Wisconsin eHealth Action Plan

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					Wisconsin eHealth
   Action Plan

               Value-based
               Purchasing




       eHealth          Prevention
      Technology        and Disease
       Platform         Management




       eHealth Care Quality and
         Patient Safety Board
Wisconsin
eHealth Care Quality and Patient
Safety Board
Chair: Helene Nelson, Secretary, Wisconsin Department of Health and Family Services

Betsy Abramson, Elder Law Attorney and Consultant

Christopher Alban, Clinical Informaticist, Epic Systems Corporation

Bevan Baker, Commissioner of Health, City of Milwaukee Health Department

Edward Barthell, Executive Vice President, Chief Information Officer, Infinity Healthcare

Gary Bezucha, Administrator, Boscobel Area Health Care

Patricia Flatley Brennan, Professor of Nursing and Industrial Engineering, UW - Madison

Gina Frank-Reece, Deputy Secretary, Wisconsin Department of Administration

Catherine Hansen, Director, Health Information Services, St. Croix Regional Medical Center

Kevin Hayden, Administrator, Division of Health Care Financing, Department of Health and Family
Services

Ravi Kalla, Chief Executive Officer and President, Symphony Corporation

Don Layden, Executive Vice President, Corporate Development, Metavante Corporation

Lois Murphy, IT Specialist, Veterans Administration

Candice Owley, President, Wisconsin Federation of Nurses and Health Professionals

Debra Rislow, Chief Information Officer and Director of Information Systems, Gundersen Lutheran

Peg Smelser, Chief Operating Officer, Wisconsin Education Association Trust

Eric Stanchfield, Secretary, Wisconsin Department of Employee Trust Funds

John Toussaint, President and Chief Operation Officer, ThedaCare

Fred Wesbrook, Past President, Marshfield Clinic

Hugh Zettel, Director, Government and Industry Relations, GE Healthcare
  Wisconsin eHealth Action Plan




                  December 1, 2006




Wisconsin eHealth Care Quality and Patient Safety Board
                                                                                               ii


                                           Foreword

This document is submitted to Governor Jim Doyle to meet the requirements set out in Executive
Order #129, November 2005, creating the eHealth Care Quality and Patient Safety Board and
directing the Board to create a five-year plan for statewide adoption of health information
technology and health information exchange.

For more information about the Wisconsin eHealth Board and its activities and for copies of this
report, visit http://ehealthboard.dhfs.wisconsin.gov.




 Suggested Citation:
 Wisconsin eHealth Action Plan. Wisconsin eHealth Care Quality and Patient Safety Board.
 December 1, 2006.
WISCONSIN eHEALTH ACTION PLAN                                                                                                                                        iii
December 1, 2006


Table of Contents
INTRODUCTION.........................................................................................................................................................1
EXECUTIVE SUMMARY...........................................................................................................................................3
CHAPTER 1: HEALTH CARE IN WISCONSIN TODAY ..................................................................................11
   Real Wisconsin Stories......................................................................................................................... 11
   Health Spending .................................................................................................................................... 12
   Health Care Today ................................................................................................................................. 15
   Investing in Health Information Technology and Health Information Exchange............................ 17
   Current Technical Environment........................................................................................................... 18
   Why Wisconsin Can Lead..................................................................................................................... 24
   eHealth Developments in Other States ............................................................................................... 25
   National eHealth Developments........................................................................................................... 26
CHAPTER 2: HEALTH CARE IN WISCONSIN IN THE FUTURE ..................................................................30
   Vision for 2012 ........................................................................................................................................ 31
   eHealth Action Plan Components........................................................................................................ 32
   2012 Measures of Success ................................................................................................................... 38
   Next Steps .............................................................................................................................................. 39
   Wisconsin Stories – in the Future ....................................................................................................... 41
CHAPTER 3: FIVE-YEAR PLAN..........................................................................................................................42
CHAPTER 4: SUMMARY OF EHEALTH WORKGROUP RECOMMENDATIONS .....................................49
   Patient Care Workgroup – Executive Summary................................................................................. 50
   Information Exchange Workgroup – Executive Summary ................................................................ 58
   Consumer Interests Workgroup – Executive Summary .................................................................... 65
   Financing Workgroup – Executive Summary..................................................................................... 72
   Governance Workgroup – Executive Summary ................................................................................. 79
APPENDICES ...........................................................................................................................................................83
   Appendix 1: Executive Order #129 ..................................................................................................... 85
   Appendix 2: Workgroup Membership and Resources ..................................................................... 88
   Appendix 3: Glossary of Terms .......................................................................................................... 91
WISCONSIN eHEALTH ACTION PLAN                                                         1
Introduction
December 1, 2006

Introduction
No patient should ever be harmed by lack of information at the point of patient
care.

Wisconsin, and the nation, must achieve this vision.

The Wisconsin eHealth Action Plan will move our state forward to develop the
health information infrastructure we need for improved health care. It is a plan to
save lives, improve the health status of the people of Wisconsin and achieve a
better return on investment in health care. This is not a plan about an information
technology project – it is about improving the health system. It will be measured
by its success in improving the health status of the people of Wisconsin.

The Action Plan was developed by the eHealth Care Quality and Patient Safety
Board, created by Governor Jim Doyle through Executive Order #129 in
November 2005. When he appointed the members of the new Board in early
2006, the Governor challenged Wisconsin to achieve statewide adoption of
electronic health records and information exchange to enable better, safer and
more efficient patient care. Among other responsibilities, the new eHealth Board
was charged to develop a five-year Action Plan with recommendations for state-
private partnerships to implement the needed statewide health information
infrastructure.

The Executive Order specifies that the Action Plan will guide Wisconsin state
government’s legislative and regulatory actions, encourage coordinated efforts in
the private health care sector, further public and private partnerships for the
development of a statewide electronic health information infrastructure, and
maximize federal financial participation to support early adoption of the
electronic health information infrastructure that provides needed information at
the point of patient care. The Executive Order also stresses the importance of
aligning state with national efforts, protecting the privacy and security of
information in electronic information exchange, and engaging consumers and
health care purchasers in improving the value of medical care while controlling
costs.

The eHealth Care Quality and Patient Safety Board took its charge seriously and
enthusiastically. The help of hundreds of volunteers from across the state
combined with extensive research allowed the eHealth Board and its five
workgroups to develop this first-ever Wisconsin eHealth Action Plan. At its
November 14, 2006 meeting, the Board endorsed the strategies and
recommendations in this plan to meet the expectations in the Governor’s
Executive Order.
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                                                                  Introduction
                                                              December 1, 2006

    With this report, the eHealth Care Quality and Patient Safety Board presents a
    compelling, achievable vision and pathway for statewide adoption of an electronic
    health information infrastructure by 2012. The eHealth Board submits this report
    to the Governor and other interested parties with the conviction that Wisconsin
    can lead the nation in delivering safe, high quality and cost effective health
    services enabled by deployment and smart use of a sound statewide technology
    platform.
WISCONSIN eHEALTH ACTION PLAN
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Executive Summary
December 1, 2006

Executive Summary
Wisconsin has an opportunity to deploy technology to transform health care; an
opportunity that did not exist just a few years ago. Our fundamental reason for
doing so is to achieve a better, safer and more efficient health system and thereby
improve the overall health of Wisconsin’s population. Wisconsin seeks better value
for the money collectively spent on prevention and treatment services which will
improve the state’s economic vitality and competitive position.

Health information today is fragmented, often inaccessible and error prone.
Patients, providers, public health authorities, and payers often make important
decisions with inadequate information. Technology provides a platform to manage
and access information to transform the health care sector, to make health care
investments more productive, and to improve the safety and quality of health care.
None of this is possible without the investment in health information technology and
exchange. Better information is needed so that all health care providers in
Wisconsin can deliver patient-centric care, consistent with the six aims for
improvement established by the Institute of Medicine for health care that is safe,
effective, patient-centered, timely, efficient and equitable. 1

There is now a wonderful opportunity to accelerate ground-breaking work
already underway in the state led by health care provider organizations,
physicians, public health, technologists, scholars, and public and private health
care purchasers. Wisconsin already enjoys a high level of information
technology adoption in health care and public health. Many large health systems
are already moving ahead with electronic health records and other investments.
In both the health care and technology sectors, Wisconsin benefits from strong
intellectual resources and a commitment to succeed in statewide health
information technology (HIT) and health information exchange (HIE).

Collaboration between Wisconsin’s public and private health care purchasers is
nationally recognized. For example, the Wisconsin Collaborative for Healthcare
Quality, the Wisconsin Health Information Organization, the Wisconsin Medical
Society and the Wisconsin Hospital Association, major insurers and provider
organizations are collaborating on the measurement and reporting of health care
quality and costs. Our work in Wisconsin is well aligned with goals of our
federal government leadership and activities in other leading states.

The eHealth Plan seeks to leverage these and other initiatives to help Wisconsin
lead the nation in transforming health service delivery using health information
technology and exchange. This five-year plan contains recommendations, plans,
and timetables to achieve the goals set out in the Governor’s Executive Order for

1
    Institute of Medicine, Crossing the Quality Chasm: A New Health System for the Twenty-first
    Century. (Washington: National Academies Press, 2001).
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                                                               Executive Summary
                                                                December 1, 2006

    statewide health data exchange between payers, health care providers, consumers
    of health care, researchers and government agencies. It also recognizes the
    essential role of consumers and patients and seeks to empower and support
    individuals to take responsibility for their own health. It balances privacy rights
    with providers’ needs to share information for safe, effective treatment.

    Health information technology and health information exchange will enable:

           Improvement in the state’s economy and competitive position as the health
           care system is transformed and health care investments result in better
           outcomes.

           A transformation of the health care sector that creates healthy cooperation
           and healthy competition among providers with patients, payers and other
           partners contributing to better outcomes.

           Improvement in the health of Wisconsin’s population through appropriate
           prevention, early intervention and treatment.

           Continuous quality improvement in health care delivery to improve value.

           Consistent practice of safe, high quality and evidence-based medicine as
           the state builds and leverages health information technology (HIT).

    This plan weaves together three strategies to take a coherent, whole-systems
    approach to transformation of the health care sector:

           Improve quality, safety and value by establishing the eHealth technology
           platform to provide needed information at the point of patient care.

           Encourage the development, alignment and implementation of value-based
           purchasing policies and actions across the public and private sectors.

           Link HIT and HIE plans to prevention and disease management activities.

    These strategies will guide the activities over the next five years. They rely on
    joint public-private ownership with active collaboration and coordination of
    related system improvement efforts. Working together, we will build on the
    strengths that exist in Wisconsin and apply the best information available from
    around the country. These strategies offer a fundamental opportunity to reform
    health care in our state and join other leaders around the country committed to
    similar national reforms.
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Executive Summary
December 1, 2006

                       eHealth Action Plan Components

1. Establish the eHealth technology platform.
   a. HIT adoption.
   b. Regional health information exchange (HIE).
   c. Statewide HIE services.
2. Value-based purchasing policies and actions.
3. Link HIT and HIE plans to prevention and disease management activities.
4. Take an incremental approach - growing thoughtfully over time with
   frequent evaluation of progress.


Here are the basic components of the plan:

1. Establish the eHealth technology platform.

   a. HIT adoption

       1) Encourage health care providers to adopt and use electronic health
          record systems by providing start-up funding for safety net providers
          and small and/or rural providers that are not able to afford them, by
          offering education and technical assistance and by endorsing
          standards for these systems to minimize the risk associated with
          purchasing decisions.

       2) Also encourage all providers to continue and increase investment in
          electronic health record systems through value-based purchasing
          strategies by public and private payers (described more fully in
          Component #2 below).

       3) Regularly monitor progress toward achieving benchmark goals for
          adoption (Component #4 below) and offer added recommendations to
          public and private partners as needed to achieve necessary progress.

   b. Regional health information exchange (HIE)

       1) Foster the creation of regional (sub-state) health information
          exchanges to enable exchange of high-value patient information to
          recognize that local needs should drive the mission and structure of
          the organization, and that, to date, local markets have had the greatest
          economic sustainability and participant trust.

       2) Focus early on timely patient information for providers when and
          where they need it for patient care – for example, comprehensive
          information on patient allergies, medications and past diagnoses.
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                                                        Executive Summary
                                                         December 1, 2006


    3) Support the Wisconsin Health Information Exchange (WHIE), a
       Regional Health Information Organization (RHIO) in Southeast
       Wisconsin, focusing on real-time information for hospital emergency
       rooms, results delivery and medication lists. Share technologies and
       lessons learned as appropriate across the state.

    4) Simultaneously encourage the development of up to four new RHIOs
       in other areas of the state by providing state-supported contracts and
       technical assistance.

    5) Limit Wisconsin funding to RHIOs meeting minimum requirements
       including:

       i.     Population served (at least one million people in the geographic
              area it covers).

       ii.    Alignment with natural “Medical Trading Areas.”

       iii.   Willingness to serve all members of the communities in the
              designated area – cannot be vendor-driven or exclusive to a
              limited subset of payers or providers.

       iv.    Independent status with broad governance including both public
              and private sector representatives and strong consumer
              representation.

       v.     Compliant with state and national standards for interoperability,
              and committed to statewide and nationwide network
              development.

       vi.    Policies and systems to assure privacy, security and
              confidentiality of health information.

       vii. Inclusion of public health agencies.

       viii. A well-developed and viable business plan.

    6) Simultaneously develop statewide health information exchange
       services to:

       i.     Serve as the link between RHIOs, other states and the
              Nationwide Health Information Network (NHIN).
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Executive Summary
December 1, 2006

          ii.    Provide basic infrastructure services that are most cost effective
                 on a statewide scale and that can leverage existing state assets,
                 such as record locator and user authentication services.

          iii.   Develop strategies to assure information access to providers
                 outside of a regional health information exchange or who
                 straddle multiple RHIOs, as may happen with rural or boundary
                 areas.

          iv.    Make practice guidelines/clinical decision support available for
                 health care providers (as a resource for their use and not a state
                 requirement).

          v.     Provide a Web portal for consumers to obtain health education
                 materials and access to the practice guidelines.

          vi.    Set standards and policies for health information exchange
                 consistent with national standards.


2. Stimulate the development, alignment and implementation of value-
   based purchasing policies and actions across the public and private
   sectors.

   a. Encourage the creation of formal partnerships between payers and
      providers – such as the Wisconsin Collaborative for Healthcare Quality,
      the Wisconsin Hospital Association, the Wisconsin Medical Society,
      Employee Trust Funds, the Wisconsin Health Information Organization
      and the Wisconsin Medicaid program - to develop standard requirements
      for reimbursement, including new Pay for Quality (P4Q) incentives.

   b. Leverage the purchasing power of state government by working in
      common to align incentives for providers to:

          Acquire use of certified EHR systems and participate in health
          information exchange.
          Use evidence-based clinical decision support.
          Support engagement of consumers in their own health care.
          Publicly report on health care outcomes.
          Participate in public health surveillance.

   c. Actively collaborate with health care purchasers, including private
      employers as well as other governmental purchasers, all payers,
      professional associations and health care providers, to promote
      consistency and alignment of incentives and other strategies for
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                                                              Executive Summary
                                                               December 1, 2006

          promoting high quality, safe and efficient health care, enabled by an
          appropriate health information infrastructure and public reporting.

       d. Create an active agenda to seek federal and foundation funding to develop
          and model these systems for the nation.

       e. Establish a contract between DHFS, ETF and the Wisconsin Health
          Information Organization (WHIO) to build a data repository to track
          outcomes, quality and cost of episodes of care for quality improvement,
          public reporting and public health assessment functions.

       f. Evaluate the impact of public reporting on health care outcomes.


    3. Link HIT and HIE plans to prevention and disease management
       activities.

       a. Identify the unique roles for HIT and HIE in population health
          improvement.

       b. Leverage the Robert Wood Johnson “Common Ground” grant to
          Wisconsin DHFS to create comprehensive and effective statewide chronic
          disease surveillance, including population health baseline information for
          the entire Medicaid population (representing 15% of the Wisconsin’s
          population).

       c. Develop a routine health risk assessment and a member agreement for the
          Medicaid population to guide taking personal responsibility for health and
          health care.

       d. Actively promote use of chronic disease management tools by safety net
          providers and continue to strengthen care management strategies across
          the Medicaid population in general.

       e. Engage long-term-care providers in eHealth implementation activities to
          address and improve the coordination of care across health settings.

       f. Conduct research through focus groups to identify the best approaches to
          engaging patients with high quality health information and decision
          support tools for making health care decisions.

       g. Develop health information system tools and research data that will
          support stronger public-private partnerships to achieve the goals of
          Healthiest Wisconsin 2010, the state health plan; for example, improving
          nutrition and physical activity, prevention of tobacco use, and other cost-
WISCONSIN eHEALTH ACTION PLAN
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Executive Summary
December 1, 2006

      effective strategies to reduce the burden and unnecessary high costs of
      chronic disease and other preventable illnesses and injuries.

   h. Establish biosurveillance capabilities across the public and private sectors
      for rapid outbreak detection, management and recovery.

   i. Assure interoperability of HIT/HIE with Wisconsin’s Public Health
      Information Network.

   j. Link clinical information to public health information initiatives in ways
      that are effective and efficient for both health care delivery and public
      health.

   k. Define respective roles of the eHealth Board and the Governor-appointed
      Public Health Council.

   l. Align the work of public health, business and medicine to foster
      collaboration and to support health care transformation.


4. Take an incremental approach - growing thoughtfully over time with
   frequent evaluation of progress.

   a. Address HIT and HIE simultaneously, recognizing that existing data is
      available for exchange without waiting for universal adoption of
      electronic health records and other technology.

   b. Establish performance goals and annual benchmarks for achieving the
      goal of statewide HIE and HIT in the plan, and initial strategies to move
      forward through voluntary public-private partnerships and investments.

   c. Actively foster continued deepening of effective public-private sector
      partnerships to achieve mutually beneficial goals of higher quality, safer
      and more efficient health care through HIT and HIE.

   d. Start with projects that build essential infrastructure while adding value
      for providers and consumers in the short term.

   e. Develop an infrastructure that is flexible, scalable, adaptable and
      replicable.

   f. Use standards consistent with national direction.

   g. Create incentives for interoperable and certified systems.
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                                                            Executive Summary
                                                             December 1, 2006

     h. Build on existing assets in the public and private sector.

     i. Promote data reuse for authorized public health and research purposes.

     j. Conduct constant surveillance of new developments in both the public and
        private sectors to keep the plan relevant and to take advantage of new
        opportunities.

     k. Establish effective communication strategies to build engagement and
        trust across all stakeholders.

     l. Monitor progress closely and adjust strategies and activities as needed,
        recognizing that this is ground-breaking work, significant in scope, and
        that there are now many interrelated activities underway within the state
        and nationwide to transform the health care sector that must be taken into
        account as this plan unfolds.
WISCONSIN eHEALTH ACTION PLAN
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Chapter 1: Health Care in Wisconsin Today
December 1, 2006

Chapter 1: Health Care in Wisconsin Today

Real Wisconsin Stories
    Mr. Robinson, a 50-year-old man without access to primary care, develops
    symptoms of a bladder infection and goes to a local emergency department
    for care. He is asked about his allergies and reports that he is allergic to
    penicillin. There is no way for the emergency clinicians to know that his past
    records in a local Milwaukee community health center indicate that he was
    admitted to another hospital several years ago after a significant allergy to
    sulfa. He is prescribed Bactrim, and suffers from a severe allergic reaction
    that develops into Stevens Johnson Syndrome. His skin peels off, he is
    hospitalized for several weeks in the burn unit receiving multiple skin grafts,
    and he becomes blind as a complication. His pain and suffering are
    extraordinary. His medical bills total over $350,000.

    Current national estimates are that one in four prescriptions taken by a
    patient are not known to the treating physician.

    Grandmother Smith is sent to the emergency room after a fall. She is
    confused and cannot report her history or the changes recently made in her
    medications. She is admitted to the hospital to learn more about her
    condition. She becomes very disoriented because of this change in living
    arrangements which causes a decline in health status, including
    incontinence. Once stabilized in the hospital she is sent to a nursing home
    because of the incontinence and disorientation.

    Every year in Wisconsin fall-related injuries among adults age 65 and over
    result in more than 24,000 visits to emergency departments.

    In 1993 an estimated 400,000 Milwaukee-area residents developed diarrhea
    in a waterborne outbreak. Public health recognition of the epidemic was
    delayed for many days, when prompt action could have prevented
    thousands of new cases.

    The current system, relying on voluntary reporting by labs and physicians
    misses about 50% of reportable conditions.

Despite the spending on health care in the US - representing 16% of the Gross
Domestic Product and rising - all Americans are at risk for receiving substandard
health care. Studies by the Rand Corporation indicate that clinicians implement
well-proven measures to prevent disease and disability only about 55% of the
time. 2


2
    E.A. McGlynn, et al, “The Quality of Health Care Delivered to Adults in the United States,”
    New England Journal of Medicine 348, no. 26 (2003): 2635 – 2645.
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                                                                                          Chapter 1: Health Care in Wisconsin Today
                                                                                                                   December 1, 2006

     Health Spending
     Current health care spending is not sustainable.

     Since the year 2000, health care spending in the U.S. has been growing even more
     rapidly than before and is projected to represent 20% of the Gross Domestic
     Product by 2015. 3 Health care costs are growing faster than both the inflation rate
     and wage growth and have the potential to erode our economic capacity.
     Nationally, annual spending on health care is almost $1.9 trillion, four times the
     amount spent on defense. This is expected to double by 2015 to $4 trillion.
     Secretary Mike Leavitt of the U.S. Department of Health and Human Services in
     a speech in Washington in September 2006 warned that “we can no longer remain
     prosperous if we allow this to continue.”


                          Macroeconomic View:
                   Total U.S. Health Care Expenditures
                                                    $644 Billion*                                                  $571 Billion*
                                                    8.2% growth                                                    8.8% growth

         *Includes physician services
         $399 Billion, 9% growth, plus
         prescription drugs/equipment
         $243 Billion, 6.6% growth




                       Small                    Large                Hospital                 Inpatient              Critical
                     Physician                 Group                Outpatient                Med/Surg                Care
                      Offices                 Practices            Departments                  Units                 Units


                                Ambulatory Care                                                    Acute Care
                               *Total health care spending: $1.878 trillion, 16% of GDP
                                                                                                                                                  1
                                                                                                                                   October 10, 2006
                   Source: “National Health Expenditures, 2004,” Health Affairs Vol. 25, No.1, 2006, pg. 186-196




     According to the Organization for Economic Cooperation and Development
     (OCED), the U.S. continues to have the highest per capita health care spending
     among industrialized countries – for 2003 it was almost two and a half times more
     than the comparable median for OECD countries. The U.S. continued to pay
     much higher prices in three health care components: physician visits, hospital
     stays and pharmaceuticals.
     3
             G.F. Anderson, et al., “Health Care Spending and Use of Technology in OCED Countries,”
             Health Affair, Volume 25, no.3 (2006): 819-831.
WISCONSIN eHEALTH ACTION PLAN
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Chapter 1: Health Care in Wisconsin Today
December 1, 2006



    The Unsustainable Cost of Health Care
                                    • $1.9 Trillion / Yr
            National Health         • 16% of GDP
             Expenditures           • 2x median of other developed
              ($ Trillions)           economies
                              3.5   • 20% of GDP projected in 2015
      3.5
        3                           • Medicare’s Projected Deficit $27
      2.5           1.8               Trillion (7x Social Security
        2                             Deficit)
      1.5
        1
            0.88                    • Unsustainable Growth – Spending
      0.5                             Doubles Every 10 Years
                                    - Health Spending Projections Office of the Actuary, CMS
        0                                 Health Affairs 2005
            1993   2004   2014      -Health Spending in the US and the rest of the Industrialized World.
                                          Health Affairs 2005




With about 2% of the national population, Wisconsin’s share of the $1.9 trillion
in health care spending is more than $38 billion per year.

Based on 2002 data from national estimates, Wisconsin’s personal health care
costs were an estimated $26.3 billion, or $4,822 per person. For this time period,
hospital costs accounted for the largest share of health care costs. Drugs were
the fastest growing component – increasing 14% annually from 1998 to 2002.

In Wisconsin, health care costs are increasing at rates higher than the general
inflation rate. Wisconsin businesses are paying almost $2,000 more in health
care costs for each employee than their peers in other states – with health benefit
costs 26.5% higher for Wisconsin employers than the national average. 4

The high cost of health care is also pricing more and more middle-class families
out of their coverage at the same time that many small businesses are being
forced to discontinue coverage for their employees. The cost of health care
benefits for Wisconsin employers is expected to see double-digit increases next
year. 5 Private health insurance premiums have risen 73% in the last five years,
forcing some businesses to drop health coverage for their employees and
prompting others to raise co-payments and premiums.

State government is the largest health care purchaser in the state as the payer for
the Medicaid, BadgerCare and SeniorCare programs for elderly, disabled and
low-income families; health care benefits for state employees, retirees and their
families; and the costs for school district employees and retirees, two-thirds of
which are paid for with state funds.

4
     Survey conducted by Mercer Health and Benefits LLC, released 11/21/06.
5
     Milwaukee Journal Sentinel 9/8/06 reporting on the annual Employee Health Care Benefits
     Survey done in cooperation with the Milwaukee Association of Commerce.
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                                                     Chapter 1: Health Care in Wisconsin Today
                                                                              December 1, 2006

                  Wisconsin State Government as a Health Care Purchaser

                                         Covered Lives                  % of Wisconsin
                                                                         Population 6
         ETF 7                                 332,875                              6%
         Medicaid 8                            851,343                             15%
         Schools 9                             339,411                              6%
         Total                               1,523,629                             27%

     State government is also the payer for a number of other smaller health care
     programs, including health services for people in prisons and other facilities and
     for some costs for the public health system.

     Health care costs crowd out opportunities for improvement and innovation in all
     other areas of the state budget. Health care competes in the state budget with
     other vital public services, including education and public safety. Controlling
     health care costs is essential to enhance the business environment for both large
     and small employers and is the key to a long-term strategy of growing the state’s
     economy.

     Despite such huge expenditures, the investment in health care spending does not
     produce desired results. Today in Wisconsin, chronic diseases take a high toll on
     the population.

     Cardiovascular disease (CVD) is the leading cause of death among men and
     women of all racial and ethnic groups. The estimated annual total cost of CVD in
     Wisconsin for 2005 was $7.5 billion including direct costs (heath care, provider
     visits, hospital and nursing home services, medications and home care) and
     indirect costs associated with lost productivity. Most of the health and economic
     burden of cardiovascular disease can be prevented and controlled by control of
     blood pressure and cholesterol, quitting smoking, increasing physical activity,
     maintaining appropriate weight and eating a healthy diet.



     6
         Based on the Wisconsin population of 5,536,201 (Source: U.S. Census Bureau, 2005
         Population Estimates).
     7
         This is the number of covered lives, both members and contracts, through the Wisconsin
         Department of Employee Trust Funds, February 2006.
     8
         From a DHFS report on Medicaid coverage as of September 2006. Includes Family Medicaid
         Programs (AFDC related Medicaid, BadgerCare, Healthy Start, Family Planning Waiver and
         Presumptive Eligibility), Elderly and Disabled Medicaid (SeniorCare, SSI and SSI-related,
         institutions and nursing home care, and community waivers programs), and other coverage
         groups including Medicare assistance, Tuberculosis-related, children in foster care and
         subsidized adoptions.
     9
         This represents the members and their dependents covered by WEA Trust as of October 31,
         2006 through its health, dental and long term care plans. Personal communication, Chrisann
         Lemery, November 21, 2006.
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Chapter 1: Health Care in Wisconsin Today
December 1, 2006

Cancer is the second leading cause of death in Wisconsin. About one-third of
cancer deaths are preventable by healthy lifestyle behaviors, especially related to
tobacco use and diet. Many cancer detection tests, which can save lives, are
underutilized in Wisconsin.

An estimated 329,490 adults (8% of the population) have diabetes with another
94,000 people undiagnosed. Many others are at increased risk of undiagnosed
diabetes because of the risk factors of age, obesity and sedentary lifestyles.
People with diabetes suffer from many diabetes-related complications or
conditions.

In the latest report from the United Health Foundation on America’s Health
Rankings for 2005, Wisconsin ranked 13th, down from 9th in 2004 as obesity and
child poverty rose. 10

          Since 1990 the prevalence of obesity in Wisconsin soared by 105% -
          from 11.3 % to 23.2 % of the population.

          Wisconsin ranked 23rd for cardiovascular deaths and 23rd for total
          mortality.

          Wisconsin suffers disproportionately high racial disparities in birth
          outcomes; for example, in infant mortality.


Health Care Today
The current paper-based health care system is error-prone, inefficient and faced
with very serious challenges. 11

Medical error, patient safety, quality and cost issues:

        1 in 4 prescriptions taken by a patient are not known to the treating
        physician.
        1 in 5 lab and x-ray tests are ordered because the originals are missing.
        18% of medical errors are estimated to be due to inadequate availability of
        patient information.
        40% of outpatient prescriptions are unnecessary.
        Patients get only 55% of recommended care.


10
     America’s Health Rankings™ - 2005 Edition: 2005 United Health Foundation
     (www.americashealthrankings.org).
11
     Presentation by Blackford Middleton, Chairman, HIMSS, Partners Healthcare, Harvard
     Medical School, accessed at himss.org/ASP/ContentRedirector.asp?ContentID=65397,
     11/20/06.
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     A fractured and “unwired” system:

               Medicare beneficiaries each see 1.3 to 13.8 unique providers annually, an
               average of 6.4 different providers per year.
               90% of the more than 30 billion health care transactions in the U.S. every
               year are conducted via mail, fax or phone.

     Paper records are very difficult to make secure and put patients at risk of
     unauthorized access as well as misuse of the information in the records. There are
     few if any audit trails about how the information in paper records is used.

     The Institute of Medicine, in a landmark report issued in 2001 - Crossing the
     Quality Chasm – found that safer, high-quality care requires redesigned systems
     of care, including the use of information technology to support clinical and
     administrative processes. 12

     There is strong public support for efforts to improve care coordination and access
     to information. On behalf of The Commonwealth Fund Commission on a High
     Performance Health System, Harris Interactive surveyed U.S. adults to determine
     the public’s perspectives on ways to improve patient care and on health policy
     priorities facing the President and Congress. Based on the representative sample
     of 1,023 adults ages 18 and older, there is a shared belief that expanded use of
     information technology, care teams, and improved delivery of preventive services
     could improve the quality of care. Patients reported recent experiences of
     wasteful, inefficient or unsafe care. In addition, half of middle-income and lower-
     income families reported serious problems paying for care and insurance
     coverage. Three-quarters of all adults said the U.S. health care system needs
     either fundamental change or complete rebuilding. 13




     12
          Institute of Medicine, Crossing the Quality Chasm: A New Health System for the Twenty-first
          Century. (Washington: National Academies Press, 2001).
     13
          C. Schoen, S.K.H. How, I. Weinbaum, J. E. Craig, Jr., and K. Davis, Public Views on Shaping
          the Future of the U.S. Health Care System, The Commonwealth Fund, August 2006.
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Chapter 1: Health Care in Wisconsin Today
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Investing in Health Information Technology and Health
Information Exchange
Despite its capacity to lower costs and improve quality of care over the long-
term, information technology represents only a tiny part of health care spending
in the U.S.


               U.S. Health Care IT Investment

                   Ambulatory IT:                                    Acute Care IT:
                       $1.1B                                             $23B
                  <1% of Revenues                                   ≈4% of Revenues




       Small              Large             Hospital    Inpatient     Critical
      Physician
        this              Group            Outpatient   Med/Surg       Care
       Offices           Practices        Departments     Units        Units



              Ambulatory Care                              Acute Care
                                                                                                1
                                                                                 October 10, 2006
     Source: DataMonitor US total HIT $24B for 2005;



The U.S. lags well behind other developed countries in investments in health
information technology and health information exchange as a strategy to
improve health outcomes and improve the return on investment in health
spending. “Other countries have accepted the idea that HIT will lower health
spending and improve outcomes. The centerpiece of most of these programs is
the electronic health record, but HIT also encompasses a wide range of services
including telehealth, electronic ordering systems, decision support tools,
networks and infrastructure.” 14

Recent survey results, published on the website of the journal Health Affairs
indicate that primary care physicians in the United States do not have the tools or
support to provide the best care possible. Commonwealth Fund researchers
surveyed 6,000 primary care physicians in Australia, Canada, Germany, the
Netherlands, New Zealand, the United Kingdom, and the U.S. The survey
focused on information technology and clinical record systems, care


14
      Anderson, Gerard F., et al, “Health Care Spending and Use of Information Technology in
      OECD Countries,” Health Affairs, Volume 25, Number 3 (2006): 819 - 831
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                                                      Chapter 1: Health Care in Wisconsin Today
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     coordination, use of teams, participation in quality initiatives, and financial
     incentives.

     Although the United States outspends the other countries surveyed (by as much as
     3 times per capita), its primary care system trails other countries in several areas.

              About a quarter of primary care doctors in the U.S. (28%) and Canada
              (23%) use electronic medical records, compared to an overwhelming
              majority of doctors in the Netherlands (98%), New Zealand (92%), the UK
              (89%), and Australia (79%).

              Less than a quarter of U.S. doctors (23%) receive computerized alerts for
              potential harmful drug does or interactions compared to the other countries
              such as the Netherlands (93%), the UK (91%), and New Zealand (87%).

              Only 40 percent of US primary care doctors can offer patients access to
              care after hours, compared to 95% in the Netherlands and 87% in the UK.

              Despite the growing interest in the U. S. in providing financial incentives
              and support to improve performance, U.S. primary care doctors are the
              least likely to receive incentives targeting quality. 15

     A European Union project has demonstrated that HIT can provide enormous
     benefits if the technology is properly implemented. The eHealth Impact Project,
     completed in May 2006, conclusively demonstrated that the benefits gained from
     implementing eHealth systems are more than two times greater than the additional
     cost of implementing them. 16



     Current Technical Environment
     To inform and improve the safety and quality of health care delivery, health
     information technology (HIT) must be adopted in ambulatory, inpatient, and other
     care settings (such as skilled nursing facilities). Safe and easy movement of
     patients across the health system, collaboration among providers, and
     management of quality, safety and public health at the population level all require
     secure health information exchange (HIE) between authorized information users.
     One charge of the Governor is to describe and monitor the development of these
     two types of technology in Wisconsin.


     15
          Schoen, Cathy; et al; “On The Front Lines Of Care: Primary Care Doctors’ Office Systems,
          Experiences, And Views In Seven Countries;” Health Affairs; Volume 25, Number 6 (2006):
          w555-w571.
     16
          “The economic benefits of information technology in health care.” Medical Technology
          Business Europe, www.mtbeurope.info, 11/22/06
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Chapter 1: Health Care in Wisconsin Today
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Health Information Technology: Ambulatory Care

The National Ambulatory Medical Care Survey (NAMCS) conducted by the
Center for Disease Control and Prevention (CDC) indicates one-quarter of
office-based physicians in the United States reported using electronic medical
record (EMR) systems in 2005. While 13% used at least some form of EMR,
only 11% included a set of key functions like electronic prescribing
(ePrescribing) and importation of laboratory results. Physicians were more likely
to use an EMR in the West (33%) and Midwest (27%) than other regions. 17

Wisconsin appears to compare favorably to these measures of EMR adoption. In
2005, MetaStar surveyed Wisconsin primary care practices and supplemented
the results with field staff knowledge. About 38% of primary care practice sites
boasted an EMR. 18

One reason for this may be the concentration of physicians in larger group
practices. The Wisconsin Medical Society reports that 67% of Wisconsin
physicians are in group practices of 50 or more physicians, considerably above
national norms. 19 Nationally, single-physician practices represent approximately
38% of all practices, while in Wisconsin this proportion appears to be about 7%
and shrinking. The presence of two major technology vendors in Wisconsin may
also contribute to higher rates of adoption.

Practice Size Distribution, Wisconsin Compared to the Nation

Single-physician practices: 7% in Wisconsin, 38.5% nationally
Two – nine/ten physician practices: 13% in Wisconsin, 49.6% nationally
>10/11 physician practices: 80% in Wisconsin, 9.7% nationally (and 2.2%
unknown)

To assess ambulatory HIT adoption over time in Wisconsin a survey has been
developed under the aegis of the eHealth Board, with data collection in progress
for representative samples of both primary care and specialty practice sites. The
survey is designed for yearly assessment and to be comparable with some
national survey efforts. 20 It assesses:


17
     CDC, National Center for Health Statistics, Electronic Medical Record Use by Office-Based
     Physicians: United States, 2005.
     http://www.cdc.gov/nchs/products/pubs/pubd/hestats/electronic/electronic.htm
18
     MetaStar, Inc. Environmental Scan, December 1, 2005 and Simmons G. The prevalence of
     EHI Technology in Wisconsin, eHealth Board, March 26, 2006
     http://ehealthboard.dhfs.wisconsin.gov/materials/materials/PrevEHITechn.pdf.
19
     Based on the Wisconsin Medical Society database of physicians, November 2006.
20
     Survey developed by Seth Foldy (Medical College of Wisconsin) and MetaStar, Inc. under
     contract with Wisconsin Department of Health and Family Services.
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                                                    Chapter 1: Health Care in Wisconsin Today
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               Practice ownership/management, type, specialty, size
               Connectedness
               Electronic claims and practice management system (PMS)
               Electronic Health Records (EHR)
               Vendors used
               Specific EHR functions installed
               Whether actively used
               Remote access
               EHR interconnection
               Impact of EHR
               Barriers to EHR implementation
               Future EHR plans
               Stand-alone e-Prescribing
               Performance measure reporting and Pay-for-Performance
               Current electronic data exchange, priorities for electronic data exchange
               Internet communications with patients.

     The survey results will guide the eHealth Board as it monitors current adoption,
     sets annual benchmarks and future goals, and measures progress over time.

     Not all EHR systems import or export data with other applications. Many
     installed products and many still marketed today lack such interoperability. The
     Certification Commission for Health Information Technology (CCHIT), a
     voluntary, private-sector certification organization (now also endorsed by the U.S.
     Secretary of Health and Human Services and the Office of the National
     Coordinator for HIT), has certified several HIT products based on functionality,
     interoperability, and security. 21 CCHIT is initially focusing on ambulatory EHRs
     for the office-based physician or provider, inpatient EHRs for hospitals and health
     systems, and the network components through which they interoperate and share
     information.

     Health Information Technology: Hospital Care.

     Two studies recently examined hospital HIT adoption in Wisconsin. The state
     has several well-established, integrated health care delivery networks with
     extensive HIE infrastructure in place. In 2005 MetaStar and the Wisconsin
     Hospital Association examined adoption of two technologies: Computerized
     Physician Order Entry (which is associated with reduced transcription errors,
     reduced administrative costs, and can be linked to clinical decision support for
     safety and cost-efficacy) and telemedicine (transmission of images or other




     21
          http://cchit.org/certified/products.htm
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Chapter 1: Health Care in Wisconsin Today
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information enabling more efficient use of limited consultation resources).22
Respondents reported the following:

Health Information Technology (HIT) in Wisconsin, April 2005
                                                          CPOE            Telemedicine
            Level of Implementation                       (n=76)             (n=74)
     Planning or Considering                                82%                   33%

     Partially Implemented – plan for more                   12%                     39%
     Fully Implemented                                        0%                      7%
     Decided Against                                          4%                      5%
     Partially Implemented—no plan for more                   1%                     15%
     Undecided                                                1%                      1%

Rural hospitals in Wisconsin face important resource limitations, but may be
advantaged by relatively lower complexity of operations than many urban
integrated care systems. Rural hospitals in Wisconsin are actively investing in
HIT despite limitations in capital and IT staff resources.

A 2006 survey of HIT adoption in 30 rural or very small hospitals (representing
22% of all Wisconsin hospitals) conducted by the Rural Wisconsin Health
Cooperative (RWHC) discovered that:

       Every hospital has a core Master Patient Index (MPI) database;
       Over 80% of respondents had installed electronic pharmacy, lab, or order
       entry systems;
       Few hospitals have interface engines, which inhibit information flow inside
       the hospital and may hinder participation in HIEs that require integration
       with multiple standards.

The conclusions from this survey include:

       1. There is significant density of HIT adoption in RWHC member hospitals,
          perhaps more than expected, given their size.

       2. HIT adoption is increasing, as many study participants noted plans for
          2007 implementations that are not reflected in this report.


22
      MetaStar, Inc. Environmental Scan, December 1, 2005 and Simmons G. The prevalence of
      EHI Technology in Wisconsin, eHealth Board, March 26, 2006
      http://ehealthboard.dhfs.wisconsin.gov/materials/materials/PrevEHITechn.pdf
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                                                        Chapter 1: Health Care in Wisconsin Today
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          3. The integrated single vendor model seems to be especially successful for
             smaller hospitals.

          4. There is low interfacing engine adoption even in high HIT density
             facilities (without exception, integrated model facilities do not own
             interface engines).

          5. Avoiding the complexities of interfacing by using an integrated strategy
             may be a key way that smaller hospitals succeed in expanding their HIT
             adoption to advanced patient safety systems.

          6. The service volume of an organization is not necessarily predictive of HIT
             adoption until you look at the lowest-volume facilities.

          7. Affiliation with a larger organization is not predictive of HIT adoption,
             though organizations with the fewest HIT systems implemented tend to be
             independent.

          8. Low volume, particularly low-volume unaffiliated, organizations may
             need help implementing EHR systems.

     The Wisconsin Hospital Association (WHA) is surveying all hospitals regarding
     the implementation and installation plans for CPOE, as well as participation in a
     variety of public reporting programs in 2006 and 2007. The eHealth Board will
     coordinate its annual survey of HIT and HIE with the WHA work.


     Health Information Exchange

     The first-ever inventory of both operational and planned health information
     exchange (HIE) projects in Wisconsin was undertaken in October and November
     2006. 23 For this purpose, HIE was defined as “organizations or projects in which
     multiple independent health-related organizations routinely send or receive
     electronic clinical information about patients for purposes other than billing or
     claims payment.” This definition is broader than just regional multi-sector, multi-
     purpose information utilities, or Regional Health Information Organizations
     (RHIOs). It also includes single-purpose projects transmitting patient information
     for public health or other purposes.

     This comprehensiveness was intentional because the goals are to:

          Track the prevalence and coverage of health information exchange in
          Wisconsin over time.

     23
          The full survey is available on the eHealth Board web site.
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Chapter 1: Health Care in Wisconsin Today
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   Assess the impact of efforts to increase health information technology and
   exchange.

   Encourage learning between exchange initiatives.

   Help people and organizations locate exchanges relevant to their interests.

Based on this survey, there are a large number of exchange projects underway in
Wisconsin, many with considerable overlap. Collectively they represent a major
pool of expertise and a constituency for statewide coordination, collaboration,
and policy initiatives.

Thirty contacts were solicited to provide detailed information using an internet
web-tool; 5 did not respond, and 6 respondents could not identify projects
meeting the definition of HIE. The remaining 19 respondents identified 14
operational exchange projects plus 12 planned exchange projects.

Of the fourteen operational HIE projects actively exchanging data, most deliver
patient information to centralized systems for public health or quality
surveillance and about half deliver patient information directly to clinical health
professionals, including public health case management. The operational
projects are sponsored by a mix of government organizations, health care
provider organizations and other non-profit organizations. While the majority of
the operating projects were established with and plan to be sustained primarily
by public funds, some are funded primarily with private funds

For the twelve projects in the planning stage, more than one-half are being
organized within non-profit organizations and more than one-half anticipate
receiving startup funding primarily from private sources. These projects will
deliver patient information to clinical health professionals and surveillance
systems.

This assessment was designed for annual re-use, permitting trends over time and
observations of changing needs as the Action Plan is implemented. We now
know that a sizable community of professionals and organizations are already
working on the transmission of electronic patient information between
organizations. Many government (primarily public health) sponsored projects
have already achieved considerable success, but most do not make clinical
information directly accessible in the clinical setting.

Existing exchange organizations express hope for better coordination,
standardization and collaboration among existing and planned exchange efforts.
Sustainable funding and improved organizational capacity and competency are
needed.
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                                                      Chapter 1: Health Care in Wisconsin Today
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     Why Wisconsin Can Lead
     Wisconsin is a state uniquely positioned to transform the health care sector
     because of its technical resources, strong industry partners in the technology and
     health care sectors, the commitment and intellectual capacity brought to this work
     and a remarkable history of collaboration across private sector competitors and
     across the public and private sectors.

     As a result of the ground-breaking work done by leading organizations such as the
     Wisconsin Collaborative for Healthcare Quality, the Wisconsin Health
     Information Organization, the Wisconsin Hospital Association and the Wisconsin
     Medical Society, both public and private sector health care purchasers will have
     the capacity to measure quality and to measure price - and therefore to measure
     the value of the investment and to purchase health care based on this information.

     As part of the development of the Action Plan, the eHealth Board and its
     workgroups carefully considered how best to build upon the various successful
     statewide and regional initiatives already underway in Wisconsin to improve the
     quality of health care and to evaluate and learn from national initiatives so that
     this plan would reflect state-of-the-art thinking. In addition to the work of the
     organizations cited above, other examples include:

          The Wisconsin Rural Health Care Cooperative, creating a shared Health
          Information service for its members;

          Private association initiatives on quality improvement and public reporting,
          such as the CheckPoint ™ program of the Wisconsin Hospital Association;
          and

          The statewide Diabetes Collaborative, which is a model for public-private
          collaboration to improve outcomes of care. In the recent report from the
          National Committee for Quality Assurance that compiles averages of all
          HEDIS measures for care provided in 2005 for commercial, Medicare, and
          Medicaid payers, Wisconsin is the top-performing state in the nation for three
          of the seven diabetes indicators for the commercial population and for two of
          the seven diabetes indicators for the Medicare population. 24

      Aligning interests and work across these and other initiatives as they develop will
      be an important activity for the eHealth Board and is reflected in the activities of
      the five-year plan.


     24
          State of Health Care Quality 2006; Industry Trends and Analysis. National Committee on
          Quality Assurance. (Washington D.C. 2006).
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As noted, unlike most states, Wisconsin has a large proportion of physicians in
large group practices, with most of these already using electronic health records
and other health information technology; as well as large health care systems -
many with advanced health information systems. There is strong commitment to
quality improvement and leadership in the health care sector, including the two
medical schools and professional associations.

The state is home to two of the world’s leading companies in electronic health
information, EPIC Systems and GE Healthcare, and to many other smaller
innovative companies working on health IT. In the public sector, Wisconsin is
developing a sophisticated public health information system as well as other
systems that can support the eHealth technology platform.

Extensive work on privacy and security issues has already been done under the
leadership of the HIPAA Collaborative of Wisconsin, providing a venue for
diverse stakeholders to uniformly address these critical issues. There is also a
history of strong public - private collaboration to address health care issues,
including great energy and enthusiasm brought to the work of the eHealth Board
over this past year that has resulted in this Action Plan.

The timing is excellent to launch this plan because of the alignment of the
leadership, technical assets and expertise that already exist in the state with the
planning done by the eHealth Board, concurrent with significant progress on
eHealth initiatives in other states and at the national level to learn from and build
upon.


eHealth Developments in Other States
Many states are now engaged in developing eHealth plans. A report from the
national eHealth Initiative based on its most recent survey on health IT found
that the level of policy activity and leadership at the state level has increased
significantly in just the past year.

   At present, 38 states are participating in a statewide or regional collaborative
   relating to HIT and HIE.

   Of those, 21 states are convening stakeholders for planning, communication
   and coordination.

   Sixteen states are providing staff to plan or manage these activities and 17
   are providing funds to support regional efforts.

   Thirty-six bills were passed in 24 states during 2005 and 2006, calling for the
   use of HIT to improve health care.
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           Ten state governors have issued executive orders to develop statewide plans. 25

     The eHealth Initiative annual survey shows the stages of development across
     regions and states.




     Source: eHealth Initiative’s Third Annual Survey of Health Information Exchange
             Activities at the State, Regional, and Local Levels; September 25, 2006;
             http://toolkits.ehealthinitiative.org/assets/Documents/eHI2006HIESurveyReportFi
             nal09.25.06.pdf; accessed October 30, 2006.

     At the time of this survey in May 2006, Wisconsin was at Stage 4. With the
     completion of this Action Plan, Wisconsin is now at Stage 5 in the planning cycle
     and ready to move into statewide implementation.


     National eHealth Developments
     The eHealth Board workgroups have done extensive research about what to
     expect from the national government and what can be learned from other states
     engaged in similar planning to take advantage of ideas, products and lessons
     learned, to be able to move this plan forward quickly and purposefully. The work
     being done nationally sets the framework and informs the timing of planned
     activities in Wisconsin.

     In August 2006 the President issued an Executive Order to improve health care
     through health information technology. This order addresses interoperability,
     health care price and quality transparency, and developing and identifying

     25
          eHealth Initiative’s Third Annual Survey of Health Information Exchange Activities at the
          State, Regional, and Local Levels; September 25, 2006;
          http://toolkits.ehealthinitiative.org/assets/Documents/eHI2006HIESurveyReportFinal09.25.06.
          pdf; accessed October 30, 2006.
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practices that promote high-quality health care including pay-for-performance
programs. The order applies to federal agencies and is intended to serve as a
vehicle for collaboration across federal agencies, state government, the nation’s
largest employers and health plans. This Action Plan establishes a path for
Wisconsin to do the same.

The Office of the National Coordinator for Health IT in the Department of
Health and Human Services (DHHS) is engaged in a number of efforts to
promote, support and fund the use of HIT and HIE and to create a nationwide
health information network (NHIN). The Office has also funded projects in
more than 30 states, including Wisconsin, to research and resolve privacy and
security issues that pose a barrier to health information exchange.

The national strategy calls for federal agencies to collaborate with private
stakeholders in developing and adopting architecture, standards, a certification
process and a method of governance for the ongoing implementation of health
IT. The American Health Information Community (AHIC) was created in
August 2005 by Secretary Leavitt of DHHS to be the forum to bring these
groups together. Wisconsin’s work will be timed to build upon the work done by
the AHIC as implementation activities begin.

For example, one of the first areas prioritized for national development was
delivering laboratory results quickly and efficiently. The approach was to
develop a “use case” – a description of how the information exchange would
work, with as much specificity as possible, to develop business needs for follow-
on activities such as data harmonization, development of the NHIN, certification
and policy analysis and development. Working with national technology
partners, the DHHS has now developed specific standards for the exchange of
laboratory data.

In addition to the work with AHIC, the Office of the National Coordinator is
now supporting the formation of a new state collaborative through a contract
with the National Governors Association to address:

   Long-term solutions to ensure privacy and security.
   State law practice-of-medicine barriers to HIE.
   Governance models.
   Sustainable business models for HIE.
   The role of private payers.
   Integration of state public health and health care programs.
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                                                                               Chapter 1: Health Care in Wisconsin Today
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                      National Health IT Initiatives
               The                                        • CCHIT provides a mechanism for
           Certification                     Health         certification of health care IT
           Commission                     Information       products
            for Health                    Technology
           Information                     Standards
           Technology                    Panel (HITSP)
             (CCHIT)        American                      • HITSP brings together relevant
                              Health                        stakeholders to identify
                           Information                      appropriate IT standards
                                           Nationwide
              Health       Community          Health
           Information                     Information
          Security and                       Network
                                                          • HISPC focuses on addressing
             Privacy                       Architecture     variations in business policy and
          Collaboration                      Projects       state law that affect privacy and
             (HISPC)                          (NHIN)
                                                            security

       Nationwide coordination of policies,               • NHIN focuses on health
      resources and priorities – Office of the              information exchange pilots
      National Coordinator (ONC) initiatives                starting in 2007
        and contracts for unifying regions




     A September 2006 report from the American Health Information Management
     Association, commissioned by the DHHS, presents the results of research and
     development of consensus standards for statewide health information exchange
     that have been very useful as the recommendations in this report were
     developed. 26 The nine states that participated in this project were California,
     Colorado, Florida, Indiana, Maine, Massachusetts, Rhode Island, Tennessee, and
     Utah. Key findings include:

            Important innovation and learning are under way in many states.
            There is no single model for state-level HIE initiatives, nor should there be.
            States are uniquely positioned to engage stakeholders for coordination of HIE
            efforts.
            States play a critical role in the NHIN and must be more fully engaged in
            partnering with the federal government in its development.
            Even the most experienced organization faces significant barriers.

     In addition to significant research about activities and plans in other states, the
     Action Plan also reflects the advice and expertise of people working on eHealth
     planning in Arizona, California, Minnesota and the national eHealth Initiative.

     A recent Health Affairs article reporting health rankings of the U.S. compared to
     other countries notes the importance of taking a coherent, whole-systems
     approach to improving outcomes of care and reducing costs – as has been done to
     create this Action Plan.

     “Bringing in effective IT for maximum national gain likely requires a critical
     mass and whole system approach that spans ambulatory, diagnostic, pharmacy
     and inpatient settings…The overall picture that emerges is one of missed

     26
          Development of State Level Health Information Exchange Initiatives. Foundation of Research
          and Education of American Health Information Management Association. September 1, 2006.
          http://www.staterhio.org/ (accessed November 22, 2006).
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opportunities and room for improvements. The findings underscore the
importance of policies that take a coherent, whole system approach rather than a
fragmented approach to change to address the interaction of access, quality and
costs. There is evidence that quality and efficiency can be improved together.
Savings can be generated from more efficient use of costly resources, producing
the same or better quality at lower resource cost. The challenge is finding
systematic ways to achieve net gains and rechannel the savings into investments
to improve coverage and the capacity to innovate. The critical importance of
improving coordination of care emerges from across multiple indicators.” 27

The 2001 report from the Institute of Medicine on the quality chasm in U.S.
health care has stimulated many of the eHealth initiatives now under way across
the nation. With this Action Plan, Wisconsin is poised to coordinate existing
and developing resources in an organized way to simultaneously tackle
connecting systems, measuring quality and price, establishing incentives for high
quality and efficient health care, and linking the eHealth technology platform to
public and private prevention and disease management activities.




27
     C. Schoen, et al, “U.S. Health System Performance: A National Scorecard,” Health Affairs 25
     (2006), September 20, 2006,
     http://content.healthaffairs.org/cgi/content/abstract/hlthaff.25.w457v1, accessed November 30,
     2006.
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                                         Chapter 2: Health Care in Wisconsin in the Future
                                                                       December 1, 2006

     Chapter 2: Health Care in Wisconsin in the
                Future
     In response to the Executive Order, the Board has developed recommendations to:

        Meet the needs of health care providers for patient information readily
        available at the point of care;

        Identify financing options for HIT and HIE;

        Identify existing eHealth resources, including funding sources, to support the
        development of a statewide eHealth information infrastructure;

        Identify technology options, and their advantages and disadvantages, for a
        statewide eHealth information infrastructure;

        Identify options for serving consumer health information needs;

        Ensure health information privacy and security in electronic health
        information exchange;

        Facilitate statewide adoption of electronic health record standards to enable
        health information exchanges across the state and nationally; and

        Create organization and governance structures for a statewide eHealth
        information infrastructure.

     These recommendations have been woven together to create a coherent, whole-
     systems approach to transformation of the health care sector that relies on three
     key strategies:

        Improve quality, safety and value by establishing an eHealth technology
        platform to provide needed information at the point of patient care.

        Encourage the development, alignment and implementation of value-based
        purchasing policies and actions across the public and private sectors.

        Link HIT and HIE plans to prevention and disease management activities.

     With this plan, Wisconsin can lead the nation in health care transformation by
     creating the technology platform to support evidence-based medicine, value-based
     purchasing, prevention and chronic disease management. In his book Purchasing
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Population Health, Paying for Results 28 David Kindig writes that “we will not
maximize the amount of health we achieve until a measure of health outcome
becomes the purchasing standard for both the public and private sectors.”

Value-based purchasing depends on the wide availability of information on
health care results and prices. Leveraging health IT is the way to secure this
information. HIE can begin without widespread adoption of HIT, using
administrative data until clinical data is widely available and easy to use.

 It is often costly and inefficient to retrieve clinical data for quality improvement
and public reporting today because of the need to conduct labor-intensive chart
reviews. While now most of the reporting about the quality and cost of health
care is based on claims or other administrative data, in the future as health
information technology (HIT) and health information exchange (HIE) ramp up,
there will be more and more use of clinical data to inform purchasing decisions.
Process data is important but it is not enough – knowing that a test was done is
helpful, but it is the test results that provide meaningful information to measure
health status. Clinical data is essential to support optimum quality improvement
and value based purchasing.


Vision for 2012

With this report, the eHealth Care Quality and Patient Safety Board presents a
compelling, achievable vision and pathway for 2012.

Our core vision is that no patient will ever be harmed by lack of information at
the point of patient care.

Health information technology and health information exchange will enable:

          Improvement in the state’s economy and competitive position as the
          health care sector is transformed and health care investments result in
          high quality health care.

          A transformation of the health care sector that creates healthy
          cooperation and healthy competition among providers, with patients,
          payers and other partners contributing to better outcomes.

          Improvement in the health of Wisconsin’s population through appropriate
          prevention, early intervention and treatment.


28
     Kindig, David A., MD, PhD. Purchasing Population Health, Paying for Results. University
     of Michigan Press. 1997.
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                                         Chapter 2: Health Care in Wisconsin in the Future
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            Continuous quality improvement in health care delivery to improve value.

            Consistent practice of safe, high quality and evidence-based medicine as
            the state builds and leverages health IT.


     eHealth Action Plan Components

                            eHealth Action Plan Components

     1. Establish the eHealth technology platform.
        a. HIT adoption.
        b. Regional health information exchange (HIE).
        c. Statewide HIE services.
     2. Value-based purchasing policies and actions.
     3. Link HIT and HIE plans to prevention and disease management activities.
     4. Take an incremental approach - growing thoughtfully over time with
        frequent evaluation of progress.

     Here is an outline of the Action Plan, as also presented in the Executive
     Summary:

     1. Establish the eHealth technology platform.

        a. HIT adoption

            1) Encourage health care providers to adopt and use electronic health
               record systems by providing start-up funding for safety net providers
               and small and/or rural providers that are not able to afford them, by
               offering education and technical assistance and by endorsing standards
               for these systems to minimize the risk associated with purchasing
               decisions.

            2) Also encourage all providers to continue and increase investment in
               electronic health record systems through value-based purchasing
               strategies by public and private payers (described more fully in
               Component #2 below).

            3) Regularly monitor progress toward achieving benchmark goals for
               adoption (Component #4 below) and offer added recommendations to
               public and private partners as needed to achieve necessary progress.

        b. Regional health information exchange (HIE)
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       1) Foster the creation of regional (sub-state) health information
          exchanges to enable exchange of high-value patient information to
          recognize that local needs should drive the mission and structure of
          the organization, and that, to date, local markets have had the greatest
          economic sustainability and participant trust.

       2) Focus early on timely patient information for providers when and
          where they need it for patient care – for example, comprehensive
          information on patient allergies, medications and past diagnoses.

       3) Support the Wisconsin Health Information Exchange (WHIE), a
          Regional Health Information Organization (RHIO) in Southeast
          Wisconsin, focusing on real-time information for hospital emergency
          rooms, results delivery and medication lists. Share technologies and
          lessons learned as appropriate across the state.

       4) Simultaneously encourage the development of up to four new RHIOs
          in other areas of the state by providing state-supported contracts and
          technical assistance.

       5) Limit Wisconsin funding to RHIOs meeting minimum requirements
          including:

           i.       Population served (at least one million people in the geographic
                    area it covers).

           ii.      Alignment with natural “Medical Trading Areas” as depicted in
                    the following map from the Dartmouth Atlas of Health Care
                    showing hospital referral patterns based on Medicare data.




                Figure 1. The Dartmouth Atlas of Health Care in the Great Lakes States,
                http://www.dartmouthatlas.org/atlases/region4.pdf, accessed on October 31, 2006.
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                                   Chapter 2: Health Care in Wisconsin in the Future
                                                                 December 1, 2006


        iii.   Willingness to serve all members of the communities in the
               designated area – cannot be vendor-driven or exclusive to a
               limited subset of payers or providers.

        iv.    Independent status with broad governance including both public
               and private sector representatives and strong consumer
               representation.

        v.     Compliant with state and national standards for interoperability,
               and committed to statewide and nationwide network
               development.

        vi.    Policies and systems to assure privacy, security and
               confidentiality of health information.

        vii. Inclusion of public health agencies.

        viii. A well-developed and viable business plan.

     6) Simultaneously develop statewide health information exchange
        services to:

        i.     Serve as the link between RHIOs, other states and the
               Nationwide Health Information Network (NHIN).

        ii.    Provide basic infrastructure services that are most cost effective
               on a statewide scale and that can leverage existing state assets,
               such as record locator and user authentication services.

        iii.   Develop strategies to assure information access to providers
               outside of a regional health information exchange or who straddle
               multiple RHIOs, as may happen with rural or boundary areas.

        iv.    Make practice guidelines/clinical decision support available for
               health care providers (as a resource for their use and not a state
               requirement).

        v.     Provide a Web portal for consumers to obtain health education
               materials and access to the practice guidelines.

        vi.    Set standards and policies for health information exchange
               consistent with national standards.
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Chapter 2: Health Care in Wisconsin in the Future
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                                Multiple RHIOs in Wisconsin
                                                                                                                                                                         NHIN
                                                                                                              Clinic Record pecialist Record
                                                                                                                           S
                                                                                         Re      Hos pital Record
                                                                                         po                                        Re
                                                                                          sit                                      po
                                                                                          or                                       sit
                                                                Clinic Record pecialist Record
                                                                             S             y                                       or
                                          Re       Hos pital Record
                                           po                                        Re of                                           y
                                           sit                                        poDo
                                                                                        Clinical IT System                          of
                                                                                                                    Index of patients records
                                           or                                         sit cu                                      Do
                                                                                        me Aggregate                    (Document-level)
                                                                                                                                   cu
                                            y                                         or
                                                                                   Clinic
                                           of                                           nts Patient Info                          me
                                                                                   al y
                                          Clinical IT System
                                          Do                                          of
                                                                                   Encou                                          nts
                                                                      Index of patients records
                                           cu                                        Do
                                                                                   nter
                                                                          (Document-level)
                                          me Aggregate                                cu
                                     Clinic Clinic Record pecialist Record
                       Re                 nts Patient Info S                         me
                                Hos pital Record
                                     al
                        po                                          Re               nts
                                     Encou
                        sit          nter                           po
                        or                                          sit
                          y
                         of
                                                                    or
                                                                      y                                                                                                            WIR
                       Clinical IT System
                       Do                                            of
                        cu                          In dex of patients records
                                                                   Do
                                                         (Document-level)
                       me Aggregate                                 cu
                  Clinic
                  al
                       nts Patient Info                            me
                                                                   nts
                                                                                                                                                                       State HIE   Medic-
                  Encou
                  nter                                                                                                                                             MPI Services     Aid
                                                                                                                                 Clinic Record pecialist Record
                                                                                                                                              S
                                                                                                           Re       Hos pital Record
                                                                                                           po                                         Re
                                                                                                            sit                                       po
                                                                                                            or                                        sit
                                                                                                             y                                        or
                                                                                                            of                                         y
                                                                                                           Clinical IT System
                                                                                                           Do                                         of
                                                                                                                                      In dex of patients records
                                                                                                            cu                                       Do
                                                                                                           me Aggregate                    (Document-level)
                                                                                                                                                      cu
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                                                                                                      al   nts Patient Info                          me
                                                                                                                                                     nts
                                                                                                      Encou
                                                                                                      nter




2. Stimulate the development, alignment and implementation of value-
   based purchasing policies and actions across the public and private
   sectors.

   a. Encourage the creation of formal partnerships between payers and
      providers – such as the Wisconsin Collaborative for Healthcare Quality,
      the Wisconsin Hospital Association, the Wisconsin Medical Society,
      Employee Trust Funds, the Wisconsin Health Information Organization
      and the Wisconsin Medicaid program - to develop standard requirements
      for reimbursement, including new Pay for Quality (P4Q) incentives.

   b. Leverage the purchasing power of state government by working in
      common to align incentives for providers to:

           Acquire use of certified EHR systems and participate in health
           information exchange.
           Use evidence-based clinical decision support.
           Support engagement of consumers in their own health care.
           Publicly report on health care outcomes.
           Participate in public health surveillance.

   c. Actively collaborate with health care purchasers, including private
      employers as well as other governmental purchasers, all payers,
      professional associations and health care providers, to promote
      consistency and alignment of incentives and other strategies for
      promoting high quality, safe and efficient health care, enabled by an
      appropriate health information infrastructure and public reporting.

   d. Create an active agenda to seek federal and foundation funding to
      develop and model these systems for the nation.
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                                        Chapter 2: Health Care in Wisconsin in the Future
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        e. Establish a contract between DHFS, ETF and the Wisconsin Health
           Information Organization (WHIO) to build a data repository to track
           outcomes, quality and cost of episodes of care for quality improvement,
           public reporting and public health assessment functions.

        f. Evaluate the impact of public reporting on health care outcomes.


     3. Link HIT and HIE plans to prevention and disease management
        activities.

        a. Identify the unique roles for HIT and HIE in population health
           improvement.

        b. Leverage the Robert Wood Johnson “Common Ground” grant to
           Wisconsin DHFS to create comprehensive and effective statewide chronic
           disease surveillance, including population health baseline information for
           the entire Medicaid population (representing 15% of the Wisconsin’s
           population).

        c. Develop a routine health risk assessment and a member agreement for the
           Medicaid population to guide taking personal responsibility for health and
           health care.

        d. Actively promote use of chronic disease management tools by safety net
           providers and continue to strengthen care management strategies across
           the Medicaid population in general.

        e. Engage long-term-care providers in eHealth implementation activities to
           address and improve the coordination of care across health settings.

        f. Conduct research through focus groups to identify the best approaches to
           engaging patients with high quality health information and decision
           support tools for making health care decisions.

        g. Develop health information system tools and research data that will
           support stronger public-private partnerships to achieve the goals of
           Healthiest Wisconsin 2010, the state health plan; for example, improving
           nutrition and physical activity, prevention of tobacco use, and other cost-
           effective strategies to reduce the burden and unnecessary high costs of
           chronic disease and other preventable illnesses and injuries.
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   h. Establish biosurveillance capabilities across the public and private sectors
      for rapid outbreak detection, management and recovery.

   i. Assure interoperability of HIT/HIE with Wisconsin’s Public Health
      Information Network.

   j. Link clinical information to public health information initiatives in ways
      that are effective and efficient for both health care delivery and public
      health.

   k. Define respective roles of the eHealth Board and the Governor-appointed
      Public Health Council.

   l. Align the work of public health, business and medicine to foster
      collaboration and to support health care transformation.


4. Take an incremental approach - growing thoughtfully over time with
   frequent evaluation of progress.

   a. Address HIT and HIE simultaneously, recognizing that existing data is
      available for exchange without waiting for universal adoption of
      electronic health records and other technology.

   b. Establish performance goals and annual benchmarks for achieving the
      goal of statewide HIE and HIT in the plan, and initial strategies to move
      forward through voluntary public-private partnerships and investments.

   c. Actively foster continued deepening of effective public-private sector
      partnerships to achieve mutually beneficial goals of higher quality, safer
      and more efficient health care through HIT and HIE.

   d. Start with projects that build essential infrastructure while adding value
      for providers and consumers in the short term.

   e. Develop an infrastructure that is flexible, scalable, adaptable and
      replicable.

   f. Use standards consistent with national direction.

   g. Create incentives for interoperable and certified systems.

   h. Build on existing assets in the public and private sector.
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                                        Chapter 2: Health Care in Wisconsin in the Future
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        i. Promote data reuse for authorized public health and research purposes.

        j. Conduct constant surveillance of new developments in both the public and
           private sectors to keep the plan relevant and to take advantage of new
           opportunities.

        k. Establish effective communication strategies to build engagement and
           trust across all stakeholders.

        l. Monitor progress closely and adjust strategies and activities as needed,
           recognizing that this is ground-breaking work, significant in scope, and
           that there are now many interrelated activities underway within the state
           and nationwide to transform the health care sector that must be taken into
           account as this plan unfolds.


     2012 Measures of Success
     Monitoring progress and adjusting strategies as needed are fundamental to this
     Action Plan. In addition to the plans to set annual benchmarks for adoption of
     HIT and HIE when the current HIT adoption survey is completed, the eHealth
     Board has established the following metrics to support the vision for 2012.

     1. Creation of the technology platform

        a. Most clinical encounters involve appropriate access to an electronic
           medical record and related health information technology (HIT) at the
           point of patient care.

        b. Most clinical encounters involve appropriate access and updates to a
           regional/state health information exchange (HIE) that will quickly access
           pertinent information about diagnoses, allergies, prescribed medicines, and
           diagnostic information, such as laboratory and radiology results.

        c. Most clinical – patient interactions have ready access to electronic
           decision support or electronic search of practice guidelines.

        d. Most clinicians are covered by e-prescribing.

        e. At least half of consumers have access to medication lists, test results and
           other health care information through a secure, online portal.

        f. At least half of consumers have an option for secure, online
           communication with their primary health care provider.
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2. Value-based purchasing

   a. Most public sector health care purchasers use consistent requirements
      and/or incentives for state contracts with health care providers, requiring:

           Acquisition and use of certified EHR systems and participation in
           health information exchange.
           Use of clinical decision support tools.
           Support for consumers’ engagement in their own health care.
           Public reporting on health care outcomes.
           Participation in public health surveillance.

   b. At least half of private health care purchasers use this same common set
      of provider requirements and/or incentives for their contracts with health
      care providers.


3. Improved health status of citizens, as measured by:

   a. Goals and objectives in the state health plan, Healthiest Wisconsin 2010.

   b. Quality and process measures endorsed by the Wisconsin Collaborative
      for Healthcare Quality.

   c. Quality and process measures endorsed by the CheckPoint ™ program of
      the Wisconsin Hospital Association.


Next Steps
Implementation activities by year are detailed in Chapter 3.

The Governance Workgroup has proposed a framework to move from the
planning stage to implementation with four advisory groups and an executive
committee overseeing the work laid out in this Action Plan; these groups will
report to the eHealth Board. The Governance Workgroup Report provides a
proposed charter for each of these advisory groups, including suggested
members, to assure broad engagement of stakeholders.
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                                                          Chapter 2: Health Care in Wisconsin in the Future
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          eHealth Governance Proposal for Wisconsin

                                              eHealth Board




                        Executive Committee



                                                                            Statewide
                              Consumer Interests
        Patient Care                                     Public Health   Health Information
                                 and Privacy
       Advisory Group                                   Advisory Group      Exchange
                               Advisory Group
                                                                          Advisory Group




                                                                            Operations




     In five years, there can be solid, dependable statewide health information exchange in
     place, based on national standards and goals and implemented in the right way, so
     that systems are easy to use and add value to patient care:

        All emergency rooms will be able to communicate with each other about patients
        that arrive at their facility and will have access to basic information about each
        patient, including a diagnostic list, allergies and medications.

        All health care providers will be able to use electronic health records, including e-
        prescribing, and have access to clinical decision support to assure that the latest
        science is known and used as care is provided to patients.

        Consumers will have access to their own health records and be both empowered
        and well positioned to be informed stewards of their own health and health care.

        State-of-the-art technical and procedural safeguards will protect the personal
        health information housed in and exchanged by each of these systems.

        Public reporting about the cost and outcome of health care (the value of the
        investment in health care) will be well-developed, widely available and wisely
        used for heath care purchasing decisions.
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Wisconsin Stories – in the Future

By 2012, with the completion of the activities laid out for the next five years, the
patients described earlier in this report will have a much improved and higher
quality experience with their health care, and health care in Wisconsin will be
transformed, to the measurable benefit of the state’s economy.

Citizens will get safe and high quality health care:

   Mr. Robinson, a 50-year-old man, develops symptoms of a bladder infection,
   and goes to a local emergency department for care. His past medical
   records are queried over the regional health information exchange system
   operated by the RHIO in this part of the state. A history of allergy to
   penicillin and sulfa is reported to the emergency room physician. Mr.
   Robinson is prescribed Cipro and recovers uneventfully in two days.

   Grandmother Smith, who was seen in the Emergency Department after a
   fall, is released back to her home because the Emergency Department
   physician could view her history through the local health information
   exchange and understand her condition, even without her help, saving
   suffering, complications, time, expense and a nursing home stay for the
   patient.


Public health systems will be able to respond immediately to outbreaks or
exposures:

    A large number of Milwaukee residents present to ERs with diarrhea. The
   City Health Department finds out about the outbreak immediately as
   information about reportable conditions is sent instantaneously by labs and
   clinicians to public health agencies, allowing immediate implementation of
   prevention and control strategies with the water supply and enabling the
   health department to educate the community about how to respond to the
   problem.
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                                                                  Chapter 3: Five-Year Plan
                                                                          December 1, 2006

     Chapter 3: Five-Year Plan
     Four sets of activities are outlined in this five-year plan:

         Establishing the eHealth technology platform

         Value-based purchasing

         Prevention and disease management

         Governance and management

     This plan reflects the current assessment of the work needed to achieve the vision
     for 2012. The plan will be reviewed and updated on a regular basis by the
     eHealth Board, with annual updates provided in a report to the Governor.

                                                       2007   2008   2009    2010   2011
      1. Establish the eHealth Technology
      Platform

      a. HIT adoption and use
      Confer with stakeholders on rural and small
      practice adoption issues including discussion
      of financial and technical assistance to
      hospitals and physicians not able to afford
      EHRs.

      Set policies and standards for HIT adoption in
      Wisconsin consistent with national
      guidelines/requirements.

      Conduct a readiness assessment about HIT
      and HIE with safety net providers – update
      annually.

      Conduct policy analysis and develop policy
      options for Medicaid reimbursement for
      acquisition or donation of EHR systems to
      safety net providers


      Provide education and technical assistance to
      safety net providers about how to select and
      implement HIT systems.

      Develop funding criteria for loans and grant
      for HIT acquisition if funds are available.
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Chapter 3: Five-Year Plan
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                                                   2007   2008   2009   2010   2011
Administer funds for HIT acquisition if funds
are available.


b. Creation of local/regional HIE
organizations

Confer with stakeholders on best ways to
stimulate and support the development of
local/regional health information exchanges.

Support Southeast Wisconsin RHIO (the
Wisconsin Health Information Exchange –
WHIE) in the development of its governance
model and the pilot of the first stage of
information exchange with first set of users - -
and supply Medicaid data for the exchange.

Set requirements for state funding of RHIOs.

Issue RFP by 9/07 for development of
regional health information exchanges, if
funds are available.

Assess and remove barriers to health
information exchange (HIE) and provide
technical assistance to local HIE efforts.

Award grants for RHIO development to
successful bidders.

Support Milwaukee-based RHIO as it gains
users and expands data available for exchange.

Support the creation of new RHIOs by policy
development, technical assistance, funding if
authorized.

Encourage raising private capital for RHIO
development.


c. Services offered by a statewide
HIE

Confer with stakeholders and conduct analysis
regarding realignment of state systems for
consumer benefit.
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                                                                  Chapter 3: Five-Year Plan
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                                                       2007   2008   2009    2010   2011
     Confer with stakeholders about services to be
     offered by statewide HIE for providers that
     are not part of a local or regional HIE,
     including the use of practice guidelines, how
     to link to personal health records, as well as
     other data sources to offer.

     Research options for clinical decision support
     systems for the statewide HIE.

     Set policies and standards for interoperability
     and clinical decision support capability across
     health information exchanges in the state,
     consistent with national guidelines.

     Inventory state assets to support HIE and the
     changes needed to make them more robust,
     standards-based, easy to use and interoperable
     (e.g., Wisconsin Immunization Registry).

     Create/adopt a record locator service including
     a master person index.

     Set up user authentication measures for the
     statewide exchange.

     Serve as bridge to Nationwide Information
     Network (NHIN) and other states.

     Health Information Security and Privacy
     Collaborative (HISPC) deliverables:
         • Interim Assessments of Variation
              (11/6/06)
         • Interim Reports of Solutions
              (12/11/06)
         • Interim Implementation Plans
              (1/15/07)
         • Final Assessment/Analysis of
              Solutions (3/30/07)
         • Final Implementation Plans (3/30/07)

     Research and resolve statewide policy issues
     around privacy and security.

     Public payers submit claims data to the
     statewide HIE including claims data from
     Medicaid, ETF, Veterans programs and their
     contracted health care providers such as
     HMOs and PBMs.
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Chapter 3: Five-Year Plan
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                                                  2007   2008   2009   2010   2011
Encourage private payers to do the same.

Acquire online practice guidelines (a
“library”) from a reputable service and make
available for clinicians and consumers through
the statewide HIE.

Operate a record locator service including a
master person index.

Operate user authentication services for the
statewide exchange.

Provide a Web portal for consumers to obtain
health education materials and access to
practice guidelines.

2. Value-based purchasing
initiatives

Confer with stakeholders on standards for
state contracts to promote HIT and HIE.

Seek federal and foundation funding to
develop and model these systems for the
nation.

Encourage creation of formal partnerships
between payers and providers to create
incentives, common reimbursement standards.

Align work products and timing with national
transparency initiative to measure quality and
price and to establish incentives for safe and
high quality care.

Establish a partnership agreement between
Medicaid and the Wisconsin Collaborative for
Healthcare Quality to develop Pay-4-Quality
(P4Q) strategies for Medicaid

Engage safety net providers in P4Q initiatives.

Leverage the purchasing power of state
government by developing new and uniform
requirements for state contracts with health
care providers to set standards for
interoperability, use of clinical decision
support, consumer engagement and public
reporting on health care outcomes.
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                                                                   Chapter 3: Five-Year Plan
                                                                           December 1, 2006

                                                        2007   2008   2009    2010   2011

     Seek support from the top 10 employers in the
     state to also adopt same contract requirements.

     Finalize contract between DHFS, ETF and
     WHIO to build data repository on episodes of
     care for quality improvement, public reporting
     and public health assessment.

     Monitor deliverables in the DHFS / ETF /
     WHIO contract.

     Conduct research on the impact of public
     reporting by the Wisconsin Collaborative for
     Healthcare Quality on the quality of care in
     Wisconsin in general and specifically for the
     Medicaid population.

     Report research results on the impact of public
     reporting – adjust policies to reflect findings.

     3. Link HIT and HIE to prevention
     and disease management strategies

     Identify the unique roles for HIT and HIE in
     population health improvement.

     Define respective roles of the eHealth Board
     and the Public Health Council.

     Assure interoperability of new HIT and HIE
     with the public health information system.

     Align the work of public health, business and
     medicine to foster collaboration and to support
     health care transformation.

     Link clinical information to public health
     information initiatives in ways that are
     effective and efficient for both health care
     delivery and public health.

     Leverage the RWJ Common Ground grant to
     create comprehensive statewide chronic
     disease surveillance systems, including the
     Medicaid population.

     Develop and implement a member agreement
     for Medicaid population to focus on taking
     personal responsibility for health care.
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Chapter 3: Five-Year Plan
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                                                   2007   2008   2009   2010   2011

Conduct a health risk assessment for all new
Medicaid recipients.

Actively promote use of chronic disease
management tools by safety net providers and
continue to strengthen care management
strategies across the Medicaid population in
general.

Support the development of a chronic disease
care management pilot for safety net providers
with access to EHRs.

Develop a new Web portal with information
about preventive services and how to handle
various health issues, starting with the
Medicaid population - Open up the customer
Web portal to all citizens with information
about preventive services and how to handle
various health issues.

Conduct cognitive research through focus
groups to identify best approaches to engaging
vulnerable patients with high quality health
information and decision support tools for
making health care decisions.

Report research results on the best approaches
for engaging patients in health information
and decision support tools – adjust policies to
reflect findings.

Develop health information system tools and
research data to support stronger public-
private partnerships to achieve the goals of the
state health plan.

Establish biosurveillance capabilities across
the public and private sectors for rapid
outbreak detection, management and recovery.

4. Governance and communications

Establish eHealth governance structure
recommended by the eHealth Board.

Represent the interests of all citizens.

Design and launch communications and
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                                                     2007   2008   2009    2010   2011
     marketing plan to engage and educate
     stakeholders about the value of HIT/HIE and
     of aligning efforts.

     Conduct an annual assessment HIT and HIE
     adoption.

     Propose additional measures to
     encourage/require adoption of HIT and HIE if
     there is not sufficient progress.

     Monitor public and private health information
     initiatives to identify opportunities for
     collaboration and to minimize redundancy;
     convene stakeholders for collaboration and
     coordination.

     Develop and implement plans to align health
     information initiatives within state
     government.

     Administer funds for eHealth initiatives
     including:
          • Medicaid Transformation Grant
              components
          • Funds for operations
          • Public health funding support
          • Grant writing

     Develop and administer contracts to support
     eHealth initiatives.

     Annually assess how well the eHealth
     governance structure is working.

     Implement the communications and marketing
     plan, including using the eHealth workgroup
     structure to establish regular communications
     and opportunities to confer with stakeholders
     about all aspects of the eHealth Five-Year
     Plan.
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Chapter 4: Summary of eHealth Workgroup Recommendations
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Chapter 4: Summary of eHealth Workgroup
           Recommendations
Under the leadership of the eHealth Care Quality and Patient Safety Board, there
have been many activities to engage stakeholders in the creation of this plan
including:

   Key informant interviews and an e-survey of stakeholders;

   An assessment of the current use of electronic health record systems and
   other health information technology in Wisconsin;

   An “eHealth Planning Forum” on May 5, 2006 at the Fluno Center to inform
   and involve stakeholders in the development of this plan; and

   Listening sessions with health care consumers and providers.

The eHealth Board has made a commitment to a transparent process with
meetings open to the public, web casts of key events, and a comprehensive
eHealth Board Web site.

Five workgroups were created to develop recommendations to the eHealth Board
for this Action Plan, each led by a member of the Board:

   Patient Care – Edward Barthell
   Information Exchange – Hugh Zettel
   Consumer Interests – Catherine Hansen
   Financing – Kevin Hayden
   Governance – Frederic Wesbrook

The recommendations from these groups have been woven together to produce
this plan and outline the specific activities by year that are described in Chapter
3. This Chapter provides the executive summaries of the five workgroup reports.

The complete report of each workgroup is presented on the eHealth Board
Web site (http://ehealthboard.dhfs.wisconsin.gov).

Appendix 2 provides a list of the volunteers who participated in the workgroups
and the staff who provided support to the workgroups and development of this
Action Plan.
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     Patient Care Workgroup – Executive Summary
     The Patient Care Workgroup was charged to:

     1. Define criteria (such as reach, feasibility and impact) to prioritize the key
        product types (such as Continuity of Care record or other abstract of medical
        history information, clinical care – public health business interoperability, e-
        Prescribe, use of statewide guidelines) and identify and prioritize the key
        product types to be implemented in the Action Plan.
     2. Define use case examples (real-world examples) that are appropriate for the
        first key products.
     3. Develop information on current use of electronic health records in Wisconsin.
     4. Identify positive opportunities and barriers to wider adoption of electronic
        health information systems in all types of medical care settings. Recommend
        strategies to take advantage of opportunities and overcome barriers to foster
        statewide adoption.

     To accomplish these charges, workgroup members prioritized outcome goals and
     information products (in collaboration with other workgroups); described a set of
     specific information products that could produce early value for patients,
     clinicians and other stakeholders; described the types of regional organizations
     needed to support such information products and a step-wise fashion in which the
     work can be approached; described functions that might best be performed at a
     statewide level; and recommended action to promote the adoption of necessary
     technology within individual organizations. An inventory of electronic health
     records and information exchange efforts is underway at the time of this report
     and will be described in later documents.

     Workgroup members first prioritized on the basis of the urgency of beneficial
     changes in health care and public health practice. (The criterion of feasibility as
     opposed to urgency was not included in this initial ranking.) A survey was
     completed by both the Patient Care and Consumer Interests workgroups.
     Answering in their professional capacities, workgroup members gave highest
     priority to (in descending order):

            Clinician access to a patient’s information between (as well as within)
            health care organizations
            Avoiding preventable hospitalizations
            Preventing medical injuries
            Accessing a common and comprehensive medication list for each patient
            Providing clinical decision support
            Avoiding duplicate procedures
            Enhancing quality management, and
            Increasing inter-provider collaboration for patient care.
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The same individuals, answering as patients or as family caregivers, also
prioritized (along with many of the above):

       Enabling the creation of patient health records (accessible and controlled
       by the patient)
       Reducing the repetition of registration and health history information
       Enhancing patient or proxy access to their clinical health records
       Enabling e-visits, and
       Increasing cost-awareness of medications, procedures, etc.

Most of these goals depend on the assembly of a patient’s health information
from across separate organizations. Several of these priorities require a focus on
Health Information Exchange (HIE) between organizations more than on the
adoption of Health Information Technology (HIT) within any individual
organization.

Feasibility: The feasibility of addressing the above goals (that were selected on
the basis of urgency) was subsequently addressed.

The workgroup concluded that the largest number of highly urgent priorities
would be addressed most rapidly by focusing on clinician access to information.
There are several rationales for this conclusion:

       Clinicians at the point of service are in the best position to improve care
       quality, safety and efficiency based on better information at the point of
       service;
       It is much easier to authorize and authenticate licensed health care
       professionals for Internet access to confidential health information than,
       for example, to provide the same level of security for members of the
       general public;
       In the interest of patient-clinician communication and patient education,
       clinicians often desire to be present when patients access their own health
       information.

For these reasons, the Patient Care workgroup decided that providing such
information to clinicians at the point of care would both provide the greatest
value and be most feasible for early HIE development. Once the infrastructure is
developed to assemble and deliver a comprehensive summary of a patient’s
health information for clinicians, it could be reused in many ways for other
desired goals, including direct patient access.

This conclusion is not meant to downplay the importance of patient access,
review and use of their own health information, tools permitting patients or their
guardians to submit information to health care providers, or enhancing clinician-
patient communication. Indeed, various Patient Health Record applications are
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     now provided to patients by health care provider organizations and by health
     plans. It will be important to link such applications to Health Information
     Exchanges so they can both benefit from and contribute to the improvement of
     information access provided by HIE. However, the challenge of validating the
     identity of millions of patients, of ensuring appropriate physician-patient
     communication, and of carefully incorporating electronic communication into the
     workflow of health care delivery argues that these information products be
     offered to patients by their own providers and plans rather than by HIE
     organizations in the near term.

     The information types listed in Recommendation 3 of this summary were selected
     as those most important to improving patient care safety, quality and value. Most
     of the information is potentially available without relying on information from
     individual providers’ Electronic Medical Records (EHRs). For example, much
     demographic information is available from claims or registration data systems;
     medication information from pharmacies, claims or pharmacy benefit
     management databases; etc. Thus summaries of such information can be created
     and shared with users from many already existing sources. They can also be
     delivered by many existing methods, including fax, secure Internet portal, or
     display from within an EHR. Because the adoption of EHR applications is likely
     to be gradual, and is not an absolute prerequisite to develop useful information
     products, it does not make sense to wait for universal EHR adoption to begin
     building Health Information Exchanges (HIE) to assemble and share such
     important information for a patient’s care.

     Nevertheless, from the perspective of improving the efficiency and quality of
     care, it is important that such information ultimately be used from within the EHR
     or other end-user application. Parallel, stand-alone information delivery systems
     often fail to be consulted, create inefficiencies in workflow, and may not interface
     with real-time automated clinical decision support systems that can alert clinicians
     of important, sometimes lifesaving, opportunities to avoid injury or implement
     prevention. Thus, while many early users may receive HIE information by fax or
     other technologies, it is critical that the data be increasingly standardized over
     time, such that it can be imported and exported automatically and used within
     EHRs and other applications. Similarly, it is important that clinicians and others
     continue to invest in EHRs and other forms of HIT that are certified to meet such
     interoperability goals. Indeed, the availability of standardized information feeds
     from an HIE and the certification of interoperable applications are likely to
     accelerate adoption of technology in the practice setting. Additional
     recommendations were also made to help accelerate HIT adoption at the same
     time that HIE networking is being established.

     The workgroup adopted the vision of Connecting for Health and the National
     Coordinator for Information Technology that at the core of regional Health
     Information Exchange would be an organization (often referred to as a Regional
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Health Information Organization - RHIO) that could help competing
stakeholders in a region organize electronic information exchange. Such
organizations were felt to be most stable and likely to be self-sufficient at the
level of the Medical Trading Area, the natural market within which most
referrals, hospitalizations, and other flows of both patients and patient
information typically occur. Such an area is the geography in which face-to-face
trust can most readily be established and within which the bulk of information is
currently exchanged (usually on paper) on a daily basis. The RHIO is the
organization through which most HIE services are selected, developed and
delivered (although technical implementation might be performed by a
contracted third party). Which services are selected would depend on the local
use cases and business cases judged to lead to a sustainable business model.

The primary functions of these RHIOs are first, to establish the fundamental
infrastructure for information exchange (including the trust, governance and
agreements that enable exchange as well as the technical infrastructure) and
second, to create exchange services that enable information to flow. Based on
these two prerequisites, the RHIO, its members, or third-party organizations can
create information products that produce real value for patients or other
stakeholders. Several use cases were developed to describe information products
likely to produce early value for different types of information exchange
stakeholders, including patients, clinicians, health care provider organizations,
service providers like laboratories, payers and care managers and public health
agencies.

Incremental development is advised at the regional level, selecting early
exchange services that:

        Are technically feasible and lay the foundation for later, more complex
        projects;

        Fall within the information-sharing willingness and trust of major
        stakeholders (including patients);

        Enable desired information products and value creation; and

        Can generate revenue to fund ongoing operation and future expansion of
        services.

Although RHIOs are most likely to be regional (sub-state, or potentially even
interstate in areas where referrals frequently cross state lines) there is also a role
for a statewide service provider whose customers are primarily regional HIEs
both inside and outside of Wisconsin. Economies of scale favor centralizing
certain business functions at a state level.
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     Patient Care Recommendations:

     1. The highest early priority for information exchange is to provide real-time
        access to a patient’s high-value clinical information, including access to
        historical data from across all sources of care (a patient-centric summary).
        The assembly and delivery of such information in this fashion is a prerequisite
        to achieving many other desired goals.

     2. Consumers desire access to electronic health information. It is unlikely that
        HIEs themselves will be able provide PHR applications directly to consumers
        in the near-term. However, other organizations (like insurance companies or
        hospitals) are providing Patient Health Records (PHR) for patient use. These
        should link to the health information exchanges to receive and contribute
        information.

     3. The highest priority information types for information exchange (not ordered
        by importance) include the following:

                   DEMOGRAPHICS
                   o Patient identity/demographics
                   o Payer/insurance coverage/eligibility
                   o Patient contact-in-emergency
                   o Advance directives

                   CARE HISTORY
                   o Patient visits and hospitalizations
                   o Visit/encounter diagnoses
                   o Discharge summaries/progress notes
                   o Procedures

                   THERAPEUTICS AND SAFETY
                   o Medications
                   o Allergies
                   o Immunizations
                   o Medical devices and implants

                   RESULTS
                   o Laboratory and other diagnostic results

        Information exchange can opportunistically deploy those classes of
        information that became available first, so as to provide value at the earliest
        opportunity.
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4. The Patient Care Workgroup recommends that requirements for prior patient
   consent that exceed Federal minimums to deliver clinical information to
   treating clinicians be reduced or eliminated so as to increase the patient
   benefit from treating clinician access to comprehensive information at the
   point of service.

5. e-Prescribing should ideally:

       Be integrated into the clinical workflow as part of an electronic medical
       record (EHR) system;

       Utilize information from both the clinician EHR and from the regional
       Health Information Exchange to improve the quality of clinical decision
       support applications; and

       Contribute information on prescribing and dispensing to the regional
       Health Information Exchange to enrich the quality and timeliness of
       exchange information.

6. While many early users may receive HIE information by fax or other
   technologies, it is critical that the data be increasingly standardized over
   time, such that it can be imported and exported automatically and used within
   EHRs and other applications. Similarly, it is important that clinicians and
   others continue to invest in EHRs and other forms of HIT that are certified to
   meet such interoperability goals. The availability of standardized
   information feeds from an HIE and the certification of interoperable
   applications are likely to accelerate adoption of technology in the practice
   setting, and vice versa.

7. Five-year goals for end-user technology include:

        Universal high-speed Internet access for health care providers, service
        providers, and other professional stakeholders;

        Affordable EHR systems capable of importing and exporting the priority
        data set accessible to all clinical providers (This is likely to emerge in
        part by Internet-served applications that reduce installation,
        maintenance, network administration and lifecycle costs for smaller
        practices.); and

        Patients should have universal access to high-speed Internet in their
        community, if not in their home.
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     8. Most information exchange should be developed at the regional (sub-state)
        level by Regional Health Information Organizations serving market-defined
        Medical Trading Areas.

     9. Inside Wisconsin a statewide organization could provide the following
        services (particularly if state government were an active participant):

     Assuring and assisting regional HIEs to utilize common standards for data
     transmission, vocabulary and other key functions to permit exchange of
     information between and beyond Wisconsin HIEs as needed.

            Leveraging existing or future statewide information systems or data sets to
            help regional HIEs implement foundational infrastructure, such as secure
            user identity management, master patient indexing, or record locating
            services. For example, a state licensing and registration system could be
            used to help validate clinical users, or the statewide immunization registry
            could provide information useful for creating a regional master patient
            index.

            Obtaining, standardizing and providing for regional HIE use data sets
            created by state government or other statewide entities (for example,
            immunization and disease registries, and Medicaid claims information).
            Access to such information could be obtained by purchase, by policy or a
            combination of the two.

            Obtaining and providing (benefited by larger-scale purchasing power) data
            sets created by national or other large scale organizations (for example,
            national laboratories or the RxHub pharmacy benefit data hub). Access to
            such information could be obtained by purchase, by policy or a
            combination of the two.

            Managing requests for information between regional HIEs: for example,
            when a patient requires care outside her home region and her provider
            seeks historical information.

            Managing interactions between regional HIEs and the Nationwide Health
            Information Network (NHIN).

     10. Regional HIEs should pursue incremental development of exchange services,
         focusing initially on those that build foundational infrastructure needed for
         later, more advanced exchange services. Early services and products should
         also be selected on the basis of a sustainable business model that creates a
         foundation of revenue and trust for later service expansions.
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11. Emerging HIE initiatives should seriously consider implementing result
    delivery and clinical document delivery as early exchange services, because
    these build foundational infrastructure, stakeholder trust and sustainable
    revenue flow and administrative savings to support additional, later exchange
    projects.

12. In regard to HIT adoption:

   a. The DOQ-IT program for adoption of electronic medical records should
      be supported and expanded. The focus should expand it to include
      specialty practices in addition to primary care.

   b. Wisconsin should ultimately subsidize only HIT which is CCHIT-
      certified and adhere to AHIC (and possibly narrower Wisconsin)
      standards.

   c. Wisconsin should address workforce issues to assure success of HIT
      adoption efforts.
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     Information Exchange Workgroup – Executive Summary
     Health information technology (HIT), including electronic health records (EHR),
     and health information exchange (HIE) provide opportunities to improve quality,
     increase efficiency, and improve the return on investment in health care. These
     technologies also present opportunities to strengthen knowledge about disease,
     treatment, and effectiveness of health care. To reach their full potential, these
     technologies must be implemented in a manner that assures consumers that
     electronic access to their personal health records will not compromise privacy or
     permit misuse.

     The Information Exchange Workgroup recognized that Wisconsin has an existing
     set of health information services that uniquely position the state to leverage
     health information exchange. Nationally, single-physician practices represent
     approximately 38% of all practices, whereas in Wisconsin this number appears to
     be about 7% and shrinking. This suggests Wisconsin may be uniquely positioned
     for rapid growth in physicians’ access to electronic medical record systems
     (compared to the national distribution of physician practice size).


     Underlying Principles

     The Information Exchange Workgroup agreed to endorse the Markle
     Foundation’s Common Framework for guidance in establishing health
     information exchange technology and policy 29 :

                   a. Technology Principles
                           i. It is preferable to implement a “Thin” network (defined as a
                              simple client program or device designed to be especially
                              small so that the bulk of the data processing occurs on the
                              server), but for flexibility a hybrid or centralized data
                              architecture may be needed to satisfy workflow or
                              implementation requirements.
                          ii. Avoid “Rip and Replace”
                        iii. Separate Applications from the Network
                         iv. Decentralization
                          v. Federation
                         vi. Flexibility
                        vii. Privacy and Security
                       viii. Accuracy

                   b. Policy Principles

     29
          For further elaboration of Common Framework principles see
          http://www.connectingforhealth.org/commonframework/#guide (accessed 10-6-06).
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                     i.   Openness and Transparency
                    ii.   Purpose Specification and Minimization
                  iii.    Collection Limitation
                   iv.    Use Limitation
                    v.    Individual Participation and Control
                   vi.    Data Integrity and Quality
                  vii.    Security Safeguards and Controls
                 viii.    Accountability and Oversight

Recommendations

1. Adopt the Markle Foundation’s Common Framework guiding principles
   listed above.

2. Leverage existing assets for the utility functions that will be provided at the
   regional and/or statewide level through the examination of state resources
   and private initiatives for opportunities to further the adoption of both HIT
   and HIE. Significant work has been done through public and private
   enterprises to establish health IT infrastructure services that could accelerate
   deployment of health information exchange. The services include the ability
   to uniquely identify patients, extensive health information repositories to
   support both clinical care delivery and the state's public health mission, and
   groundbreaking public/private sector initiatives to establish an IT-enabled
   health care quality measurement infrastructure.

3. Expand broadband access to areas around the state through promotion of the
   BadgerNet Converged Network (BCN), which unites the separate data and
   video networks.

4. Drive HIT adoption and develop HIE simultaneously.

5. Conduct further analysis on possible tax breaks and incentives to ensure that
   small providers are not forced out of the exchange, and if provided, tie
   financing to adoption of products that are consistent with national
   requirements (i.e., Health Information Technology Standards Panel (HITSP)
   standards, Certification Commission for Health IT (CCHIT) certification) for
   emerging Wisconsin health information exchanges.

6. Promote HIT adoption among small and rural providers by:

       Promoting applications that are thin, complete EHR systems;

       Ensuring that costs associated with the exchange do not place an undue
       burden on small volume facilities.
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               Developing a means to assist these entities in interfacing with the
               exchange (funding and technical assistance);

               Allowing for a flexible flow of clinical information that does not force
               small hospitals into predetermined data exchanges where large hospitals
               and their outreach programs accrue the benefits.

     7.     Given the broad mix of hospital and physician practice HIT density in the
           state, as well as the unique health care delivery economics in the various rural
           and urban settings, facilitate and optimize health information exchange based
           on the needs of the local communities through the creation of Regional Health
           Information Organizations (RHIOs) – starting with information about
           allergies, medications, and diagnoses through a local/regional health
           information exchange.

     8. Provide incentives such as start-up funds or technical assistance to develop up
        to five RHIOs in Wisconsin (considering factors such as minimum
        populations served or organized consistent with existing medical trading area
        patterns 30 ).

     9. Require that all Wisconsin RHIOs meet minimum requirements including:

               Population served (at least one million people in the geographic are it
               covers);

               Alignment with natural medical trading areas;

               Willingness to serve all members of the communities in the designated
               area – cannot be vendor-driven or exclusive;

               Independent with broad governance including both public and private
               sector representatives and strong consumer representation; and

               Administrative competency on EHRs.

     10. Develop a set of statewide health information exchange services to:

               Serve as the link between RHIOs, other states, and the Nationwide Health
               Information Network (NHIN).

               Provide basic utility-type services that are most effective at the state level
               and that can leverage existing state assets such as record location and user
               authentication services.
     30
          The Dartmouth Atlas of Health Care in the Great Lakes States,
          http://www.dartmouthatlas.org/atlases/region4.pdf, accessed on October 31, 2006.
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       Improve the ease, quality and effectiveness of state-hosted health
       information systems to exchange patient information with existing
       provider HIT systems.

       Provide basic patient information to providers that do not have access to
       a regional health information exchange.

       Provide practice guidelines/clinical decision support for health care
       providers.

       Provide a Web portal for consumers to obtain health education materials
       and practice guidelines.

       Research and resolve policy issues that are barriers to health information
       exchange.

11. Adopt hybrid architectural models in which some data is centralized and
    other information is stored at locations where care is provided. Data
    providers have a choice of maintaining constant access to their own data
    servers or allowing their data to be stored in a central location for retrieval.
    This model allows for the greatest flexibility for data providers. This will
    minimize the concerns related to trust and allow centralization for timeliness
    in accessing the information when needed.

12. Determine the preferred method for establishing a master person/patient
    index to uniquely identify the correct patient with high accuracy, as a key to
    secure a uniform exchange, at the highest level possible. This will ensure the
    provider accesses the right information about the right patient, increasing
    confidence in the exchange and improving patient care.

13. Provide policies for auditing and security at the local level. These policies
    should ensure appropriate access is being provided at the local level;
    compliance should dictate when the organizations are to be included in the
    exchange. The workgroup noted that this may result in a financial burden for
    small provider groups and clinics, but that it also allowed for more local
    control.

14. Focus security at the local level. The workgroup discussed the concept of
    imposing the most stringent security upon all participants in the exchange.
    Due to the challenge this could impose on small organizations, the group
    recommends further examination of how this is addressed in other states,
    with the assumption that the current HIPAA requirements would be the
    minimum security level.
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     15. Adopt the following phasing structure to accelerate clinical information
         exchange access and use by health care professionals near-term while
         recognizing and planning for incremental enhancements to both clinical
         information breadth and depth.

        Phase 1: Share Care Status Information: Includes clinical messaging of
        information like lab results, diagnostic imaging reports, discharge summaries,
        and correspondence including structured medical summaries available from
        clinical EHR systems to support transition or continuity of care among
        providers; enables shared views of encounters, results and medications from
        sources like pharmacy benefit managers, claims data, immunization
        summaries, etc.

        Phase 2: Share highly structured and standardized information for
        import/export by HIT applications including order entry, e-prescribing,
        patient-managed (PHR) information, and images.

        Phase 3: Advanced Clinical Support and Advanced Access Control: Extends
        information access control in more sophisticated ways (roles and context-
        sensitive access, patient-managed controls); and enables dynamic queries of
        structured information by clinical decision support systems and other
        applications (algorithms to improve safety, quality, value and public health
        protection).

        Phase 4: Collaborative Care, Active Quality Reporting and Health
        Surveillance: Deepen workflow-oriented collaborative services, such as e-
        visits, electronic referrals, and future generations of real-time interaction
        between clinicians, service providers, patients, public health, care managers,
        quality and safety initiatives.

     16. Complete a more comprehensive survey of HIT in Wisconsin targeting a
         broader audience than the one completed by MetaStar in 2005 as a means of
         providing an accurate representation of statewide HIT adoption.

     17. Based on recommendations from the Consumer Interests Workgroup and
         technology complexities associated with the current policy, the Information
         Exchange Workgroup suggests the following changes to state policy:

        a.  Allow redisclosure of patient information between providers for care
           purposes without explicit patient consent. Currently, if one provider sends
           patient information to another, the provider receiving that information
           cannot redisclose that information without explicit patient consent.
        b. Develop policy recommendations that address the need for health
           information exchange to support the need for parents, caregivers, and
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       other patient advocates to facilitate the movement of health information
       as needed for those in their care.

   c. Give careful consideration to redesigning enforcement for special-
      protection data, such as mental health, HIV testing, etc.

18. Wherever possible, encourage the RHIOs to develop a mapping or card
    catalog method that would allow for segregation of health information and
    demographic information. Examples include the Connecting for Health
    Record Locator Service and the Integrating the Healthcare Enterprise (IHE)
    Cross-Enterprise Document Sharing (XDS) models.

19. Adopt standards and interoperability specifications developed by the Health
    Information Technology Standards Panel (HITSP) to facilitate the exchange
    of information across systems, and make these a condition for entities to
    participate in the HIE. Where possible, state government should use its
    ability to leverage its contracts for health care technology to promote the use
    of these standards and interoperability specifications.

20. Because health care technology and exchange are new concepts, develop
    infrastructure that is flexible, accessible, scalable, adaptable, and replicable.
    As part of this effort, employ open standards, so interoperable systems are
    designed. National policy should drive these standards, but if there is a need,
    develop additional standards at the state level.

21. Establish a multi-stakeholder panel to make recommendations to the Board
    regarding national health information exchange initiatives and their impact
    on the state's roadmap.

22. Promote e-prescribing as a visible, near-term example to consumers of how
    HIT can improve patient safety, convenience, and consumer empowerment,
    and leverage its use to accelerate broader HIT adoption in the ambulatory
    care setting.


Next Steps

The Information Exchange Workgroup made significant progress towards its
assignments. As implementation activities begin, it will be necessary to consider
the following activities:

       Finalize recommendations on architectural requirements.

       Identify a minimum set of standards to support recommendations and an
       initial set of business opportunities for the advancement of HIT.
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     Continue to monitor and coordinate activities with the Nationwide Health
     Information Network pilot program, related HITSP interoperability, and
     other national efforts that may influence ongoing HIE technology planning
     and implementation.

     Continue to identify and promote use of appropriate existing state
     information technology assets to increase the value of information
     exchange for both private and public sector health care delivery.

     Continue discussion on the role of the patient in accessing his/her own
     health information.

     Prioritize the use cases developed by the Patient Care Workgroup that
     would have the most impact and create technical requirements for their
     implementation.

     Establish criteria for a qualitative analysis of the HIT density indicators,
     such as levels of system adoption.

     Expand the HIT density study to include:
        a. Indicators to include additional HIT systems.

        b. All hospitals in Wisconsin.

        c. Out-of-state hospitals, in order to determine whether the Wisconsin
           experience is characteristic or anomalous.

     Expand the HIT density study to determine status of HIT linkages between
     rural hospitals and public health immunization registers and other
     population health initiatives.
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Consumer Interests Workgroup – Executive Summary
SUMMARY OF RECOMMENDATIONS

Accurate, understandable information is critical to high quality health care and
improved population health. Electronic health records (EHR), health
information technology (HIT), and health information exchange (HIE) provide
opportunities to empower consumers and ensure robust patient data are available
to providers at the point of treatment, dramatically improving both quality and
efficiency of care. HIT and HIE also enable enhanced monitoring of the
individuals and entities that access patient health information, serving as a
double-check to patient privacy. As well, these technologies present
opportunities to strengthen knowledge about disease, treatment, and
effectiveness of health care. Some consumers have expressed concerns that
patient information within EHRs and HIE will be misused. These
recommendations reflect the Consumer Interests Workgroup’s efforts to balance
the benefits of HIT/HIE with privacy concerns to achieve optimal patient care.

Underlying Principles

The Consumer Interests Workgroup has adopted the principles below as the
foundation for each charge listed in their charter. These principles were
developed by the Markle Foundation’s Personal Health Technology Council.

 1. Individuals should be able to access their health and medical data
    conveniently and affordably.

 2. Individuals should be able to designate someone else to have access to and
    exercise control over how their records are shared.

 3. Individuals should receive easily understood information about all the ways
    that their health data may be used or shared.

 4. Individuals should be able to review which entities have had access to their
    personal health data.

 5. Electronic health data exchanges must protect the integrity, security,
    privacy, and confidentiality of an individual's information.

 6. Independent bodies, accountable to the public, should oversee the
    electronic health data exchanges. No single stakeholder group should
    dominate these oversight bodies. Consumer representatives selected by
    their peers should participate as full voting members.

Actions and Recommendations
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     Charge 1: Understand consumer expectations regarding electronic health data
     exchange.

     The workgroup undertook an extensive review of national surveys and literature
     capturing consumers’ views of HIT, HIE, and EHR. In addition, the group
     organized a listening session for Wisconsin advocacy groups and consumers. These
     efforts captured consumer support for a transition from paper health records to EHR
     and HIT as well as concern about the privacy, security, and confidentiality of
     personal health information in an electronic environment. Privacy concerns were
     most notable for more sensitive types of health information, particularly mental
     health and domestic violence. Research and discussion of consumer expectations
     set the stage for consideration of all other charges.

     Charge 2: Identify HIE and HIT outcomes that are highest priority from the
     consumer perspective.

     The Consumer Interests Workgroup identified the following outcomes as its highest
     priorities:

       • Improved patient care through appropriate consumer and provider access to
         health information and evidence-based decision support.

       • Privacy, security, and confidentiality of personal health information.

       • Improved communication among all parties relevant to patient care.

       • Improved consumer understanding of patient rights, responsibilities, and
         benefits associated with personal health information and health information
         exchange.

       • Increased patient participation in decision-making regarding one’s own health,
         health care, and health information.

     The group also noted the importance of reliable and accurate identity verification
     mechanisms supporting health information exchange: poor identity matches can
     result in inadvertent disclosure of personal health information and substantially
     increase the risk of medical errors.

     Charge 3: Define acceptable and unacceptable data use policies to maintain
     privacy and security, including agreements for patient consent and use of data.

       • Rec. 3.1: Personal health information should be included in an exchange
         available to health care providers for treatment purposes; patients should not
         be able to opt-in to, or out of, this exchange.
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  • Rec. 3.2: Data use policies should: (1) balance patients’ right to privacy
    with providers’ need to access health information to provide optimal care;
    and (2) differentiate among the areas delineated by HIPAA (treatment,
    health care operations, payment, research, and public health).

Charge 4: Make recommendations on whether health information with special
protections will be included in electronic health data exchange.

  • Rec. 4.1: The Wisconsin legislature should amend Wisconsin law
    governing disclosure of health information to providers to be consistent
    with HIPAA, which does not require patient consent to disclose
    information to providers about mental health and developmental disabilities
    for treatment purposes. This recommendation:

     o Aims to improve providers’ ability to give patients optimal care;
     o Increases Wisconsin’s potential to participate in multi-state exchanges
       for treatment; and
     o Rests on the assumption that participating organizations have security
       measures that sufficiently protect all personal health information.

     While this recommendation goes forward, it was not unanimously
     supported. Some workgroup members expressed concerns about stigma,
     potential bias in care, and patients withholding information to the detriment
     of their health and health care.

     Rec. 4.2: The Wisconsin legislature should review Wisconsin Statutes
     protecting patient rights and revise them as necessary to ensure that any
     provider or entity that provides unfair or inappropriately discriminatory
     treatment is subject to severe penalties.


     Rec. 4.3: The Wisconsin legislature should review Wisconsin Statutes
     protecting patient rights and revise them as necessary to ensure that any
     provider or entity that deliberately or inadvertently mishandles,
     inappropriately shares, or inappropriately distributes personal health
     information is subject to severe penalties. Penalties should reflect the
     egregiousness of the act.

   • Rec. 4.4: Health information exchanges must protect the integrity, security,
     privacy, and confidentiality of all personal health information and
     recognize that some types of information are especially sensitive. Thus,
     organizations participating in exchange should consider appropriate
     additional technical and/or procedural safeguards for more sensitive types
     of health information.
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     Charge 5: Define acceptable and unacceptable data use policies for oversight
     purposes, including public health and research.

     The recommendations below apply specifically to data used for public health and
     research purposes. Policies governing data use for other oversight purposes, (e.g.,
     quality improvement, health care operations, safety initiatives, utilization review,
     etc.) should be discussed in the next phase of Wisconsin’s eHealth Initiative.

       • Rec. 5.1: Data use agreements and policies that support HIE should ensure
         that: (1) all reports and publicly available data sets resulting from provider-
         submitted identifiable data continue to include only de-identified data; and (2)
         strict controls continue to govern access to, and use of, reported data.

       • Rec. 5.2: Designated public health entities should support and leverage new
         capabilities available through HIE and electronic reporting to improve the
         health of the public.

       • Rec. 5.3: As new data sources emerge, policies governing access to health
         care data for research purposes should consider the original purpose of data
         collection, such as: data captured by providers at the point of care, held by an
         HIE, or collected explicitly for research purposes.

     The group also noted that designated public health entities’ ability to collect
     identified personal health information for statutorily mandated purposes will be
     enhanced as a result of HIE.

     Charge 6: Define guidelines and examples that clarify how data sharing can
     balance the requirement to protect privacy and security with the need to share
     information to improve care.

     Wisconsin’s eHealth Initiative is in the process of identifying privacy and security
     policies and practices that may impact the exchange of health information as part of
     the national Health Information Security and Privacy Collaboration (HISPC)
     project. These activities will form the basis for the selection of real-world examples
     that best demonstrate how data sharing can balance patient privacy and system
     security with the need to share information to improve patient care.

     Charge 7: Identify options to help consumers manage their own health care,
     advocate for themselves, and support mutual accountability for health.

       • Rec. 7.1: Holders of personal health information should ensure that
         individuals are able to conveniently and affordably access their health
         information, including which entities have had access to this information.
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  • Rec. 7.2: The state should undertake an education campaign that
    communicates the purpose, capabilities, and system safeguards of exchange
    as part of Wisconsin’s eHealth Action Plan. Education materials and
    activities must be easily understandable and accessible for Wisconsin
    consumers regardless of health literacy, reading skill, computer
    proficiency, or geographic location. Materials and activities must
    appropriately address the language, educational, and cultural needs of
    consumers of all backgrounds (be culturally competent) and be easily
    accessible for all Wisconsin residents.

  • Rec. 7.3: All relevant stakeholders should share financial responsibility
    (costs) and benefits (savings) affiliated with HIT and HIE.

  • Rec. 7.4: Consumer representatives should have roles equal to those of
    other stakeholders in the ongoing governance of Wisconsin’s HIE
    activities.

  • Rec. 7.5: The state should raise consumer awareness of personal health
    records (PHRs) as a mechanism to manage one’s health and health care.

Charge 8: Identify legal actions required for the priorities recommended by the
clinical work team.

 •   Rec. 8.1: The Wisconsin legislature should amend Wisconsin law
     governing disclosure of health information to providers for treatment
     purposes to be consistent with HIPAA. (Charge #4)

 •   Rec. 8.2: The Wisconsin legislature should review Wisconsin Statutes
     protecting patient rights and revise them as necessary to ensure that any
     provider or entity that provides unfair or inappropriately discriminatory
     treatment is subject to severe penalties. (Charge #4)

 •   Rec. 8.3: The Wisconsin legislature should review Wisconsin Statutes
     protecting patient rights and revise them as necessary to ensure that any
     provider or entity that deliberately or inadvertently mishandles,
     inappropriately shares, or inappropriately distributes personal health
     information is subject to severe penalties. Penalties should reflect the
     egregiousness of the act. (Charge #4)

 •   Rec. 8.4: The Wisconsin legislature should amend law to support
     electronic reporting of health related data to statutorily identified entities.
     (Charge #5)

 •   Rec. 8.5: As Wisconsin’s eHealth Initiative moves forward with the
     HISPC project and other eHealth activities, the eHealth Board should
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          monitor potential impacts on Wisconsin Statutes and recommend changes as
          warranted.

     Charge 9: Fulfill responsibilities required by the state’s contract with Research
     Triangle International (RTI) for the Health Information Privacy and Security
     Collaboration (HISPC).

     The first two phases of the HISPC project are complete. Two volunteer
     workgroups, Variations and Legal, reviewed scenarios designed by RTI and
     highlighted potential procedural and legal challenges to health information
     exchange. A number of Consumer Interests Workgroup members were active
     participants in both workgroups. Consumer Interests Workgroup members will
     continue to play an active role in the Solutions and Implementation phases of the
     HISPC project.


     Next Steps

     The Consumer Interests Workgroup has made significant progress towards each
     of its charges and has initiated dialogue with individual consumers and consumer
     groups. As Wisconsin advances towards adoption and implementation of
     interoperable electronic health records, it will be crucial for the eHealth Board to
     continue engaging consumers and their advocates in constructive, open
     discussions. The following activities should also be high priorities for the eHealth
     Board in the next stages of Wisconsin’s eHealth Initiative:

        1. Define specific recommended guidelines and real-world examples that
           clarify how data sharing can balance the requirement to protect patient
           privacy and system security with the need to share information to improve
           patient-centered care.

        2. Develop recommendations for actions that will prevent breaches of
           privacy, security, or confidentiality of patient health information, within
           organizations and in the exchange of information among organizational
           systems, as well as remedies for any breaches that occur.

        3. Develop specific mechanisms to accommodate patient concerns and
           complaints related to health information exchange.

        4. Build understanding of, and support for, health information exchange
           among consumers and health care providers through education efforts.

        5. Guide implementation of the consumer interests and privacy components
           of the eHealth Action Plan; assess and report on progress annually.
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   6. Develop policy statements and recommendations regarding use of health
      information for purposes other than treatment (e.g., patient safety
      initiatives, quality improvement, health care operations, payment, law
      enforcement, etc.)

   7. Develop policy statements and recommendations that empower
      consumers to manage their health, health care, and health information.

   8. Oversee preparation of final reports for the Health Information Security
      and Privacy Project.
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     Financing Workgroup – Executive Summary
     The business case for the adoption of health information technology (HIT) and
     participation in health information exchange (HIE) lies in promises of improved
     clinical processes and workflow that lead to safer, higher quality care, reduced
     administrative expenses, decreased clinical and administrative redundancies and
     improved coding. The system as a whole promises a more robust ability to report
     measures of quality and track outcomes. This will in turn strengthen purchasers’
     ability to design value-based purchasing that pays for quality – the truest return on
     investment for this endeavor.

     But these goals will require substantial up-front investments in electronic health
     records (EHRs) and their interoperability among providers. To date, despite great
     promise and ambitious national plans, EHR adoption rates remain low, with less
     than 20% of U.S. physician practices fully automated, and only about half of
     hospitals even partially so. Fully operational health information exchange
     requires that HIT penetrate beyond physician offices and hospitals, pharmacies
     and laboratories, to include long-term care facilities and local health departments.

     Wisconsin has a number of strengths that are likely to place it somewhat ahead on
     the natural curve of technology adoption: More than half of Wisconsin’s
     physicians practice in large integrated group practices. Wisconsin is home to
     industry leaders in the arena of electronic medical records and HIT. Pioneering
     efforts are underway through the Wisconsin Collaborative for Healthcare Quality
     (WCHQ), Wisconsin Health Information Organization (WHIO), the Wisconsin
     Hospital Association’s Checkpoint program, and four demonstration projects
     supported by grants from the federal Agency for Healthcare Research and Quality
     (AHRQ).

     Nonetheless, to many physicians, the business case remains uncertain. Current
     reimbursement policies pay for diagnostics and treatment, not for outcomes or the
     handling of information; the gains in quality or reductions in cost are likely to first
     accrue to payers and purchasers. As well, small practices simply lack the
     $20,000-$40,000 per physician in up-front investment capital and lost
     productivity needed to acquire and start-up an EHR system. Beyond physicians,
     advanced connectivity among the range of providers is an essential goal of the
     Wisconsin and national eHealth initiative, and will most certainly require
     significant investments.

     National estimates of the costs to deploy HIT and HIE across the entire spectrum
     of health care in the U.S. range from $115 billion for the HIT costs 31 to $156

     31
          Hillestad, R, Bigelow J, Bower A, et al. Can Electronic Medical Record Systems Transform
          Health Care? Potential Health Benefits, Savings, and Costs. Health Affairs Sept/October 2005
          Vol. 24(5):1103-1117.
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billion for the connectivity infrastructure required for a Nationwide Health
Information Network, 32 to $276 billion for all providers to achieve full HIE. 33
This suggests, through crude estimates allotting Wisconsin 2% of these costs in
proportion with its share of the U.S. population, a need for $2.3 billion to as
much as $5.5 billion investment in Wisconsin.

More refined Wisconsin-specific financial projections depend on estimates of the
current level of HIT adoption among Wisconsin’s physicians and hospitals.
Beyond this, statewide interoperability will require resources both to fill the
adoption gap and to adapt current and legacy systems.

Assume for now a hypothesized 35% adoption gap among physicians and
hospitals. Wisconsin would then require resources in the range of $1 billion-
$2.8 billion to build a universal EHR and information-sharing infrastructure
through regional health information organizations (RHIOs). Such resources
could come through several venues.

Most of the funds for HIT acquisition, start-up, and maintenance will continue to
come through private investment, particularly as HIT becomes part of standard
medical practice and the baseline cost of doing business. As the market moves
naturally in that direction, the prices for HIT should moderate. However, timely
universal adoption and participation in HIT/HIE – including providers and
facilities of all sizes and throughout the state – will require public and private
sector seed money and incentives. As well, the success of this enterprise for all
providers and their patients will require a continued redesign of payment systems
to support value, quality, and outcomes.

The business case for HIT/HIE depends on support from multiple stakeholders.
Purchasers may design pay-for-quality incentives for HIT adoption, with
expectation about improved quality and more transparency to support value-
based purchasing. Providers’ business plan for HIT investment may rely on the
hope of “billing optimization,” which could be perceived by purchasers and
payers as counter to their interests. Ultimately, stakeholder equity and the public
good of reduced costs and improved quality will require that HIT go beyond
what Sidorov and colleagues 34 refer to as “simple engraftment into the current
health care system” -- to include re-engineered processes along with concomitant
changes in the current reimbursement model.



32
     Kaushal R, Blumenthal D, Poon E, et al. The Costs of a National Health Information Network.
     Annals of Internal Medicine Vol. 143(3):165-173.
33
     Walker J, et al. The Value of Health Care Information Exchange and Interoperability. Health
     Affairs, January 13, 2005. http://content.healthaffairs.org/cgi/content/full/hlthaff.w5.10/DC1,
     accessed November 30, 2006.
34
     Sidirov J. It Ain’t Necessarily So: The Electronic Health Record and The Unlikely Prospect of
     Reducing Health Care Costs. Health Affairs July/August 2006. Vol 25(4):1079-1085.
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     Financing Workgroup Goal: Develop options for funding electronic health
     records in all size health care settings and for the operation of a statewide public-
     private health information infrastructure.

     Strategy: The best strategy for overcoming the barrier to HIT adoption is to
     increase the value proposition of EHRs.

     Findings and Premises underlying Recommendations:

        1. HIT/HIE is a public good and the investment in its development and
           operations should be partially funded from public sources.

        2. Financing is needed for three levels of infrastructure: 1) appropriate HIT
           adoption and use by providers, 2) HIE through RHIOs or other exchange
           mechanisms at the regional level, and 3) statewide HIE.

        3. A fully implemented HIE environment requires consistency of platforms
           and standards for inter-operability that do not yet exist, and must be
           developed at the national level.

        4. Approach must be statewide, politically feasible, and consistent with
           federal initiatives.

        5. The RHIO concept does not capture a standard set of information
           exchange activities or functions, and thus the acronym does not describe
           any specific model. Financing will need to target individual functions and
           step-wise, phased-in modular adoption of functions. The definition of the
           scope and functions of a state-level RHIO effort will determine the
           strategies for obtaining long-term sustainable financing.

        6. Regional HIE can reduce the costs of system start-up as well as
           maintenance, through shared services and economies of scale.

        7. Up-front subsidies may not support ongoing HIT use and investment.
           Ideally public and private reimbursement systems should be aligned to
           produce long-term return-on-investment (ROI), fostering long-term use of
           and continued investment in HIT and HIE, while preserving market price
           pressures on vendors. Nevertheless, assistance with short-term
           capitalization of HIT may be needed for low-margin safety-net providers.

        8. The plan will require phase-in over time, but HIE promotion should not
           crowd out resources to bring all providers to a baseline level of capability
           for internal clinical and patient safety systems and the internal capture and
           aggregation of data. As well, incentives must not crowd out private sector
           market developments and within-enterprise investment priorities.
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   9. Any State incentives for adoption must recognize and reward the
      investments already made by early adopters/investors/pioneers while
      promoting broader diffusion of technology.

   10. Marginal costs must, to the greatest extent possible, correspond with
       marginal benefits. This will vary by type of provider/constituent, but
       each stakeholder needs to realize a proportional ROI. The financial
       contributions to fund the initiative should be equitable among the key
       health care stakeholders (public/private as well as provider, payer and
       purchaser) and proportionate to the use/benefit.

   11. The system requires re-engineering processes and workflow, and
       adoption phase-in will incur productivity costs.

   12. HIE must accommodate existing efforts and incorporate legacy systems.
       New systems must avoid creating multiple login environments where
       HIT exists but interface capability is currently lacking. At the same time,
       existing initiatives will need to evolve to meet the promise of emerging
       technology.

   13. Organizations - particularly low-volume unaffiliated – may need help
       financing and implementing EHR systems. Many rural hospitals in
       particular lack interface engines and interface expertise, and often have
       limited IT resources in house. They will need interfacing hardware,
       software, and expertise resources to participate in HIE.

   14. Costs of participation in HIE need to be scaled for smaller rural
       communities, with consideration of the relative benefits in various
       markets.

   15. HIE will allow for flexible flow of clinical data across systems and
       referral centers, rather than limiting access within existing referral
       relationships and proprietary networks.

   16. The actual RHIOs will develop business plans and a clear value model
       for each HIE function they pursue, with specific capital and operating
       expenses and potential revenue sources identified.

A. Recommendations regarding the roles of the public and private sectors:

   1. State government should use its leverage as a purchaser and payer to
      drive HIT adoption.
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        2. State government programs, including Medicaid, ETF, biosurveillance,
           and public health services, should tie in with the state-level HIE
           architecture rather than create stand-alone, parallel (silo) data systems.
           Integration of such programs into state and regional HIE can minimize
           redundancies and disruptions to clinical workflow. Savings and benefits
           should be returned to participants in the form of economic or other
           incentives for providers to adopt and participate in the system.

        3. The eHealth Action Plan should leverage Wisconsin’s strength and talent
           in the HIT industry to develop non-proprietary/open source EHR products,
           to improve the value of what is delivered, and to assist with customizing
           or adapting it for application.

        4. The eHealth Action Plan should pursue EHR group purchasing strategies,
           as well as possible contributions from payers that are potential
           beneficiaries of providers’ use of HIT.

        5. Private industry, health care organizations and purchasers all have a key
           role in HIE development. Purchasers and payer organizations should
           develop and implement value-based purchasing strategies, including pay-
           for-quality programs that encourage HIT adoption and use. Such
           strategies must coalesce around common quality, value, safety and data
           standards.

        6. Savings in one sector may need to be shared with others to overcome early
           mismatches between the costs and benefits of those joining the exchange.

     B. Recommendations on specific funding sources:

     The eHealth Financing Workgroup recommends that the Governor and legislature
     consider the following measures to support the goals of Wisconsin’s eHealth
     Action Plan.

     1. Revenue Bond:

           State Legislature authorize a call for officially designated RHIOs or like
           structures;

           RHIO would be eligible for financing HIE through state bonding
           authority;

           State must pay its proportionate share (ETF, Medicaid) if other sectors
           participate;

           Bond issue would be paid by users’ revenue, not repaid by GPR.
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       State should pursue the feasibility of a tax-exempt lease as a preferred
       financing approach.

2. Shared Services:

Wisconsin’s eHealth Initiative, as a public-private collaboration, could
coordinate/integrate key and necessary administrative and other activities that
maximize efficiencies and reduce total cost/resource allocation across various
initiatives. Among potential immediate opportunities for collaboration: legal,
insurance, IT-data elements and architecture, HIPAA regulations, accounting,
vendor RFP processes, evaluation, and acquisition.

3. Tax Credits and Exemptions:

The U.S. Department of Health and Human Services recently issued new
regulations that relax the restrictions (known as Stark and anti-kickback rules) on
donations of e-prescribing software and hardware to physicians. The Wisconsin
legislature and Governor should consider adopting tax exemptions on donated IT
systems consistent with these changes and with related federal tax exemptions.
In addition, Wisconsin’s and other states’ legislatures have considered creating
an income and franchise tax credit for health care providers in an amount that is
equal to or some proportion of the amount that the health care provider pays in
the taxable year for information technology hardware or software that is used to
maintain medical records in electronic form. As well, Wisconsin might create an
individual and corporate income tax exemption for interest on bonds or notes
issued by the Wisconsin Health and Educational Facilities Authority for
purposes related to the purchase of information technology equipment by health
facilities.

4. Medicaid and ETF Incentive Payments

Several states around the country provide examples of the kind of leverage the
State of Wisconsin might exert in its role as a major purchaser of health care
services. For example, legislatures in Wisconsin and other states have considered
directing state Medicaid agencies to make an annual incentive payment to
hospitals that establish and maintain a physician order entry record system.

5. Blue Cross/Blue Shield Endowment:

Wisconsin’s two medical schools, University of Wisconsin and Medical College
of Wisconsin, are the stewards of the endowment funds that resulted from
Wisconsin BC/BS conversion to a private shareholder corporation. These funds
are guided by a five-year plan, approved by Wisconsin’s Commissioner of
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     Insurance. The funds have developed a significant reserve. The next five-year
     plan is being developed and is scheduled to take effect in 2009.

        The eHealth Financing Workgroup recommends that the Insurance
        Commissioner and the two medical schools carefully study Wisconsin’s
        eHealth Action Plan and consider strategic and programmatic investment
        opportunities, recognizing the goals and mission shared by the two
        enterprises.

     C. Recommendations for targeted financing:

     1. Focus on smaller, rural, and safety net providers: Direct resources to those
        stakeholders who must be engaged but who may lack the resources to
        contribute financially (safety net providers, FQHCs, RHCs, CAHs, local
        health departments).

     2. Action Plan Function Phase-In: Treat solo and small-practice physician
        offices as a special case; pursue their conversion on a "special track” and
        special adaptation timeline basis.

     3. Demonstration Project Funds: Provide funds for demonstration projects
        that model collaboration in HIT purchasing, support and information
        exchange.

     4. Focus on Early Wins: Target investments first at functions that promise
        early wins, such as e-prescribing and disease registries.

     The Wisconsin Department of Health and Family Services has begun taking steps
     in the direction recommended by this report. In October 2006 DHFS submitted a
     Medicaid Transformation Grant proposal to the federal Centers for Medicare and
     Medicaid Services (CMS) that includes three provisions consistent with the
     recommended eHealth financing strategy: 1) operational and technical assistance
     to advance the adoption of EHRs by safety net providers; 2) HIE focused on the
     Medicaid and General Assistance Medical Program (GAMP) populations in
     Milwaukee County, and 3) pay-for-quality incentives to encourage standard data
     collection and quality reporting.
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Governance Workgroup – Executive Summary
The Governance Workgroup was created by the eHealth Care Quality and
Patient Safety Board in May 2006 to develop an organizational and governance
structure for statewide health information exchange and to assure good
communication across stakeholders about the eHealth initiative and its expected
benefits.

To implement a workable statewide HIE in the next five years, the project should
have a credible identity and a means to dispose of the many problems, questions,
obstacles, and differences of opinion that will surely arise. This requires a
coherent structure so that there is coordinating authority and a home for
problems.

Provider and public acceptance, support, and funding are essential. Wisconsin’s
eHealth Initiative will have a much better chance of getting acceptance and
support (particularly federal support) if it is clear that a single entity with a
diverse board of all key stakeholders (including the State) has responsibility and
accountability for the HIE/HIT initiative.

An incremental process is expected as has occurred in Minnesota, Arizona and
other states. This is a new enterprise still in its formative stages, it will take time
to stabilize, and it is important to assure coherence and accountability so that
plans can be executed. While this is all still in the formative stages, a diverse
board of key stakeholders (namely the existing eHealth Board) is needed to
retain overall responsibility; standing committees of the Board should be
established to attend to the key functions.

The buy-in and ownership of the Legislature are needed as this initiative moves
forward. At some point enabling legislation should be pursued – it need not be
prescriptive and should provide some funding. If there is legislation it would be
most helpful if it is very general instead of specific about things such as
committee structure so there is flexibility to respond to new issues.

While it is important to build from work being done nationally, there is excellent
work underway in Wisconsin that should not be slowed down while waiting for
federal action. There are now many significant initiatives underway in
Wisconsin to leverage health information to improve the quality and safety of
health care. Some Wisconsin organizations are far ahead of what other states are
trying to do and it is important to build from this base.

There is real added value to convene leaders, align interests, build synergy about
how these various initiatives can come together, and to take ownership of the
goals for health information exchange so that there is a coordinated and
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     systematic approach to improving health care quality and safety and reducing
     health care costs. This will build on the strengths that exist in Wisconsin and
     apply the best information available from around the country. The private-sector
     people who have acquired practical experience should be invited to guide
     development of the new statewide HIE to avoid “re-inventing the wheel” and
     build on what has already been done.

     A pluralistic representative board with structured workgroups is a workable
     structure. While a large and diverse board is desirable in terms of broad
     stakeholder representation, implementation can be problematic under a large
     board. Therefore it is also important to have an executive committee whose
     members are committed to implementation and smaller subunits to oversee
     implementation (operations) and other key functions.

     The committee structure that the eHealth Board established to develop the Action
     Plan for the Governor has worked very well and should form the basis for the
     future structure, with appropriate adjustments to reflect the move to
     implementation mode.

     Summary of Recommendations

     1. Establish a governance structure under the leadership of the current eHealth
        Board to oversee implementation of the eHealth Action Plan.

     2. Review the current composition of the Board to determine if there is
        appropriate representation of stakeholder expertise and views for the
        implementation phase; if not, recommend to the Governor additional
        stakeholder groups to be represented on the Board.

     3. Create five committees reporting to the eHealth Board to begin work in
        January 2007:

        a. Executive Committee

        b. Patient Care Advisory Group

        c. Consumer Interests and Privacy Advisory Group

        d. Public Health Advisory Group

        e. Statewide Health Information Exchange Advisory Group

     4. Assign state staff to provide or contract for specific statewide services in
        support of Health Information Technology (HIT) and Health Information
        Exchange (HIE), including these functions:
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   a. Represent the interests of all citizens;

   b. Convene, educate and facilitate public and private health information
      initiatives;

   c. Administer funding;

   d. Remove barriers to health information exchange;

   e. Set statewide HIE policy and standards, including policies for HIT
      adoption;

   f. Align health information initiatives within state government;

   g. Provide technical assistance to local and regional HIE efforts;

   h. Serve as bridge to the Nationwide Health Information Network (NHIN)
      and to other states;

   i. Monitor developments with the many public and private health
      information initiatives underway to identify opportunities for
      collaboration and to minimize redundancy;

   j. Develop and implement a communications and marketing plan;

   k. Staff the eHealth Board and its committees; and

   l. Support technology operations that are statewide in scope (based on
      recommendations of the Information Exchange Workgroup).

5. Align the assignments to these workgroups with the national agenda and
   work of the American Health Information Community (AHIC) so that
   Wisconsin is poised to act as national standards and prototypes are readied.

6. Align interests and work activities under the leadership of the eHealth Board
   across the significant health information initiatives that are underway or that
   will develop in Wisconsin to assure a coherent, whole-system approach to
   change.

7. Include language in the 2007 – 2009 Governor’s Budget to:

   a. Express the support of the Legislature for the goal of delivering health
      care that is safe, effective, patient–centered, timely, efficient and
      equitable;
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        b. Charge the eHealth Board with the responsibility to lead the
           implementation of the Wisconsin eHealth Action Plan, which identifies
           the strategies and steps to be undertaken over the next five years to
           leverage health information technology and exchange to improve the
           quality and reduce the cost of health care in Wisconsin;

        c. Require an annual report from the Board to the Legislature as well as the
           Governor; and

        d. Direct the Department of Health and Family Service (DHFS) to provide
           staff support to the eHealth Board and its operations.

     8. Conduct an annual assessment of the strengths and weaknesses of the
        governance structure and recommend changes if needed to assure an effective
        and responsive structure and to make assignments for the coming year.

     9. Once the eHealth Implementation Plan is approved, address legal implications
        of the governance structure including the specific authority of government and
        operating rules for the eHealth Board to provide clarity on respective roles,
        including authority to execute contracts and apply for grants.

     10. Develop a communications and marketing plan early in 2007 using models
         available from national organizations and other states; assign responsibilities
         related to the plan to the Operations staff, under the direction of the Statewide
         Health Information Exchange Advisory Group. Create opportunities for joint
         sessions with CEOs and CIOs of health care provider organizations as part of
         this communications plan.
Appendices
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                                                       Appendix 1: Executive Order #129




                                   Executive Order # 129

           Relating to the Governor’s eHealth Care Quality and Patient Safety Board




 WHEREAS, a statewide eHealth information infrastructure would improve the quality and
 reduce the cost of health care in Wisconsin by:

    1. Ensuring health information is available at the point of care for all patients; and
    2. Reducing medical errors and avoiding duplicative medical procedures; and
    3. Improving coordination of care between hospitals, physicians, and other health
       professionals; and
    4. Furthering health care research; and
    5. Providing consumers with their health information to encourage greater participation
       in their health care decisions; and

 WHEREAS, Wisconsin must control health care costs as a key to a long-term strategy of
 growing our state’s economy by reducing state expenditures and enhancing the business
 environment for both large and small employers; and

 WHEREAS, a statewide eHealth information infrastructure must be organized and structured
 in a manner to protect the privacy and security of health information; and

 WHEREAS, on April 12, 2004, President Bush called for widespread adoption of
 interoperable electronic health records (“EHRs”) within 10 years and established the Office of
 the National Coordinator for Health Information Technology (“ONCHIT”); and

 WHEREAS, ONCHIT issued a Framework for Strategic Action: The Decade of Health
 Information Technology: Delivering Consumer-centric and Information-rich Health Care (the
 “Framework”), outlining four requirements for achieving the President’s goal of widespread
 adoption of health information technology (“HIT”), including the need to:

    1. Develop interoperability standards; and
    2. Support and encourage the development and use of EHRs and electronic data
       exchange infrastructure; and
    3. Establish policies and regulation consistent with these goals and information security
       requirements; and
    4. Create an Internet-based architecture for nationwide health information exchange;
       and

 WHEREAS, the Framework’s goals are consistent with those of the State of Wisconsin to
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achieve 100% electronic health data exchange between payers, health care providers,
consumers of health care, researchers, and government agencies as appropriate; and

WHEREAS, the federal Department of Health and Human Services (“DHHS”) estimates that
savings of $140 billion per year, or close to 10% of total health spending in the United
States, could be achieved through effective deployment of health information technology by
reducing duplicative care, lowering health care administrative costs, and avoiding errors in
care; and

WHEREAS, the federal government intends to financially support local and statewide
initiatives aligned with federal efforts to achieve the President’s health information
technology goals; and

WHEREAS, establishing a Wisconsin Action Plan for Health Care Quality and Safety will
guide legislative and regulatory actions, encourage coordinated efforts in the private health
care sector, further public and private partnerships for the development of a statewide health
information infrastructure, and maximize federal financial participation to support the goal of
early adoption of an eHealth information infrastructure;

NOW, THEREFORE, I, JIM DOYLE, Governor of the State of Wisconsin by the authority
vested in me by the Constitution and the Laws of this State, and specifically by Wis. Stat. §
14.019, do hereby:

     1. Create a Board for eHealth Care Quality and Patient Safety (“Board”); and
     2. Direct the Board to comprehensively review issues surrounding the creation of an
        eHealth information infrastructure in Wisconsin and develop guidance - to be known
        as the “Wisconsin Action Plan for Health Care Quality and Safety” - for the users of
        such infrastructure; and
     3. Provide that members of the Board shall be appointed by, and serve without
        compensation at the pleasure of, the Governor; and
     4. Provide that the Chairperson of the Board shall be designated by the Governor from
        among the Board’s membership; and
     5. Direct the Board to develop recommendations for:
            1. Identifying existing eHealth resources, including funding sources, to support
                the development of a statewide eHealth information infrastructure; and
            2. Identifying technology options, and their advantages and disadvantages, for a
                statewide eHealth information infrastructure; and
            3. Identifying options for serving consumer health information needs; and
            4. Insuring health information privacy and security in electronic health
                information exchange; and
            5. Facilitating statewide adoption of electronic health record standards to enable
                health information exchanges across the state and nationally; and
            6. Creating organization and governance structures for a statewide eHealth
                information infrastructure; and
     6. Direct the Board to submit the Wisconsin Action Plan for Health Care Quality and
        Safety to the Governor, detailing recommended actions and key milestone dates to
        achieve within the next five years the goals stated in this Executive Order. Direct the
        Board to solicit input from health care industry executives, technology leaders,
        content experts, major employers, community leaders and interested government
        agencies in developing the action plan; and
     7. Provide that the action plan should consider the extent to which an integrated or
        interoperable system or underlying technology may be cost effective, including by
        assessing benefits of the system for supporting rapid deployment for supporting
        medical care practitioners, promoting accurate and appropriate shared information
        about individual patients among health care providers, and standardizing
        performance indicators among health care provider organizations to improve
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       organization performance and public reporting of quality, safety and efficiency data
       for consumers and health care purchaser decision making; and
    8. Provide that the Board shall annually assess the extent to which automated
       information and decision support systems are used by health care providers in
       Wisconsin and annually assess options and progress on the action plan to achieve
       automation of all health care systems by 2010; and
    9. Provide that the Board annually report to the Governor on its plans, activities,
       accomplishments, and recommendations.

 IN TESTIMONY WHEREOF, I have hereunto set my hand and caused the Great Seal of the
 State of Wisconsin to be affixed. Done at the Capitol in the City of Madison this second day
 of November, in the year two thousand five.

 JIM DOYLE


 Governor


 By the Governor:


 DOUGLAS LA FOLLETTE


 Secretary of State
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                                   Appendix 2: Workgroup Membership and Resources
           eHealth Care Quality and Patient Safety Board
              Workgroup Membership and Resources
                                          August 31, 2006


1. PATIENT CARE
Members                                            Resources
Chair: Edward Barthell, Infinity Health care       Sandy Bissen, Executive Director, Wisconsin
Gary Bezucha, Boscobel Area Health Care            Health Information Management Association
Michael Gorczynski, Aurora Health Care             Kathy Blair, City of Milwaukee Epidemiologist
Janice Hand, MCW Department of Pediatrics          Judy Fryback, Director, Disability Determination
                                                   Bureau, DHFS
Eric L. Heiligenstein, University of Wisconsin-
Madison, University Health Services                Laura Kreofsky, First Consulting Group
Murray Katcher, Division of Public Health, DHFS    Jeff Marcus, Medical Director, Central Wisconsin
                                                   Center
Lowell Keppel, Blue Cross Blue Shield of
Wisconsin                                          Debbie Siegenthaler, Lafayette County Health
                                                   Department
Colette Lasack, Gundersen Lutheran
                                                   Kathi Steele, Director of Nursing, Central
Dana Richardson, Wisconsin Hospital Association
                                                   Wisconsin Center
Robert Schmitt, American Cancer Society
                                                   Herb Thompson, Bureau of Information Systems,
Maureen Smith, University of Wisconsin School of   DHFS
Medicine and Public Health
                                                   Jesi Wang, Doctor’s Office Quality—Information
Jon Temte, University of Wisconsin Dept. of        Technology (DOQ-IT) Manager, MetaStar
Family Medicine
                                                   Denise Webb, Medicaid Liaison, Division of
Frederic Wesbrook                                  Health Care Financing, DHFS
                                                   Arthur Wendel, Epidemic Intelligence Service
                                                   (EIS) Officer, Division of Public Health, DHFS

                                                   Lead Staff
                                                   Seth Foldy, Medical College of Wisconsin
                                                   Susan Wood, Department of Health and Family
                                                   Services


2. INFORMATION EXCHANGE
Members                                            Resources
Chair: Hugh Zettel, Government and Industry        Keith Haugrud, SAS Institute, Inc.
Relations, GE Health care Technologies             Terry Hiltz, Public Health Information Network
John Hartman, Visonex Corporation                  (PHIN) project manager, Division of Public Health,
Scott Novogoratz, Advanced Health care             DHFS
Debra Rislow, Gundersen Lutheran                   Laura Kreofsky, First Consulting Group
Susan Turney, Wisconsin Medical Society            Matt Miszewski, State Chief Information Officer
Denise Webb, Medicaid Liaison, Division of         Debbie Rickleman, Wisconsin Hospital Association
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Health Care Financing, DHFS                        Vinny Taneja, Northwoods Consortium
Louis Wenzlow, Rural Wisconsin Health              Epidemiologist
Cooperative                                        Lorna Will, Surveillance Epidemiologist, Division
                                                   of Public Health, DHFS

                                                   Lead Staff
                                                   Stacia Jankowski, Division of Public Health, DHFS


3. CONSUMER INTERESTS
Members                                            Resources
Chair: Catherine Hansen, Health Information        Kathy Johnson, Privacy Officer, DHFS
Services, St. Croix Regional Medical Center        Greg Schneider, Winnebago Mental Health
Betsy Abramson, Elder Law Attorney                 Institute
Patricia Flatley Brennan, UW School of Nursing     Amy Wergin, Public Health Nurse Manager,
and College of Engineering                         Manitowoc County Health Department
Nancy Davis, Ministry Health Care                  Ben Wollman, Community Advocates
Patricia Finder-Stone, Public Health Advocate
                                                   Lead Staff
Ken Germanson, Community Advocates
                                                   Alison Bergum, UW Population Health Institute
Dianne Greenley, Disability Rights Wisconsin
Jay Gold, MetaStar
Chrisann Lemery, WEA Trust
Susan Manning, Independent Health Care
Consultant
Sadhna Morato-Lindvall, American Cancer Society
Paul Smith, University of Wisconsin Dept. of
Family Medicine

4. FINANCING
Members                                            Resources
Chair: Kevin Hayden, Division of Health Care       Fredi-Ellen Bove, Budget Director, DHFS
Financing, DHFS                                    Denise Webb, Medicaid Liaison, Division of
Kendra Jacobsen, Madison Patient Safety            Health Care Financing, DHFS
Collaborative                                      Greg Wass, ACS Government Solutions
Jim Johnston, Department of Administration         Theresa Wedekind, Injured Patient and Families
Budget Office                                      Compensation Fund, Office of the Commissioner
Bradley Manning, Wisconsin Medical Society         of Insurance
Josephine Musser, WPS Health Insurance             Lead Staff
Nancy Nankivil-Bennet, Department of Employee      Donna Friedsam, UW Population Health Institute
Trust Funds
Donald Percy
Chris Queram, Wisconsin Collaborative for Health
care Quality
Greg Simmons, MetaStar
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Tim Size, Rural Wisconsin Health Cooperative




5. GOVERNANCE
Members                                            Resources
Chair: Frederic Wesbrook                           Fredi-Ellen Bove, Office of Strategic Finance,
                                                   DHFS
Steve Brenton, Wisconsin Hospital Association
                                                   Seth Foldy, Medical College of Wisconsin
Gina Frank-Reece, Department of Administration
Peg Smelser, WEA Trust                             Lead Staff
John Toussaint, ThedaCare                          Susan Wood, DHFS
Susan Turney, Wisconsin Medical Society


6.   EHEALTH BOARD STAFF AND CONSULTANTS

Alison Bergum, UW School of Medicine and Public Health
Seth Foldy, Medical College of Wisconsin
Donna Friedsam, UW School of Medicine and Public Health
Lawrence Hanrahan, Division of Public Health, Department of Health and Family Services
Stacia Jankowski, Division of Public Health, Department of Health and Family Services
Susan Wood, eHealth Chief of Staff, Department of Health and Family Services
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                                                                      Appendix 3: Glossary of Terms

Glossary of Selected Terms Related to eHealth35

ASTM – ASTM International is a not-for-profit standards developing organization with an
interest in extending comprehensive standards in the health care community, including
specification for the Continuity of Care (CCR) Record.

American Health Information Community (AHIC) – The Community was formed on
September 13, 2005, by the Health and Human Services (HHS) Secretary Michael O. Leavitt to
help advance efforts to reach President Bush’s call for most Americans to have electronic health
records within ten years. The Community has formed six workgroups: Biosurveillance; Chronic
Care; Confidentiality, Privacy, and Security; Consumer Empowerment; Electronic Health
Records; and Quality.

Agency for Healthcare Research and Quality (AHRQ) – The lead federal agency charged
with improving the quality, safety, efficiency, and effectiveness of health care for all Americans.
As one of 12 agencies within the Department of Health and Human Services, AHRQ supports
health services research that will improve the quality of health care and promote evidence-based
decision making.

BadgerNet Converged Network (BCN) – A Wisconsin project to provide dynamic, scalable
bandwidth on a vendor-managed network to primarily public entities across the state. 36

Blue Cross/Blue Shield (BC/BS) – The insurance corporation that when converted to a private
shareholder corporation, directed its public assets to a public health endowment fund. The fund
is split between Wisconsin’s two medical schools, which distribute partnership grants in support
of the fund’s mission.

Centers for Medicare and Medicaid Services (CMS) – The federal agency that runs the
Medicare program, and works with the States to run the Medicaid program to ensure that the
beneficiaries receive high quality health care. CMS is responsible for oversight of HIPAA
administrative simplification transaction and code sets, health identifiers, and security standards.

Certification Commission for Health Information Technology (CCHIT) – A voluntary,
private-sector organization to certify HIT products, initially focusing on ambulatory EHRs for
the office-based physician or provider, inpatient EHRs for hospitals and health systems, and the
network components through which they interoperate and share information. The American
Health Information Management Association (AHIMA), the Healthcare Information and
Management Systems Society (HIMSS) and The National Alliance for Health Information

35
     Based on the Minnesota Department of Health, Minnesota’s Glossary of Selected Terms Related to e-Health,
     http://www.health.state.mn.us/e-health/glossary.html, accessed November 6, 2006.
36
     Department of Administration, BadgerCare Converged Network,
     http://www.doa.state.wi.us/pagesubtext_detail.asp?linksubcatid=1030andlinkcatid=308andlinkid=, accessed
     November 21, 2006.
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Technology (Alliance), three leading HIT industry associations, joined forces and committed
resources during its organizations phase.

Client Assistance for Re-employment and Economic Support (CARES) – The Wisconsin
eligibility determination system used for Medicaid, FoodShare, Wisconsin Works, and Child
Care.

Computerized Provider Order Entry (CPOE) – A computer application that allows a
physician’s orders for diagnostic and treatment services (such as medications, laboratory, and
other tests) to be entered electronically instead of being recorded on order sheets or prescription
pads. The computer compares the order against standards for dosing, checks for allergies or
interactions with other medications, and warns the physician about potential problems.

Consolidated Health Informatics (CHI) Initiative – One of the 24 Presidential eGovernment
initiatives, with the goal of adopting vocabulary and messaging standards to facilitate
communication of clinical information across the federal health enterprise.

Continuity of Care Record (CCR) – A core data set of the most relevant administrative,
demographic, and clinical information about a patient’s health care, covering one or more health
care encounters. It provides a means for one health care practitioner, system, or setting to
aggregate all of the pertinent data about a patient and forward it to another practitioner, system,
or setting to support the continuity of care.

Decision-Support System (DSS) – Computer tools or applications to assist physicians in clinical
decisions by providing evidence-based knowledge in the context of patient-specific data.
Examples include drug interaction alerts at the time medication is prescribed and reminders for
specific guideline-based interventions during the care of patients with chronic disease.
Information should be presented in a patient-centric view of individual care and also in a
population or aggregate view to support population health management and quality
improvement.

DICOM – Digital Imaging and Communications in Medicine, a standard in the field of medical
informatics for exchanging digital information between medical imaging equipment (such as
radiological imaging) and other systems, ensuring interoperability. The standard specifies a set of
protocols for devices communicating over a network; the syntax and semantics of commands and
associated information that can be exchanged using these protocols; and a set of media storage
services and devices claiming conformance to the standard, as well as a file format and a medical
directory structure to facilitate access to the images and related information stored on media that
share information. 37

Doctor’s Office Quality-Information Technology (DOQ-IT) - a national initiative that
promotes the adoption of Electronic Health Record (EHR) systems to improve quality and safety
for Medicare beneficiaries in small- and medium-sized physician offices.

Edge Server – A server located at a point near the end users.

37
     Definition obtained from http://www.webopedia.com/TERM/D/DICOM.html, accessed November 6, 2006.
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Electronic Health Record (EHR) – A real-time patient health record with access to evidence-
based decision support tools that can be used to aid clinicians in decision-making. The EHR can
automate and streamline a clinician's workflow, ensuring that all clinical information is
communicated. It can also prevent delays in response that result in gaps in care. The EHR can
also support the collection of data for uses other than clinical care, such as billing, quality
management, outcome reporting, and public health disease surveillance and reporting.

Electronic Medical Record (EHR) – See Electronic Health Record (EHR).

Electronic Prescribing (eRx) – A type of computer technology whereby physicians use
handheld or personal computer devices to review drug and formulary coverage and to transmit
prescriptions to a printer or to a local pharmacy. E-prescribing software can be integrated into
existing clinical information systems to allow physician access to patient-specific information to
screen for drug interactions and allergies.

Enterprise Architecture – A strategic resource that aligns business and technology, leverages
shared assets, builds internal and external partnerships, and optimizes the value of information
technology services.

Federal Health Architecture (FHA) – A collaborative body composed of several federal
departments and agencies, including the Department of Health and Human Services (HHS), the
Department of Homeland Security (DHS), the Department of Veterans Affairs (VA), the
Environmental Protection Agency (EPA), the United States Department of Agriculture (USDA),
the Department of Defense (DoD), and the Department of Energy (DOE). FHA provides a
framework for linking health business processes to technology solutions and standards, and for
demonstrating how these solutions achieve improved health performance outcomes.

Federated HIE Model – A model in which health information is stored where care is provided,
and accessed remotely as needed.

Health Information Exchange (HIE) – The electronic mobilization of health care information
across organizations through shared infrastructure between organizations. Shared community-
level information services are built once for many users. Examples include results delivery,
historical patient information such as a prescribed medication list, and other products, which are
supported by regional implementation of technologies. These technologies may include a secure
Web portal, health care terminology translation tools, a master patient index (MPI),
authentication and authorization infrastructure, and products that aggregate information from
multiple sources.

Health Information Technology (HIT) – The application of information processing involving
both computer hardware and software that deals with the storage, retrieval, sharing, and use of
health care information, data, and knowledge for communication and decision making.
Examples of HIT include electronic health record systems, laboratory information systems,
administrative and billing systems, and workflow systems.
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Health Information Management Systems Society (HIMSS) – A health care industry member
organization focused on providing global leadership in the use of HIT and management systems
in providing quality patient care.

Healthcare Information Technology Standards Panel (HITSP) – A multi-stakeholder
coordinating body designed to provide the process within which stakeholders identify, select, and
harmonize standards for communicating and encouraging broad deployment and exchange of
health care information throughout the health care spectrum. The Panel’s processes are business
process and use-case driven, with decision making based on the needs of all NHIN stakeholders.
The Panel’s activities are led by the American National Standards Institute (ANSI), a not-for-
profit organization that has been coordinating the U.S. voluntary standardization system since
1918.

HISPC – Funded by AHRQ through RTI and the National Governor's Association, the Health
Information Security and Privacy Collaboration has subcontracted with 33 states and 1 territory.
HISPC subcontractors will engage state leadership and a broad range of stakeholders in health
information exchange to assess the variations that exist at the organization level with respect to
privacy and security practices and policies - and the legal bases for such practices and polices,
where applicable.

HIPAA – The Health Insurance Portability and Accountability Act of 1996 (HIPAA, Title II).
HIPAA required the Department of Health and Human Services to establish national standards
for electronic health care transactions and national identifiers for providers, health plans, and
employers. It also addressed the security and privacy of health data.

HIPAA Collaborative of Wisconsin (HIPAA COW) – A non-profit organization open to
entities considered to be Covered Entities, Business Associates, and/or Trading Partners under
HIPAA, as well as any other organization affected by HIPAA regulation.

HL7 – An acronym for Health Level 7, the international standards-setting organization, which
develops standards for health care and is the interface standard for communication between
various systems employed in the medical community. HL7 has adopted a standard for Clinical
Document Architecture (CDA), a standard for the functionality of an Electronic Health Record
System (EHR) and a standard Reference Information Model (RIM).

Hybrid HIE Model – A model in which some data is centralized and other information is stored
at locations where care is provided. Data providers have a choice of maintaining constant access
to their own data servers or allowing their data to be stored in a central location for retrieval.

Interface engines – A software program designed to simplify the creation and management of
interfaces between application systems. They are members of a class of software products called
"middleware" that relieves applications and their systems-level communications substructure of
the responsibility for owning and managing the functions of integration. To some extent the
need for interface engines is avoided by using integrated software applications provided by a
single vendor.
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Master Patient/Person Index (MPI) – A way to uniquely identify a patient in relation to his or
her medical records.

Medicaid (MA) – A joint federal/state program established in 1965 under Title XIX of the
Social Security Act to pay for medical services for people with disabilities, people 65 years and
older, children and their caretakers, and pregnant women who meet the program's financial
requirements. This program is administered in Wisconsin by the Department of Health and
Family Services (DHFS). In State Fiscal Year 2005, budgeted expenditures (both state and
federal) for Wisconsin Medicaid totaled $4.5 billion. Enrollment totaled 827,000 people, or 15%
of Wisconsin’s population.

Medical Group Management Association (MGMA) – The mission of MGMA is to continually
improve the performance of medical group practice professionals and the organizations they
represent.

Medical Trading Area (MTA) – The natural market within which most referrals,
hospitalizations, and other flows of both patients and patient information typically occur.
Another term for this is a medical referral area.

Nationwide Health Information Network (NHIN) – A national effort to establish a network to
improve the quality and safety of care, reduce errors, increase the speed and accuracy of
treatment, improve efficiency, and reduce health care costs.

OASIS – OASIS (Organization for the Advancement of Structured Information Standards) is a
nonprofit, international consortium whose goal is to promote the adoption of product-
independent standards for information formats such as Standard Generalized Markup Language
(SGML), Extensible Markup Language (XML), and Hypertext Markup Language (HTML).
Currently, OASIS (formerly known as SGML Open) is working to bring together competitors
and industry standards groups with conflicting perspectives to discuss using XML as a common
Web language that can be shared across applications and platforms.

Office of the National Coordinator (ONC) – The National Coordinator for Health Information
Technology serves as the U.S. Department of Health and Human Services (HHS) Secretary's
principal advisor on the development, application, and use of health information technology;
coordinates HHS health information technology programs; ensures that HHS health information
technology policy and programs are coordinated with those of other relevant executive branch
agencies; and to the extent permitted by law, develops, maintains, and directs the implementation
of a strategic plan to guide the nationwide implementation of interoperable health information
technology in both the public and private health care sectors that will reduce medical errors,
improve quality, and produce greater value for health care expenditures.

Pay for Quality (P4Q)/Pay for Performance (P4P) –A method of providing incentives, both
financial and recognition, for quality outcomes in health care, rather than paying simply for
services.

Public Health Information Network (PHIN) – A national initiative led by the Centers for
Disease Control and Prevention (CDC) to implement a single information network that will
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                                                                                       Appendix
                                                                                 December 1, 2006

integrate, functionally and organizationally, public health partners across the nation. PHIN
establishes technical and data standards and work specifications, and provides a process for
developing and implementing specifications and standards.

Regional Health Information Network (RHIN) – The health information exchange system
operated by a RHIO.

Regional Health Information Organization (RHIO) – An independent corporation established
to operate an exchange of clinical health information among competing stakeholder
organizations supporting multiple use cases. A RHIO is the organization through which most
HIE services are selected, developed, and delivered (although technical implementation might be
performed by contracted third parties).

Return on Investment (ROI) – The actual or perceived future value of an expense or
investment. This can be in terms of dollars saved or productivity.

Rural Wisconsin Health Cooperative (RWHC) – A Wisconsin organization owned and
operated by 29 rural acute, general medical-surgical hospitals. The Agency for Healthcare
Research and Quality awarded a planning grant to the organization in October 2004 to begin
work on behalf of a collaborative of 19 health care organizations, both rural and urban, to
improve the quality of care and efficiency of service delivery by leveraging health information
technology.

Thin Network or Client – A simple client program or device designed to be especially small so
that the bulk of the data processing occurs on the server.

Use case – A description of how the information exchange would work, with as much specificity
as possible, to develop business needs for follow-on activities such as data harmonization,
development of the NHIN, certification and policy analysis and development.

Wisconsin Collaborative for Healthcare Quality (WCHQ) – A voluntary consortium of
organizations learning and working together to improve the quality and cost effectiveness of
health care for the people of Wisconsin. Members are a group of multi-specialty physician
groups, hospitals, health plans, employers and labor organizations from geographically diverse
areas of the state. The collaborative was founded in 2003 on the principle that by focusing on
improving quality, better care and more rational costs will result.

Wisconsin Department of Health and Family Services (DHFS) – The Wisconsin agency
responsible for programs that address child welfare, long term care, physical and developmental
disability, sensory disability, substance abuse, mental health, public health, regulation and
licensing of a variety of facilities, operation of care and treatment facilities, the food stamp
program, medical assistance and health care for low-income families, elderly and disabled
persons.

Wisconsin Department of Employee Trust Funds (ETF) – The Wisconsin agency for
administering retirement and other benefit programs for participants and employers in the
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Appendix
December 1, 2006

Wisconsin Retirement System (WRS), covering state and local government employees and
retirees.

Wisconsin Health Information Exchange (WHIE) – A RHIO in Southeast Wisconsin that is a
membership organization of health care entities to create, govern and continuously improve
regional exchange of health information. The mission of WHIE is to provide a system where
diverse stakeholders collaborate to enable secure, confidential exchange of health information
between authorized users, with a vision of a world where health professionals and patients access
information securely, when and where needed, to improve the safety, quality and efficiency of
health care and public health.

Wisconsin Health Information Management Association (WHMA) – A not-for-profit
organization that develops products and provides services regarding guidelines to ensure
confidentiality of patient information, advance workforce excellence, and foster best practices in
health information management.

Wisconsin Health Information Organization (WHIO) – A Wisconsin membership
organization established in August 2005 to create the state’s largest warehouse of information on
the cost and outcome of health care provided by hospitals and doctors. Health information from
the member organizations will be aggregated, analyzed and reported across episodes of care to
help members improve their services and to support purchasing for value.

Wisconsin Immunization Registry (WIR) – A computerized Internet database application
developed to record and track immunization dates of Wisconsin's children and adults.

Wisconsin Public Health Information Network (WPHIN) – A network under development by
the Wisconsin Department of Health and Family Services that will provide statewide and
community-level population data needed for community health status assessment, policy
development, assurance, service delivery, resources management and accountability.

				
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