you
    submit.  Questions may be submitted at any time during the presentation.  Simply click on the
    Q&A button at the bottom of your screen, then type your question into the Q&A box and select
    Submit.  We welcome your questions and comments on the upcoming presentation and we look
    forward to an engaging dialogue that will promote the spread of healthcare innovations.

    Today's slides are available by clicking on the widget at the bottom of your screen that says
    Download Slides.  This will generate a PDF version of the presentation that you can download
    and save, as desired.

    The presenter that you will hear from today is an Innovator from AHRQ Health Care Innovations
    Exchange.  The exchange includes a profile that provides background on the Delaware Health
    Information Network that you will be hearing about.  For those of you who are new to the
    Innovations Exchange, I'll take just a minute to give you an overview.

    AHRQ created the Innovations Exchange to speed the implementation of new and better ways of
    delivering healthcare.  The Exchange offers busy health professionals and researchers a variety
    of opportunities to share, learn about, and ultimately adopt evidence-based innovations and tools
    suitable for a range of healthcare settings and populations.  The site includes a searchable
    database of quality tools and service delivery innovations.  More recently added are the policy
    innovations, such as what you will hear about today.  The Exchange also contains both successes
    and attempts, Innovators' stories and lessons learned, and expert commentaries.

    To assist you in implementing these innovations, AHRQ also supports learning and networking
    opportunities, such as web seminars, TweetChats, and podcasts.  We post new content to the
    website every two weeks on a range of topics and hope that you will sign up to stay connected
    with us, if you have not already done so.

    We have a number of upcoming web events to share innovative healthcare strategies and
    promote the spread of innovations.  Our next learning and networking event is our upcoming
    TweetChat called “Chats on Change: Home Base Program for Veterans with PTSD.”  Join us on
    Twitter on Tuesday, June 18th at noon Eastern, for a live Tweet Chat with Dr. Rebecca
    Weintraub Brendel, Clinical Director of the Veterans Program at the Red Sox Foundation and
    Massachusetts General Hospital Home Base Program; and Dr. Benjamin Miller, Assistant
    Professor in the Department of Family Medicine at the University of Colorado Denver School of
    Medicine.  

    We will discuss how the Boston Red Sox Foundation has teamed with Massachusetts General
    Hospital to support veterans with PTSD and their families.  You can use the #AHRQIX hashtag
    to participate in the conversation.  Please visit our website for more information at
    http://innovations.ahrq.gov. The website also holds an archive of our past web events, podcasts
    and TweetChats, and we also invite you to take a look and download some of those materials that
    may be useful to you in your practice or setting.

    Now, let's turn to our agenda for today.  It is my pleasure to introduce our moderator, Dr. Gerry
    Fairbrother.  Dr. Fairbrother is a Senior Scholar at AcademyHealth and is an Adjunct Professor
    at the George Washington University.  She has over 20 years of experience leading health
    services' research and evaluation projects and leads several quality improvement projects.  Gerry
    also serves on the CMS Technical Expert Panel on National Impact Assessment of CMS Quality
    Measures and on the National Policy Advisory Committee of the National Institute of Children's
    Healthcare Quality.  Gerry?

    Gerry Fairbrother:  Thank you, Judi.  We'll be hearing today from two HIEs, so I'd like to start
    by providing a little background.  HIEs and others we've seen an enormous growth in
    technology, spurred in part by the HITECH Act.  We've seen an increase in electronic health
    records adoption, and not only mere adoption but an increase in Meaningful Use; partly because
    of those provisions that were promulgated to ensure technical standards and to ensure that quality
    standards are in place.

    We've also seen an increase in communitywide technology represented by the Beacon
    Communities Program, also funded through the HITECH Act.  Then, we've seen a growth in
    Health Information Exchanges at both state and regional levels.

    The next slide shows the enormous increase in adoption of electronic health records in office-
    based practices.  The blue line at the top shows the adoption of any sort of EHR.  As you can see,
    about 72% of office-based practices have adopted those.  The green line represents adoption of
    EHRs that meet particular standards.  That's lower, but still an impressive growth; and 40% of
    office-based practices have installed EHRs that do meet a set of standards.

    The next slide shows the Beacon Communities throughout the country.  There are 17 of them,
    again funded by the HITECH Act, to put in place electronic health records communitywide to
    promote exchange of information in the community and to enable monitoring of conditions
    communitywide.

    HIEs, though, are key in all of these endeavors.  To quote a recent article, “The Health
    Information Exchange is a key driver of efficiency gains.”  Therefore, these authors say, “The
    success of HITECH hinges, in part, on whether we can jumpstart HIEs.”

    HIEs are different in different communities.  They cover different areas and they have different
    locuses of responsibility.  There are state level HIEs represented by Delaware, whom we'll hear
    from in a moment and represents one of these.  The Delaware HIE is linked to other states, but
    it's a Delaware HIE.  

    There can be local and regional HIEs covering an area within a state, or even across states.  The
    HIE in Cincinnati, Ohio; Cincinnati is located in the corner of Ohio right next to Kentucky and
    Indiana, so its HIE covers the tri-state area of Ohio, Indiana, and Kentucky.  There are also
    regional HIEs in Buffalo and Indiana, are also examples of regional HIEs.  Then there are
    market-based approaches represented by Minnesota, from whom we'll hear in a moment, and
    Arizona.

    At the same time that there's been this explosive growth in technology, there's also been a growth
    in Accountable Care Organizations.  These Accountable Care Organizations need population
    management at the ACO system level.  They need to have a data warehouse.  They need to be
    able to have a registry function so that they can see, for example, what proportion of their let's
    say diabetic patients have their blood sugar, their HbA1c in control.  So the ACOs need the same
    kind of functionality that we used to talk about needing at HIEs.

    They also need to be able to move electronic data around among the entities in the ACOs.  Some
    HIEs have adjusted to become connectors between the ACOs.  Others have made other types of
    adjustments, or no adjustments, but in any case it perturbation in the system to have this advent
    of ACOs.

    Important functionality of HIEs, and we'll hear about this later, includes the technology that you
    need to improve quality; like data exchange, like alerts to let providers know when a patient has
    gone into the hospital or ED, and like population management.

    But beyond technology, HIEs need to make a business case in order to stay in existence and
    there's a need for a strong governance structure.  So as David Blumenthal, the former head of
    ONC said, “HIE is dependent on government to change the way care is paid for … things not
    related to technology need to happen.”  A further indication that more than technology is needed
    to make HIEs workable.

    Now, we'll hear from representatives from two different HIEs; the Delaware Health Information
    Network, and then a reaction from a representative from Minnesota.  We'll hear how they're
    organized and then challenges and lessons learned.  You will hear echoes of the challenges
    across the two presentations.

    Now, I'd like to introduce our first speaker, Dr. Jan Lee, who will discuss Delaware Health
    Information Network.  Dr. Lee is the Executive Director of the Delaware Health Information
    Network, or DHIN.  Previously, she was Vice President of Knowledgebase and Content for
    NextGen Healthcare, a vendor of health information technology products and services, where she
    was responsible for development of clinical content in 26 medical specialties for the NextGen
    electronic health record.  She transitioned to NextGen from a 23-year career in the United States
    Air Force, where she led EHR implementation in 75 facilities throughout the Air Force for the
    Department of Defense.  Dr. Lee?

    Jan Lee:  Thank you very much, Gerry.  The legislation establishing the Delaware Health
    Information Network, or DHIN, was passed in 1997.  If you think back that far, that was when
    maybe 10% to 15% of practices nationwide had EHRs, so it was very different environment at
    the time.  A full decade of planning and work went into preparing to go live in May 2007, and I'll
    tell a little bit more about that preparation on the next slide.

    We were able to get started with a grant from the Agency for Healthcare Research and Quality
    under the State and Regional HIE Demonstration Project.  That funding, along with funding from
    the State of Delaware and private sources enabled us to contract for a technology solution.  In
    May 2007, DHIN became operational with data senders and end users in each of Delaware's
    counties.

    Over the next several years we added functionality, added new data senders, grew the user base
    and all of that I will go into in more detail on succeeding slides.  But I'm happy to say that today
    DHIN is an independent not-for-profit public instrumentality, fully self-sustaining from the
    services that we provide.

    Let's get back to the 10-year period of planning between the enabling legislation and the actual
    go live.  A great many activities and decisions were undertaken during that time period.  First of
    all, there's establishing governance, and it definitely needs to represent a broad coalition of
    stakeholders.  We had many stakeholder groups who provided input on both the business
    requirements and the technical requirements.

    Business requirements, of course, should be the key drivers and our stakeholders there helped us
    to define the “must have” data elements for a complete clinical information sharing utility.  Then,
    the planning process included a technical requirements' definition that was completed in August
    2005 and enabled us to go out with an RSP to actually acquire the solution.

    Among the critical questions that need to be answered before you select a technical solution are
    questions of your patient consent model and your data model.  The consent model refers to the
    consent of the patient for their data to be shared across the network.  An opt-in model requires
    that each patient must individually give consent for their data to be shared before it is exposed on
    the network.  Whereas, an opt-out model assumes that all patient results are in the network unless
    the patient specifically opts out of allowing their data to be shared.  In Delaware, we made the
    decision to adopt an opt-out patient consent model, but I stress that that was with the input of
    patients and consumer advocacy groups in our governance process.

    The other major decision is the data model and that refers to how or even whether the data sent
    in by multiple organizations is comingled.  We adopted a hybrid model and this involves the data
    in the source systems of the data-sending organizations that are sent over a secure VPN interface
    to a data stage in a hosted datacenter.  The fact that it's one hosting datacenter implies a
    consolidated model, but the fact that each data sender has their own data stage and that the data
    is housed separately and never comingled in storage makes it look more like a federated model.  
    That's why we say that we've actually got a hybrid.

    This arrangement in principle allows any member of DHIN to withdraw membership, if they
    choose to do that, and take their data with them.  That's important, because by law in Delaware
    the data senders retain business ownership of their data.  DHIN is just the steward and not the
    owner, and written data use agreements govern how the data may be used, by whom, and under
    what conditions.

    I think the other elements on this screen are self-explanatory so we'll move on.

    When we get our market survey in Delaware to determine what Exchange services the healthcare
    community would value and use, by an overwhelming majority the most valued service was
    electronic results delivery, especially lab results.  When we went live in 2007, all we offered was
    electronic delivery of lab results, pathology reports, radiology reports and ADTs, or admission,
    discharge and transfer reports.

    In 2010, we added transcribed reports, so that includes such things as discharge summaries,
    history physical, operative reports and so forth.  It was not until 2009 that discovery tools were
    added, which allowed a user to search for results of tests they had not personally ordered or
    query-based exchange.  

    By that time there was two years' worth of data aggregated in the hosted datacenter, so when
    providers did a search there was actually something to find.  This was the real birth of the
    Community Health Record.  Data from many disparate data senders is stored in a manner that
    allows it to be easily searchable and discoverable by properly-privileged users of the network.

    The information in the Community Health Record can be accessed by a user in several ways.  
    The most desirable way is that data coming into the DHIN Community Health Record directly
    populates the ordering provider's electronic health record through an interface.  In this setting,
    the user may not even actually be aware of the fact that they're getting their results through
    DHIN, because they stay in the workflow of their EHR until and unless they have to do a search
    for something that they didn't personally order.

    One of the services that DHIN has provided is to certify interfaces between the DHIN
    Community Health Record and various EHRs.  We contract with the EHR vendors to create a
    single interface to DHIN, across which all result types from all data senders will flow.  The
    contract specifies that once we've certified that interface, the vendor must offer it at a steeply
    discounted rate to all users of that EHR in Delaware.  We currently have certified interfaces to 13
    different EHRs and we have others that are in varying stages of beta testing and contracting.

    The second way that information in the Community Health Record can reach a provider is
    through the Auto-print function.  The practice must have the DHIN utility installed on a
    computer or server, which is always on and connected to the Internet.  Based on configuration
    settings which the practice chooses, results are queued up to print on a designated network
    printer at designated times and in the order that the practice designates.  This allows them to
    capture some administrative efficiencies and allows DHIN to provide value even for practices
    that are still using a paper record system.

    The third way to receive results from the Community Health Record is in a clinical inbox
    accessed through a web portal called ProAccess.  Much like an email inbox, the results of tests
    the provider has ordered are sent to their electronic clinical inbox and when they login into
    ProAccess that is their initial point of entry.  Of note, ProAccess is also the tool used to search
    for unknown data on a known patient, or to search for data on a previously unknown patient.  

    It should also be mentioned that clinical data in the Community Health Record can be delivered
    into a personal health record which the patient controls.  With the Meaningful Use Stage 2
    requirement that at least 10% of a provider's patients must actually view their data online and
    download or transmit it, we do expect that adoption of this functionality is going to increase over
    time.

    This slide illustrates the growth in adoption of DHIN.  Our denominator for this slide is our best
    estimate of the number of providers in Delaware who place orders and would, therefore, expect
    to receive their results electronically.  By the end of calendar year 2012, we were up to 98%
    adoption and that's probably a steady state considering that there are always providers entering
    practice and leaving practice.

    I would also point out that our largest year-to-year jump in adoption was between 2008 and
    2009, and interestingly that represents the time when we introduced the query tools that allow a
    provider to query the Community Health Record for previously unknown results.  This illustrates
    the very obvious truth, that when they perceive value in the tool it definitely drives adoption.

    This slide illustrates current membership in DHIN as of May 2013.  I'm very proud to say that
    participation in DHIN is and always has been completely voluntary.  This growth has occurred
    because of a clear and compelling value proposition.  We've had very strong community support
    and lots of principal persuasion to draw in later adopters, but no one has ever been forced against
    their will to join DHIN.

    As a matter of fact, we've had several out-of-state labs and a Maryland hospital near the Southern
    Delaware border who have come to us requesting to join DHIN because of the value they see in
    participating.  We've also entered an agreement with the Maryland State HIE to exchange ADTs
    on residents of our own state who've been seen in a hospital in the other state.

    We're very focused on the continuum of care and closing gaps in the continuum of care.  In
    2012, we were successful in enrolling all of Delaware's skilled nursing facilities in DHIN, and
    we're now actually up to 80% of the assisted living facilities, along with a small number of home
    health and hospice organizations participating.

    The benefits listed on this slide are as of November 2011.  It looked at the period from 2009
    when we introduced query tools to 2011, and we are currently in the process of updating this for
    the period of 2011 to 2013.  So I hope that within a few months we will actually be able to
    provide updates to this with even more exciting benefits to document.

    The data senders in DHIN saved over $2 million in the cost of results delivery over that two-year
    period by having DHIN deliver the results electronically.  Now the data senders only get that
    savings if they are using DHIN to deliver results instead of, not in addition to the ways that they
    previously did so.  

    One of our key business metrics is our signoff rate.  When a practice signs off, they are agreeing
    to accept DHIN as the report of record and shut off all other methods of results delivery.  Our
    signoff rate is now at 78%.  That's considerably higher than it was in November 2011 when this
    result was obtained, and so I think that as we update this toward the end of 2013, we're going to
    see that the savings to the data senders is dramatically larger.

    The providers and practices within EHR also get a significant savings from the steeply
    discounted cost of the interface to DHIN, because a single interface can get them all result types
    from all senders.  That one interface is offered at markedly lower than usual market rate.  Each
    practice with an interface to DHIN can save anywhere from $18,500 to $28,500 in the cost of
    their EHR interfaces.

    Now, one of the presumptive benefits of a longitudinal Community Health Record is that it
    allows you to avoid unnecessary repetition of tests.  DHIN has actually seen a 30% to 33%
    reduction in the ratio of high-cost labs and radiology studies to unique patients in the database
    over the two-year period from 2009 to 2011.  That rate appears to be continuing to drop.  Besides
    the cost savings to the health plans, there is also a very real reduction of risk exposure for the
    patients in avoiding unnecessary radiation, as well as avoiding lost work time and out-of-pocket
    co-pays that go with redundant testing.  Both payers and patients get a benefit from that
    reduction in redundant testing.

    Public Health has seen improved efficiency in timeliness of receiving required reporting to them.  
    We do have many patient stories of benefits that they've received, but of course it's harder to get
    a population-level metric in that setting.  So we have a lot of stories, but no metrics.

    Summing up the current services that DHIN offers, we still offer our results delivery and
    discovery tools that comprise the Community Health Record.  The Community Health Record is
    our core service and it will always be the heart and soul of what DHIN offers.

    We also support the Public Health reporting requirements of Meaningful Use, and I'm happy to
    say that we had started work on that even before the HITECH and Meaningful Use came along.  
    We've already discussed our Public Health reporting and the steeply-discounted EHR interfaces,
    so I won't belabor that further.

    This has been a very busy year for us in terms of development of new services.  Meaningful Use
    is creating a demand for exchange services well beyond simple electronic results delivery.  
    Because DHIN is already the trusted provider of information exchange in Delaware, we find that
    the providers and hospitals are naturally looking to DHIN to provide solutions for the
    Meaningful Use interoperability requirements.

    We're currently developing an event notification system, which will allow us to notify providers
    and health plans when one of their patients has been discharged from the hospital or emergency
    department.  This will promote continuity of care, early follow up and case management, and it
    will allow providers to bill under the new E&M codes for care transition management.

    We're working with several EHR vendors to be able to query as well as update the state
    immunization registry from within the user's EHR.  We're conducting a pilot with two of our
    hospitals to enable the end user to click on a link in the radiology report that they already receive
    through DHIN and be taken to the actual image, and this supports one of the Meaningful Use
    Stage 2 menu objectives.

    We're working on tools to enable the patient to receive updates of their chart in the Community
    Health Record on their mobile device, as well as to engage in secure messaging with their
    provider.  We expect to become an exchange partner on eHealth Exchange just as soon as our
    vendor successfully completes confirmation testing of the technology.  This will allow us to
    exchange data with federal partners such as the VA, Department of Defense and Social Security
    Administration, as well as with other HIEs.

    We're working with Public Health to integrate the newborn screening registry into the
    Community Health Record.  We're working on a link inside ProAccess to the Delaware
    Prescription Monitoring Program.  That is actually in testing right now and should go live within
    a matter of a couple of weeks.

    We're in pilot testing with several practices to incorporate continuity of care documents into the
    Community Health Record.  We're very excited about that, because it will be our first
    opportunity of incorporating ambulatory practice-level data into the Community Health Record.

    Our long-term vision for DHIN is a very expansive one.  The value in the Community Health
    Record is greatest when all the patients are in it, all of their data is in it, and all of the healthcare
    community is using it.  For all practical purposes, we have all Delaware citizens and all
    Delaware providers in.  

    We are still looking for ways to add other data types that would add even more to the value of
    the Community Health Record.  We're beginning to explore the potential to layer on analytic
    tools that will allow the data to be used for more than just point of care clinical decisions.  There
    are technology, privacy and security, consent, data use agreements and legal issues that all have
    to be dealt with, but these tools will be critical assets in the formation of Accountable Care
    Organizations and patient-centered medical homes in Delaware.

    By any measure DHIN is a mature, highly-successful state HIE.  This slide encapsulates some of
    the lessons learned; things that I believe we did right.  Consensus building is slow, but it is
    essential if you're going to make progress with business competitors.  Start with those who are
    willing to work with you.  Don't wait until everybody is ready to jump in.  Find what your
    market values and will use and do that extremely well.

    One of the things that we did in DHIN, and I do believe this was a good decision, was we started
    with a small set of functionality that we knew our community would value.  We've used that to
    drive adoption and utilization, and now as we add new functionality we've already got a built-in
    echo chamber of people who are accustomed to using DHIN.

    I would also say it's important to provide value for everyone, not just the technology elite.  You
    need to measure the value of what you're doing, because that's what's going to persuade the late
    adopters to come in, and success begets success.

    Finally, there are barriers that have to be addressed and overcome.  Technology issues are not
    trivial.  You should get a good consultant and get strong technical input from all of the
    organizations that are committed to the effort.  Trust is an issue.  Data senders must decide not to
    compete on the basis of the data.  Providers must decide whether they are going to trust all of the
    data in the Community Health Record, or trust it all equally, and whether they trust the patient
    matching algorithms.  

    Patients have to decide whether they trust that the privacy and security of the system gives them
    adequate protection.  There's a natural reluctance to change.  Some people just prefer the devil
    they know.  There will always be early adopters and late adopters.  Early adopters tend to be
    more fault tolerant than later adopters.  At this stage of DHIN's adoption curve, our users expect
    us to be just as reliable and available as electricity.

    Meet your users where they are, not where you wish they were.  There's always going to be a
    mix of the tech-savvy and the tech-averse; sometimes within the same organization.  

    Finally, a major issue that must be addressed by a state HIE or other public HIE whose members
    are business competitors is the business model for the HIE.  What is the fair way to distribute the
    cost of providing the HIE services across all of those who receive value for the services?  The
    HIE does have to be viewed as a business with a revenue stream to support every service offered.

    I'll just conclude by saying, if it were easy anybody could do it.  So I'll turn it back over now to
    Gerry to introduce our next speaker.

    Gerry Fairbrother:  Thank you, Dr. Lee, for an excellent presentation.  Before I introduce our
    next speaker, let me remind the listeners to send in questions that you may have.  There's a
    question-and-answer period at the end.

    Next, we'll hear from Jennifer Fritz, who will discuss Minnesota's approach to their HIE.  
    Jennifer is the Deputy Director from the Office of Health Information Technology at the
    Minnesota Department of Health.  Ms. Fritz is responsible for the direction of Minnesota e-
    Health programs, including Minnesota e-Health Initiative, Minnesota's Health Information
    Exchange Oversight Program, Minnesota's State Health Information Exchange Cooperative
    Agreement, and activities related to privacy and security, health informatics and data standards.

    Prior to serving as Deputy Director, she served as Program Manager on the State Health
    Information Exchange activities with responsibilities for developing and implementing
    Minnesota's strategic plan for Health Information Exchange.  Jennifer?

    Jennifer Fritz:  Thank you, Gerry.  I'm going to share a slightly different perspective than Jan,
    really one that is coming from a state that sees multiple Health Information Exchange entities
    and acts in more of a role of government oversight.  First, I'm going to start with a little bit of
    Minnesota history.

    Thinking about e-Health and Health Information Exchange in Minnesota, Minnesota first
    established its e-Health Initiative in 2004, which legislatively chartered an advisory committee to
    make recommendations on e-Health to the Commissioner of Health.

    As a result, Minnesota has really taken a little more of a policy-oriented approach to e-Health
    Health Information Exchange over the years.  For example, recently Minnesota's privacy laws
    were updated to enable electronic exchange of information and this was pre-HITECH.  Still,
    Minnesota actually has a much stricter privacy requirement than most states.

    Thinking about post-HITECH, as most of you know HITECH passed in 2009, and in response to
    ONC's requirements for Health Information Exchange governance, Minnesota adopted a market-
    based approach to Health Information Exchange and passed a law requiring all entities providing
    HIE services in the state to get certified.  That's our HIE Oversight Law, which was passed in
    2010.

    As of May 2013, Minnesota has four state-certified HIE service providers that are currently
    operating in the state and we have other entities that are exploring whether or not they should be
    certified as well.

    Although it was passed prior to the HITECH Act, Minnesota adopted an e-prescribing mandate
    requiring e-prescribing by 2011.  Then also a mandate for interoperable electronic health records
    by 2015.  The 2015 mandate is significant because it includes all types of healthcare providers,
    including providers not eligible for Meaningful Use, and the mandate also has the Health
    Information Exchange component requiring providers to connect to a state-certified HIE service
    provider in Minnesota.

    Now, I'm going to talk just a little bit about the state certification role in oversight.  Essentially,
    that state certification establishes oversight by the Commissioner of Health to protect the public
    interest on matters pertaining to Health Information Exchange.  Our office at the Department of
    Health oversees that process.  It requires state certification of authority to operate two types of
    entities in the state.  One is the Health Information Organization, and the other type is a Health
    Data Intermediary.

    What it does is it allows market-based innovation and approach for the provision of HIE services
    in Minnesota.  What we see is that we have multiple HIE service providers operating in the state
    and then that they must be certified in order to operate in the state.

    Here's a pictorial view of what HIE looks like in Minnesota.  On this slide you can see what it
    looks like with one HIO, which is kind of the more robust type of HIE entity operating in the
    state.  There's statewide HIE by connecting to Minnesota healthcare providers, and then there's
    also connectivity to the Nationwide eHealth Exchange.

    The next slide here shows what it looks like when you have multiple entities operating in the
    state.  So really the challenge that we see in Minnesota is the interoperability requirements
    between them.  You have HIO #1 and HIO #2 just as an example.

    What we've done to address the interoperability requirements in Minnesota is what we call a
    Statewide Shared Services.  That's services that are utilized by HIE service providers that are
    competitors to one another to be able to share information about the providers across the state.  
    In this picture, you see the Statewide Shared Services as sort of the interoperability component
    between them, and then you see multiple HIE service providers in the picture; so HIO #1, HIO
    #2, and then you also see the health data intermediaries also with connectivity to the Nationwide
    eHealth Exchange.

    There are some pros and cons to a market-based approach to Health Information Exchange.  On
    the one hand, it does allow for more private sector investments and innovations.  For example, in
    Minnesota we really haven't had to invest significantly in the HIE infrastructure from a
    government standpoint.  It allows for more maybe adaptability to changes in technology trends
    or requirements.  For example with Meaningful Use changes, it allows for that adaptability.  It
    also gives providers multiple options, because maybe they have different needs depending on
    what their HIE needs are.

    On the other hand, it can also create a little bit more confusion in the marketplace.  As I
    mentioned, it does create challenges around interoperability, because when you have multiple
    entities you want to make sure that the information can flow across the network of HIE service
    providers.

    From our perspective in the government role, there are also many aspects to monitor.  For
    example, we're constantly having to monitor the technology trends, various policy and legal
    changes, both nationally and within the state, to make sure that we're implementing our oversight
    program appropriately.

    This next slide represents several different types of settings that we think are important for
    Health Information Exchange.  In this case just as an example, these are actually the settings that
    are required to have an interoperable electronic health record by 2015 in Minnesota.  When we
    think about Accountable Care and HIE, I think these are settings that are important to consider
    when considering marketing or building any type of HIE infrastructure.

    Next, I want to talk a little bit about the future of HIE in Minnesota.  We know that there are
    multiple entities providing HIE services in the state.  As I mentioned, interoperability continues
    to be a big need for us and we'll be continuing to implement the Statewide Shared Services to
    support our ongoing interoperability needs.

    Secondly, we know there are more entities out there providing HIE services and we'll be working
    to continue to certify those entities to make sure that they go through the right process.  We've
    seen that the HIE market can change quickly and it requires constant monitoring of national
    activities in order to stay current.  We also know that Minnesota's HIE oversight law at some
    point will probably need to be updated to more accurately reflect the current HIE marketplace, as
    it has changed in the last few years.

    The next slide continuing on the future of HIE in Minnesota, we know that because of having
    multiple entities providing HIE services and potentially the type of confusion that it can create
    by providers in the marketplace, we will want to continue focusing on providing provider
    education on the HIE options.  For example, helping them explore what HIE solution might best
    suit their needs.  We know that we will be focusing on privacy and security to really help
    increase the adoption of HIE, which currently privacy and security is sort of a barrier to HIE
    adoption in Minnesota.

    Then, we'll also work on interstate and national connectivity to other HIEs.  We're seeing HIE
    service providers starting to move from more basic HIE to what I consider more advanced,
    which is really moving more towards analytics, more towards the type of HIE that's needed for
    Accountable Care.

    Now, I want to just reflect a little bit on the lessons learned from Delaware.  First, I really want
    to commend Delaware's achievements that they've made in HIE.  It sounds like they've made
    remarkable progress, both in terms of HIE adoption by providers, as well as actually
    demonstrating outcomes.

    First, I want to comment on the comment about consensus.  We have seen that achieving
    consensus can be a lot of work, but it's really the key for sustainability.  In Minnesota, we've
    found this to be true in regard to shared services where natural HIE competitors have come
    together to reach consensus regarding technical aspects of shared services.  We've also worked
    together on a policy and governance framework, as well as sustainability plans for how they're
    going to sustain those services together.

    We've also found it's helpful to start with those motivated to do HIE. In Minnesota, the providers
    that we've seen more enthusiastic regarding HIE have actually been providers not eligible for
    Meaningful Use.  In our case, we've actually seen quite a bit more interest from providers such as
    local public health and long-term care.  We've created programs for the broad continuum of
    providers to encourage those ready and interested in HIE to participate.  Because there will be a
    range of providers interested in HIE, those with and without certified EHR technology, it's
    important that HIE service providers anticipate the range of HIE needs from more basic needs to
    more advanced.  

    Those options need to create value based on business needs.  We're seeing especially with the
    evolving models of healthcare, for example in Accountable Care, that this is really important.  
    Coincidentally, we have also found that this is a little bit harder to do in Minnesota when there is
    market-based approach, because there is more competition in the marketplace.

    The next slide is really just a reflection on some of Delaware's barriers.  In Minnesota, we have
    also found that it's critical to monitor emerging trends in technology and adapt the HIE solutions
    based on changes in medical practice.  The types of HIE services that were being offered in
    Minnesota only three years ago are much different today.  For example, it's really because of
    Accountable Care and the need for more advanced data analytics and HIE solutions resulting
    from that.

    We've also found that scalable trust and, for example the work like national groups like Direct
    Trust are working on, is foundational for expanding HIE beyond just a community.

    Finally, Jan's comment about the natural reluctance to change I think is true in Minnesota as
    well.  We hear from providers that they want HIE solutions that are directly in their workflow
    and at the point of care in order to create value and willingness to change the way they're doing
    care just through HIE.

    The next slide continues talking about Delaware's barriers and reflecting in Minnesota.  We
    believe that early adopters can be great champions for HIE to others.  Although in Minnesota's
    experience it's difficult to get those early adopters to make those investments, especially if there
    isn't a critical mass exchanging.  Actually, that's been one of our challenges in Minnesota.

    We have found that thinking of the range of providers that want to participate in HIE, but
    meeting them where they are in terms of HIE readiness and capabilities is a first start to getting
    provider adoption of HIE.  Again, in Minnesota the providers that have had a higher demand for
    HIE have actually been the providers not even eligible Meaningful Use.  But, on the other hand,
    some of those providers might be the types of providers that are needed for Accountable Care.

    Finally, a comment about the business model for HIEs where members or providers are business
    competitors; we think about the goals of Accountable Care and the responsibilities that go with it
    much more as a collaborative model that will be needed in order to achieve those outcomes of
    increased quality of care and lower healthcare costs.

    A couple of final observations about the HIE marketplace and Accountable Care.  We know that
    there are going to continue to be many types of entities providing HIE services.  For example,
    Stage 2 Meaningful Use really kind of fosters more of a market-based approach to HIE.  The
    challenge we see will be finding ways to create interoperability between these entities across
    communities statewide and even across state borders.

    We've seen that the evolution from more basic HIE to more advanced HIE that sustainable HIE
    service providers really need to be able to offer value-based services.  Many times that means
    going above and beyond the basic HIE services and also the basic requirements for Meaningful
    Use.

    We've experienced in Minnesota a lag in provider adoption of HIE.  We think actually it might
    be due to the somewhat lower HIE requirements for Meaningful Use, at least for Stage 1.  But
    we think that that will be increasing with Stage 2, and then also as the demand for Accountable
    Care increases.

    Finally, we think it's also important to consider the range of settings interested in HIE, especially
    in the Accountable Care model.  HIE service providers will need to adapt their offerings and how
    they market their services with this in mind.

    So thank you and now I'll turn it back over to Gerry.

    Gerry Fairbrother:  Thank you, Jennifer, that was excellent.  We've had a number of questions
    come in.  The first one is on this exact point.  It's about Accountable Care Organizations and the
    relationship.  So recognizing that the state HIE governance structure in Delaware and Minnesota
    are very different and that Delaware does not yet have Accountable Care Organizations, what do
    each of you see as the role of the HIEs in each of your states, if any, in supporting ACOs in the
    future?  Are the HIE entities in your states working with ACO administrators or those interested
    in forming ACOs to discuss exchange and connectivity?  Why don't we start with Jan and then
    go to Jennifer.

    Jan Lee:  I would be glad to.  In Delaware, we do not yet have any ACOs.  We do have a couple
    of different hospitals that are contemplating moving in that direction and are sort of lining up
    their resources and their plans to do so.  I will tell you that each of them sees DHIN as being
    absolutely critical to their ability to do that.

    We're also working, as many other states are, with the State Innovation Model's Planning Grant.  
    With Delaware being a small state, DHIN is a major existing IT resource that everybody believes
    should be leveraged for any additional HIE needs to support new models of care delivery and
    payment.  

    So, we are very busy right now doing the planning around what would it take to add in the kind
    of actuarial and analytic tools that would be needed to support these new models of care delivery
    and payment.  There's every expectation that we will leverage the tools that DHIN already has,
    which includes identity matching tools.  It's not just the data in the system that is a valuable
    resource.  It's the identity matching tools, it's provider registries, it's patient registries that already
    exist.  So yes, I think that we are very much going to be involved in the move ahead to forming
    ACOs.

    Gerry Fairbrother:  Thank you, Jan.  Jennifer, can you speak to this a little bit more?  I know you
    covered some of this in your slides.  Can you speak a little bit more to the HIE and Accountable
    Care Organizations?

    Jennifer Fritz:  Yes, absolutely.  So in Minnesota we definitely see alignment between HIE and
    ACOs.  In Minnesota, we currently have three of the pioneer ACOs in the state.  We also have
    our state Medicaid agency that has been funding or developing sort of an ACO type of model
    across the state with Medicaid activities.  We're also one of the state innovation model testing
    states, so we're going to be working on developing what we're calling the Minnesota
    Accountable Health Model.

    There will be a fair amount of ACO activity happening in the state, and through our state
    certification process we do see that that plays a role.  So for example, we anticipate that the HIE
    entities that are providing those services to the ACO organizations or ACO communities, we
    anticipate that they will at some point need to be certified.  We are hearing interest right now
    from the community about that, and so we expect that those players will be expanding our HIE
    marketplace in Minnesota.

    Gerry Fairbrother:  Thank you both.  The second question and this is also to both of you, is
    around using your HIE as a registry.  The specific question is whether it's being used to collect
    HEDIS data.  But, you could speak to it more broadly as a registry to create a denominator and
    the denominator could be the HEDIS population, and then the numerator of how many people
    pass.  

    That's broad enough, but there is a second part of it which has to do with consumer reminders for
    preventive care.  So first, the registry function particularly used to collect data for HEDIS
    purposes, and then reminders and alerts.  Jennifer, let's start with you.

    Jennifer Fritz:  Both of those services I would say are services that we would consider valuable
    in Minnesota.  I don't know that any of the service providers that are currently certified offer
    either of those services.  I know that there has been some interest around the quality measures
    and I think there's some exploration there.  In terms of the consumer-based reminders, I'm
    actually not aware of anyone working on that currently, although I wouldn't be at all surprised if
    that doesn't emerge in the near future.

    Gerry Fairbrother:  Thank you, that's good.  Jan, do you want to tackle this question now?

    Jan Lee:  We are not currently a registry for HEDIS, because we're not getting health plan-level
    data yet.  But again, I would say that the basic underlying infrastructure of DHIN puts us in a
    position to, if anyone is going to do that statewide, it's going to be DHIN.  Because again, we
    already have the matching tools, the algorithms in place and so forth and it would be a relatively
    low lift to leverage the functionality and the technology that we already have to layer on those
    services.  That's some of the discussions that are taking place right now with our State Innovation
    Model's Planning.

    What was the second piece of that?

    Gerry Fairbrother:  It had to do with alerts or reminders.

    Jan Lee:  We are working on an alert function for health plans and providers.  The patient
    engagement tools that we're in the process of implementing right now are really intended not so
    much to push out reminders of when things are due, because that's not really information that
    DHIN necessarily has available.  I mentioned we're not currently getting a lot of input from the
    ambulatory practices.  Now if that changes and we have the data sources, then there's certainly
    a lot more we can do with it.

    What we do expect to provide to consumers is the ability to anytime new data comes in to the
    Community Health Record, no matter who the data sender is, as new data comes into DHIN, we
    are going to be able to push that right out to the patient so that they are immediately aware of the
    fact that new data has come in and they may wish to engage with their providers around a
    discussion of those results.

    Gerry Fairbrother:  Thank you.  So, we have a number of other questions, but I believe we're out
    of time.  So I thank you both for a really interesting presentation.  I've enjoyed moderating it and
    I'll turn it back to Judi Consalvo.

    Judi Consalvo:  Thank you, Gerry.  Thank you very much and I want to thank our presenters as
    well as our audience.  Please remember to complete the web event evaluation.  It helps us to
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