hawaii_state_hie_plan_10-22-2010_resubmission-no_budget by zhouwenjuan

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									         State of Hawai‘i
Health Information Exchange Plan
               October 22, 2010
                     Final




   Hawai‘i Health Information Exchange (HIE)
(This page is left intentionally blank)
         State of Hawai‘i
Health Information Exchange Plan

            Strategic Plan
             October 22, 2010




 Hawai‘i Health Information Exchange (HIE)
           Hawai‘i Health Care Acronyms
AARP:       American Association of Retired Persons
CCR/CCD:    Continuity of Care Record/Continuity of Care Document
CHC:        Community Health Centers
CLH:        Clinical Laboratories of Hawai‘i
CMS:        Center for Medicare and Medicaid Services
CPOE:       Computerized Provider Order Entry
DLS:        Diagnostic Laboratory Services
EHR:        Electronic Health Record
EMR:        Electronic Medical Record
FQHC:       Federally Qualified Health Center
HCBCC:      Hawai‘i County Beacon Community Consortium
HHIC:       Hawai‘i Health Information Corporation
HHSC:       Hawai‘i Health Systems Corporation
HIE:        Health Information Exchange
HL7:        Health Level Seven
HMSA:       Hawai‘i Medial Service Association
HPH:        Hawai‘i Pacific Health
HPREC:      Hawai‘i Pacific Regional Extension Center
ICD9:       International Statistical Classification of Diseases and Related Health
            Problems
MU:         Meaningful Use
NHIN:       Nationwide Health Information Network
ONC:        Office of the National Coordinator for Health Information Technology
PHI:        Personal Health Information
PICHTR:     Pacific International Center for High Technology Research
PIN:        Program Information Notice
REC:        Regional Extension Center
SCC:        State Coordinating Committee for Health Information Technology
SDE:        State Designated Entity
TAMC:       Tripler Army Medical Center
VAPIHCS:    Veterans Administration Pacific Islands Health Care System
VLER:       Virtual Lifetime Electronic Record
TABLE OF CONTENTS
HEALTH INFORMATION EXCHANGE PLAN
EXECUTIVE SUMMARY                                                                                                                                                             I
  OVERVIEW ...................................................................................................................................................... I
  MARKET READINESS ASSESSMENT....................................................................................................................... II
  COMMUNITY COLLABORATION .......................................................................................................................... III
  HIE DOMAIN COMMITTEES .............................................................................................................................. IV
  FINANCE COMMITTEE ...................................................................................................................................... IV
  TECHNICAL INFRASTRUCTURE COMMITTEE ............................................................................................................ V
  LEGAL AND POLICY COMMITTEE ........................................................................................................................ VI
  DATA ACCESS AND MANAGEMENT COMMITTEE .................................................................................................. VII
  AUDIT COMMITTEE ........................................................................................................................................ VII
  GOVERNANCE COMMITTEE .............................................................................................................................. VII
  CONCLUSION ............................................................................................................................................... VIII
  1.       INTRODUCTION ..................................................................................................................... 1
           1.1           The Unique Nature of Hawai‘i Health Care ....................................................................................... 1
  2.             ENVIRONMENTAL SCAN......................................................................................................... 3
           2.1           Overview ........................................................................................................................................... 3
                 2.1.1       Health Care Coverage .................................................................................................................. 3
           2.2           Assessment of Current EHR Capacity and HIE Activities.................................................................... 4
                 2.2.1       Hospital EHR Adoption................................................................................................................. 5
                 2.2.2       Physician EHR Adoption ............................................................................................................... 6
                 2.2.3       EHR: Veterans Affairs (VA) and Department of Defense (DoD)................................................... 7
                 2.2.4       Additional Components of Health Information Exchange............................................................ 9
                 2.2.5       Community Health Centers, Federally Qualified Health Centers, and Rural Health Clinics ....... 16
                 2.2.6       Regional and Private HIE Initiatives ........................................................................................... 16
           2.3           Beacon Grant Activities ................................................................................................................... 17
                 2.3.1       Decision Support Programming (Intelligence) ........................................................................... 18
                 2.3.2       Personal Health Records Capability ........................................................................................... 18
           2.4           HIE Data Feeds ................................................................................................................................ 18
                 2.4.1       Telehealth .................................................................................................................................. 19
                 2.4.2       Meaningful Use .......................................................................................................................... 19
           2.5           Electronic Prescribing ...................................................................................................................... 20
           2.6           Laboratories .................................................................................................................................... 22
           2.7           Clinical Summaries and Patient Engagement .................................................................................. 23
                 2.7.1       Summary of Care........................................................................................................................ 23
                 2.7.2       Public Health Reporting ............................................................................................................. 25
                 2.7.3       Eligibility and Claims .................................................................................................................. 26
                 2.7.4       Broadband Capability................................................................................................................. 26
           2.8           HIE Collaboration Activities ............................................................................................................. 29
           2.9           Environmental Scan Findings .......................................................................................................... 30
  3.             HHIE BACKGROUND............................................................................................................. 33
           3.1           Planning Process.............................................................................................................................. 33
           3.2           Guiding Principles............................................................................................................................ 34
           3.3           Vision and Mission .......................................................................................................................... 35
           3.4           Goals and Objectives ....................................................................................................................... 36
  4.             GOVERNANCE ...................................................................................................................... 37
           4.1       Overview ......................................................................................................................................... 37
           4.2       Governance Structure ..................................................................................................................... 37
               4.2.1    Hawai‘i Health Information Exchange Organizational Structure................................................ 38
           4.3       Governance Process ........................................................................................................................ 39
           4.4       Accountability.................................................................................................................................. 40
           4.5       Governance Deliverables................................................................................................................. 41
  5.             TECHNICAL INFRASTRUCTURE.............................................................................................. 42
     5.1           Overview ......................................................................................................................................... 42
     5.2           Addressing Deployment Challenges ................................................................................................ 43
     5.3           Technical Architecture..................................................................................................................... 43
     5.4           Defining and Prioritizing Services/Functions ................................................................................... 45
     5.5           Supported Services—Data Elements............................................................................................... 47
     5.6           Supported Services—Standards and Quality Reporting Requirements........................................... 47
     5.7           National Health Information Network (NHIN) Functions and Interoperability ............................... 48
     5.8           Patient Identity Management ......................................................................................................... 48
     5.9           Service Implementation Schedule................................................................................................... 49
     5.10          Technical Infrastructure Deliverables.............................................................................................. 49
6.         BUSINESS AND TECHNICAL OPERATIONS ............................................................................. 51
     6.1           Operations Activities ....................................................................................................................... 51
     6.2           Community Outreach ...................................................................................................................... 51
     6.3           HPREC Collaboration ....................................................................................................................... 53
           6.3.1      Provider Outreach...................................................................................................................... 54
           6.3.2      Qualification of Priority Primary Care Physicians....................................................................... 54
           6.3.3      Qualification of Vendors ............................................................................................................ 55
           6.3.4      HPREC Sustainability .................................................................................................................. 57
     6.4           Business Operations and Administration ........................................................................................ 58
     6.5           Progress Toward Meaningful Use ................................................................................................... 58
7.         LEGAL AND POLICY .............................................................................................................. 60
     7.1           Overview ......................................................................................................................................... 60
     7.2           Core Values and Principles .............................................................................................................. 61
     7.3           Privacy and Security and State Laws ............................................................................................... 62
     7.4           Policies and Procedures .................................................................................................................. 62
     7.5           Trust Agreements............................................................................................................................ 64
     7.6           Supervision ...................................................................................................................................... 64
8.         FINANCE .............................................................................................................................. 65
     8.1           Financial Controls and Reporting .................................................................................................... 65
     8.2           Sustainability/Business Plan ............................................................................................................ 66
9.         ONGOING STRATEGIC PLANNING......................................................................................... 68

1.         OPERATIONAL PLAN INTRODUCTION................................................................................... 70
     1.1           General Components ...................................................................................................................... 70
     1.2           Hawai’i HIE Project Plan .................................................................................................................. 71
2.         GOVERNANCE ...................................................................................................................... 77
     2.1           Hawai‘i HIE Governance Authority .................................................................................................. 77
           2.1.1     Health Information Partnership for Hawai‘i HIE ........................................................................ 78
           2.1.2     Development of Statewide Policy Guidance .............................................................................. 78
3.         COORDINATION WITH ARRA AND OTHER HEALTH CARE PROGRAMS .................................. 79
     3.1       Coordination with State Medicaid................................................................................................... 79
     3.2       Coordination with HPREC................................................................................................................ 80
         3.2.1    Provider Outreach...................................................................................................................... 80
         3.2.2    Qualification of Priority Primary Care Physicians....................................................................... 81
         3.2.3    Qualification of Vendors ............................................................................................................ 81
     3.3       HPREC Sustainability ....................................................................................................................... 82
4.         GAP ANALYSIS ..................................................................................................................... 82
     4.1       Receipt of Structured Laboratory Results ....................................................................................... 82
           4.1.1  Meeting Gaps - Laboratory ........................................................................................................ 83
           4.1.2  HDOH Activities.......................................................................................................................... 83
     4.2       E-Prescribing.................................................................................................................................... 84
         4.2.1    Meeting Gaps – E-Prescribing .................................................................................................... 85
     4.3       Summary of Care Across Unaffiliated Organizations....................................................................... 86
     4.4       PIN Requirements and Meaningful Use .......................................................................................... 87
5.         TECHNICAL INFRASTRUCTURE.............................................................................................. 93
     5.1           HIE Services ..................................................................................................................................... 94
     5.2           Data Access and Management ........................................................................................................ 96
  6.            BUSINESS AND TECHNICAL OPERATIONS ............................................................................. 98
          6.1           Infrastructure .................................................................................................................................. 98
          6.2           Auditing and Data Repository ......................................................................................................... 99
          6.3           Scalability ........................................................................................................................................ 99
  7.            LEGAL AND POLICY .............................................................................................................. 99
          7.1           Requirements .................................................................................................................................. 99
                7.1.1      Opt In/Opt Out as the Baseline Consent Process..................................................................... 100
                7.1.2      Privacy and Security ................................................................................................................. 100
  8.            FINANCE ............................................................................................................................ 102
          8.1       Audit.............................................................................................................................................. 102
          8.2       Federal Requirements ................................................................................................................... 102
          8.3       Operating Budget .......................................................................................................................... 103
              8.3.1    Operating Cost Statement ....................................................................................................... 103
          8.4       Budget Justification ....................................................................................................................... 103
  9.            HIE SUSTAINABILITY........................................................................................................... 110
          9.1           Creation of Demand for HIE Products and Services ...................................................................... 112
  10.           RISK ASSESSMENTS............................................................................................................ 114
  11.           COMMUNICATIONS PLAN.................................................................................................. 119
APPENDICES                                                                                                                                                              121
  A-1 ONC SUBMISSION LETTER .....................................................................................................................121
  A-2 HAWAI‘I HIE STATE HIE AWARD 4-YEAR PROGRAM BUDGET SUBMITTED TO ONC ...........................................122
  A-3 BYLAWS OF THE HAWAI‘I HEALTH INFORMATION EXCHANGE.........................................................................126
  A-4 CURRENT FUNCTIONALITIES FOR DATA EXCHANGED WITHIN THE MAJOR HOSPITALS & EHR VENDORS IN HAWAI‘I .129
  A-5 BASIC DATA FOR HAWAI‘I HOSPITALS ........................................................................................................130
  A-6 LIST OF ALL STAKEHOLDER MEETINGS AS PART OF THE STRATEGIC AND OPERATIONAL PLANNING PROCESS............132
  A-7 BOARD MEMBERSHIP AND STAKEHOLDER REPRESENTATION ..........................................................................134
  A-8 PROPOSED NOMINATION PROCESS FOR HAWAI‘I HIE BOARD........................................................................135
  A-8 CURRENT BOARD CHARTERS AND COMMITTEE MEMBERS .............................................................................137
  A-9.1 EXECUTIVE COMMITTEE ......................................................................................................................138
  A-9.2 GOVERNANCE COMMITTEE ..................................................................................................................139
  A-9.3 FINANCE COMMITTEE .........................................................................................................................140
  A-9.4 AUDIT COMMITTEE ............................................................................................................................141
  A-9.5 LEGAL AND POLICY COMMITTEE............................................................................................................142
  A-9.6 TECHNICAL INFRASTRUCTURE COMMITTEE ..............................................................................................144
  A-9.7 DATA ACCESS AND MANAGEMENT COMMITTEE ......................................................................................146
  A-10 HAWAI’I HIE PRIVACY AND SECURITY POLICY ...........................................................................................148
  A 11 - LIST OF TECHNICAL FEATURES CONSIDERED FOR FUTURE INCLUSION IN THE SYSTEM .......................................151
  A-12 LISTING OF DATA ELEMENTS DEVELOPED FOR PRIORITIZATION BY DATA ACCESS & MANAGEMENT COMMITTEE ...155
  A-13 COMPLETE LIST OF DATA ELEMENTS CURRENTLY COLLECTED BY HHIC..........................................................159
  A-14 INVENTORY OF LEGAL AND POLICY REQUIREMENTS....................................................................................171
  A-15 INVENTORY OF APPLICABLE STATE AND FEDERAL LAWS AND RULES REGARDING SECURITY AND PRIVACY..............178
  A-16 RULES FOR THE BOARD OF PHARMACY AND CONTROLLED SUBSTANCES .........................................................197
  A-17 MEMORANDUM OF AGREEMENT STATE HIT COORDINATOR AND HAWAI‘I HIE ..............................................198
  A 18 DRAFT REQUEST FOR INFORMATION (RFI) ............................................................................................202
RESOURCES                                                                                                                                                               220
Executive Summary
Overview
In September 2009, the Governor of Hawai‘i designated the Hawai‘i Health Information
Exchange (HIE), a 501(c)(3) non-profit organization, as the State Designated Entity (SDE)
to apply for, develop, and implement a statewide health information exchange through
the U.S. Department of Health & Human Services, Office of the National Coordinator for
Health Information Technology, State Health Information Exchange Cooperative
Agreement Program.

The State HIE planning activities are overseen by the State Coordinating Committee
(SCC) for Health Information Technology. The SCC monitors and assists in the
development and adoption of the State Plan and needs to approve the plan before it is
submitted to the Office of the National Coordinator for Health Information Technology
(ONC).

In developing the State HIE Plan, Hawai‘i HIE’s vision is to facilitate the exchange of
health information to enable quality health care statewide by providing reliable health
information when and where it is needed.

In pursuit of this mission and all of its activities, Hawai‘i HIE adheres to a set of guiding
principles that include:

        1)       Be Inclusive

        2)       Commit to Quality

        3)       Create User Value

        4)       Be Transparent

        5)       Assure Privacy and Security

        6)       Be Sustainable

        7)       Assure Manageability

        8)       Adopt Relevant Rules and Standards

        9)       Use the Present to Achieve the Future

In accord with these principles, Hawai‘i HIE pursues the following goals:

        1)       Achieve the two-year objectives established by ONC for each of its five
                 specified domains of activity: governance, finance, technical
                 infrastructure, business and technical operations, and legal and policy;
Hawai‘i Health Information Exchange
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        2)       Ensure full statewide participation in all aspects of Hawai‘i HIE plan
                 development with special attention given to ensure participation by
                 neighbor island communities;

        3)       Promote health information exchange through the creation and
                 implementation of a stakeholder-centered governance process that
                 organizes stakeholders in an effective manner, takes inventory of
                 resources and needs of individual stakeholders, and provides effective
                 coordination of programs;

        4)       Develop plans to build shared infrastructure (near term) that is
                 sustainable (long term);

        5)       Assist eligible providers so they have connectivity and knowledge in order
                 to become “meaningful users” of health information exchanges;

        6)       Develop cooperative, synergistic relationships with relevant state
                 agencies to enable maximum use of health care data at all levels, e.g. use
                 of an immunization registry;

        7)       Establish effective coordination leading to beneficial information
                 exchange with all interested stakeholders;

        8)       Engage independent physicians on all levels of information exchange,
                 providing technical education and assistance especially through the
                 cooperative efforts of the Hawai‘i Pacific Regional Extension Center
                 (HPREC);

        9)       Develop stakeholder agreements on data standards to be utilized at the
                 state level. Ensure that standards and technical architecture are
                 compatible with national standards as they are created;

        10)      Establish a privacy framework to guide the development of health
                 information exchange such that consumers will have both knowledge of
                 and confidence in the processes by which such information is
                 exchanged; and

        11)      Emphasize the role of Hawai‘i HIE in bringing improved health care to all
                 the people of Hawai‘i, especially in promoting the public interest as the
                 SDE for health information exchange.

Market Readiness Assessment
An environmental scan of the health information environment in Hawai‘i reveals an
uneven development of the precursors of health information exchange and the progress
of users at all levels toward Meaningful Use of health care data as defined by ONC.

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Judged in terms of the creation and adoption of electronic health records (EHRs), most
hospitals, some recently installed, have such capacity. Other facilities, such as the
Federally Qualified Community Health Centers (FQHCs), also possess EHRs, as do the
federal health care facilities offering care to both active duty personnel, along with their
beneficiaries, and veterans. Implementation of EHRs in private physician offices is
modest with respect to their total number within the healthcare community. Many
existing EHRs provide administrative support rather than clinical engagement and
exchange. Currently, most of the data that organizations capture in EHRs is utilized
internally, rather than being exchanged between these organizations. Filling this gap is
the primary challenge of Hawai‘i HIE.

With respect to electronic claims capacity and transactions, Hawai‘i has established
effective coverage throughout the state with only small areas uncovered by such
services. Significant numbers of prescriptions are electronically ordered and filled,
(approximately 10 percent of eligible prescriptions are delivered electronically1), and
pharmacy capacity to accept and fill via e-prescribing is steadily growing, as is the
number of physicians currently using such systems. Laboratory ordering and reporting
shows a similar picture indicating that active exchanges or ordering exist for about 50
percent of hospitals, although this is less common for independent physicians. Results
delivery takes place at a level of 90 percent for hospitals and approximately 20 percent
for independent providers. The use of electronic data for public health purposes varies
by type and specific programs within the departmental program requiring such data.
The Department of Health is developing increased public reporting capacity, including a
proposed bio-surveillance system called the Hawai‘i Health Emergency Surveillance
System. Much data of public interest is gathered and disseminated by the Hawai‘i
Health Information Corporation (HHIC) from data drawn from hospitals, including
various forms of emergency room occurrences.

Broadband coverage within the state, a critical component of effective health
information exchange, is widespread—covering about 99 percent of the state’s
population. Currently, however, overall speeds are slow compared with mainland
counterparts. Rural areas, including some neighbor islands, require improvement to
bring them up to acceptable standards. Both public and private initiatives are either
planned or underway to increase broadband capacity in areas that can benefit from
health information exchange.

Community Collaboration
A growing component of health information exchange in Hawai‘i is the presence of
regional health information exchange on neighbor islands, specifically the North Hawai‘i
Health Information Exchange (NHHIE) and the Hawai‘i County Beacon Community
Consortium (HCBCC) in Hilo, Hawai‘i Island. As these programs develop, they will
become major components of the Hawai‘i HIE network of exchange linkages.

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    Surescripts 2009 Report

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In addition to being the SDE, the Hawai‘i HIE is also the recipient of the ONC Health
Information Technology Regional Extension Program whose purpose is to assist primary
care providers in the adoption of EHRs in Hawai‘i and the Pacific Territories.

Another important area of collaboration is with the State Coordinating Committee for
Health IT (SCC). Hawai‘i HIE has formed ongoing points of interaction (and in some cases
reporting) with the SCC, specifically with the director of the state Medicaid program and
the designated representative of the Department of Health.

Collaboration extends into Hawai‘i’s educational system. Hawai‘i’s community college
system is a sub-recipient of an ONC program providing funding for community colleges
to educate health information technology professionals in workforce development.

HIE Domain Committees
The Hawai‘i HIE governance structure is based on the ONC domain structure that has
guided strategic planning. Board members serve on active working committees that
review issues and make recommendations for Board action. These committees have an
open membership for interested non-Board members. An executive committee
composed of committee chairs serves through the authority of the Board and meets
twice per month with the Executive Director. During the strategic planning process, the
committees were responsible for developing content and making decisions on matters
within their designated domain purview. Results of committee activities are posted on
the Hawai‘i HIE website and committee and Board meetings are open to public
participation. In line with our guiding principles, an explicit commitment of Hawai‘i HIE is
the transparency of operation and responsibility to the whole community of Hawai‘i
within its role as the SDE. To better align itself to these responsibilities, the Board is
currently reviewing various processes to expand the frame of representation of the
Board and to revise its nomination processes. The Governance and Legal and Policy
Committees often share overlapping responsibilities, and their chairs serve on both
committees.

Finance Committee
Hawai‘i HIE is charged through ONC guidelines to develop a sustainable financial
structure that assures transparency and audited reporting. Hawai‘i HIE utilizes the
Pacific International Center for Higher Technology Research (PICHTR) as its fiscal
intermediary, and through it conducts accounting and reporting activities. The finance
committee has conducted various exercises to develop a set of assumptions and
principles that are guiding the development of this aspect of the plan. While the
development of an explicit plan for financial sustainability is a second year goal under
the ONC timetable, the committee anticipates a working draft in the first quarter of
2011. While currently heavily dependent on federal funds to build an operational
exchange, the long-term business case is to be based on the need to generate services



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suitable for an equitable fee/payment structure to support a state HIE that is recognized
and supported by the entire stakeholder community.

Technical Infrastructure Committee
The technical infrastructure committee has agreed that the architecture of Hawai‘i HIE
will be a hybrid model—a design most likely to produce maximal benefit at reasonable
cost. Through this process, the committee also adopted a set of guiding principles for
subsequent development. It has identified five functional requirements to be
accomplished in Phase I of development including:

•   Data transformation services;
•   A clinical portal;
•   Audit trail services;
•   Patient/provider identifier services;
            o CCD (key clinical information, e.g. problem list, medication list and
                 allergies);
            o Provider registration in the form of Master Clinician Index containing all
                 relevant information on all registered clinicians within HHIE; and
•   Cross-enterprise user authentication services.

Phase II development will focus on a second set of seven elements to be developed
including:

•   Lab results exchange,
•   Medication history exchange,
•   Medical encounter notes,
•   Radiology results exchange,
•   Population health services,
•   Patient consent management services, and
•   De-identification services.

A further exercise has listed desirable data elements to be included within these
architectural capabilities. The plan calls for a Request for Proposal (RFP) to be extended
to the vendor community soon after approval of the strategic and operational plans by
the ONC. A follow-through process will be undertaken for the second group of
capabilities as soon as practicable.

As the SDE, Hawai‘i HIE is responsible for providing a set of statewide services that
include:

        1) Development of a shared HIE services program to operate as a standard for
           interoperability within the state of Hawai‘i;



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        2) Securing consensus on a technical design and approach suitable for the
           demands of the unique Hawai‘i environment;

        3) Directing and managing the design and development of a service
           architecture, service inventory, and service design;

        4) Developing and managing the RFP process to assure transparency and
           effectiveness;

        5) Contracting with vendors selected through the competitive RFP process for
           hardware, software and services. Reviewing and managing vendor contracts
           throughout the implementation process for compliance; and

        6) Planning design and implementation steps to assure connectivity to national
           data sources and shared services leading to full participation in the
           Nationwide Health Information Network (NHIN).

In addition, the organization is mandated to provide various services to the community.
The most important mandate is to offer providers, specifically the independent
physician community, services that assist them in the adoption of EHRs and the
development of health information exchange capability that satisfy the Center for
Medicare and Medicaid Services (CMS) Meaningful Use requirements. Working closely
with the Hawai‘i Pacific Regional Extension Center (HPREC), Hawai‘i HIE is seeking to
become a “one-stop” information source to assist such adoptions and implementations
by providing information through multiple sources, personal contacts and follow-
through, supplemented by various public meetings throughout the islands including the
Pacific Territories who will be encouraged to collaborate in efforts to support their
exchange initiatives.

Legal and Policy Committee
Developing a legal and policy plan that invites broad participation in health information
exchange and provides optimal privacy and security protection is a primary
responsibility of the legal and policy committee. Through a set of open meetings, the
committee has identified a key group of individuals whose expertise in security and
privacy policies has assisted in the creation of an inventory of relevant state and federal
laws affecting both privacy and security. This inventory has been employed to develop a
prioritized set of further reviews (assisted by outside counsel) that will result in draft
agreements for initial participation in health information exchange activities and affect
public policy. This review will also identify “gaps” that exist in both law and policy that
may be addressed at the next session of the Hawai‘i state legislature, and opportunities
to put in place policy levers that advance HIT and HIE.




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Data Access and Management Committee
The Data Access and Management Committee maps best with the ONC domain of
Business and Technical Operations, but also overlaps with the Technical Infrastructure
and Legal and Policy Committees. All these committees share various members in an
effort to provide continuity between them. The four requirements for this domain are
being developed in coordination with the State of Hawai’i Department of Health and
Department of Human Services, and through other healthcare reform activity,
particularly around the CMS definition of Meaningful Use and the Medicaid Health IT
plan.

The Data Access and Management Committee has focused most of its attention on the
joint role that it plays with the Technical Infrastructure Committee by developing
inventories of the kinds of data that might be employed in HIE and their sources within
Hawai‘i, as well as being sensitive to national efforts to develop data transfer standards.
They have reviewed a full list of data elements of possible relevance to HIE, and began
an exercise of prioritizing these in terms of their relative immediacy for utilization and
implementation by Hawai‘i HIE.

Audit Committee
If there is an annual audit, then Audit Committee will become a permanent committee
and its duties will include review of the annual audit of the Hawai‘i HIE, review of the
annual audit, selection of the auditor, and other matters relating to the audit of the
Hawai‘i HIE. As mentioned in the Finance Committee section, the Hawai‘i HIE conducts
all of its accounting and reporting activities through its fiscal intermediary, PICHTR.

Governance Committee
The Governance Committee is charged with meeting the specified deliverables for the
finance domain of the plan as established by ONC. In June, the meeting was attended by
a representative of the Department of Health and of the Department of Human Services
to review progress of the committee to date. The representatives also agreed to review
the draft material for the Strategic Plan and provide feedback.

The Governance Committee is working to expand the board with greater representation
of constituents. It is important that Hawai‘i HIE have sufficient representation from a
variety of hospitals. The Governance Committee is currently reviewing a proposal to
enlarge the Board. This proposal includes the following issues:

        1) Enlarging the overall Board membership and add new stakeholders, and/or
           increase their relative share;

        2) Adding the HCBCC Executive Director as a regular board member;



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        3) Adding at least three state representatives as ex officio members,
           representing Hawai‘i HIE’s relationship to the state as the SDE; and

        4) Adding to draft proposal the provision for a physician advisory board to be
           constituted in 2011.

The Governance Committee is also concerned with creating a new nominating procedure to
enhance transparency and participation.

Conclusion
The Strategic Plan is accompanied by an operational plan that has been mapped to
agree with the structure of the former. The operational plan specifies coordinated
activities to implement the strategic plan by giving detailed attention to who will be
responsible for each activity identified and how that given activity will be brought to
fruition.

The State Plan reflects the high priority that Hawai‘i’s collective stakeholders, public and
private, place on advancing HIE and expanding the adoption of EHRs while ensuring that
consumers’ information and interests are protected. American Recovery and
Reinvestment Act (ARRA) funding and collaboration with ONC will accelerate and
enhance the state’s implementation of a statewide HIE.




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1.         Introduction

1.1        The Unique Nature of Hawai‘i Health Care

Hawai‘i is a unique place in many ways, not the least of which is its geography. The only
island state within the nation, it is comprised of eight main islands, seven of which are
inhabited (O‘ahu, Maui, Hawai‘i, Kaua‘i, Moloka‘i, Lāna‘i, and Ni‘ihau). Collectively, they
extend over 400 miles of ocean, creating land masses of approximately 7,500 square
miles, of which Hawai‘i Island (the Big Island) makes up approximately two-thirds of the
total land mass. The inhabited islands are but the southernmost reach of an archipelago,
stretching over 2,000 miles in length that extends from Hawai‘i Island in the south,
almost to the International Date Line in the northwest. Hawai‘i is also one of the most
remote geographic areas in the world, illustrated by the air mile distances from
Honolulu to San Francisco (2399 miles), Honolulu to Washington, D.C. (4835 miles) and
Honolulu to Tokyo (3818 miles). With a population of approximately 1.3 million,2
Hawai‘i is also one of the least densely populated states, with approximately 172
persons per square mile. This combination of relative isolation, island separation, and
the large number of sparsely populated rural areas makes health care delivery and
accessibility an ongoing challenge. Perhaps the most challenging factor is the
extraordinary amount (and cost) of air travel required for the various participants in
health care environment. This ranges from neighbor island patients needing to travel
inter-island to seek health care (including those transported by air ambulance) to Oahu-
based physicians traveling to neighbor islands on a regular basis to supplement these
under-served environments.

With respect to health and healthcare matters, Hawai‘i is distinctive in a variety of
important ways. Each of these distinctions help to structure and define how health care
is provided in Hawai‘i. These distinctions include:

Primary care-oriented health system: Through the 1960s, Hawai‘i was still an
environment dominated by a plantation economy, then transformed rapidly into a
tourism-oriented economy. Many of the people inhabiting the islands at that point were
tied in some ways to plantations, either directly or through historical family ties. The
plantation economy naturally pushed people toward a primary care-oriented medical
system; tendencies that have persisted in later decades.

Employer-mandated health insurance: Hawai‘i is the only state that, from the mid-1970s
until the onset of health care reform, has had an employer-mandated health insurance
system, which while imperfect in providing health care for all, provides health care
coverage for most. It has also allowed Hawai‘i, throughout many decades, to have,
compared to other states, the smallest proportion of its population without health
insurance coverage.


2
    1,295,178 according to the U.S. Bureau of the Census in 2009

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Health insurance coverage: Quite unlike most states throughout much of this period, the
health care insurance environment in Hawai‘i consists primarily of two health plan
carriers. The Hawai‘i Medical Service Association (HMSA) and Kaiser Permanente
currently share approximately 88 percent of the market (HMSA) 68 percent; Kaiser
Permanente approximately 20 percent). The remainder of the health insurance market
has been occupied by smaller plans, some local and some national, which have flowed in
and out of the overall market.

Public and private hospital system coverage: Restructured in 1996 as a public benefit
corporation of the State of Hawai‘i, Hawai‘i Health Systems Corporation (HHSC)
currently operates 14 facilities on four islands, ranging from comprehensive hospitals, to
local clinics, to long-term and veterans-care facilities. Each hospital, while remaining
part of the overall system, operates with its own board. Many of the remaining hospital
beds in the state are concentrated into three systems: The Queen’s Health System,
which operates The Queen’s Medical Center in urban Honolulu; Hawai‘i Pacific Health
(HPH), which operates four medical centers, three on O‘ahu and one on Kaua‘i; and
Kaiser Permanente, which operates a comprehensive medical center on O‘ahu and
multiple clinics on the neighbor islands and provides tertiary care referral hospitals for
the residents of island territories.3

Health disparities: Historically, and for some of the reasons suggested above, the
population of Hawai‘i is remarkably healthy and has enjoyed more than sufficient
medical care services, with one notable exception. The health of the native population
and others of Polynesian ancestry, lag behind other groups in the state’s multi-ethnic
population in almost all critical health and longevity indicators. The health and health
care needs of this population stand at the center of public health care considerations,
and have been recognized within the Native Hawaiian Health Care Improvement Act of
1985, which, among other provisions, establishes native Hawaiian health care clinics
throughout the islands.4

Medicare reimbursement: In part because of its relative isolation from the rest of the
United States, which adds significant transportation costs to many portions of the
economy, Hawai‘i is an expensive place to live and to do business. For example, judged
by the Cost of Living Index, during the 4th quarter of 2009 it was the most expensive
place to live in the US, with a COLI of 163 compared with the next highest, Washington,
D.C. with 137.9.5

Disaster readiness: Hawai‘i is also unique in terms of the array of natural disasters to
which it is susceptible. They range from hurricanes (as recent as the Category Four
Hurricane Iniki that struck Kaua‘i directly in 1992—the 3rd most destructive in the U.S.),
to earthquakes (6.7 MMS in 2006, felt mainly on Hawai‘i Island causing power outages

3
  Details of Hawai’i health care entities, including their relative size, are given in Appendix 4.
4
  Native Hawai‘i Health Care System, 2010
5
  Cost of Living, 1st Quarter 2010

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on Maui, Hawai‘i Island and O‘ahu), to volcanic eruptions (the current eruption of
Kilauea having recently passed its 10,000th day), and tsunamis that have previously
wrought significant devastation, including destroying much of central Hilo in 1946 and
1960. Such devastations, when they do occur, profoundly stress health care facilities in
terms of both destruction and service demands. Such situations may be compounded by
the geographical isolation within the archipelago of the smaller population
concentrations, like Lāna‘i and Moloka‘i, which are also those that are least provisioned
for HIE connectivity and services.

Cultural competency: For the better part of a century, Hawai‘i has been the most
ethnically diverse population among the 50 states. This legacy carries with it a particular
set of cultural expectations and capabilities that influence the ways that health care is
conceptualized and realized. Within this view of population diversity must also be added
the reality that on any given day of the year, the population of the state is
supplemented by a visitor count of approximately 130,000 and a military-affiliated
population of similar dimensions. Each of these important statistics raise sets of distinct
issues for health care and health information exchange.

In total, each of these factors has an impact on how health care information is
generated, deployed, used, and exchanged (or not) within Hawai‘i. The significance of
these introductory remarks is that in many important ways Hawai‘i, as an environment,
is different from its sister states, and these differences reveal many issues concerning
health information exchange.6

2.         Environmental Scan

2.1        Overview

To date, there has been no comprehensive health IT assessment known to evaluate
statewide health information exchange (HIE) readiness in Hawai‘i. As health IT becomes
an imperative for organizational efficiencies, stakeholders are beginning to participate in
this assessment.

This environmental evaluation reflects a compilation of input provided by Hawai‘i HIE’s
key community stakeholders in regards to assessing, measuring, and quantifying the
marketplace and its commitment to ongoing participation.

2.1.1       Health Care Coverage

As a result of more than 30 years experience with an employer-mandated health care
system, Hawai‘i has a relatively small proportion of its population without insurance
coverage. Recent studies place that figure of those without health care insurance in the
range of 7.5-8.0 percent or approximately 97,000 persons. With respect to the total

6
    For additional health facts about Hawai‘i see the Appendices.

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population, approximately 60 percent of insurance coverage is employer based and 2.7
percent individually based. Medicaid provides insurance coverage for 12.3 percent of
the population and Medicare 13.8 percent; other public plans provide 3.2 percent.7

Expressed differently, government programs extended to 36 percent of covered lives,
with Medicare accounting for 35 percent of government-covered lives, with QUEST and
Medicaid representing 29 percent and 8 percent respectively. QUEST is Hawai‘i’s
government Medicaid program that provides health coverage through manage care
plans for eligible lower income Hawai‘i residents to achieve:

•     Quality care,
•     Universal access,
•     Efficient utilization,
•     Stabilized costs, and
•     Transformation in the way health care is provided.
Current QUEST enrollment amounts to 10.6 percent of all covered lives. Within QUEST,
HMSA represents the largest share with 50 percent. AlohaCare is the next largest plan
with 36 percent of all QUEST covered lives.

A percentage approximately equal to QUEST (around 10.5 percent) constitutes the Fee-
for-Service market, while approximately 23 percent of subscribers are in Health
Maintenance Organizations (HMOs) and about 38 percent in Preferred Provider
Organizations (PPOs).

In terms of the overall insurance coverage, Hawai‘i is dominated by two entities: Hawai‘i
Medical Services Association (HMSA) and Kaiser Permanente. HMSA, with more than
690,000 members, represents approximately 68 percent; Kaiser, with approximately
225,000 members, has 20 percent. AlohaCare is the third largest plan with
approximately 70,000 members. Commercial insurance companies account for about 4
percent, and the other remaining plans, 8 percent. In 2007, one in 11 people in Hawai‘i
carried coverage from more than one health plan—a trend that is continuing to grow.8

2.2        Assessment of Current EHR Capacity and HIE Activities

EHR adoption and HIE capabilities vary across the islands of Hawai‘i. There is a relatively
small number of practices using high-level, sophisticated EHRs that utilize information
exchange, affecting virtually every aspect of care for the patients involved. In general,
these activities reside overwhelmingly in hospital systems. The majority of providers,
including organized hospitals, smaller physician practices, stand-alone entities and

7
    Russo, et. al, 2009, Health Trends, 2010, Kaiser Family Foundation, State Facts 2010
8
    Data in this section was accessed through Hawai‘i Health Tends 2010 and Kaiser Family Foundation State
    Health Facts.

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independent physicians, have either adopted EHRs with limited integration with other
providers and/or ancillary services, or are on a developmental track toward effective
EHR adoption. In addition, significant numbers of physicians, practices, hospitals, and
clinics continue to rely on paper-based patient records.

Hawai‘i HIE is committed to the use of its environmental scan as a dynamic tool and will
continue its development into a comprehensive database of capability and readiness. In
the 2009 survey, each component within the process has been identified within its
relevant stakeholder capacity. Many such stakeholders already sit as members of the
Hawai‘i HIE Board, often in the capacity as CEO or CIO of their respective organizations.
Other relevant stakeholders are being recruited to an expanded Hawai‘i HIE Board.
Hawai‘i HIE, through this process, is developing a Readiness Index that is tied to a
process of soliciting stakeholder input on a regular, three-month schedule. This will
produce a dynamic, up-to-date assessment of readiness throughout the process of
moving from planning into the stages of implementation for Hawai‘i HIE and will be
submitted to ONC as a supplemental deliverable to the Grants contract.

2.2.1       Hospital EHR Adoption

The most highly integrated systems of clinical data and attendant information gathering
and exchange take place within Kaiser Permanente, Hawai‘i Pacific Health, The Queen’s
Medical Center, and federal hospitals (e.g. Tripler Army Medical Center and the VA
Pacific Islands Health Care System Ambulatory Clinic) and community clinics. Smaller
hospitals, such as the Castle Medical Center, a component of Adventist Health, have
integrated data exchange of more limited proportions with mainland counterparts.9

In Hawai‘i, with its 225,000 members, Kaiser Permanente employs 4,400 total staff of
which 400 are physicians. It maintains a 278-bed hospital on O‘ahu and 18 outpatient
clinics on O‘ahu, Maui, and Hawai‘i Island. The EHR system is central to the Kaiser model
of integrated care, framed by its goal and vision of “all of the information about all of
the patients all of the time.”

Hawai‘i Pacific Health (HPH), the State’s largest care delivery network, provides one of
the most comprehensive health information exchanges in Hawai‘i. HPH is a non-profit
parent company of four hospitals and three physician groups. Hospitals include
Kapi‘olani Medical Center for Women and Children, Pali Momi Medical Center, Straub
Hospital (all on O‘ahu) and Wilcox Health on Kaua‘i with a total of 553 acute care beds
and 1,342 physicians on medical staff. Physician groups include Straub Clinic, Kaua‘i
Medical Clinic, and Kapi‘olani Medical Specialists. HPH operates 44 outpatient centers
throughout the islands and provides physicians to rural locations (e.g. Lāna‘i) who have
the capacity to electronically link with other physicians in all of its facilities through its
Epic EHR system, resulting in effective integration of health records, electronic

9
    Data in this section were extracted from presentations made during a stakeholder meeting on April 23,
    2010. See bibliography for further information.

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prescribing, and full exchange within the system. The system also interfaces (via HL7)
with the State’s two largest laboratories: Clinical Laboratories of Hawai‘i (CLH) and
Diagnostic Laboratory Services (DLS). HPH, The Queen’s Medical Center, and Kaiser
Permanente all use the Epic EMR System, making future health information exchange
between these systems very realistic at minimal cost.

The Queen’s Healthcare System owns and operates The Queen’s Medical Center, the
largest private hospital in Hawai‘i, and Moloka‘i General Hospital. A non-profit facility,
The Queen’s Medical Center provides 505 acute care beds, employs 3,000 persons and
has over 1,200 physicians on staff. Operating with an Epic system, its very size makes it
among the largest integrated “systems” in Hawai‘i.

Figure 1: Distribution of Major Hospitals in Hawai‘i




The issue of health information exchange is further detailed below in the section 2.2.8
entitled “Clinical Summaries and Patient Engagement.”

2.2.2     Physician EHR Adoption

Fully developed EHRs have been adopted for a minority of independent physicians.

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With the exception of Kaiser-Permanente, physicians associated with HPH, the Queen’s
Hospital, federal military and veterans facilities, and the federally qualified health care
centers exchanging information from the physician-to-physician perspective, it is clear
that for very many physicians, HIE is limited, existing mostly within individual health care
centers but not between facilities.

In the current environment, the two largest labs are developing interfaces with various
vendors, of which there are currently 30 different versions. Data from these two labs
(who serve some clients jointly and others individually), indicate that the number of
functional EHRs with which they exchange data is approximately 600. Discussions to
explore portal expansion are beginning, and outcomes of this effort are pending.

Data compiled by the HPREC has determined the number of primary care physicians
(PCP) in Hawai‘i operating in groups of under 10 to be 960 PCPs, with 102 on the Hawai‘i
Island, 27 on Kaua‘i, 652 on O‘ahu, and 179 on Maui/Moloka‘i. These small practices are
the target group for adoption of EHRs over the next three years.

For the Independent Physician (IP) sector, one dominant Practice Management (PM)
and EHR vendor is TeamPraxis. Their practice management software, ConnxtMD, to over
1,000 physicians, and their EHR system, Allscripts, is used by nearly 200 physicians.

2.2.3     EHR: Veterans Affairs (VA) and Department of Defense (DoD)

Health care services for veterans constitute a small but distinct portion of Hawai‘i’s
health care activity. The VA Pacific Islands Health Care System (VAPIHCS) provides
ambulatory and aging care through clinics located on O‘ahu, Kaua‘i, Maui, Hilo and Kona
(located on Hawai‘i Island), the U.S. Territory of Guam and American Samoa, and has
outreach clinics on Moloka‘i and the Commonwealth of Saipan. The mission of VAPIHCS
is to provide care for 127,600 veterans residing in the Pacific. Of these, the VAPIHCS
served over 22,500 in 2006 with 198,000 clinic visits.

VAPIHCS has a strong interest in the development of Hawai‘i HIE because 60-70 percent
of veterans receive at least part of their care through community providers. On O‘ahu,
VAPIHCS utilizes the Tripler Army Medical Center (TAMC) for inpatient care; however,
roughly half of all clinical consultations on O‘ahu are delivered by community providers.
On the neighboring islands, the VA Clinics are completely dependent on the surrounding
health care community for the provision of emergency services, hospitalization,
laboratory, radiology, and specialty consultations.

The VA has completely converted to the use of electronic health records. No paper
charts are employed. As a result, health care information generated outside its walls
must be re-entered into its electronic systems. Within TAMC, information is viewed
through the Janus system, a browser-based dual provider view that displays Composite
Health Care System (CHCS) data from the Department of Defense (DoD) and
Computerized Patient Record System (CPRS) Veterans Health Information Systems and

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Technology Architecture (VistA) data from the VA in a single, chronologically sorted
view.

Hawai‘i is an integral part of the Army’s Telemedicine and Advanced Technology
Research Center (TATRC), an organization that is fully committed to the creation of
cutting-edge bedside technologies that can deliver real-time data and better clinical
decision support. Furthermore, TATRC has been active in the development of the
Nationwide Health Information Network (NHIN) and the federal Virtual Lifetime
Electronic Record (VLER) program and seeks to serve as an interface organization when
the Hawai‘i HIE is ready to connect to the national infrastructure.

TAMC is the DoD tertiary care facility within the Pacific Basin. Its mission is to ensure the
readiness of the Armed Forces through the delivery of health care, which it
accomplishes by providing acute and tertiary care to all eligible personnel along with the
highest level of graduate medical education, and by conducting clinical research to
support its graduate medical education role. TAMC’s beneficiary population includes
156,000 potential patients living in the state of Hawai‘i. Its close association with the
Department of Veterans Affairs brings to its catchment another 127,600 eligible
patients.

TAMC and the other DoD military treatment facilities on the island of O‘ahu have used
electronic clinical and medical record systems since 1990. Usage features a robust
ambulatory EHR that shares clinical documentation and patient data across the DoD
worldwide. The inpatient system has been in use for the past two years. Both
ambulatory and inpatient systems have used Computerized Provider Order Entry (CPOE)
for most of their lifespan. The emergency department uses a state-of-the-art
commercial emergency department information system. Digital radiography has been
used for the past 15 years. The global DoD ambulatory EHR supports 77,000 active
users, averages 140,000 new encounters per day, and maintains clinical data on 9.6
million beneficiaries.

Data sharing among the DoD and VA sites has been critical for the co-management of
shared patients. TAMC has supported telemedicine for many years, ranging from
intensive care medicine support in the Far East (eICU), pediatric and adult specialty
remote consultation, and more recent experience with tele-traumatic brain injury and
tele-behavioral health support.




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2.2.4     Additional Components of Health Information Exchange

The following HIE initiatives comprise components, data sources and desired functionality, as follows.

Healthy Hawai’i Initiative

The purpose of the Healthy Hawai’i initiative is to educate on leading causes of preventative deaths, encourage the public to
incorporate healthy choices into their lifestyles, and reduce the burden of chronic disease.

Table 1: Health Information Exchange Components
        Component                           Purpose                                Current Data Sources                 Desired Functionality
  Syndromic               To provide early detection and warning         •    Over-the-counter pharmacy sales   •   Expanded data sources – FQHCs,
  Surveillance            for community health issues such as                                                       providers, ARCH/LTC, etc,
                                                                         •    Air quality from remote
                          pandemic influenza, communicable                    monitoring stations – sulfur      •   Expanded data elements -
                          diseases, and environmental hazards.                dioxide                               prescription drugs
                                                                         •    Lab-reportable diseases           •   Standardized and formatted for
                                                                                                                    real-time or batch upload into
                                                                         •    Emergency department data –
                                                                                                                    the Hawai’i Health Emergency
                                                                              patient chief complaint data in
                                                                                                                    Surveillance System (HHESS)
                                                                              free text
  Chronic Disease         To promote health and reduce the               •    Risk factor surveillance data     •   Support chronic disease
  Prevention and          burden of chronic diseases for the                  (phone-based, self-report)            prevalence and incidence
  Population              people of Hawai’i by engaging and                                                         calculation, expanded to include
  Management              empowering the community, influencing                                                     race and ethnicity data
                          social norms and supporting and                                                       •   Annual or semi-annual batches to
                          encouraging healthy lifestyles.                                                           support disease registries for
                                                                                                                    heart disease, stroke, cancer,
                                                                                                                    diabetes mellitus, asthma/COPD
                                                                                                                •   Actual values (lab, stage, etc.) to



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      Component                             Purpose                                 Current Data Sources           Desired Functionality
                                                                                                               establish severity and disease
                                                                                                               burden
                                                                                                           •   Lifestyle data – clinically derived
                                                                                                               BMI (not self report), smoking
                                                                                                               status, physical activity status,
                                                                                                               etc.
                                                                                                           •   Demographic data – County, ZIP
                                                                                                               code, neighborhood, household
                                                                                                               information, etc.




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Emergency Medical Services System Branch
The Emergency Medical Services System Branch aims to minimize death, injury, and disability due to life threatening situations by
assuring the availability of high quality emergency medical care through the development of a system capable of providing
coordinated emergency medical and health services.
     Component                              Purpose                               Current Data Sources                     Desired Functionality
  Injury Prevention       To provide statewide leadership in             •    Hawai’i Health Information          •   As it relates to poisoning, opioid
  and Control             preventing death and disability                     Corporation                             overdose, sulfur dioxide, and
                          associated with injuries in Hawai‘i. This                                                   suicides, additional clinical and
                                                                         •    Hawai’i EMS Information System
                          is accomplished by educating,                                                               administrative data
                                                                              (HEMSIS) – real-time centralized
                          supporting and mobilizing individuals               data warehouse of ambulance         •   Periodic look-back for analysis
                          and organizations to incorporate                    data                                    and evaluation
                          comprehensive injury prevention
                          strategies in their on-going efforts.          •    DOH Vital Statistics – electronic   •   Annual or semi-annual
                                                                              birth and death records                 prevalence and incidence data
                                                                                                                  •   BAC lab data for MVC-related
                                                                                                                      injuries
                                                                                                                  •   Linked patient care summaries to
                                                                                                                      outcomes along continuum of
                                                                                                                      emergency or trauma care –
                                                                                                                      facility and practitioner,
                                                                                                                      ambulance, etc.
                                                                                                                  •   Traffic data




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Disease Outbreak and Control Division
To monitor and investigate known and emerging infectious diseases, monitoring and implementing programs to control vaccine-
preventable diseases, and coordinating and implementing public health preparedness planning and related activities.
     Component                             Purpose                     Current Data Sources                          Desired Functionality
Immunization              The goal of the Hawai’i Immunization        • Paper and electronic records from           • 100% provider participation,
Registry                  Program is to prevent diseases such             private providers                            currently less than 1%
                          as measles, mumps, rubella, polio,          •    500 – 1000 paper forms per week          •   Unique patient identifier
                          chickenpox, hepatitis B, hemophilus              requiring data entry
                          influenza B, influenza, and pneumonia                                                     •   Hospital birth and death data
                          through immunizations. Shots or             •    DOH Stop Flu at School paperwork
                                                                                                                    •   Demographic data
                          vaccinations are required for pre-          •    Electronic lab data from SLD, CLH,
                          school, kindergarten, 7th grade and              DLS, Kaiser and DoD
                                                                                                                    •   Standardized ethnicity data
                          college/university attendance in                                                          •   COFA status, including island of
                          Hawai’i.                                    •    Proprietary formats requiring
                                                                                                                        origin
                                                                           transformation and loading by DOH
                                                                                                                    •   Military/civilian status
                                                                      •    Hawai’i Health Information
                                                                           Corporation – for research only
Disease                                                               •    Paper and electronic records from        •   Unique patient identifier
Investigation                                                              private providers and labs
                                                                                                                    •   Standardization according to HL7,
                                                                      •    Paper records from facility infection        SNOMED, and LOINC
                                                                           control practitioners
                                                                                                                    •   Enriched encounter date – date
                                                                      •    Electronic Hawai’i State Labs Division       of admission, date of discharge
                                                                           data on influenza and leptospirosis
                                                                                                                    •   Electronic consent mechanism
                                                                      •    Electronic death record data related
                                                                                                                    •   Medical examiner data
                                                                           to influenza and pneumonia
                                                                      •    74 other lab-reportable conditions
                                                                           electronically




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     Component                             Purpose                     Current Data Sources                        Desired Functionality
                                                                      • Newborn Hepatitis-B status from
                                                                          birth hospitals on paper
                                                                      •    Custom disease surveillance database
                                                                           that houses all investigation data,
                                                                           including patient interviews and
                                                                           clinically derived information
                                                                      •    Communicable disease reporting
                                                                           (mandated by law)
                                                                      •    Provider portal for direct data entry
                                                                      •    Paper forms still the norm




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Communicable Diseases Division
The purpose of the Communicable Diseases Division is to monitor the number of cases of tuberculosis and Hansen's disease, and
other transmittable diseases.
      Component                             Purpose                               Current Data Sources                 Desired Functionality
  Tuberculosis            The purpose of the TB Control Program      •        DOH TB clinic records and      •   Laboratory and patient care
  Control                 is to reduce the incidence of tuberculosis          patient charts, paper-based        summaries that accompany patient
                          in the state by providing effective                                                    on intake and discharge
                          prevention, detection, treatment and                                               •   Demographic data for diagnosed
                          educational services.                                                                  patients – age, gender, ethnicity,
                                                                                                                 socio-economic status, education
                                                                                                                 level, COFA origin, insured status
  Sexually                To provide statewide leadership and       •         Patient charts from contract   •   Sharing of DOH STD/HIV is
  Transmitted             coordination for the prevention,                    physicians                         questionable due to sensitive
  Disease/AIDS            treatment, care and surveillance of                                                    nature of diagnoses
                                                                    •         In-house testing data
  Prevention              infections transmitted primarily through                                           •   Demographic data for diagnosed
                          sexual contact or injection drug use; and •         Medication dispensing data
                                                                                                                 patients – age, gender, ethnicity,
                          assure the accessibility and delivery of                                               socio-economic status, education
                          client-centered, non-judgmental, and                                                   level, COFA origin, insured status
                          comprehensive services with the spirit of
                          aloha and respect.                                                                 •   Medical history
                                                                                                             •   Annual or semi-annual prevalence
                                                                                                                 and incidence data




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State Labs Division
The State Labs Division administers a statewide program which conducts analytical testing services in support of environmental
health and communicable disease control activities, as well as public health emergency preparedness and response efforts.
     Component                         Purpose                                Current Data Sources                        Desired Functionality
  State Labs             SLD provides consultative and           •   Existing data exchange for influenza with   •   Standardized formats for
  Division               other related laboratory services           DLS, Kaiser, Penco, and select sentinel         influenza exchange with Tripler,
                         to departmental programs, health            physicians                                      Kaiser, DLS, CLH
                         care providers, institutions, and       •   Provider and lab portal for direct data     •   CLH/DLS information is paper-
                         various federal, state, county, and         entry and                                       based and transcribed
                         city agencies including the
                         certification of certain types of       •   Lab dashboard for pushing out individual    •   As reference laboratory, i.e.
                         laboratories, and the licensing of          lab results (Kaiser, DLS)                       second tier, availability of first
                         clinical laboratory personnel and                                                           tier data would be useful for
                                                                 •   Public Health Interoperability Program
                         medical review officers. SLD                                                                epidemiological trending
                                                                     (PHLIP)
                         participates in environmental and                                                       •   Antibiogram function – real time
                         public health training, research,       •   Real-time uploads to CDC
                                                                                                                     bug/drug specific reference tool
                         exercises, and investigations.          •   Pass-through epidemiological findings           for providers
                                                                     (lab results) from STD program,
                                                                                                                 •   Else retrospective reporting that
                                                                     environmental programs (e.g. water
                                                                                                                     matches scripts/providers and
                                                                     quality, food safety), disease outbreak
                                                                                                                     lab specimens to adjust
                                                                     and communicable disease programs,
                                                                                                                     treatment plan
                                                                     reference lab for private labs, etc.,
                                                                     though SLD is not the repository of         •   Portal for public entities like
                                                                     record                                          FQHCs to do online SLD/lab
                                                                                                                     orders
                                                                 •   SLD data warehouse to organize all data
                                                                     passing through is being conceptualized




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2.2.5 Community Health Centers, Federally Qualified Health Centers, and Rural
Health Clinics

Community Health Centers (CHCs), also known as Federally Qualified Health Centers
(FQHCs), form a community-based non-profit network that serves approximately 10
percent of the Hawai‘i population and targets those who are among the highest risk for
poor health and face the most severe access barriers. They are funded primarily by
third-party payers, with the single largest source of support being Med-Quest
(Medicaid). CHCs also benefit from ongoing grant support from the federal Health
Resources and Services Administration (HRSA) and the State of Hawai‘i.

Fourteen CHCs are distributed across six islands and care for 125,000 people to whom
they provide medical, dental, and mental health care services, as well as 340B
prescription drug pricing and a variety of other support and prevention-oriented
services. The clinics directly employ 150 medical clinicians, 35 dentists and hygienists,
and 40 mental health providers. CHCs strive toward the patient-centered medical home
(PCMH) model of care, which emphasizes enhanced access, a team model of care,
establishing a long-term primary care relationship, promoting care management and
measuring quality and outcomes. EHRs are in the process of being implemented at all 14
CHCs: four employing NextGen (the longest established); six Centricity; three
eClinicalWorks; and one SageIntergy.10

In addition to the CHCs, Hawai‘i has several Rural Health Clinics (RHCs), including Ka‘u
Hospital Rural Health Clinic in Pahala on Hawai‘i Island and Molokai General Hospital
Rural Health Clinic in Kaunakakai on Molokai. These RHCs are located in rural, medically
underserved areas and receive separate reimbursements from the standard medical
office under the Medicare and Medicaid programs.

2.2.6       Regional and Private HIE Initiatives

On Maui, the Wellogic EHR system was utilized for data exchange in a pilot program
enabling a limited exchange of data between some Maui Memorial Medical Center
systems, CLH, and within practices of the Maui Medical Group. Although the Wellogic
pilot phase ended in September 2010, lessons learned will be applied and existing data
exchange elements will be sought to be repurposed.

The North Hawai‘i Health Information Exchange (NHHIE) on the Hawai‘i Island was
formed over the past two years and organized around Wellogic. With the goal of
providing comprehensive “one-patient-one-record” access to patient information across
all venues of care, NHHIE has combined the efforts of a broad stakeholder coalition that
includes the North Hawai‘i Community Hospital, Waimea area providers, the Hamakua
Health Center, the two primary labs (CLH and DLS), the Hawai‘i Independent Physicians

10
     Information provided by Hawai’i Primary Health Care Center during Stakeholder Presentations

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Association, Surescripts, Wellogic, and eQHIP. NHHIE anticipates interfaces to the major
participants to be operational by the end of 2010. NHHIE estimates 140 providers will
have access to patient information through its exchange. The goal is to have 100% of
North Hawai‘i physicians exchanging patient data by the end of 2011 11

In addition, Hawai‘i Pacific Health (HPH) has an existing exchange today that spans four
islands, four hospitals, three employed physician groups, and one independent practice
of 24 physicians, with plans to begin expanding this exchange to ten more practices
before June 2011. Queens and HPH also plan to exchange information in Spring of 2011.
Together, these practices and hospitals serve about half the State's population.

2.3        Beacon Grant Activities

In May 2010, the University of Hawai‘i, Hilo College of Pharmacy, became the recipient
of the $16 million Hawai‘i County Beacon Community Consortium (HCBCC) award from
the U.S. Department of Health and Human Service Office of the National Coordinator of
Health Information Technology (ONC). Supported by a broad coalition of users and
other stakeholders on Hawai‘i Island, the goal of the HCBCC is to “implement a region-
wide health information exchange and patient health record solution and utilize secure,
Internet-based care coordination and telemedicine tools to increase access to specialty
care for patients with chronic diseases such as diabetes, hypertension, and obesity in
this rural, health-professional shortage area.” Organized around Microsoft’s Amalga
system, the HCBCC program is also conceived as a cornerstone in the national
movement to ensure that patients have a medical home. The HCBCC Program is viewed
as a catalyst for linking these endeavors within an overall health care environment that
is primarily rural, highly extended, and historically bereft of a sufficient health work
force. Health information exchange between rural areas and urban centers is viewed as
a primary leveraging tool in this challenging environment.

Strategically, the HCBCC Program will function as a regional health information
exchange within the Hawai‘i Island setting, and in time be linked to the rest of the state
through exchanges with Hawai‘i HIE.

The program is anticipated to enable the following percentages of primary care
providers in Beacon coverage areas to achieve meaningful use along these timelines:

•      40% of providers by October 1, 2011
•      55% of providers by March 31, 2012
•      60% of providers by March 31, 2013




11
     Wellogic, Project Summary, North Hawai’i Health Information Exchange, 2010

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2.3.1     Decision Support Programming (Intelligence)

A total of $2,105,240 is budgeted for purchase, configuration, implementation and
support of industry leading decision support system including all required infrastructure.
This includes $165,000 for hardware and hardware support and $1,260,000 for clinical
rules engine and decision support/outcome reporting software including annual
maintenance. The budget includes $680,240 for the implementation of the clinical rules
engine and the development of reports for public health purposes, clinical workflow
support, quality improvement, and state surveillance. The implementation of the clinical
rules engine for decision support will support the planned quality improvement projects
with no additional development fees. Training of end users is included in the
implementation budget to allow for ad-hoc queries and other reporting needs in
support of various quality improvement projects. The implementation plan will procure
the clinical rules engine with required configuration and training early in the project
lifecycle to support core initiatives such as personal health records and telehealth. Also,
the early implementation of the clinical rules engine will evolve to address chronic
conditions and health disparities for all residents of the Big Island through a series of
quality improvement action cycles.

2.3.2     Personal Health Records Capability

A total of $1,615,800 is budgeted for implementation of an industry leading personal
health records for rollout to every willing and able resident of Hawai’i County. The
planned hardware including ten (10) internet servers and related operating software are
budgeted at $315,000. This includes the required maintenance and support at 20% per
year. The primary component of the budget is the design and customization effort
budgeted at $1,300,800. This effort provides for the integration of the different data
sources to supply required clinical data to the PHR as well as return patient provided
information to the HIE and provider’s EMR. The effort will also integrate secure
messaging and online scheduling. The budget also provides funding integrate physician
developed care plans and enhance PHR with self care process and tools. The plan is to
coordinate resident outreach marketing efforts with required training and support to
improve overall adoption and utilization. While the initial marketing will reach all
175,000 estimated residents, focused campaigns will target chronic disease patients,
underserved populations, and remote population areas.

2.4     HIE Data Feeds

A total of $607,711 is budgeted to add 36 additional data feeds from healthcare
providers to the Big Island Health Information Exchange building upon the other HIE
projects. The planned data feeds will include service providers that are not currently or
planned to be connected with existing HIE projects such as additional primary care
providers, specialty providers including radiology providers, State of Hawai’i Disease
Threat Surveillance database, and the Kidney Foundation of Hawai’i database as well as

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enhance existing interfaces for Federally Qualified Health Centers, Big Island clinics, and
independent physician association member EMRs. Average cost of the data feed is
estimated at $16,111 with a total of 36 data feeds planned. Travel and training are
including in the budget in the amount of $24,333 with most of the development
conducted through remote access.

2.4.1     Telehealth

A total of $1,493,397 is budgeted for the purchase of a state-of-the-art video, audio, and
medical information technology to overcome geographic barriers to create remote
connections to provide a patient experience similar to what most people experience
when they visit their physician. This total includes $839,263 for the equipment including
remote monitoring devices, online care video and audio devices, touch screens and
health kiosks. The equipment also includes the funding for Cisco Systems TelePresence
solution or equivalent that will close the distance barriers for patients who need to see
specialists not available in their community. A budgeted amount of $654,134 is planned
for the telecommunications, consulting and renovations to implement the planned
remote monitoring devices, kiosks and other telemetry devices.

The budget plans for a total of 40 "health kiosks" (0.25 per 1,000 residents) for fixed
locations throughout the Hawai’i County. There are two types of health kiosks planned:
free standing kiosks and soft kiosks with PCs or laptops. The 10 free standing kiosks are
budgeting at $15,000 each with the soft kiosks budgeted at $3,000 each totaling
$240,000. A total of 1800 video cameras with microphones, with estimated cost of
$100,000, is planned to pilot using online care visits delivering behavioral and chronic
diseases care to patients with transportation barriers provided that they have PCs and
broadband connections (covers 1% of residents). The fixed kiosks and portable kiosks
are planned to support residents who do and do not have access to PCs and broadband
connections.

2.4.2     Meaningful Use

A total of $750,000 is budgeted to improve the alignment and successful adoption of
meaningful use goals. The budget provides funding for four meaningful use service
bundles:

Privacy and security services for auditing and corrective actions, ($250,000) services to
develop state surveillance reporting, and ($100,000) services to develop EMR usage and
reporting improvements to meet meaningful use criteria and ($250,000) services to
perform physician meaningful use reviews and corrective action plans for meaningful
use compliance ($150,000).




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2.5        Electronic Prescribing

Recent data reflects that an estimated 975 in-state active providers currently use or
have implemented electronic prescribing systems. Although data are yet to be validated,
in 2009, 10 percent of prescriptions in Hawai‘i were electronically ordered and filled.12
This number, however, may be rapidly changing reflecting structural changes in
pharmacies and with upcoming provider incentives acknowledging Meaningful Use of
electronic health records. Recent pharmacy acquisitions are similar to the consolidations
of health care plans and laboratories, in which two firms (in this case national firms),
CVS (formerly Longs Drugs) and Walgreens control most of the pharmacy market.
Costco, Walmart, and Target are also increasing their share of the Hawai‘i pharmacy
market. Hawai‘i HIE will continue to gather data on e-prescribing by all entities in the
market as it continues to develop, as outlined in the table below.

Table 2: Electronic Prescribing and Refill Requests
                              Activity                                        2007                2008               2009
 Total prescriptions routed electronically                                   14,974              53,946             558,800
 Percent eligible prescriptions routed                                         0%                  1%                10%
 electronically
 Physicians routing prescriptions at year end                                   17                 66                400
 Community pharmacies activated for e-                                         112                 136               154
 prescribing at year end
 Percent physicians routing prescriptions                                      1%                  3%                16%
 electronically
 Percent patients with available prescription                                 13%                 49%                100%
 benefit/history information
 Percent community pharmacies e-prescribing                                   65%                 72%                75%
 activated
(Source: Hawai‘i Progress Report on E-prescribing, Surescripts. Available at: http://www.surescripts.com/about-e-
prescribing/progress-reports/state.aspx?state=hi&fullscreen=true&background=off&mode=print)


CVS and Walgreens will soon represent approximately 85 percent of the Hawai‘i
prescription market. In part as a result of their recent arrival into the Hawai‘i market,
both entities are making significant investments in their electronic systems, which
should (in theory) provide additional incentives for EHR vendors and adopters to make
greater use of this possibility. In 2008 (the latest data available), about 11.5 million retail
prescriptions were filled (some current estimates place this around 13 million)
representing a value of about $780 million. Regulatory issues will be important in the
further development of e-prescribing. Although there is an increase in the number of e-
prescriptions being conveyed to pharmacies through the Surescripts network today,
some barriers must be overcome for all prescribers to embrace this technology. When

12
     2009 Surescripts Progress Report on E-Prescribing

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e-prescriptions were first conveyed to pharmacies via the Surescripts network, local
pharmacies were unfamiliar with their pharmacy system’s workflow management for e-
prescriptions and unsure of the various regulatory requirements governing e-
prescribing. This resulted in a high volume of clarification calls to e-prescribers by
pharmacists for additional prescription information or for an orally ordered prescription.
These conditions led some non-e-prescribers to refrain from registering and some e-
prescribers to unregister with Surescripts. Surescripts and other intermediaries have
challenges to overcome in resolving data flow issues between provider organizations,
EHR/e-prescribing vendors and pharmacies. As part of the overall strategy, resolution of
data issues and increased prescriber education are anticipated to overcome reluctance
to e-prescribe based on initial perceptions. In addition, the RECs will educate and
promote e-prescribing to primary care providers as they adopt EHRs to assist them in
reaching meaningful use.

Furthermore, providers are challenged with specific rules around the prescribing of
controlled substances, and statutory revision is necessary to the HRS 329 Uniform
Controlled Substances Act that will not preempt the recent Drug Enforcement Agency
(DEA) regulatory changes and allow controlled substance prescriptions to be conveyed
electronically to pharmacies in Hawai‘i. Even though more stringent requirements will
be necessary on the part of prescribers to electronically convey controlled substance
prescriptions than are required for non-controlled substance prescriptions, authorized
prescribers are now allowed to convey all of their prescriptions electronically and
maximize the number of e-prescriptions being conveyed to pharmacies.

In order to meet the milestones set by ONC, Hawai’i HIE stakeholders have discussed
how e-prescribing might be incorporated into existing interoperable systems. Hawai’i
laboratories already have established interfaces with most EHRs and some EMRs in the
within the state, America Samoa, Guam and CMNI. With the approval of 33 EHRs by
ONC-ATCB, there is a possibility of using the labs as a case study to exchange data by
creating a separate e-prescribing environment. The lab infrastructure would have to
partition its existing data receiving hub, hosting a secured domain with a secured portal
connecting to Surescripts or a similar network. Technically, the EHR would be able to
send a prescription order electronically to the temporary hub and have the script
translated and sent to the network’s message center. As those agreements and ports
already exist, the connection from the lab to the EHR is already functional from the
existing communications connections. The portal from the Lab hub to the network will
need to be defined and established as well as the translation application, and all other
technical functional components need to be tested and validated. This exercise, as an
option to meet pending deadlines, would also address the critical policy issues that will
eventually arise prior to setting up the production system, regardless if this is
implemented or not.




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2.6     Laboratories

Diagnostic Laboratory Services (DLS) and Clinical Laboratories of Hawai‘i (CLH) account
for approximately 70 percent of the laboratory market in Hawai‘i and serve almost 90
percent of Hawai‘i’s patient population along with those of Guam and Saipan. They
provide clinical, cytology, pathology, diagnostic and other testing services (e.g. wellness
screens and drug tests) to medical centers, hospitals, clinics, individual physician
practices and the community. The two laboratories serve about 4,200 physicians,
performing about 13 million procedures a year, or approximately 70 percent of the
laboratory and pathology tests performed in Hawai‘i.

In addition, DLS and CLH maintain EHR results that utilize standardized Health Level
Seven (HL7 version 2.3.1) codes. CLH and DLS are supporting about 1 million order and
result transactions per day to EHR systems through their own systems, but these do not
currently support patient identifiers, provider identifiers, or orders and results codes. In
addition, DLS and CLH do not currently use LOINC (Logical Observations Identifiers,
Names, and Codes) for their EHR interfaces, making it difficult for health care providers
to consolidate results from both sources. Thus, while volumes certainly support current
Meaningful Use standards, the integration of services remains an ongoing challenge. It is
the goal of these laboratories and of Hawai‘i HIE to develop common ordering and
results standards in order to facilitate access to usable lab summaries within and across
patient visits, resulting in enabling providers with improved decision support. To address
the need to standardize, DLS and CLH are forming partnerships with developers of
middleware with the goal of implementing a single gateway. With the attempts of the
major labs in the Hawai‘i market to standardized, it is hoped that labs with a smaller
percentage of market share will follow suit.

Of physicians who utilize an EHR, it is estimated that approximately 50 – 70 percent are
able to connect to both CLH and DLS. To date, these laboratories have diagnostic health
messages that have interfaced successfully with up to 22 different types of EHRs (with
others in development) resulting in a combined estimate of over 800 EHR result
interfaces in operation. These EHR systems are utilized by single-physician offices as well
as clinics.

DLS and CLH have collectively interfaced with most of the major hospital information
systems in the State. Interfaces with hospital information systems include bi-directional
transmissions of both orders and results. Currently, electronic clinical laboratory
ordering is being done in the State of Hawai‘i. For hospitals, it is approximately 90
percent. For independent providers, it is approximately 20 percent.

In the current environment, the two labs have developed 30 different interfaces for
various vendors. Twenty-two of these are already successful. However, most of the
EHRs are focused around three primary vendors. The expectation is that a move to
standardization is soon to occur, in part stimulated by the adoption with Hawai‘i HIE of


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interface standards. Clearly, the interests of the labs, public health, and HIE are aligned
in the direction of increasing standardization.

The challenges that these laboratories have encountered with EHRs are mainly:

             • Reconciliation of patient identification, to be addressed through a
               statewide Master Patient Index;
             • Expedited transfer of reports from one physician to another (information
               is difficult to collate from one client to another for trending/matching is
               lacking), to be addressed through a Clinician Index and secure messaging;
             • Persistent inability to update results correctly due to EHR upgrades
               (correctly linking old results, new results, and final results)

2.7     Clinical Summaries and Patient Engagement

Generally, in Hawai‘i, the nature of clinical summary exchange is hospital-centric. With
the exception of hospitals and physicians affiliated with Hawai‘i Pacific Health or with
Kaiser Permanente, physician-to-physician exchange occurs only in small numbers.

Other forms of communication and limited information exchange exist. Two years ago,
HMSA deployed a web-based software platform that enabled a consolidated,
coordinated, and integrated view of a QUEST member. HMSA’s platform is currently
supporting the coordination of care and exchange of information for the entire HMSA
QUEST population (over 100,000 members).

In January 2009, HMSA introduced a virtual clinic, known commonly as HMSA’s Online
Care (HOC). More than 140 physicians have signed on, and more than 1,000 patients
have registered. Using HOC, HMSA members can view their claims-based health records
through a browser-based application.

Kaiser Permanente, Straub Clinic, Kapi‘olani Medical Specialists, and Kaua‘i Medical
Clinic patients are also offered an online experience and can view their electronic health
records through an online system (via Epic Systems ‘MyChart’ application). Patients can
access time-saving features such as: online appointment scheduling, prescription refills,
24/7 online access to laboratory test results, and access to eligibility and benefits
information, as well as children’s immunization records.

2.7.1     Summary of Care

In the current health care environment, significant amounts of reporting on quality-
related variables drawn from hospital data are provided by the Hawai‘i Health
Information Corporation (HHIC), Hawaii’s leading primary health care information
organization. HHIC’s mission is to collect, analyze, and disseminate statewide health
information in support of efforts to continuously improve the quality and cost-efficiency
of health care services provided to the people of Hawai‘i. HHIC is a private, not-for-
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profit corporation established in 1994 by the state’s major private health care
organizations. HHIC maintains one of Hawaii’s largest health care databases, including
inpatient, emergency department, and financial data. As an independent organization,
HHIC brings both the objectivity and required expertise to enable health care facilities,
health plans, public and private organizations, and communities to make the most of
the data available, both locally and nationally.

HHIC provides updated quality improvement reports to hospitals on key topics of
importance including patient safety, mortality, utilization, and prevention. In addition,
specialty reports are also available to providers based on certain needs. These reports
include such topics as Medicare One Day Stay and Medicare Skilled Nursing Facilities
(SNF) Transfer Three Day Stays, Episiotomy, Third and Fourth Degree Laceration, and
Vaginal Birth After Cesarean (VBAC). Its current data assets include inpatient discharge
data (1995-2010), matched mothers and babies data (2000-2010), emergency
department data (2000-2010), hospital financial data/Hawai‘i Data Bank program 2000-
2010, ambulatory surgery data (under development) and a Hawai‘i active physicians
database (under development). Providers will be able to access the data when the
exchange is operational and they are enrolled, but not from the HHIC data repository. A
partnership with HHIC and Hawai‘i HIE has begun and will be formalized in the 3rd
quarter of 2011.

Currently, HHIC is exploring ways to expand its data assets to include outpatient data
that reflects the patient experience across the continuum of care. A complete list of
data elements gathered by HHIC appears in Appendix 4.

HHIC supports an active data storage warehouse that provides an interactive platform
for data users to explore market share, financial status, public health reporting,
population-based reports, quality and safety, manpower, and resource utilization. The
data are regularly used in public information, research reports and policy discussions.
Frequent data users reflect the interests and needs of hospitals, public health, research,
health plans, and policy makers. The significant challenge and opportunity for Hawai‘i
HIE lies in expanding the range of quality reporting that will be available for outpatient
interactions with physicians and ancillary facilities.

In addition to HHIC, HMSA continues to invest in technology and education as a way to
facilitate the adoption of mechanisms for improving the quality of the services provided
to its members. HMSA has three separate Pay-for-Performance Quality Programs in
place: the Quality & Performance (Q&P) program for HMSA’s HMO Health Centers
established in 1997; the Provider Quality Service Reporting (PQSR) program established
in 1998; and the Hospital Quality Service Reporting (HQSR) established in 2000. These
programs continue to evolve along with the implementation of health care reform.

And finally, the major laboratories have reporting capabilities (for patient management
reports) that can be provided monthly, quarterly and annually. Clearly, with regard to


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quality reporting, the challenges lie with utilizing health information exchange to
provide access to effective clinical data.

2.7.2     Public Health Reporting

Currently, much of the public health reporting system is maintained by individual
programs within the Hawai‘i State Health Department focused upon particular
conditions or populations, each maintaining separate databases which are not linked
with one another. Often these do not contain individual health records. While programs
within the Department do contract for patient care, patient care records are based in
the provider’s office and only summary records are maintained by the program
involved. The Department requires that certain diseases (many of which are
communicable) be reported to the department by the responsible provider. These
reports are most often made by telephone or fax, not electronically.

The State of Hawai‘i Department of Health (DoH) does not have bi-directional
interchanges for public health reporting. Because of consent issues, flat file transfers are
limited to H1N1 influenza file transmissions. An early estimate of the rate at which
providers electronically transmit required data, such as immunization records, indicates
that it may soon be available since the DoH does have the consent on the “regular”
school influenza.

In addition, the DoH does not have bi-directional interchanges for laboratory data, but
anticipates an interchange for influenza surveillance data with participating laboratories
and sentinel physicians in the near future. Currently, the major laboratories are
submitting data electronically to DoH. The laboratories also have several tools (systems)
that are used to generate statistical reports such as financial and aggregated patient
results.

The DoH is very close to implementing a biosurveillance system (Hawai‘i Health
Emergency Surveillance System or HHES) that takes flat file information from hospital
emergency departments, labs, and emergency medical services. Today, all of Hawai‘i
Pacific Health hospitals and The Queen’s Medical Center are actively working to set data
standards for this effort.

Hawai‘i Health Information Corporation (HHIC), as part of its data warehousing
activities, collects data of direct public health relevance from hospital data including
injuries, chronic diseases, hospital-acquired infections, maternal and child health, and
disease investigation. These data are usually available about three months after they are
generated.

In a bill signed into law on May 17, 2010 by the Governor, the Hawai‘i State Department
of Health was given the authority to establish the Hawai‘i Immunization Registry. The
purpose of the registry is to maintain a single statewide repository of immunization
records to aid, coordinate, and help promote efficient and cost-effective screening,

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prevention, and control of vaccine-preventable diseases, including pandemic influenza.
The Department is engaged in a wide range of efforts to improve care and information
capacity within rural Hawai‘i and for behavioral health endeavors, which are in early
stages of development. As individuals and families move or change health care providers, the
Registry will consolidate their immunization records, making them easily accessible to new
immunization providers and ensuring that patients receive the immunizations that they need
and that they don’t receive additional, unnecessary doses of vaccine. The Registry is a valuable
tool for the management and reporting of immunization information for parents/guardians,
public and private health care providers, and State public health professionals.13

2.7.3     Eligibility and Claims

Approximately 88 percent of all eligibility checks can be satisfied among the two widely
used systems: HMSA’s Hawai‘i Healthcare Information Network (HHIN) and Kaiser
Permanente. As of May 2009, the number of HMSA participating providers was 5,422
(including but not limited to physicians) representing 80 facilities.

Electronic claims exchange is well established in Hawai‘i. HMSA has been providing
electronic claims transactions for more than 25 years. In 2009, 90 percent of claims
transactions were processed electronically through electronic data interchange (EDI).
HMSA’s Hawai‘i Healthcare Information Network (HHIN) provides eligibility and claim
status information through a browser-based interface. The number of HMSA
participating providers utilizing electronic claims submission continues to grow. In 2008,
3,628 providers (68 percent of the total) utilized HHIN to verify eligibility. The 2009
numbers were approximately 3,800 (70 percent of total) indicating increased
awareness.

In Hawai‘i’s major laboratories, over 90 percent of claims are processed electronically.
Some eligibility checking is done for patients covered under Medicare and various
Medicaid programs, including AlohaCare, HMSA QUEST, Evercare and ‘Ohana Health
Plan. Eligibility checking is not done for patients covered under private insurance
companies.

2.7.4     Broadband Capability

Robust exchange of health care data will ultimately depend on connectivity. The most
recent comprehensive examination of broadband capability within Hawai‘i was
compiled by the Hawai‘i Broadband Task Force that suspended operations in June 30,
2009 after having met for approximately two years. As the map of broadband coverage
below indicates, broadband availability is a distinctly urban phenomenon, but overall,
broadband is available to over 99 percent of Hawai‘i households. Broadband speeds,
however, lag far behind their mainland counterparts. Hawai‘i was recently ranked 49th

13
  Information gathered from the Hawai‘i Department of Health website:
 https://hir.doh.hawaii.gov/HIRPRD/portalHeader.do.

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out of 50 states in overall network speed14 and last among states with broadband
subscribers with effective speeds that exceed 5 Mbs with only 2.4 percent of its
connections meeting that standard. It is important to realize that these data measure
subscriber effective speeds and not overall system capacity. As such, they tend to reflect
current market conditions in which price is a limitation on effective subscriber speed.
Given price relief, which has already occurred throughout the market through
competitive engagement by providers at the level of overall system capacity, speeds
have increased, although at this point the precise comparative data are not available.

As a result, broadband services are available to the vast majority of the population and
certainly among the hospital, independent physician community and stand-alone
medical facilities population, but at speeds which lag behind national standards. Low
broadband speeds can have a significant adverse effect on EHR transmission time,
especially for those patients whose physicians have accumulated their health data over
a period of many years. These broadband speed limitations, however, are minimized by
the exchange features of the hybrid model being proposed by Hawai‘i HIE, which parcels
exchanges by individual requests.

Figure 2: Broadband Coverage in Hawai’i




14
     Akamai - State of the Internet Report, May 2008

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The Broadband Task Force Report paid specific attention to the range of medical/health
care uses for broadband, including telehealth, electronic record and data exchange, and
medical education. The committee determined that the significant burden of health
information exchange would, in the near future, be borne by optical cable rather than
through wireless services. In 2007, Hawai‘i was the recipient of a new federal grant of
up to $4.9 million over three years to build a broadband network linking 96 rural and
urban health care providers throughout Hawai‘i and the Pacific island region. The
project’s area extends 6,200 miles from the continental U.S. to American Samoa, Guam
and the Commonwealth of the Northern Mariana Islands (CNMI). Once the network is
functional, rural health care providers will be able to tap the expertise of modern
medical centers, concentrated in urban areas, at speeds of up to 1 billion bytes per
second. This endeavor, termed The Pacific Broadband Telehealth Demonstration Project
managed by the University of Hawai‘i, is organizing to connect over 90 health care
providers to the State of Hawai‘i Telehealth Access Network (STAN) with its high-speed
capacity. These health care providers will be ready to interconnect with the entity that
emerges as the Hawai‘i HIE to meet the needs of those health care providers in Hawai‘i.
Many of these health care providers, including the major health care providers in the
Pacific territories, will also qualify for the Rural Health Care Program established by the
Federal Communications Commission (FCC) under the Telecommunications Act of 1996
for long-term network connectivity. Many of the Hawai‘i State Government providers will also
be connected with internal connectivity of 1 Gbps.15

A survey by the National Rural Health Resource Center provides a snapshot of clinic and hospital
broadband connectivity, as follows:




15
  Pacific Broadband Health Demonstration Project 2010, and Hawai‘i Broadband Task Force Final Report,
 2009. Cf. p. 18.

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2.8     HIE Collaboration Activities

Hawai‘i HIE is actively engaged in multiple collaboration activities, with the most active
described as follows.

Table 3: Hawai‘i HIE Collaboration Activities
 Category              Description
 State (DoH and        Hawai‘i HIE, as the SDE for health information exchange, is collaborating
 Medicaid)             closely with the State Medicaid Director, who participates in multiple SDE
                       activities including attending and contributing to various committee meetings
                       throughout the strategic planning process. The state is developing its
                       Medicaid HIT plan with SDE input. Coordination of the Medicaid incentives for
                       EHR adoption with the SDE will help recipients to be successful in achieving
                       Meaningful Use and will also encourage participation in HIE. Collaboration
                       with the Department of Health (DoH) exists through participation of the
                       Director’s designee in the committee process of Hawai‘i HIE. Both the State
                       Medicaid Director and the DoH designee have been attentive to this planning
                       process and active in providing important input to it.
 Federal               Hawai‘i HIE is committed to working openly and collaboratively with staff and
                       consultants associated with ONC and other private sector consultants
                       recommended by staff. During the planning process, such personnel were
                       invited to Hawai‘i to provide input for broadly based stakeholder meetings. It
                       is the intention to continue such activities to the extent they may be available
                       as part of the ongoing effort to educate both the consumer and practice
                       communities about health information exchange.
 HCBCC and             The development of the HCBCC project and the North Hawai‘i Health
 NHHIE                 Information Exchange (NHHIE) on Hawai‘i Island provides a unique
                       opportunity for three organizations in the early stages of development to
                       collaborate across a range of activities. The Executive Director of Hawai‘i HIE
                       sits on the board of the HCBCC project, and the governance committee
                       currently recommends reciprocity of this arrangement. Continued outreach
                       to NHHIE is being explored currently. Other interested parties to these
                       activities have a long history of collaboration on other statewide information
                       projects, e.g. the creation and development of the Hawai‘i Health Information
                       Corporation (HHIC).
 Education             The University of Hawai‘i, John A. Burns School of Medicine (JABSOM) and the
                       William S. Richardson School of Law are increasingly engaged in a range of
                       health policy related issues, many of them associated with a forecasted
                       critical shortage of physicians throughout the state, and reaching out to other
                       health policy areas of interest such as privacy and security policy. Developing
                       an improved health information exchange is viewed by Hawai‘i HIE, HCBCC,
                       and NHHIE as a critical element in extending medical services under
                       conditions of limited access. The Associate Dean of JABSOM sits on the board
                       of Hawai‘i HIE and the College of Pharmacy, located at the Hilo campus of the
                       University of Hawai‘i, was the recipient of the HCBCC award. Cooperation
                       extends through to the community college campuses of the University of

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 Category              Description
                       Hawai‘i where training programs are being developed to support workforce
                       development skills in electronic health data exchange.
 Regional              Hawai‘i HIE, as the SDE for health information exchange, is collaborating
 Extension Center      closely with the State Medicaid Director, who participates in SDE activities.
 (REC)                 The state is developing its Medicaid HIT plan with SDE input. Coordination of
                       the Medicaid incentives for EHR adoption with the SDE will help recipients to
                       be successful in achieving Meaningful Use and will also encourage
                       participation in HIE. Coordination with the developing HIT Regional Extension
                       Center is enhanced by the fact that its ARRA grant has been jointly provided
                       to Hawai‘i HIE and the HPREC. Planning and operation for both activities exist
                       with a partially shared administrative framework. Hawai’i HIE will actively
                       seek and pursue opportunities for collaboration with those entities where
                       patients and providers are jointly served.

2.9     Environmental Scan Findings

The plan reviews the current health care status and HIE readiness among Hawai‘i’s
health care stakeholders, focusing particularly in response to the Stage One Meaningful
Use criteria. The following findings from the environmental scan suggest the kinds of
challenges that Hawai‘i HIE faces and the potential, actual barriers that need to be
overcome to effect exchange.

        1) In terms of health care insurance coverage, pharmacy organization, and
           laboratories, the market status of Hawai‘i tends to differ from many other
           states. In each of these three critical environments, two organizations control
           about 80 percent of the market. This means that in these areas where steps
           are being taken to develop electronic transmission of data within their
           chosen data footprint, the impact on the state is large.

        2) A similar situation exists for hospitals. Most of the hospital capacity is
           centralized on Oahu, which represents about 70 percent of the overall
           population of Hawai‘i. Of this overall capacity, the bulk of the hospital market
           for both inpatient and outpatient care is represented by three organizations:
           Hawai‘i Pacific Health, The Queen’s Medical Center, and Kaiser Permanente.
           All three implemented the same electronic medical record system, and all
           three are linked to various subordinate clinics through outer island locations;
           which perforce, are integrated into their electronic systems. The capacity of
           the remainder of the hospital and clinic system of Hawai‘i ranges from those
           that have EHRs to those that do not. Several units of the Hawai‘i Health
           Systems Corporation are in their first stage of adoption. This means that
           physicians within these hospital systems are sharing EHRs and, in some
           instances, across multiple facilities located at considerable distances.



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        3) The VA/DoD and the FQHCs are additional examples of stakeholder networks
           that have adopted EHRs and have employed them in meaningful ways. The
           statewide challenge is to develop effective interfaces between these data
           rich sources with the planned Hawai‘i HIE interface engine; such that the
           goals of Meaningful Use can be met. Within the areas of e-prescribing and
           labs, significant progress has been made through existing capacity and efforts
           that are underway to extend the levels of adoption and use. It is essential for
           Hawai‘i HIE to develop an effective model of exchange that ensures the
           participation of these critical entities which are responsible for such a large
           portion of the relevant health information exchange.

        4) The level of EHR adoption and use by independent physicians in Hawai‘i
           indicates the least amount of current capacity and utilization. These settings
           are where most patients interact with their medical providers, and where the
           greatest challenges continue to exist to create and extend capacity ultimately
           from which patients, as consumers, will draw the most benefit. Hawai‘i HIE’s
           challenge is to create a significant presence within this provider community
           through its multiple education and outreach activities, and combine with the
           efforts of the HPREC to supply providers with the information, expertise, and
           assistance they require to foster initial adoption and movement toward
           Meaningful Use.

        5) On Maui and the Hawai‘i Island, the emerging presence of locally focused
           health exchange activities, especially those being generated by the HCBCC,
           represents a significant opportunity for organizations in the process of
           formation to work cooperatively and share expertise. The actual challenges
           of creating and sustaining such cooperation are great, but the reality is that
           for the state as a whole, effective health information exchange cannot be
           obtained without it. As specific regions develop their infrastructure and HIEs,
           reinforcement of local leadership and collaboration with on-the-ground
           working groups will provide the capacity to support and participate in health
           information exchange.

        6) Establishing and maintaining cooperation with the branches of state
           government that both oversee and interact with health information
           exchange is critical both in the short and long terms. The development of the
           proposed public health registries by the Department of Health creates a vital
           interface with the Hawai‘i HIE that requires close and repeated cooperation.
           Similarly, the interests and capabilities of Hawai‘i HIE will depend
           significantly on working cooperatively and with shared objectives with the
           Medicaid program.

The environmental scan reveals that the major barriers to developing effective health
information exchange are:

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        1) Assisting providers at all levels to understand the nature of Meaningful Use
           and forming the dynamics of health information exchange around the
           attainment of Meaningful Use;

        2) Creating a technical infrastructure for health information exchange that is
           effective and sustainable; and

        3) Ensuring that the governance structure of the organization is fair, open and
           responsible.

The following table displays the challenges and gaps acknowledged throughout the
planning process, and includes strategies to meet these gaps noted in the Operational
Plan.




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Table 4: Summary of Requirements
           HIE Requirements                                           Reference
           Monitor & Track MU                                         Section 4
                    Health Plans                                      Section 3.1
                    Pharmacy                                           Section 4.2
                    Laboratory                                        Section 4.1
                    Public Health                                     Section 3
                    Medicaid                                          Section 2.1, 3.1
                    Medicare                                          Section 2.1
                    VA                                                Section 4.4
                    FQHC (CHC)                                        Section 4.4
                    EDI Claims                                        Section 5.1
           Transparent Multi-Stakeholder Process                      Section 2
           Federal Government Participation                           Section 2.1
           Recommended roles for HIT Coordinator                      Section 2.1
           Sustainability Plans                                       Section 9
           Project Management Plan                                     Section 1.2
           Risk Assessment                                            Section 10
           HIE Architecture and Standards                             Section 5,6
           Privacy and Security                                       Section 7


3.      HHIE Background

3.1     Planning Process

As indicated in the environmental scan, the degree of electronic usage, storage and
exchange of health care data is uneven—well-developed in some areas of Hawai‘i and
barely existing in others. The public-private conversation about health care data in
Hawai‘i is long-standing, stretching back at least to the Governor’s Blue Ribbon
Committee on Healthcare Costs, established by Governor John Waihe‘e in 1992.

Hawai‘i HIE was originally created as a membership organization supported by major
health care plans and providers in 2007. Hawai‘i HIE was transformed into a 501(c)(3)
non-profit organization in September 2009, and was named the SDE by the Governor of
the State of Hawai‘i for the purpose of receiving and implementing American Recovery
and Reinvestment Act (ARRA) grants for health information exchange in the State of




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Hawai‘i. This designation was further defined in substance by a Memorandum of
Agreement between Hawai‘i HIE and the State of Hawai‘i.16

Hawai‘i HIE draws important lessons learned and insights from a pilot program,
supported by a grant from the Agency for Healthcare Research and Quality (AHRQ). The
four-year program represented a collaboration between two O‘ahu clinics, Kalihi-Pālama
Health Center and Kokua Kalihi Valley, and two hospital systems, The Queen’s Medical
Center and Hawai‘i Pacific Health. The pilot aimed to improve health care for vulnerable
patient populations transitioning between CHC and hospitals through the development
and implementation of a master patient registry (MPR) for 250,000 patients producing
approximately 500,000 visits.

Stakeholder input has been central to all aspects of the strategic planning process. This
process was designed to be open, transparent, and collaborative. Beginning in March
2010, Hawai‘i HIE conducted a series of meetings in which the ONC Toolkit requirements
were reviewed and utilized as a basis for the subsequent planning process. Over the
course of several meetings, ONC domain-specific objectives and deliverables were
determined, and inventories created and assessed in the domain areas of governance,
technical infrastructure, finance, business and technical operations, and legal and policy.
All meetings were open to the public and broader stakeholder participation was
specifically invited. In addition, a “stakeholder presentation day” was held on April 23rd
at which 15 major stakeholders were invited to make presentations emphasizing their
organizations’ engagements in and/or readiness for HIE. In early May, an ONC
consultant provided a broad orientation to HIE for a sizeable stakeholder group,
followed by a more focused presentation on technical infrastructure issues. In June,
after preliminary frame work had been created on all areas of the plan, additional
stakeholder meetings were conducted on each of the neighbor islands to provide
information and solicit reactions to the planning efforts to date and elicit further input.17

3.2        Guiding Principles

In pursuit of this mission and throughout its activities, Hawai‘i HIE adheres to these
guiding principles:

Be Inclusive. Hawai‘i HIE is committed to broad stakeholder engagement (statewide,
urban/rural, large/small organizations, consumers/providers) in shaping its services, and
establishes policies and procedures that assure fair representation and participation in
decision-making, programs and services. It actively seeks to reduce barriers to improve
the delivery of care for all stakeholders. Through this process, stakeholders will be
organized, their resources and needs established, and relevant programs coordinated.



16
     The scan of the Memorandum of Agreement appears in Appendix 15.
17
     A complete list of stakeholder meetings appears in Appendix 5.

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Commit to Quality. Hawai‘i HIE is committed to creating an open and respectful data-
sharing environment. Data integrity is the cornerstone that assures quality provider
information and patient care; therefore, Hawai‘i HIE will establish and maintain the
highest quality control procedures and standardized metrics while continuing to assure
ease of access and functionality for users.

Create User Value. Hawai‘i HIE will develop a model of health information exchange
that provides demonstrable benefits across the full range of its stakeholder community
in order to significantly increase the overall value of health care in Hawai‘i. The central
beneficiary of this goal is ultimately the patient, and through improved patient welfare
the health status of all Hawai‘i citizens. As the Hawai’i HIE develops in interim steps
according to the phases of meaningful use, growth will be not only regulated by annual
requirements but will be responding to user demand. As the Hawai’i HIE user base
grows, client needs will identify specific elements demanded for clinical care and plans
for growth.

Be Transparent. Hawai‘i HIE maintains clear, open and constant two-way
communications with its stakeholders, the public-at-large, and within Hawai‘i HIE itself.

Assure Privacy and Security. Hawai‘i HIE ensures consumers’ privacy at all times by
maintaining security on its products, engaging in regular system audits, and meeting all
state and federal standards on privacy.

Be Sustainable. Hawai‘i HIE’s own sustainability will be a direct result of providing
quality services for its stakeholders, creating an outstanding value proposition, and
investing in infrastructure that is flexible and useable for a long period of time.

Assure Manageability. Hawai‘i HIE will gain optimal success by prioritizing its activities
and making incremental progress, with “first steps first” being its operational code.
Once developed, the technical infrastructure will succeed by keeping its design simple
but effective.

Adopt Relevant Rules and Standards. Hawai‘i HIE will develop effective rules and
governance models to facilitate the sharing of data, with a central focus on building
trust among participants.

Use the Present to Achieve the Future. Make maximum use of “what already exists”
throughout the health care community, building on existing capacity and making
maximum use of integrated incremental steps.

3.3     Vision and Mission

The Hawai‘i HIE vision is that public health and health care in the State of Hawai‘i will
have been positively transformed by the exchange of critical health care information.
The mission of Hawai’i HIE is to create a system of care that can be easily accessed, as

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appropriate, by all interested parties, including consumers and providers, with total
confidence in the security and validity of the information and to provide reliable health
information when and where it is needed.

3.4     Goals and Objectives

Hawai‘i HIE seeks throughout this planning process to establish simple but meaningful
goals that are targeted toward assisting stakeholders to make substantial and significant
process within a reasonable period of time toward the exchange of health care data in
ways that will result in an appreciation of its benefits. Further, Hawai‘i HIE has also been
mindful of, and attentive to, both the challenges and limitations of the current
economic climate that creates a setting for this activity. The organization and the
prospects for its endeavors have relied significantly on private sector stakeholders who
have to date leveraged its activities. Thus, its goals and objectives are meant to be in
line with its guiding principles of working simply but effectively and with maximum
managed efficiency. Furthermore, Hawai‘i HIE is also aware of the special relationship it
enjoys with the State of Hawai‘i as its SDE in this endeavor and has sought, again, to
focus on manageable goals that demonstrably create value for the citizens of the state.

These goals are to:

             • Achieve the two-year objectives established by ONC for each of the five
                 domains.
             •   Ensure full statewide participation in all aspects of Hawai‘i HIE
                 development with special attention given to ensure participation by
                 neighbor island communities.
             •   Promote health information exchange through the creation and
                 implementation of a stakeholder-centered governance process that
                 organizes stakeholders in an effective manner, takes inventory of
                 resources and needs of individual stakeholders, and provides effective
                 coordination of programs.
             •   Develop plans to build shared infrastructure (near term) that is
                 sustainable (long term).
             •   Assist eligible providers so they have connectivity and knowledge in order
                 to become “Meaningful Users” of electronic health records.
             •   Develop cooperative, synergistic relationships with relevant state
                 agencies to enable maximum use of health care data at all levels, e.g.
                 immunization registry.
             •   Establish effective coordination leading to beneficial information
                 exchange with all interested stakeholders.
             •   Engage independent physicians on all levels of information exchange,
                 providing technical education and assistance especially through the
                 cooperative efforts of the Regional Extension Center.

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             • Develop stakeholder agreements on data standards to be utilized at the
               state level. Ensure that standards and technical architecture are
               compatible with national standards as they are created.
             • Establish a privacy framework to guide the development of health
               information exchange such that consumers will have both knowledge of
               and confidence in the processes by which such information is exchanged.

4.      Governance

4.1     Overview

When the Hawai‘i HIE established itself as a 501(c)(3) private, non-profit organization,
its structure transitioned from a membership-based organization to a non-member
organization in order to accommodate the diverse needs of the board stakeholders.
Within its status as a SDE, its explicit goal is to develop and implement a statewide
health information exchange that will ultimately link to the national health information
network. As a 501(c)(3) non-profit organization, it is governed by prevailing state law
and other regulatory rules that apply to this class of organizations and takes its statutory
form and function from them, which in turn dictates aspects of its governance
framework.

4.2     Governance Structure

As the SDE, Hawai‘i HIE reports to state government through the State Coordinating
Committee for Health Information Technology (SCC), which consists of the Comptroller
of the Department of Accounting and General Services (DAGS) or designee; the Director
of the Department of Business, Economic Development, and Tourism (DBEDT) or
designee; the Director of the Department of Health (DoH) or designee; the Director of
the Department of Human Services (DHS) or designee; and the Insurance Commissioner
or designee. The State HIT Coordinator, currently the state ARRA coordinator located in
the Department of Budget and Finance, has served as chair of the SCC since designation.

The SCC reviews drafts of the Strategic Plan, makes comments and recommendations to
Hawai‘i HIE as appropriate, attends meetings of Hawai‘i HIE, and has authority to accept
and approve the final Strategic and Operational Plans. The State HIT Coordinator serves
as the liaison (State Liaison) with the Executive Director of Hawai‘i HIE. As State Liaison,
the State HIT Coordinator is authorized to receive drafts of the Strategic and
Operational Plans, receive notices of meetings, offer comments and recommendations
on behalf of the SCC, and provide such assistance as may be requested by Hawai‘i HIE to
develop such plans. The State Liaison is responsible for distributing drafts, reports,
notices and other information to the SCC received from Hawai‘i HIE.

Hawai‘i HIE is mandated through its by-laws to represent specific stakeholder groups to
be in compliance with Division A, Title XII of the Health Information Technology Act of

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2009. Such interests include health care providers, health plans, patient or consumer
organizations, health information technology vendors, health care purchasers and
employers, public health agencies, health profession schools, universities and colleges,
clinical researchers, and other users of health information technology such as the
support and clerical staff of providers and others involved in the care and coordination
of patients.18

4.2.1        Hawai‘i Health Information Exchange Organizational Structure

The current Hawai‘i HIE Board of Directors currently consists of 21 members, one of
which is the Executive Director of Hawai‘i HIE serving as an ex officio member.
Identified by stakeholder interests, the Board currently consists of representatives from
hospital systems (5), independent physicians (2), ancillary services (medical laboratories)
(2), the University of Hawai‘i Medical School (1), Community Health Centers (CHC) (2), a
health data reporting entity (1), health plans (3), business (2), and two public members,
one of whom represents retired citizens.19

Figure 3: Hawai‘i Health Information Exchange Governing Structure




The Board of Hawai‘i HIE is committed to a process that assures transparency of
decision-making and outcomes, ensures active linkage with important interest groups
throughout the community, and promotes long-term sustainability. As a result of

18
     Organization by-laws are found in Appendix 2
19
     Appendix 6 lists the Hawai’i HIE board members and their affiliations.

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feedback received during this strategic planning process indicating that consumer and
physician groups may be under-represented in the current board structure, the Board is
currently reviewing a proposal to expand the number of board members to gain greater
representation from constituents of the stakeholder community that are either
currently absent from the Board (e.g. State representatives, pharmacy interests, nurses)
or considered under-represented (e.g. consumers, independent physicians). The Board
is simultaneously reviewing a proposal from its governance committee to adopt a
revised process that will seek nominations from stakeholder groups, including the
public, by a broad and inclusive process. As a part of this review, the Governance
Committee will develop a proposal to establish a physician advisory group. A specific
schedule for moving these issues toward board decision is contained in the Operational
Plan.

This proposal also provides for ex officio participation by interested parties, most
specifically the executive director of the HCBCC program and members of the SCC. The
executive director of the HCBCC program has also been invited to join the Board. The
proposal as drafted specifies the steps to be taken to gain input to the process and
assure transparency for nominations to the Board.20 Stakeholder representation is
further evidenced by the invitation of experts from the community who are requested
to work with committees to provide advice and critique committee tasks. Such persons
are frequently among the most knowledgeable in the community with respect to the
subject matter on which they have been asked to advise.

4.3     Governance Process

The Hawai‘i HIE governance process is organized through its seven committees
consisting of the Executive Committee, Governance Committee, Finance Committee,
Audit Committee, Legal and Policy Committee, Technical Infrastructure and Standards
Committee, and Data Access and Management Committee. Committee charges are
contained in the Hawai‘i HIE Committee Charters.21 The Executive Committee operates
under the authority of the Board of Directors and meets frequently (usually bi-weekly)
with the Executive Director to review operations and policy. It reviews issues and
schedules them for the attention of the Board and consequent action at the Board’s
discretion. Committees consist of board members and individuals from various
stakeholder interests who either request or are requested to sit with committees
dedicated to their appropriate interest. Board meetings take place on a bi-monthly
schedule and are open to the public. They are advertised to the stakeholder community
and minutes appear on the Hawai‘i HIE website. Given the overlapping nature of Hawai‘i
HIE committees, largely mirroring in this respect that of the HIE domain structure itself,
board members frequently sit on more than one committee.22


20
   The draft nomination process is contained in Appendix 7.
21
   Located in Appendix 8
22
   See Appendices 5-8 for a full statement of the Committee Charters and Committee membership.

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4.4     Accountability

As the SDE, Hawai‘i HIE is developing accountability through the formation and adoption
of extensive policies for privacy and security (the purview of the Governance, Data
Access and Management, and Legal and Policy Committees). Draft policies will be
formulated over the next three to five months and reviewed by the respective
committees leading to revision and adoption. These will be further reviewed through
presentations to the extensive health care community. Members of the SCC are invited
to participate in committee meetings throughout this process. When finalized, the draft
policies will be presented to the SCC to review and assure effective integration with
existing state law. Where legal gaps are judged to exist, the legislature will be
approached to develop what are believed to be appropriate remedies. Accountability
ultimately depends on the capacity to provide oversight and transparency of HIE
sufficient to protect the public interest. Goals of the processes of policy review and
development and the expansion of board membership are to assure that oversight and
transparency are being achieved. In this view, accountability is fostered (if not fully
guaranteed) by transparency and participation in critical decisions. The following
structural revisions to the governance process are designed to achieve this outcome.

The Technical Infrastructure and Standards Committee is designing the state HIE
architecture to enable the development of interchange of health care data within the
state and with external entities. As the technical exchange must be flexible in order to
interface with various components within and outside of the state and adhere to the
timelines set out by ONC, we are proposing to allow existing infrastructures to be
maintained by their respective organizations. When federal guidelines become clearer,
instances of rebuilding will be minimized. The committee charge is to monitor the
progressive development of national standards and assure that those adopted by
Hawai‘i HIE are compatible with these external standards. In addition, it is the
responsibility of the Executive Director, in consultation with the board and on
advisement of the Technical Infrastructure Committee, to establish and maintain
effective communication about the processes being developed to assure positive
engagement and to continually assess progress toward Meaningful Use.

Fiscal integrity is accomplished through the utilization of an external fiscal
intermediary—the Pacific International Center for High Technology Research (PICHTR)—
for Hawai‘i HIE which administers all federal grants in accordance with appropriate
federal audit and review standards, and bears the responsibility for transparent
accounting and compliance in relevant areas (e.g., hiring, procurement, and
disbursement) with existing state and federal law. The Hawai‘i HIE Audit Committee is
charged with developing and reviewing fiscal procedures and policies; reviewing the
annual budget of the Corporation and making recommendations about the budget to
the board; developing a plan to transition from federal and/or state funding to other
funding sources to sustain Hawai’i HIE; and reporting periodically on the financial status
of the Hawai‘i HIE to the board. In addition, the Executive Committee and board receive

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monthly statements and updates on financial matters from the Executive Director and
Treasurer. All board meetings are open to the public.

4.5     Governance Deliverables

The two-year deliverables for the Governance Committee established by ONC have
been specified for all states and have served to orient the activities of the Governance
Committee. Requirements are listed below, with items in bold indicating status of
activities at the time of plan submission.

Table 5: Governance Requirements
 Requirement                                                                        Timeline
 1. Establish a governance structure that achieves broad-based                      To be
     stakeholder collaboration with transparency, buy-in and trust.                 accomplished in
                                                                                    year one
 2. Set goals, objectives and performance measures to be                            To be
     established by the Secretary through the rulemaking process for                accomplished in
     the exchange of health information. Determine consensus                        year two
     among the health care stakeholder groups, which will
     accomplish statewide coverage of all providers for HIE
     requirements related to Meaningful Use criteria. This
     deliverable drives portions of the agendas of several
     committees.
 3. Ensure the coordination, integration, and alignment of efforts                  To be
     with Medicaid and public health programs through efforts of                    accomplished in
     the State Health IT Coordinators. These coordination,                          year one
     integration, and alignment efforts will be accomplished through
     the governance structure and its reporting structure, and by the
     fact that the Executive Director serves as such for both Hawai‘i
     HIE and the Regional Extension Center.
 4. Establish mechanisms to provide oversight and accountability of                 Has been
     HIE to protect the public interest. These mechanisms are built                 accomplished in
     into the existing governance structure through its committee                   year one
     structure mandated in its by-laws, transparent policies, and
     reporting structure created by the state government.
 5. Account for the flexibility needed to align with emerging                       To be
     nationwide HIE governance that will be specified in future                     accomplished in
     program guidance. The Governance Committee has accepted                        year one
     monitoring and review of emerging national governance
     modalities as one of its standing tasks, in coordination with the
     Technical Infrastructure Committee.



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5.      Technical Infrastructure

5.1     Overview

Hawai‘i HIE is committed to the overall goal of improving health care delivery and the
Meaningful Use of health care data through improved health information exchange
across the wide spectrum of physicians, hospitals, payers, labs, pharmacies, community
health centers and data repositories that serve public health functions and to align with
national standards for health information exchange as they are developed.

Furthermore, the organization directs the efforts of the HPREC to increase the use of
EHRs by 1,000 approved providers and actively work toward the goal of achieving
Meaningful Use.

Hawai‘i HIE will develop a hybrid model for data exchange. This general architectural
concept best suits the development of effective data exchange in a state characterized
by wide differences within the practice community. Because the notion of a hybrid
model of exchange can cover wide ranges of specific differences, the Technical
Infrastructure Committee has proceeded by developing an inventory of prioritized
functions, which it is believed will best serve this high degree of heterogeneity. The
approach to system development can be described in terms of the few but important
principles that the committee has adopted to guide development. These are
intentionally both spare and pragmatic:

             • Keep it simple. The degrees of individual differentiation that already exist
               within vendor models being employed by various stakeholders can better
               be served by developing a system that emphasizes simplicity in
               architecture and function.
             • Use what is there. The emphasis will be on building a system that
               performs desired functions and meets standards while maximizing the
               use of “off the shelf” technology and minimizing “in-house” design
               efforts.
             • Build step-by-step. The system as a whole is conceived of as being
               developed through a set of carefully staged and integrated steps that
               over time can yield a larger and more comprehensive exchange.
             • Develop basic interchange functionality first. In line with these
               principles, Hawai‘i HIE’s goal is to create, in a timely manner, a basic
               system based on essential interchange functions to which additional
               elements can be added.

Hawai‘i HIE also takes, as a given, the considerable differences in functional approaches
that define the current HIE environment. From this perspective, its overarching goal is
building effective bridges to better operate an exchange. However, the committee is
also very much aware that significant portions of the practice community (in

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conventional medical care, but also in behavioral health or oral health) may in the
future seek to participate in HIE. Developing a hybrid model that creates simple but
effective standards is a major and essential task of this planning group.

Finally, this effort has been guided by the recognized need to be mindful of the constant
and progressive development of national standards, successes, and new technologies
being developed within the vendor community, and the emergence, at regional and
national levels, of HIE best practice communities to which Hawai‘i will be a full
participant. To participate requires a simple model to which modifications can be
efficiently made.

5.2     Addressing Deployment Challenges

HIE in Hawai‘i currently exists in a variety of discrete locations and at varying levels of
complexity. As established in the environmental scan, the degree of expertise with
respect to EHRs ranges from extremely limited (as the majority of the independent
physician community lacks EHRs), to sophisticated application and linkage within the
hospital community and health care plans, being defined at the end of the continuum by
full integration within these units. A useful visualization of this degree of heterogeneity
is to picture health information technology and exchange as diverse as the islands
themselves—units of coherence separated by significant barriers of non-connectivity.

The task for Hawai‘i HIE in this diverse environment is to respect the initiatives that
already exist among EHR users and the highly organized centers of health care activity,
while seeking to provide effective means of exchanging data that contribute
demonstrable value to users. To do so, the efforts of the Technical Infrastructure
Committee focus on acknowledging such differences and, through interactive
stakeholder involvement, they strive to develop priorities for the functions around
which the initial architecture will be built.

A separate but coordinated effort through the Data Access and Management
Committee is to list and prioritize the kinds of data that could be exchanged (and
perhaps ultimately should be exchanged), in stages that parallel the developing
architecture. The process for achieving both the initial points of departure and the
eventual range of projected functionality was similar to that followed in other domain
areas. Open meetings of interested stakeholders were held at which consensual
decisions were made on the overall form of the architecture (i.e. federated, hybrid, or
centralized) and the nature of functions to be addressed. This activity involved
developing a list of functions and then prioritizing them with respect to whether they
were of immediate or lesser concern.

5.3     Technical Architecture

Hawai‘i HIE will develop an exchange architecture based on a hybrid design. One version
of that design appears in Figure 4 and in greater detail in the Operational Plan.

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Although federated is the preferred architecture, the Hawai’i HIE's hybrid design should
be able to support storing data for entities whose system architecture and/or location
infrastructure lacks the ability to support reasonable response time to remote real-time
query causing timeouts, wait-errors and other latency issues during HIE data exchanges.

The overarching goal is to design a model with the capability to draw information from
wherever it resides. Physically, elements can be located in multiple sites. Hawai'i HIE
acknowledges that each organization has established policies and security structure
previously, specific to their customer bases. As Hawai‘i is creating the exchange drawing
from current individual repositories, it would be technically efficient and cost effective
to pass only the information requested by the clinical user and store only the minimum
essential HIE data elements necessary for reporting purposes. This will achieve the
purpose of minimum use of bandwidth of bulk data transmissions, gain trust of privacy
and security stakeholders in feeding HHIE incrementally, and allow resources to be
allocated at a manageable growth rate.

As Hawai‘i HIE moves beyond the initial strategic planning phase, the Technical
Infrastructure Committee, supplemented by both formal and informal industry and
interest group consultants/advisors, will develop a hub structure that is appropriate for
Hawai‘i’s particular geographic and usage needs. The virtue of the hub model is that it
provides common interfaces to accommodate multiple data sources. The challenge of
the model is that in the current environment, significant data and technology
differences exist between the large providers of data (primarily hospitals) and smaller
offices. The ultimate design will need to accommodate the range of EHRs and create a
data aggregator system that works with these differences. The expectation is that these
differences will range from stand-alone systems to those that exist within vendor-
hosted systems.

Figure 4: Hybrid Design




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5.4     Defining and Prioritizing Services/Functions

In its initial form, the Hawai‘i HIE system will be organized around the performance of
the following infrastructure requirements and functions (I refers to infrastructure and F
to function) generated by the Technical Infrastructure Committee. The process of
developing these structural elements followed that of the other Hawai‘i HIE
committees. During an open meeting process, decisions were made on basic
architectural type, and a “long list” of desirable system features was developed. Then,
through a further set of meetings, the list was narrowed down based on the principles
articulated above. The first five items, I1 – I5, will become the first stage of system
development; those listed as F1 – F7, will constitute the second stage. It is anticipated
that the following services will be procured through separate Request for Proposals
(RFPs). This process if further detailed in the Operational Plan.




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Table 6: Stage I and II of System Development
Stage I
I1 Data                    A mechanism for facilitating the intake of data in largely standardized
Transformation             format from multiple disparate sources in real-time or batching through the
Services                   use of an integration engine, which collates data into consolidated and
                           uniform format for display or exchange. The translation application
                           transmits actual data from one system to HHIE and reformats it to another
                           system through HL7 messaging.
I2 Clinical Portal         A web-based service offered to providers for accessing, viewing and
                           downloading clinical data available from data sources connected to an HIE.
I3 Audit Trail Services    A mechanism for tracking when, where and what data was accessed and
                           who accessed the data through an HIE entity.
I4 Patient Identifier      A methodology and related services used to uniquely identify an individual
Services                   person as distinct from other individuals and connect his or her clinical
                           information across multiple providers using an Enterprise Master Patient
                           Index (EMPI).
I5 Cross-Enterprise        A mechanism for identifying and authenticating clinical system users to
User Authentication        validate their right to access clinical information based upon privacy rules,
Services                   patient consent and individual user and organizational roles.
Stage II
F1 Lab Results             A mechanism for facilitating the delivery of patient lab results for use in
Exchange                   clinical care.
F2 Medication History      A mechanism for facilitating the delivery of patient prescription history to
Exchange                   providers for use in prescribing, clinical care and medication management.
F3 Medical Encounter       A mechanism for facilitating the delivery of medical notes for use in clinical
Notes                      care, including medical history, allergies, medication list, vital signs, etc.
F4 Radiology Results       A mechanism for facilitating the delivery of patient radiology interpretations
Exchange                   for use in clinical care.
F5 Population Health       A set of services that fulfill various state and federal public health and
Services                   chronic disease management practice requirements—such as
                           biosurveillance, predictive modeling and health risk assessment—by
                           leveraging and aggregating data available through an HIE entity.
F6 Patient Consent         A process for defining levels of patient consent and for tracking those
Management Services        consents and authorizations to share personal health information through
                           an HIE entity.
F7 De-identification       A mechanism for removing demographic and other person-identifying data
Services                   from personal health information and other health care data so that they
                           can be used for public health reporting, quality improvement, research,
                           benchmarking and other secondary uses.



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Selection of these elements is viewed as being consistent with both the ONC PIN and
Meaningful Use requirements for this domain and the two-year deliverables specified
for technical infrastructure. However, it is recognized that these priorities have been
revisited and reconciled against the Meaningful Use Final Rule published in July 2010.
While these functional elements could be expanded to include others and reflected as
such in the forthcoming RFP, it is the position of this plan and those working to develop
a technical infrastructure, that this selection provides a strong base of functionality that
can support significant differences in clinical organization and practice. In addition, this
set of functions is consistent with the principles articulated above that hold Hawai‘i HIE
to the practice of beginning with deliberate and measured goals that have a strong
prospect of being achieved.23

5.5        Supported Services—Data Elements

Consistent with the rest of its structure and the overarching procedure pursued
throughout this planning process, the Data Access and Management Committee,
working with a group of representative stakeholders, conducted a similar exercise
extending over several meetings to determine the sources of data that should be sought
for possible exchange (e.g. hospitals, free-standing medical entities, independent
physicians, labs, etc.), and the HIE data types that should be accommodated by
exchange (e.g. administrative, patient demographics, admissions/discharges,
prescriptions, etc.). Further refinement of the number of data types that can be
accommodated in stage one will be discussed by the relevant committees leading up to
their full specification in the RFP process.24

The overall goal of this process is to integrate the perspectives of four essential interests
in health information exchange—patients, physicians, hospitals and ancillary providers,
and health plans—in determining an effective set of priorities for data element build-
outs in the various stages that overall HIE development will occupy over the coming
months. This effort in turn will be coordinated with the ongoing developmental efforts
of the Technical Infrastructure Committee as it refines the overall technical architecture
and functionality of the exchange model. Overlapping membership between the two
committees assigned these tasks promotes coordination between them.

5.6        Supported Services—Standards and Quality Reporting Requirements

Although Hawai‘i is not as diverse in usage patterns for EHRs as some states, it does
display differences between the individual protocols characteristic of different systems.
Over the period of technical infrastructure implementation in the next two to three
years, Hawai‘i HIE will convene and facilitate a user data standards task group with
representation open to all interested users and vendors to promote common standards
of exchange. These activities will be informed continuously by ongoing national

23
     The full range of functional elements considered by the committee appears in Appendix 8.6.
24
     The full list of data elements reviewed by the committee is listed in Appendix 11.

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conversations concerning the development of Meaningful Use and health information
exchange best practices.

One of the precepts of effective health information exchange is to facilitate improved
quality, safety and efficiency of health care. Ultimately, it is expected that public
measurement of this effectiveness will serve as the basis for aligning incentives to best
performance. Such measurement must be based on complete, comprehensive, and
transparent information gathered from all providers and payers (insurance plans) in the
care delivery process. Given the importance and breadth of the required data, it will be
essential that a neutral, non-profit entity serve as the data and reporting custodian
without favor or bias toward specific insurance plans or providers. The Hawai‘i HIE will
either serve in this role or identify a neutral third party through an RFP process, and
partner with them to meet the quality reporting requirements.

5.7      National Health Information Network (NHIN) Functions and
         Interoperability

Throughout the technical design and implementation process, the working group of
staff, stakeholder expert assistance, and contracted vendors will review the ongoing
development of standards for the NHIN and assure that such standards are met and
compatibility achieved with Hawai‘i HIE.

5.8      Patient Identity Management

Issues of patient identity management are foremost among the concerns with health
information exchange among Hawaiians. These issues have been extensively addressed
by the Legal and Policy Committee and are represented in its contributions to the legal
and policy domain section of this report.

Again, the structure of the Hawai‘i HIE in organizing its committees with overlapping
membership helps to ensure that matters, such as privacy and security policy with
respect to patient identity, are effectively reviewed by the Legal and Policy Committee
chair who sits with that working group. Patient identification services and audit trail
management are two of the five core functions identified for the first stage of the
exchange system development.

The patient identifier service is a reconciliation service providing a definitive mechanism
for matching all records from existing systems for a patient. Exchange performance will
depend critically on the ability to reconcile all records appropriate to a specific
individual and to avoid collating records that are from different individuals. The
following capabilities relate to patient record identification and matching:
      1) Probability Scoring parameters by acceptable matched algorithm;
             a. Configuration adjustment and maximum amount of adjustments;


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      2) Record locator services and patient matching algorithms without the use of
         Social Security Numbers;
      3) Verifying performance characteristics of accurate record matching algorithms;
      4) Resolution of discrepancies and duplicates;
             a. Resolution of unmatched patients and determination of threshold;
             b. Resolution of match patients in error;
             c. Process of notifying users that information used was matched incorrectly
                and resolved.
      5) Design of architecture to leverage or interact with the proposed state-wide
         record locator service;
      6) Design of architecture to be integrated into a statewide and potentially a
         nationwide network;
      7) Use of phonetic algorithm to address Hawai‘i’s specific geographical uniqueness
         with population names; and
      8) Development of patient identifier and matching to re-establish after patient
         demographics change (e.g. maiden to married last name).

Clinical records will remain in the source system with explicit data exchanged or stored
into the Exchange’s cached area. It is the intention that only data required to meet the
requirement of the Hawai’i HIE are held in the Hawai’i HIE.

5.9      Service Implementation Schedule

The goal of this plan and its accompanying operational plan is to initiate health
information exchange within six months of plan approval by ONC. A single feature of the
technical infrastructure model, detailed in table five, is to create a bundle of core
functions/services (identified as I-1 through I-5 above) that can be brought into service
through relative simplicity of design and by maximizing the capabilities of the larger
health care systems to provide exchangeable data within this framework. Stage Two is
targeted for completion within the two-year window of ONC approval, but the intention
is to target implementation earlier than this timeframe. The RFP for Stage Two
functionality will be scheduled to go to vendor review as Stage One is becoming
operational. These targets are in turn associated with the sustainability model described
within the finance section below, as it is dependent on developing a climate of support
and concurrence within the stakeholder community on the values of effective exchange
to be gained within their own health care operations.

5.10     Technical Infrastructure Deliverables

Year markings indicate that work within the category will extend across both years with
some components completed in the first and some in the second.


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Table 7: Technical Infrastructure Deliverables
                               Technical Infrastructure                                    Year
Develop or facilitate the creation of a statewide technical infrastructure that 2011
supports statewide HIE. While the state may prioritize among these HIE services
according to its needs, HIE services to be developed include:
        •   Electronic eligibility and claims transactions

        •    Electronic prescribing and refill requests                                    2011
        •    Electronic clinical laboratory results delivery                               2011
        •    Electronic public health reporting (i.e. immunizations, notifiable            2012
             laboratory results)
        •    Quality reporting                                                             2012
        •    Prescription fill status and/or medication fill history                       2012
        •    Clinical summary exchange for care coordination and patient
             engagement                                                                    2011
Leverage existing regional and state level efforts and resources that can advance 2011
HIE, such as master patient indexes (MPIs), health information organizations
(HIOs), and the Medicaid Management Information System (MMIS).
Develop or facilitate the creation and use of shared directories and technical
services, as applicable for the state’s approach for statewide HIE. (Directories may
include but are not limited to: Providers (e.g., with practice location(s),
specialties, health plan participation, disciplinary actions, etc.), Laboratory Service
Providers, Radiology Service Providers, Health Plans (e.g., with contact and claim
submission information, required laboratory or diagnostic imaging service
providers, etc.)).
Shared services may include but are not limited to: Patient Matching, Provider
Authentication, Consent Management, Secure Routing, Advance Directives and
Messaging.
Develop or facilitate the creation of a statewide technical infrastructure that 2011
supports the following activities:
       •    Data Transformation Services
        •    Clinical Portal                                                               2011
        •    Audit Trail Services                                                          2011
        •    Patient Identifier Services                                                   2011
        •    Cross-Enterprise User Authentication Services                                 2011
        •    Lab Results Exchange                                                          2012
        •    Medication History Exchange                                                   2012
        •    Medical Encounter Notes                                                       2012
        •    Radiology Results Exchange                                                    2012
        •    Population Health Services                                                    2012


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                               Technical Infrastructure                                    Year
        •    Patient Consent Management Services                                           2012
        •    De-identification Services                                                    2012


6.      Business and Technical Operations

6.1     Operations Activities

Under the direction of the Hawai‘i HIE board of directors and in cooperation with the
State of Hawai‘i Information Technology Coordinator, Hawai‘i HIE, as the SDE for
providing health information exchange services, will be responsible for providing the
following operational activities:

             • Development of a shared HIE services program to operate as a standard
                 for interoperability within the state of Hawai‘i;
             •   Securing consensus on a technical design and approach suitable for the
                 demands of the unique Hawai‘i environment;
             •   Directing and managing the design and development of a service
                 architecture, service inventory, and service design;
             •   Developing and managing the RFP process to assure transparency and
                 effectiveness;
             •   Contracting with vendors selected through the competitive RFP process
                 for hardware, software and services. Reviewing and managing vendor
                 contracts throughout the implementation process for compliance; and
             •   Planning, design and implementation steps to assure connectivity to
                 national data sources and shared services leading to full participation in
                 the NHIN.
             •   These features have been discussed through preceding sections of this
                 plan.

6.2     Community Outreach

Hawai‘i HIE has staff to dedicated to outreach and linkage with the surrounding
community. In an island state, this endeavor will require a systematic and sustained
approach to providing information, education, and direct assistance to all within the
broader stakeholder community who require such assistance. Hawai‘i HIE views its role
as both a creator and provider of such information and knowledge. The close
organizational relationship between Hawai‘i HIE and the HPREC allows for focused and
targeted engagement within the provider community and beyond into the broader
stakeholder community.




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Hawai‘i HIE will put forth a strong marketing effort to assist in both the creation and
dissemination of information about health information exchange. Elements of the
marketing effort will feature the following:

Developing an interactive website that includes press releases, meeting minutes, a
calendar of events, a forum, webinars, and information on the Hawai‘i HIE and its role in
the State HIE Program. The goal of developing this website is to make it as complete a
“one-stop” information source as it can be. Updates will occur regularly;
           • Sending direct mail featuring information on the Hawai‘i HIE and its role
               in the State HIE Program to all providers and other interested consumers
               as identified;
           • Surveying providers to create a customer profile that will assist staff in
               assessing the state of knowledge about HIE and enable benchmarking of
               needs and capabilities;
           • Creating collateral material including fact sheets and informational
               brochures; and
           • Conducting periodic focus groups to gain input for continuous
               improvement of the Hawai‘i HIE effort.

The broader communication and education strategy will focus on the full utilization of
available technologies. Webinars will be developed and scheduled continuously to
provide an overview of the Hawai‘i HIE and its role in the State HIE Program. E-
newsletters with updates on the plan developments and Hawai‘i HIE news will be
coordinated throughout the national health information community to provide an ever-
growing context within which Hawai‘i health information exchange exists. Social media
communication tools such as Facebook, Twitter, and LinkedIn will be deployed to create
viable networks of both providers and consumers of health information exchange.
Hawai‘i HIE has a ning that will allow providers to post questions and comments. These
will serve to alert staff to emerging concerns and issues and to develop proactive
responses to them.

The Hawai‘i HIE has held provider and community presentations on O‘ahu and the
Neighbor Islands to inform and to solicit their input about the development of the
Strategic and Operational Plans, and will continue to do so as implementation proceeds.
During the planning process, Hawai‘i HIE has supplied key stakeholders and community
members with informational brochures, fact sheets, use case examples, and Domain
meeting minutes/summaries in order to keep them up-to-date on the status of the
Hawai‘i HIE and the State HIE Program. Stakeholders and the community can access
information regarding the Hawai‘i HIE and the State HIE Program on the website and
ning, and can receive updates via email. These steps within the planning process are to
establish the relationships and habits of use that will be required during the
implementation process.



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6.3     HPREC Collaboration

Hawai‘i HIE received an award for a designated Regional Extension Center under the
Regional Centers Cooperative Agreement on 3/31/2010.

The Budget Period award amount is $5,879,716 and is for a period of 4/06/2010
through 4/05/2012. The total amount is comprised of $1,500,000 in core funding and
$4,359,716 in direct assistance based on a required ONC target of 1,000 PPCPs. The
Project Period is from 4/06/2010 through 4/05/2014.

On August 27, 2010, Hawai’i HIE was notified by the Office of the National Coordinator
that our application for Supplemental Funding for Critical Access Hospitals (CAHs) and
Rural Hospitals was approved in the amount of $144,000. As a result our total funding is
now $6,003,716.

Hawai‘i HIE is in the process of entering into contractual agreements with two (2)
strategic partners to help develop, implement and manage the overall efforts of the
Hawai‘i Regional Extension Center (HPREC) project. Mountain Pacific Quality Health
Foundation is responsible for the Hawaiian Islands and Telecommunications and
Information Policy Group (TIPG) is responsible for the Pacific Region including Guam,
American Samoa and the Commonwealth of the Northern Mariana Islands.

It should be the intent and strategy of HPREC not to propose that these incentive
payments will offset the capital investment for EHR adoption. Return on investment
(ROI) should be discussed in relation to the opportunities to improve patient care by
having the ability to share information between different providers and facilities and the
operational efficiencies realized through improved work flow redesign, reduced costs
for paper records such as storage, printing, and faxing in addition to reduced lost or
misplaced patient records.

HPREC faces difficult challenges in achieving the requirements of converting 1,000
PPCPs to EHR and achieving meaningful use in a period of 4 years. Direct Assistance
provided during the budget period of 4/06/10 through 4/05/12 will expire on 4/16/12.
Should HPREC not be able to transition 1,000 PPCPs to EHR adoption and achieve
meaningful use during this period, direct assistance funding might no longer be available
for the remaining project years. It is our understanding it will be up to the ONC to make
the determination and it will be on a case by case basis.

Toward that end, it is imperative all of the critical action items necessary for success be
identified, a Strategic Plan developed to track the completion of these tasks and an
implementation schedule developed and monitored on a monthly basis to validate the
Strategic Plan.

As part of the Office of the National Coordinator (ONC) REC Application, a detailed plan
was submitted and approved as part of the Grant award. Based on the key activities

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template which was required to be completed, HPREC developed and expanded an
Outreach Activities spreadsheet detailing the required tasks and completion dates from
which we developed a strategic approach to identifying tasks and timelines in order for
project implementation.

Follow up plans are required each quarter during the project period. The Q2 plan was
submitted on August 12, 2010. ONC requested minor revisions which were made on
September 2, 2010 and again on September 12, 2010. On September 17, 2010 ONC
notified HPREC that the Q2 Plan had been approved.

6.3.1     Provider Outreach

Hawai‘i HIE, Mountain Pacific Quality Health Foundation (MPQHF) and
Telecommunications and Information Policy Group (TIPG) have been meeting weekly
over the past 6 weeks to discuss, determine and outline the mutually agreed essential
tasks at hand that HPREC must address successfully in order to meet the requirements
of the REC Grant. The success of meeting the timeline action items is critical to the
success of HPREC and the improvement and coordination of health care in Hawai‘i and
the Pacific Region.

Based on the ONC REC Plan, there are certain milestones which are required in order to
receive maximum Total Direct Assistance estimated to be $4,359,716 with a target
enrollment of 1,000 PPCP clinicians (providers). Based on current provider data which
has been filtered to eliminate non-qualifying providers, we believe an accurate total
target enrollment to be 876 PPCP providers for Hawai’i and 124 for the Pacific Region.

Target enrollment for PPCPs varies from state to state. As an example, California over
6,000; Arizona: 1,950 and Vermont: 1,300. CMS established the individual REC target
goals based on 30% of PPCPs in the region but not less than 1,000 PPCPs; whichever was
greater.

6.3.2     Qualification of Priority Primary Care Physicians

Hawai‘i is very unique having (3) different federal grants as part of the ARRA and HITECH
acts of 2009. Hawai’i HIE is the State designate Entity (SDE) for HIE, HPREC is the REC for
Hawai’i and the Pacific Region and the Island of Hawai‘i, University of Hilo School of
Pharmacy received a Beacon Grant. Beacon Grants will support the Beacon Community
Cooperative Agreement Program and be funded from the American Recovery and
Reinvestment Act (ARRA).

The program will focus on improving health in the grant communities, with emphasis on
using healthcare IT to improve measurable healthcare statistics such as a decrease in
smoking rates, reduced hospital readmission rates, a lower number of people with
obesity and high blood pressure, improved care for people with diabetes, and decreased
healthcare disparities among populations.

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Toward that end, Hawai’i HIE, HPREC and Beacon on Hawai‘i are separate organizations
but work in a collaborative fashion working toward the same goals of developing a state
electronic health exchange network and providing education to the community in order
to be more informed and take a more active role in their health.

6.3.3     Qualification of Vendors

HPREC has been in discussion with the current major EHR vendors in Hawai‘i to
determine and assess their readiness for providers adopting EHR technology. Upcoming
meetings are being scheduled to determine possible synergies related to work forces
going forward.

Draft vendor qualification criteria are as follows:

MEANINGFUL USE
  • Vendor agrees to contractually comply with current and future Meaningful Use
     criteria:
  • Vendor has current CCHIT Certification.
  • Vendor will contractually agree to meet Meaningful Use eligibility and ONC
     Electronic Health Record system certification criteria.
  • Vendor agrees to contractually commit to having the capability to report all CQM
     measures as they become available, at no additional cost.

FUNCTIONALITY
Vendor must provide a complete integrated solution covering the following system
functions:
   • EHR
   • Practice Management/Billing
   • Clinical Decision Support
   • Patient Portal/ web based with security functionality
   • e-Prescribing/ and medication reconciliation
   • Laboratory interfaces/in a standardized format (Orders, Solicited and Unsolicited
       Results)
   • Incorporation of any other third party products (other than Vendor products) to
   achieve any of the above (indicating which functions use third party products).

BUSINESS REQUIREMENTS
   • Vendor has been in the EHR business for at least five years.
   • Vendor is amenable to utilizing a Software Escrow or providing the Source Code
      to the Purchaser.
   • Vendor is amendable to providing or facilitating alternative financing options for
      providers.
   • Vendor agrees to contractually place a cap on annual cost increases for vendor
      support and maintenance contracts.

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INTEROPERABILITY
   • The vendor will contractually agree to have the ability to exchange data with the
      Hawai’i State HIE (HHIE) using the supported HHIE formats.
   • Vendor will generate as well as accept HL7 Continuity of Care Documents (CCD)
      as structured data (not images).
   • Vendor will contractually agree to support bi-directional interfaces with DLS,
      CLH, and other labs in the State of Hawai’i.
   • Vendor has a direct electronic Rx interface with Surescripts and other e-
      Prescribing systems in the State of Hawai’i.

STANDARDS
Vendor must use/support at least the following EHR standards: LOINC, CCD, ASC X12N,
HL7, CCR, IHE, ICD-9 and ICD-10 (with a conversion strategy to meet Federal timelines),
SNOMED-CT, RxNORM, NCPDP, and other relevant national standards and certifications.

PRIVACY/SECURITY
   • Vendor is compliant with HIPAA and ARRA Privacy and Security Rules and other
      regulatory requirements (CMS, State a Local laws).
   • Vendor has role-based access controls.
   • Vendor’s system has the ability to configure security features (e.g., password
      policy, lockouts, timeouts).

TECHNICAL ARCHITECTURE
Vendor is amenable to negotiating a service level agreement for performance.

IMPLEMENTATION
Vendor will provide on-site training as part of their implementation process, if
requested.

SUPPORT/HAWAI’I SUPPORT
   • Vendor can already or will contractually agree to implement and support any
     local laws, regulations, taxes (e.g., Hawai’i G.E.T.).
   • Vendor has at least two practices in Hawai’i live on an EHR/PM system.
   • Vendor will provide 24/7 support and will negotiate a Service Level Agreement.
   • Vendor has a local Hawai’i support presence or is willing to establish a local
     Hawai’i support presence.
   • Vendor has at least one MD on staff or in a consulting role.
   • Vendor will make a demonstration system available and commit resources
     locally for select users to trial the system as part of the evaluation process.
   • Vendor will provide implementation training locally for Hawai’i Pacific REC staff
     at no cost.



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    •   Vendors who are Application Service Providers shall have established disaster
        recovery and business continuity plans that insure no data loss and minimum
        downtime.
    •   Vendors that provide a hosted or SaaS option shall have data center facilities
        that meet best practice guidelines for environmental controls (e.g., power,
        temperature, humidity, fire), physical security, system security, and
        telecommunications connectivity. Third party certifications (e.g., SAS 0) of the
        facility are preferred.

GOVERNMENT HEALTHCARE REPRESENTATION
The vendor will warrant that they: (1) are not excluded from participation in Federal
health care programs; (2) have not been convicted of any crimes relating to healthcare;
and (3) will notify purchaser immediately should any of the representations become
incorrect.

MEDICARE ACCESS
The vendor will contractually provide that specified Federal agencies may have access to
a vendor's books and records to verify the nature and extent of the costs of services
furnished under the contract.

In discussions with MPQHF and Hawai‘i HIE it is agreed that here should be at least 3-4
and perhaps 5 qualified EHR vendors (certified by CMS, ONC-ATCB) selected for the
provision of EHRs services to Hawai‘i providers. Ideally the final list should be kept to a
minimum for a variety of reasons.

Selected EHR vendors must be capable of interfacing with the other selected EHR
vendors to ensure seamless functionality and exchange of electronic health information
between providers, in practices and amongst Hospitals. EHR vendors must provide
verification that they have been certified by CMS and are in compliance with this
requirement in order to be selected as a qualified vendor.

6.3.4     HPREC Sustainability

The HITECH award budget period is from 4/06/10 through 4/05/12 and the project
period is from 4/06/10 through 4/05/14. For the budget period HPREC receives
operational funds from the stakeholders of HPREC. After the initial budget period
expires, significant operational funding will cease and HPREC will need to have reached
sustainable operational functionality through provider participation in the EHR program.

Should HPREC not meet the projected goal of 1,000 providers converting to EHR and
meeting meaningful use criteria, HPREC is at financial risk going forward for years 2012
and 2014.




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6.4     Business Operations and Administration

The business operations of Hawai‘i HIE will require strong financial management. The
services provided by its well-known and respected fiscal intermediary, Pacific
International Center for High Technology Research (PICHTR), allow it to effectively
manage both its state HIE grant and its REC grant. The basic committee structure of the
board provides for oversight throughout the administrative process. The organization’s
treasurer, who is also chair of the Financial Committee, provides close review of the
budget and all operational expenditures. Financial reports are provided regularly to the
Executive Committee and to the board during the scheduled bi-monthly board
meetings, which are open to the public. The oversight of personnel policies and actions
provided by the Legal and Policy Committee ensures compliance in these critical areas.
This committee and the Governance Committee share the responsibility for ensuring
that appropriate policies are in place and that the organization is in compliance with
them.

It is of critical importance to emphasize that the Board of Hawai‘i HIE, members of
which populate these committees, is comprised of many leaders within the Hawai‘i
health care community at the very highest levels. Collectively, they represent in one
way or another the vast majority of transactions that make up the health care system,
and oversee most of its private sector expenditures, as well as public sector
expenditures for which they are service providers. The expertise represented here is
exercised through the range of activities described in this document with respect to the
many committee functions and activities. It is this expertise that is brought to bear on its
charges to the operational staff, beginning with the Executive Director, and throughout
its processes of review of administrative performance. Where necessary, this essential
expertise is augmented by utilization of other expertise (including technical,
communication, financial, legal, and beyond) drawn from the various organizations
represented within the organization, as well as contracted consultants with specialized
health care information expertise.

At the operational level, the Executive Director prepares an annual budget and reviews
expenditure patterns with the treasurer and the president; and on a periodic basis with
the Executive Committee and Board. The Executive Director also prepares the out-year
budget and subjects it to periodic adjustment as appropriate.

6.5     Progress Toward Meaningful Use

Monitoring and assessing progress toward Meaningful Use is a high-priority task of
Hawai‘i HIE. Given the nature of its stakeholder board, this process begins with a
continuous monitoring of Meaningful Use definitions, standards, and rules at the federal
level. The Hawai‘i HIE staff seeks to disseminate these informational elements
throughout the stakeholder community. Where appropriate, this content permeates the
committee structure.


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More specifically, the technical and data elements of Hawai’i HIE are cast within the
framework of Meaningful Use. As Hawai’i HIE moves forward with implementation, the
empirical relevance of Meaningful Use will come to have broader understanding and
acceptance within the Hawai‘i health care stakeholder community. The outreach
activities of the HPREC are integral in supporting this process. Again, having both the
HIE and REC grants “under the same (administrative) roof” significantly impels this
process. Also, it is important that the constituent stakeholders of Hawai‘i HIE include
those with the most to gain in terms of its putative benefits from making significant
progress toward achieving Meaningful Use.

Guided by the Meaningful Use Program Information Notice (PIN) from ONC released on
July 6, 2010, staff is developing a Meaningful Use “index” which will provide for an
ongoing, up-to-date review of Meaningful Use progress throughout the state.25 These
data are reflected in the Environmental Scan in Section 2.

As required by ONC, initial data points are being collected for:

             • Percentage of health plans supporting electronic eligibility and claims
               transactions;
             • Percentage of pharmacies accepting electronic prescribing and refill
               requests;
             • Percentage of clinical laboratories sending results electronically; and
             • Percentage of health departments electronically receiving immunizations,
               syndromic surveillance, and notifiable laboratory results. [Note: Hawai‘i
               has only a state level department of health. Therefore, this reporting
               modality will yield only a bio-modal score: “0” or “100.” Hawai‘i HIE will
               work with the Department of Health to develop a level of compliance
               indicator that accurately reflects the percentage of immunization and
               notifiable laboratory results that are being electronically transmitted to
               the Department.]

Additional elements will be added to the index as data becomes available and as system
functionality grows. This index will employ a checklist against which Meaningful Use
progress can be measured. As emphasized above, cooperation with all participating
organizations engaged in this process is critical, and Hawai‘i HIE’s staff is continually
working to expand the network of providers and other organizations who will contribute
these data.




25
  The PIN can be found at http://statehieresources.org/wp-content/uploads/2010/07/Program-
 Information-Notice-to-States-for-HTML_7-6_1028AM.htm

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Table 8: Business and Technical Operation Deliverables
                                   Deliverable                                       Year
Provide technical assistance as needed to health information organizations           2011
(HIOs) and others developing HIE capacity within the state.
Coordinate and align efforts to meet Medicaid and public health                      2011-2012
requirements for HIE and evolving Meaningful Use criteria.
Monitor and plan for remediation of the actual performance of HIE                    2012
throughout the state.
Document how the HIE efforts within the state are enabling Meaningful Use            2011-2012
of EHRs.


7.      Legal and Policy

7.1     Overview

A proof of a concept pilot program for exploring many of the legal and policy dimensions
of health information exchange was developed in Honolulu in 2004-2007 from a U.S.
Department of Health and Human Services, Agency for Health Care Research and
Quality, Health Information Technology Demonstration Grant, called Holomua. From it
has come both a legacy of policies that govern participation in exchange privacy and
security agreements as well as experienced personnel who have been drawn into the
current process as expert advisors. These documents have contributed to the formation
of an inventory of relevant federal and state statutes and policies that will be employed
over the next 3-5 months to develop a full array of participation, consent, privacy and
security agreements appropriate to exchanges within Hawai‘i HIE. The organization
recognizes the critical nature of these agreements and protections and board members
representing consumers have been continually mindful of the need to make careful
decisions with respect to the substance of these agreements. The Hawai‘i HIE also
strives to ensure that a broad and extensive program of public education is undertaken
to provide information about such agreements and protections and to enable public
“buy-in” to them as a critical prerequisite to health information exchange.

The State of Hawai‘i has a history of providing legal protection for various classes of
health-related data affecting groups within the population, many of which statutes
amplify similar federal protections. The Legal and Policy Committee has conducted an
extensive inventory and analysis of the legal and policy context that authorizes and
allows it, as an entity, to identify specific authorizations and agreements to fully
operationalize health information exchange. This review and consequent authorization
includes a full range of participatory and trust agreements and allows the committee to




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identify possible barriers to success and to ensure that a complete and comprehensive
array of agreements exists for maximal participation by all relevant stakeholders.26

At the time of preparing this plan, the committee distilled its inventory into a set of
policies and agreements that will be required for health information exchange to
commence, with a target date of April 2011 to operate with the first elements of data
exchange. To assist in this process, the Executive Director is currently developing an RFP
which will be extended to engage expert legal assistance intended to (a) review the
committee’s inventory collection and analysis efforts; (b) supplement them where
necessary; (c) develop policies compliant with relevant federal and state statutes; and
(d) identify possible gaps in state law that may require remedy. The current timetable
for this activity is designed to bring relevant issues to the attention of appropriate
legislative committees prior to the convening of the Hawai‘i state legislature in January
2011.

7.2        Core Values and Principles

In developing a legal framework for health information exchange, Hawai‘i HIE must
remain mindful to ensure that the broad policy environment within which it operates is
continually guided by an agreement with the core values and principles that underlie
such exchanges. These have been detailed above in Section 3 of this plan. They are
grounded in the need to ensure that:

                • The system as a whole operates to improve both individual patient health
                  and positively contributes to the overall health of the people of Hawai‘i;
                • In both the short- and long-run, economies are effected that will reduce
                  the overall costs of health care;
                • The rights of users in the system are protected to the full reach of
                  existing law; and
                • As the environment for health information exchange develops, policies
                  are quickly developed to continue to protect these rights.

Toward these ends, the Legal and Policy Committee will function as an expert
workgroup whose task is to conduct regular reviews of the legal/policy environment and
to make appropriate recommendations to the board for action where indicated. It is the
task of the committee to also conduct periodic reviews of Hawai‘i HIE performance in
these areas to assure compliance and to provide consultation to the Executive Director
and the board when legislative activity may be required to further the activities of the
organization.




26
     This inventory is available in Appendix 8.5.

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7.3     Privacy and Security and State Laws

As indicated above, an inventory of relevant legislation for health information exchange
has been conducted in two parts. The first is made up of a review of applicable state
privacy laws. Categorically these include legal and regulatory provisions dealing with:
minors; in-patient psychiatric patients; criminal offender drug test results; mental
health, mental illness, drug addiction and alcoholism; sterilization of incapacitated
person(s); congenital syphilis; HIV/ARC/AIDS; newborn screening; donor registry;
hospital; EMS; mental health or substance abuse programs; skilled nursing/intermediate
care facilities; health plans; and providers.

The second part of the review seeks to identify existing barriers to the operation of
health information exchange within the full context of privacy and security
requirements. The Legal and Policy Committee, with the assistance of contracted
counsel, will continue to conduct this review through the fall of 2010 and develop
proposals for legislative action, where appropriate, pursuant to the opening of the next
legislative session in January 2011.

7.4     Policies and Procedures

To ensure that the planning process across the Legal and Policy domain is
comprehensive, the committee’s inventory of relevant statutes and policies included a
review of existing documents extending beyond the aforementioned issues of privacy
and security. Each of the following categories was populated with an itemization of key
elements. For each item within the category an additional assessment was done to
ascertain whether further action was required to render it an effective deliverable
within the scope of this plan, and its relative priority toward completion. This exercise
included the following major items:

                 1) Structural Artifacts: Documents or descriptions that enable the
                    existence of Hawai‘i HIE as an entity. These include the entity legal
                    structure, a participant agreement, a data use agreement, a consent
                    agreement, a revenue sharing agreement, and an inter-HIE
                    agreement;

                 2) Policies, Standards and Guidelines: Documents that provide
                    governance of the Hawai‘i HIE as an entity. These include privacy
                    policies, security policies, security standards, data management
                    policies, and a code of business conduct;

                 3) Processes and Procedures: Documents that describe how key
                    activities should be executed in compliance with existing policies,
                    standards and guidelines. These are typically defined and executed by
                    individuals or other contracted individuals of the Hawai‘i HIE. The
                    underlying assumption is that this list will evolve over time as the

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                     organization matures. These include breach notification, consent
                     process (for patients), and operating procedures (e.g. business
                     process management, data, interchange, access provisioning, etc.);

                 4) Services: Activities that the Legal and Policy Committee may seek to
                    make available either by recommending contract creation or direct
                    execution. Many of these are specified within the Hawai‘i HIE
                    committee charter document. These include legislative analysis,
                    advancing HIE issues in ways that could impact future legislation, legal
                    services including analysis of legal issues, incident management,
                    monitoring controls and enforcement; and

                 5) Other: While provided in other portions of the Hawai‘i HIE charter
                    document, the Legal and Policy Committee may also review, when
                    appropriate, aspects of human resource policy within the
                    organization for compliance and effectiveness, as well as audit
                    policy.27

The more comprehensive review of all existing policies and relevant statutes to be
immediately undertaken, will seek to determine where state law may be deficient in
permitting full and effective health care information. Based on this examination,
proposals will be generated for legislative consideration.

As indicated in many other portions of this plan, the unique committee structure of
Hawai‘i HIE leads purposefully to the sharing of responsibilities across committees. This
operates in practice as members of the Governance Committee, Finance Committee,
and Technical Infrastructure Committee—who themselves represent major stakeholder
groups in Hawai‘i health care—design and extend the apparatus for health care
information exchange throughout the islands. This leads necessarily to regular
engagement with those within the state, including officers within state government,
whose concerns are very much focused on the needs of underserved populations and/or
public health functions as well as stewardship for the general public interest. As
indicated in other portions of the plan, to take but one example, ongoing efforts exist to
engage the broader health policy environment through such activities as developing
programs with the medical and law schools of the University of Hawai‘i, Mānoa and now
(with the advent of the HCBCC) the College of Pharmacy at the University of Hawai‘i,
Hilo. Many of the public events developed by these entities involve members of the
state legislature with a particular interest in health policy. The long-term goal is to
develop, within Hawai‘i, a committed and knowledgeable health policy “group” that can
assist in developing appropriate research to support further necessary policy
engagements throughout the health care community.


27
 This information is also included in Appendix 13, supplemented by a review of pharmacy law in
 Appendix 14.

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7.5     Trust Agreements

Previous trust agreements are being used as models, consolidated and made available
for an analysis of appropriateness and relevance for broader utilization by Hawai‘i HIE.
These are being reviewed by the Legal and Policy Committee and key advisors from
within the health care community over the next three to six months to cover the full
range of exchange relationships within which Hawai‘i HIE may enter. The goal is to
complete this review in a timely manner to meet the target established by the technical
and data components to begin actual data exchange.

7.6     Supervision

Overall supervision is provided for both legal and policy matters through the ways in
which Hawai‘i HIE is structured and governed. The chairs of the standing committees
constitute most of the Executive Committee. The Executive Director reports to the
board through the Executive Committee. The Legal and Policy Committee is charged
with providing financial oversight as a shared function with the Finance and Audit
Committees. The Executive Director, the Executive Committee, and in particular the
Treasurer, review the reports of Hawai‘i HIE’s fiscal intermediary, PICHTR. An explicit
function of the Legal and Policy Committee is the review of implementation activity as
reported through Hawai‘i HIE staff. When desired, external expert personnel are called
on to provide advice, analysis of policy and implementation and/or research on policy
and/or legal matters relevant to HIE.




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Table 9: Legal and Policy Deliverables
                                  Deliverable                                       Year One
Identify and harmonize the federal and state legal and policy requirements          2011
that enable appropriate health information exchange services that will be
developed in the first two years.
Establish a statewide policy framework that allows incremental                      2012
development of HIE policies over time, enables appropriate, inter-
organizational health information exchange, and meets other important
state policy requirements such as those related to public health and
vulnerable populations.
Implement enforcement mechanisms that ensure those implementing and                 2011
maintaining health information exchange services have appropriate
safeguards in place and adhere to legal and policy requirements that
protect health information exchange, thus engendering trust among HIE
participants.
Minimize obstacles in data sharing agreements, for example, developing              2011
accommodations to share risk and liability of HIE operations fairly among all
trading partners.
Ensure policies and legal agreements needed to guide technical services             2011
prioritized by the state or SDE are implemented and evaluated as a part of
annual program evaluation.


8.      Finance

8.1     Financial Controls and Reporting

During its period of development, Hawai‘i HIE distributes responsibility for its financial
controls through its committee structure, which established a Finance Committee
chaired by its Treasurer and consists of key stakeholders. As stated above, its fiscal
intermediary, PICHTR, provides accounting and reporting services. Current Finance
Committee members include the following stakeholders: one member from the State
Hospital Corporation (as chair), the CIO of a major private sector hospital entity, the CEO
of the Hawai‘i Primary Care Association (which represents all community health
centers), a physician who is also the head of the primary association of independent
physicians, and the Executive Director of the Honolulu Chamber of Commerce. In
addition, Hawai‘i HIE by-laws also establish an Audit Committee charged with selection
of an external auditor and review of the external audit. The organization’s budget is
reviewed quarterly by the Executive Director and presented for comment and revision
to the Executive Committee of the Board of Directors.




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8.2     Sustainability/Business Plan

The business case for Hawai‘i HIE is being developed through the stakeholder strategic
planning process based on exploration of a derived benefit model of revenue creation
that over time is designed to yield a sustainable funding base. Under development by
the Finance Committee, the core of the model is the identification and specification of
values (benefits) to be derived by specific stakeholder groups within the broader Hawai‘i
community and the articulation of a charge and revenue structure, balanced in terms of
those values and benefits. Initially, the model begins by identifying four distinct value
communities—patients, physicians and other providers, health plans and the state itself.
Revenue assessment will be developed based on the relative benefit gained by each
stakeholder community. This approach is based on the realization that as the
development process proceeds over time yielding greater use of EHRs across the state
and an increase of exchange modalities, the articulation of benefits will change, and the
revenue base represented by each stakeholder segment will change as well.

In August, the Finance Committee, meeting with external consultants, began the
process of transforming many of the ideas contained in the derived benefit exercise into
a set of assumptions and principles that could lead to development of a full-scale
funding review based on the goals of gaining increasing sustainability. Through this
exercise, the following assumptions were agreed upon concerning the scope of
revenues and expenditures:

             • Reflects that initial funding will be focused around developing core
                 infrastructure plus prioritized functional use cases;
             •   Excludes costs to implement or upgrade EHRs;
             •   Utilizes or expands upon existing contracts and/or successes
                 (Immunization and Emergency Surveillance Infrastructure and other HIE
                 licenses such as HCBCC program, DoD and VA);
             •   Coordinates with other programs (example HPREC and HCBCC);
             •   Explores Medicaid fair share through 90/10 administrative funds;
             •   Explores Medicare fair share; and
             •   Continues to explore grant opportunities which utilize HIE data for
                 research purposes.

With these as key assumptions about the near-future scope of Hawai‘i HIE activities,
revenue provision will be sought in accordance with these principles:

             • Revenues should be high enough to cover costs and promote
               sustainability.
             • Revenues should be low enough to encourage broad participation.
             • Stakeholders will adhere to paying “Fair-Share” (Fair-Share methodology
               may vary).

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             • A value-base model that matches functionality will be employed.
             • Individual provider adoption may lag as value is derived.
             • Transaction and usage fees for providers and payers will be avoided,
               which may discourage use/access to health information for treatment
               purposes.
             • Multiple consumer models (per click, subscription, other) will be
               explored.
             • Commitment will be made to providing services at a reduced cost for
               providers that serve the underserved.
             • “Public benefit” support will be explored.

As follow up to current discussion, a further meeting of the Finance Committee is
scheduled to develop various scenarios will be developed based on variable budgetary
and revenue assumptions. The purpose of this exercise is to develop a sustainable
model for HIE development that can be provided to the board for review and adoption
by the end of the calendar year. Seeking buy-in from the full range of interested parties
involved in health information exchange is the goal.

A central task over the period 2010-2013 is to leverage the efforts of the HPREC by
working throughout the stakeholder environment to provide technical assistance to
health care providers in order to implement EHRs and meet the CMS definition of
Meaningful Use. Sustainability of the HPREC in its development of continuing support
services to providers also needs to be considered in a use-benefit model to which users
at all levels can subscribe, and which yields revenues that are considered both equitable
and sufficient for the continued performance and sustainability of health information
exchange when federal funding is reduced. This is consistent with the current project of
developing a multi-factor value/benefit model that can differentiate funding streams
according to specific derived benefits.

As health information exchange develops across the country, it is the goal of Hawai‘i HIE
to be intimately involved in reviewing the performance of other HIEs across the country;
the research that will be accumulated at the national level on state performance; and
the analysis of various funding mechanisms under different combinations of
circumstances. The Finance Committee of Hawai‘i HIE will conduct this research in
conjunction with staff over the coming years, assess it for relevance to the operating
model of Hawai‘i HIE, and make recommendations for changes in that model as
appropriate. In addition, Hawai‘i HIE will seek to work with the University of Hawai‘i’s
John A. Burns School of Medicine to pursue additional grant funding that could support
research of mutual interest and benefit.




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9.      Ongoing Strategic Planning
Hawai‘i HIE is prepared, as part of ONC grant requirements, to approach follow-up
activities to this strategic planning exercise as detailed below.

Requirement 1: Develop a plan to monitor and maintain a targeted degree of
participation of HIE-enabled state-level technical services. Hawai‘i HIE has interpreted
such targets in two ways. A plan for creation and operationalization of specific data
exchange is being developed through an RFP process, seeking to initiate exchange of
health care data within six months of approval of the planning process, and then
proceeding through further RFPs in three increments of roughly equal reach and
complexity. These activities will be fully monitored and reported publicly on the Hawai‘i
HIE website. In addition to this effort, a second meaning, given to technical services in
this regard, has resulted in continued outreach to the provider community to adopt
EHRs and engage in exchange activities with particular attention to the achievement of
Meaningful Use. These efforts will continue through the close coordination between the
Regional Extension Center and the Hawai‘i HIE. The latter activity produces its own
mandated reporting, which will be shared through Hawai‘i HIE sources. Efforts to assure
the alignment of state laws on privacy and security discussed above should also be
considered as part of this ongoing effort.

Requirement 2: Update Strategic and Operational Plans annually beginning one year
from the notification date of the award. Such updates are to focus specifically on
statewide HIE alignment with other federal programs. This requirement will lie within
the domain of the Executive and Project Directors and be completed on schedule.

Requirement 3: Participate in the nationwide HIE program evaluation. The assumption
is that this evaluation will be conducted nationally and regionally by ONC. Hawai‘i HIE
looks forward to the review and the opportunity to learn more about its activities from
comparative analysis that will assist in its efforts to engage in continuous quality
improvement of health information exchange.

Requirement 4: Plan for Hawai‘i HIE evaluation. As part of its grant requirements, the
organization is required to conduct an external evaluation of its program with an effort
equal to 2 percent of its total costs.




Hawai‘i Health Information Exchange
900 Fort Street Mall | Suite 1300 | Honolulu, HI 96813 | Tel: 808-441-1346 | Fax: 808-441-1472   68
         State of Hawai‘i
Health Information Exchange Plan


         Operational Plan
             October 22, 2010




 Hawai‘i Health Information Exchange (HIE)



                                             69
1.     Introduction
The Hawai‘i Health Information Exchange’s (Hawai‘i HIE) Operational Plan builds upon
the Hawai‘i HIE Strategic Plan, which adheres to the guidelines of the Office of the
National Coordinator for Health Information Technology (ONC).

The Operational Plan references both the mandated requirements of the Program
Information Notice (PIN) and the associated two-year deliverables.

The Operational Plan seeks to answer, within each ONC specified domain including
governance, finance, technical infrastructure, business and technical operation and legal
and policy, a set of practical questions:

       1) Which task owners will complete the work?

       2) How will the work be accomplished?

       3) And, what are the timelines for completion?

Dedicated workgroups, consisting of members from board committees, experts within
the stakeholder community, and dedicated organizational staff, will be tasked for each
specific section of the Operational Plan and become an integral part of the progressive
implementation of the plan. Such informal workgroups, when they form, will be under
the guidance of board committee chairs. The process is designed to be transparent and
open to public review.

1.1    General Components

In following the organization of the Strategic Plan, in addition to specifying how a given
aspect of the plan is to be accomplished (by whom and when), each section contains a
brief narrative specifying how an aspect of the plan embodies its overall goals and
objectives, and its guiding principles. As stated in the Strategic Plan, Hawai‘i HIE seeks
to:

           •   Be Inclusive
           •   Commit to Quality
           •   Create User Value
           •   Be Transparent
           •   Assure Privacy and Security
           •   Be Sustainable
           •   Assure Manageability
           •   Adopt Relevant Rules and Standards, and
           •   Use the Present to Achieve the Future.



                                                                                       70
These tenets are similar to those provided by ONC in its statement of principles
applicable to HIE throughout several states, and to which Hawai‘i HIE subscribes,
namely:

           • Support privacy and security;
           • Focus on desired outcomes, especially Meaningful Use of EHRs;
           • Support HIE services and adoption for all relevant stakeholder
             organizations, including providers in small practices, across a broad range
             of uses and scenarios;
           • Be operationally feasible and achievable, building on what is already
             working;
           • Remain vigilant and adapt to emerging trends and developments; and
           • Foster innovation.

Reiteration and articulation of these principles can be observed through the Strategic
Plan’s Environmental Scan that contributes to this dynamic leveraging element. The
underlying premise is that Hawai‘i HIE is itself an evolving organization and therefore,
will continue to maintain Environmental Scans. In time, this will result in discrete
databases which will be used to assist further decision making.

1.2    Hawai’i HIE Project Plan

Hawai‘i HIE will create a project management plan that will be a formal, approved
document that defines how the HIE project will be executed, monitored and controlled.
It will summarize and detail the subsidiary management plans and other
planning/agreement documents. The objective of the project management plan is to
define the approach to be used by the team to deliver the agreed upon project
management scope.

The Hawai‘i HIE has created a chart that outlines specific milestones that are based on
the committees’ recommendations. Staff will create a detailed MS Project file which will
list timelines, milestones, resources and interdependencies for all the planned tasks, as
required. This file will be used as a measure to gauge development and implementation
progress. It is understood that this will be used only as a tool, as Project Management
Professional (PMP) methodology describes project management with significant
interaction.




                                                                                      71
     Table 10: Hawai‘i HIE Project Plan

Tasks                                                 Owners                                                     Start Date    End Date
ONC Requirements                                                                                                    7/8/2010     7/25/2011
 2010 PIN/MU Requirements                              HHIE Staff                                                   7/8/2010     7/16/2010
  2011 PIN/MU Requirements                             HHIE Staff                                                  7/15/2011     7/25/2011
  2012 PIN/MU Requirements                             HHIE Staff                                                  9/13/2010     9/21/2010
  2013 PIN/MU Requirements                             HHIE Staff                                                  9/13/2010     9/21/2010
  Submit State Plan to ONC                             HHIE Staff                                                  9/13/2010     8/31/2011
  Resubmit State Plan to ONC                           HHIE Staff                                                  9/24/2010     10/8/2010
  2011 Update State Plan to ONC                        HHIE Staff                                                   6/3/2011     8/31/2011
  2012/2013 Update State Plan to ONC                   HHIE Staff                                                  9/13/2010     9/13/2010
Lab Results                                                                                                        10/4/2010     1/20/2012
  Standardized Lab Messaging Policy                    Tech Committee, Data Access and Management                  10/7/2010     1/10/2011
  Conduct Meetings to Explore Lab Expansion            Tech Committee, Data Access and Management                  10/7/2010     1/31/2011
  Receipt of Structured Lab Results                    Data Access and Management, Tech Committee                  12/1/2010     6/30/2011
  Sending Structured Lab Data                          Data Access and Management, Tech Committee                  1/10/2011     3/18/2011
  Send Lab Data with LOINC                             Data Access and Management, Tech Committee                   3/7/2012      6/5/2012
  EHR Received Structured Lab Data (LOINC if avail)    Data Access and Management, Tech Committee                  1/10/2012     2/27/2012
  Policy and Guidelines                                Legal/Policy Committee                                      10/4/2010     4/29/2011
  Auditing Reports By Quarter                          HHIE Staff                                                   4/8/2011     1/20/2012
e-Prescribing                                                                                                      9/13/2010     1/20/2012
  Vendor Algorithm Tied to Medication List             Data Access and Management, Tech Committee                  1/17/2011     5/31/2011
  Refill Messaging                                     Data Access and Management, Tech Committee                   4/1/2011     8/31/2011
  Medication History Availability                      Data Access and Management, Tech Committee                   5/2/2011     6/17/2011
  Medication History Lookup                            Data Access and Management, Tech Committee                   5/2/2011     6/17/2011
  Medication Management                                Data Access and Management, Tech Committee                   5/2/2011     6/17/2011
  Retail Pharmacy Capability                           Data Access and Management, Tech Committee                   5/2/2011     6/17/2011
  Policy and Guidelines                                Legal/Policy Committee                                      9/13/2010     9/13/2010
  Auditing Reports By Quarter                          HHIE Staff                                                   4/8/2011     1/20/2012
Sharing Patient Care Summaries Across Organizations                                                               10/18/2010     1/20/2012
  Vendor Algorithm Tied to Clinical Notes              Data Access and Management, Tech Committee                 12/13/2010     4/15/2011
  Meeting with Hospitals for Epic Exchange             HHIE Executive Director, HHIE Staff, Vendors, Hospitals    10/18/2010     2/18/2011




                                                                                                                                72
Tasks                                                      Owners                                                                                                 Start Date    End Date
  BAA (Business Associate Agreements)                       Legal/Policy Committee, Vendors, Hospitals                                                               1/3/2011      5/6/2011
  Policy Agreements (Security, Use, Termination,            HHIE Executive Director, HHIE Staff, Hospitals, Legal Advisor, Legal/Policy Committee, Primary Care
  Corrections                                               Physicians, Vendors                                                                                      1/3/2011      5/6/2011
  Policy and Guidelines                                     Legal/Policy Committee                                                                                   1/3/2011      5/6/2011
  Auditing Reports By Quarter                               HHIE Staff                                                                                               4/8/2011     1/20/2012
Exchange                                                                                                                                                            11/1/2010     1/20/2012
  Hardware Specification Requirements                       Technical Committee                                                                                    12/13/2010     2/18/2011
  Software Application Specification Requirements           Project Director, Technical Committee                                                                  12/13/2010     4/15/2011
  Purchase Request                                          Pacific International Center for High Technology Research, Technical Committee, Vendors                  5/2/2011     5/19/2011
  Technical Facility Location (HIE rack, infrastructure)    Board of Directors, HHIE Board President, HHIE Executive Director                                      11/15/2010     1/14/2011
  Network Subscription Agreement Review & Signature         Pacific International Center for High Technology Research, Technical Committee, Vendors                  4/1/2011      6/2/2011
  Policy and Guidelines                                     Legal Advisor, Legal/Policy Committee                                                                   11/1/2010      3/4/2011
  Leasing Requirements                                      HHIE Executive Director, Executive Committee, Technical Committee, Vendors                               2/4/2011     5/20/2011
  Install Hawai`i HIE Edge Server Hardware & Software       HHIE Staff, Technical Committee, Vendors                                                                 5/2/2011     5/30/2011
  Production Pilot Activities                               HHIE Staff, Technical Committee, Vendors                                                                 3/4/2011     5/13/2011
  Auditing Reports By Quarter                               HHIE Staff                                                                                               4/8/2011     1/20/2012
Legal                                                                                                                                                               9/13/2010     1/20/2012
  Create Agreements with Consortium                         Legal Advisor, Legal/Policy Committee                                                                   10/5/2010    12/17/2010
  Create Public Policy Agreements/Guidelines                Legal Advisor, Legal/Policy Committee                                                                   10/5/2010     4/28/2011
  Create Security Breach Action Plan                        Legal Advisor, Legal/Policy Committee                                                                  10/25/2010     4/22/2011
  Build Policy Inventory Analysis                           Legal Advisor, Legal/Policy Committee                                                                   9/27/2010     10/8/2010
  Legal Counsel Contract                                    Legal Advisor, Legal/Policy Committee                                                                   9/13/2010     10/8/2010
  2011 Legislative Session                                  Legal Advisor, Legal/Policy Committee                                                                   1/26/2011     4/28/2011
  Action Plan for Security Attacks                          Data Access and Management, Technical Committee                                                         1/10/2011      3/4/2011
  Create Packets for Public Trust                           HHIE Staff                                                                                              11/1/2010     3/16/2012
  Auditing Reports By Quarter                               HHIE Staff                                                                                               4/8/2011     1/20/2012
Goals, Objectives and Performance Measures*                                                                                                                          8/2/2010      3/1/2012
  Kalihi-Palama                                             HHIE Executive Director, Hospitals, HHIE Staff, Project Directors, Vendors                               1/3/2011      3/1/2012
  Strab                                                     HHIE Executive Director, Hospitals, HHIE Staff, Project Directors, Vendors                               1/3/2011     5/12/2011
  Kapiolani                                                 HHIE Executive Director, Hospitals, HHIE Staff, Project Directors, Vendors                               1/3/2011     5/12/2011
  Pali Momi                                                 HHIE Executive Director, Hospitals, HHIE Staff, Project Directors, Vendors                               1/3/2011     5/12/2011
  Wilcox                                                    HHIE Executive Director, Hospitals, HHIE Staff, Project Directors, Vendors                               1/3/2011     5/12/2011




                                                                                                                                                                                 73
Tasks                              Owners                                                                         Start Date    End Date
 Queens                             HHIE Executive Director, Hospitals, HHIE Staff, Project Directors, Vendors       1/3/2011     5/12/2011
 Kaiser                             HHIE Executive Director, Hospitals, HHIE Staff, Project Directors, Vendors       1/3/2011     5/12/2011
 DLS                                HHIE Executive Director, Hospitals, HHIE Staff, Project Directors, Vendors       1/3/2011     5/12/2011
 CLH                                HHIE Executive Director, Hospitals, HHIE Staff, Project Directors, Vendors       1/3/2011     5/12/2011
 DOH Immunization                   HHIE Executive Director, Hospitals, HHIE Staff, Project Directors, Vendors       1/3/2011     5/12/2011
 DOH Pandemic                       HHIE Executive Director, Hospitals, HHIE Staff, Project Directors, Vendors       1/3/2011     5/12/2011
 DOH TB                             HHIE Executive Director, Hospitals, HHIE Staff, Project Directors, Vendors       1/3/2011     5/12/2011
 DHS Medicaid                       HHIE Executive Director, Hospitals, HHIE Staff, Project Directors, Vendors       1/3/2011     5/12/2011
 Surescripts                        HHIE Executive Director, Hospitals, HHIE Staff, Project Directors, Vendors       1/3/2011     5/12/2011
 EHR Vendors                        HHIE Executive Director, Hospitals, HHIE Staff, Project Directors, Vendors       1/3/2011     5/12/2011
 Payers                             HHIE Staff                                                                       1/3/2011     5/12/2011
 State Hospitals                    Hawai’i Department of Health and Human Services                                  2/1/2011     2/13/2012
 PAPD Plan                          Hawai’i Department of Health                                                     8/2/2010      3/1/2011
 Auditing Reports By Quarter        HHIE Staff                                                                       4/8/2011     1/20/2012
 Finance                                                                                                            9/13/2010     1/20/2012
 ▪ Quarterly Review                 Audit Committee, Pacific International Center for High Technology Research      9/13/2010     9/13/2010
 ▪ Contract Procurement             Audit Committee, Pacific International Center for High Technology Research     11/29/2010      1/7/2011
 ▪ Hardware Procurement             Audit Committee, Pacific International Center for High Technology Research       1/7/2011     2/28/2011
 ▪ Resource Allocation              Audit Committee, Pacific International Center for High Technology Research      10/1/2010     4/29/2011
 ▪ Auditing Reports By Quarter      HHIE Staff                                                                       4/8/2011     1/20/2012
 RFI                                                                                                                 9/9/2010     1/20/2011
 Draft                              HHIE Staff                                                                       9/9/2010     9/30/2010
 Technical Meeting                  All                                                                             9/16/2010     1/20/2011
 Identify Exchange Vendors          Data Access and Management, Project Directors, Technical Committee, Vendors      9/9/2010     10/5/2010
 Exchange Review of Requirements    Data Access and Management, Project Directors, Technical Committee, Vendors      9/9/2010     10/4/2010
 Final Version                      Data Access and Management, Project Directors, Technical Committee, Vendors     9/30/2010     10/1/2010
 RFI Announcement                   Data Access and Management, Project Directors, Technical Committee, Vendors     10/1/2010    10/15/2010
 RFI Open Period                    Data Access and Management, Project Directors, Technical Committee, Vendors     10/1/2010    10/15/2010
 RFI Review                         Data Access and Management, Project Directors, Technical Committee, Vendors    10/11/2010    10/29/2010
 RFI Top Vendor Selection           Data Access and Management, Project Directors, Technical Committee, Vendors     9/16/2010    10/12/2010
 Request for Proposal Process                                                                                       9/16/2010     2/18/2011




                                                                                                                                 74
Tasks                                         Owners                                                                                              Start Date    End Date
  Review RFI to include in the RFP             Data Access and Management, Project Directors, Technical Committee, Vendors                          9/16/2010     10/7/2010
  RFP Draft                                    Data Access and Management, Project Directors, Technical Committee, Vendors                         10/21/2010    11/23/2010
  RFP Announcement                             Data Access and Management, Project Directors, Technical Committee, Vendors                         11/29/2010    12/17/2010
  Receive and Answer Bidder Questions          Data Access and Management, Project Directors, Technical Committee, Vendors                         11/29/2010    12/10/2010
  Responses Received                           Data Access and Management, Project Directors, Technical Committee, Vendors                         12/13/2010    12/30/2010
  Preview Vendor Responses                     Data Access and Management, Project Directors, Technical Committee, Vendors                         12/31/2010      1/7/2011
  Narrow to Top 5 Vendors                      Data Access and Management, Project Directors, Technical Committee, Vendors                          1/10/2011     1/12/2011
  Site Visits/Presentations                    Data Access and Management, Project Directors, Technical Committee, Vendors                          1/13/2011     1/21/2011
  Perform Due Diligence on top 2 Vendors       Data Access and Management, Project Directors, Technical Committee, Vendors                          1/24/2011      2/1/2011
  Vendor Selected                              Data Access and Management, Project Directors, Technical Committee, Vendors                           2/2/2011     2/10/2011
  Obtain Technical and Data Access Approval    Board Chair, Board of Directors, HHIE Board President, HHIE Executive Director, Project Director    12/31/2010     1/19/2011
                                               Board Chair, Board of Directors, Legal/Policy Committee, Pacific International Center for High
  Obtain Board Approval                        Technology                                                                                           1/20/2011     1/28/2011
                                               Board Chair, Board of Directors, Legal/Policy Committee, Pacific International Center for High
  Contract Negotiations                        Technology                                                                                           1/31/2011     2/17/2011
                                               Board Chair, Board of Directors, Legal/Policy Committee, Pacific International Center for High
  Technical Contract Signed                    Technology                                                                                           2/18/2011     2/18/2011
 Implementation                                                                                                                                     9/13/2010     10/4/2011
  Interface Requirements Gathering             Data Access and Management, Technical Committee, Vendors                                            10/14/2010    10/22/2010
  Provider/Patient Directory                   Data Access and Management, Technical Committee, Vendors                                             1/31/2011     3/11/2011
  Secure Transmissions                         Data Access and Management, Technical Committee, Vendors                                             3/14/2011     4/22/2011
  Interface Development                        Data Access and Management, Technical Committee, Vendors                                             4/25/2011      6/3/2011
  RLS System Development                       Data Access and Management, Technical Committee, Vendors                                             9/13/2011    10/22/2011
  Technical Infrastructure Design              Data Access and Management, Technical Committee, Vendors                                            10/25/2010     11/2/2010
  Design Specification                         Data Access and Management, Technical Committee, Vendors                                             11/3/2010    11/11/2010
  Data Transformation Services                 Data Access and Management, Technical Committee, Vendors                                            11/12/2010    11/22/2010
  Clinical Portal                              Data Access and Management, Technical Committee, Vendors , Hospitals, PCPs                          11/23/2010     12/1/2010
 Audit Trail Services                                                                                                                              10/18/2010    10/26/2010
  Privacy and Security                         Legal Advisor, Legal/Policy Committee                                                               10/18/2010    10/26/2010
  Patient identifier Services                  Data Access and Management, Technical Committee, Vendors, Hospitals, Primary Care Physicians        10/28/2010     11/5/2010
  Master Clinician Index                       Data Access and Management, Technical Committee, Vendors, Hospitals, Primary Care Physicians         11/8/2010    11/16/2010
  Medication History Exchange                  Data Access and Management, Technical Committee, Vendors, Hospitals, Primary Care Physicians        11/17/2010    11/25/2010




                                                                                                                                                                 75
Tasks                                                   Owners                                                                                              Start Date    End Date
 Medical Encounter Notes                                 Data Access and Management, Technical Committee, Vendors, Hospitals, Primary Care Physicians        11/26/2010     12/6/2010
 Radiology Results Exchange                              Data Access and Management, Technical Committee, Vendors, Hospitals, Primary Care Physicians         12/7/2010    12/15/2010
 Population Health Services                              Data Access and Management, Technical Committee, Vendors, Hospitals, Primary Care Physicians        12/16/2010    12/24/2010
 Patient Notification and Consent                        Data Access and Management, Technical Committee, Vendors, Hospitals, Primary Care Physicians        12/27/2010      1/4/2011
 Technical Infrastructure Design                                                                                                                               1/3/2011      3/9/2011
 Requirements Gathering                                  Data Access and Management, Technical Committee, Vendors, Hospitals, Primary Care Physicians          1/3/2011     1/11/2011
 Training                                                Data Access and Management, Technical Committee, Vendors, Hospitals, Primary Care Physicians          3/1/2011      3/9/2011
 Create Manual for End Users On Hawai`i HIE Portal                                                                                                            9/13/2010     7/11/2011
 Train End Users on Hawai`i HIE Portal                   HHIE Staff                                                                                            3/1/2011      7/4/2011
                                                         Data Access and Management, Hospitals, HHIE Staff, Primary Care Physicians, Technical Committee,
 End User Privacy & Security Training                    Vendors                                                                                               3/1/2011      7/4/2011
                                                         Data Access and Management, Hospitals, HHIE Staff, Primary Care Physicians, Technical
 Agreements                                              Committee, Vendors                                                                                    3/1/2011     7/11/2011
 Conferences/Meetings Other                                                                                                                                   10/4/2010     11/8/2010
 Hawai‘i Medical Association                             HHIE Executive Director, HHIE Staff, Project Directors                                               10/4/2010     10/4/2010
 eHealth Initiative                                      HHIE Executive Director, HHIE Staff, Project Directors                                               10/4/2010     10/7/2010
 HPCA                                                    HHIE Executive Director, HHIE Staff, Project Directors                                               10/7/2010     10/8/2010
 Rural Health Association                                HHIE Executive Director, HHIE Staff, Project Directors                                               10/8/2010     10/8/2010
 American Congress of Obstetricians and Gynecologists    HHIE Executive Director, HHIE Staff, Project Directors                                              10/14/2010    10/18/2010
 HiMSS Brown Bag (Host)                                  HHIE Executive Director, HHIE Staff, Project Directors                                              10/27/2010    10/27/2010
 Hawai‘i Independent Physicians Association              HHIE Executive Director, HHIE Staff, Project Directors                                              10/27/2010    10/27/2010
 Hawai‘i Primary Care Association                        HHIE Executive Director, HHIE Staff, Project Directors                                              10/29/2010    10/29/2010
 American Academy of Pediatrics, Hawai‘i                 HHIE Executive Director, HHIE Staff, Project Directors                                               11/4/2010     11/4/2010
 Hawai‘i Association of Osteopathic Physicians and
 Surgeons                                                HHIE Executive Director, HHIE Staff, Project Directors                                               11/8/2010     11/8/2010
 ONC Meeting with Pacific Island Territories             HHIE Executive Director, HHIE Staff, Project Directors                                              12/14/2010    12/16/2010


     *As HHIE develops, incremental steps will be conducted for early adopters. HHIE will invite all that are listed above as a community effort, however it is
     recognized that those who are able and have cleared policies to exchange clinical data will be adopted first.




                                                                                                                                                                           76
2.      Governance
Much of the governance structure was put in place through the transitioning of the
Hawai‘i HIE into a private, not-for-profit organization. This Governance section focuses
on developing a more inclusive stakeholder board through a broader and more
transparent nominating structure. Beyond these structural considerations, other
domain requirements, especially those relating to policy issues, are shared functions
with the Legal and Policy Committee. For detailed information regarding the
Governance structure, please refer to this Domain in the Strategic Plan.

2.1     Hawai‘i HIE Governance Authority

Hawai‘i recognizes the importance of a multidisciplinary, multi-stakeholder governance
structure for statewide HIE that will achieve broad-based stakeholder collaboration.
Transparency, buy-in and trust are essential. Hawai‘i’s approach to governance includes
state government collaboration alongside a strong private sector combined with public
input to achieve synergistic effort and efficiency of existing and future resources. The
approach also maintains local and regional participation that fosters trust that is
essential to patient and provider endorsement and adoption of statewide HIE.

The Hawai‘i HIE was incorporated on September 4, 2009 as a non-profit organization
bringing together Hawai‘i local, regional and state electronic health information
initiatives and resources to form a collaborative partnership and framework (see
Appendix 2 for a list of the by-laws). Hawai‘i HIE seeks to improve access to health
information so that health care providers and consumers can make better, more
informed health care decisions.

Key participants include:

             •   Patients,
             •   Other HIOs,
             •   Health insurers,
             •   Self-insured employers,
             •   Hospital industry,
             •   Physicians, and
             •   Pharmacies.

The Hawai‘i HIE Board of Directors has the authority and responsibility to manage the
overall policy direction of Hawai‘i HIE. The Board has ultimate authority to determine
the technical, business and legal policies that will constitute statewide policy guidance
based on recommendations from the Executive Committee and subject to such approval
requirements; as specified under the contract between the State and Hawai‘i HIE.



Hawai‘i Health Information Exchange
900 Fort Street Mall | Suite 1300 | Honolulu, HI 96813 Tel: 808-441-1346 | Fax: 808-441-1472   77
2.1.1     Health Information Partnership for Hawai‘i HIE

The Hawai‘i HIE was named the SDE for HIE on September 4, 2009 by the Governor of
the State of Hawai‘i, Linda Lingle. The SDE designation authorizes the Hawai‘i HIE to act
as a separate health information technology entity and to collaborate the exchange
initiative with the Hawai‘i State Health IT Coordinator, Medicaid Health Director,
Department of Health, and other designated state departments, private companies and
payers, and other health-related community organizations.

There are continuing weekly meetings with the State Health IT Coordinator to discuss
the direction of the Hawai‘i HIE and plans to involve the State. Periodic meetings with
the Medicaid Director also occur to develop health care information sharing strategies
and barriers.

Involvement from private companies is a growing asset that is utilized in the
development of the technical infrastructure for the Hawai‘i HIE. This partnership will
involve trust in the sharing of sensitive information that includes PHI and proprietary
application design developed by these individuals.

The payers also hold the majority of the patient market that will involve decisions
affecting policy making, data integration, and community outreach. In Hawai‘i, payer
organizations contribute a considerable amount of patient health improvement
outreach in which Hawai‘i HIE would like to be involved.

Also on the Board of Directors is the State Director for the Hawai‘i AARP, along with
another public member whose input provides consumer and community perspectives
that will provide assistance in the direction of developing needed consumer acceptance.
Public representation will be increased in the board restructuring to be presented for
decision in fall 2010.

2.1.2     Development of Statewide Policy Guidance

Statewide policy guidance comprises the technical, business and legal rules that
participants in the statewide collaboration process agree to abide by in their exchange
of health information.

The Hawai‘i Health IT Coordinator will work with other State agencies to provide
enhanced access to the network via the expansion of broadband programs. The
Coordinator will also provide a strategic leadership role in identifying additional value-
added services the network can offer its stakeholders in the future.




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3.      Coordination with ARRA and Other Health Care Programs
Hawai’i HIE is working to coordinate efforts with three other ARRA programs:

             • The HPREC, for which Hawai‘i HIE is the REC grant recipient;
             • The HCBCC held by the University of Hilo, College of Pharmacy; and
             • The CMS EHR Education Health IT Incentive Program coordinated by the
                 Medicaid Director of the State of Hawai‘i Department of Human Services.

Hawai‘i HIE has been contributing and will continue to contribute to all ONC-related
initiatives within the state to the best extent possible. Coordination with the HCBCC
program is rapidly developing through regularized contacts and points of information
exchange. As staffs build, regular coordination meetings will be scheduled.

Other initiatives consist of:

             • Developing a collaborative plan with the Hawai‘i Department of Health to
                 assist existing IT program initiatives and develop the data exchange for
                 targeted public health programs;
             •   Working with members of the previous Broadband Task Force and private
                 sector tele-communications companies regarding infrastructure use and
                 best practices to develop recommended options regarding data
                 transferring networks;
             •   Reaching out to the community to provide educational benefits and
                 public outreach to demonstrate the need to analyze health data
                 information within Hawai‘i, the region, and the nation;
             •   Creating an audit process to validate that data across systems will be
                 formatted to standardization and importability;
             •   Developing security and privacy enforcement across partnerships to
                 continue to gain trust and foster partnership; and
             •   As a health care collaborative, continuing to seek other funding
                 opportunities that may assist in the maintenance of the partnership.

3.1     Coordination with State Medicaid

Cooperation with the Medicaid program is accomplished through regular contact with
its director, who also serves as a member of the State Coordinating Committee for
Health Information Technology and will sit on the Board of Hawai‘i HIE as an ex officio
member.

Also, Hawai‘i HIE is working with the State of Hawai‘i Department of Human Services
Med-QUEST Division (MQD) to assist in the development of a State Medicaid Health
Information Technology Plan (SMHP). The SMHP will serve as the strategic vision to

Hawai‘i Health Information Exchange
900 Fort Street Mall | Suite 1300 | Honolulu, HI 96813 Tel: 808-441-1346 | Fax: 808-441-1472   79
enable the DHS-MQD to achieve its future vision by moving from the current HIT
landscape to the desired HIT landscape. This will include a comprehensive HIT road map
and Strategic Plan over the next 5 years.

Table 11 State Medicaid Planning and Implementation Timeline




3.2     Coordination with HPREC

3.2.1     Provider Outreach

Hawai‘i HIE, Mountain Pacific Quality Health Foundation (MPQHF) and
Telecommunications and Information Policy Group (TIPG) have been meeting weekly
over the past 6 weeks to discuss, determine and outline the mutually agreed essential
tasks at hand that HPREC must address successfully in order to meet the requirements
of the REC Grant. The success of meeting the timeline action items is critical to the
success of HPREC and the improvement and coordination of health care in Hawai‘i and
the Pacific Region.

Based on the ONC REC Plan, there are certain milestones which are required in order to
receive maximum Total Direct Assistance estimated to be $4,359,716 with a target
enrollment of 1,000 PPCP clinicians (providers). Based on current provider data which
has been filtered to eliminate non-qualifying providers, we believe an accurate total
target enrollment to be 876 PPCP providers for Hawai’i and 124 for the Pacific Region.


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Target enrollment for PPCPs varies from state to state. As an example, California over
6,000; Arizona: 1,950 and Vermont: 1,300. CMS established the individual REC target
goals based on 30% of PPCPs in the region but not less than 1,000 PPCPs; whichever was
greater.

3.2.2     Qualification of Priority Primary Care Physicians

Hawai‘i is very unique having (3) different federal grants as part of the ARRA and HITECH
acts of 2009. Hawai’i HIE is the State designate Entity (SDE) for HIE, HPREC is the REC for
Hawai’i and the Pacific Region and the Island of Hawai‘i, University of Hilo School of
Pharmacy received a Beacon Grant. Beacon Grants will support the Beacon Community
Cooperative Agreement Program and be funded from the American Recovery and
Reinvestment Act (ARRA).

The program will focus on improving health in the grant communities, with emphasis on
using healthcare IT to improve measurable healthcare statistics such as a decrease in
smoking rates, reduced hospital readmission rates, a lower number of people with
obesity and high blood pressure, improved care for people with diabetes, and decreased
healthcare disparities among populations.

Toward that end Hawai’i HIE, HPREC and Beacon on Hawai‘i are separate organizations
but work in a collaborative fashion working toward the same goals of developing a state
electronic health exchange network and providing education to the community in order
to be more informed and take a more active role in their health.

3.2.3     Qualification of Vendors

HPREC has been in discussion with the current major EHR vendors in Hawai‘i to
determine and assess their readiness for providers adopting EHR technology. Upcoming
meetings are being scheduled to determine possible synergies related to work forces
going forward.

HPREC has a prequalified vendor list referenced in the Strategic Plan.

In discussions with MPQHF and Hawai‘i HIE it is agreed that here should be at least 3-4
and perhaps 5 qualified EHR vendors (certified by CMS, ONC-ATCB) selected for the
provision of EHRs services to Hawai‘i providers. Ideally the final list should be kept to a
minimum for a variety of reasons.

Selected EHR vendors must be capable of interfacing with the other selected EHR
vendors to ensure seamless functionality and exchange of electronic health information
between providers, in practices and amongst Hospitals. EHR vendors must provide
verification that they have been certified by CMS and are in compliance with this
requirement in order to be selected as a qualified vendor.


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3.3     HPREC Sustainability

The HITECH award budget period is from 4/06/10 through 4/05/12 and the project
period is from 4/06/10 through 4/05/14. For the budget period HPREC receives
operational funds from the stakeholders of HPREC. After the initial budget period
expires, significant operational funding will cease and HPREC will need to have reached
sustainable operational functionality through provider participation in the EHR program.

Should HPREC not meet the projected goal of 1,000 providers converting to EHR and
meeting meaningful use criteria, HPREC is at financial risk going forward for years 2012
and 2014.

4.      Gap Analysis
Hawai‘i HIE is committed to tracking Meaningful Use adoption of EHRs and plans to
track detailed adoption metrics over the grant period for each of the HIE Program
Information Notice’s (PIN) three main areas:

             • Receipt of structured laboratory results,
             • Electronic prescribing, and
             • Clinical summary exchange.

4.1     Receipt of Structured Laboratory Results

Referring to the Strategic Plan’s Environmental Scan, Hawai‘i has two clinical diagnostic
laboratories that share 70 percent of the market; Clinical Laboratories of Hawai‘i (CLH)
and Diagnostic Laboratory Services (DLS). Each currently maintains well over two dozen
interfaces to the primary EHRs proliferated in the state and are working to
accommodate as many as 30.

More than 95% of the state's hospital information systems interface orders and results
electronically with their labs. There are about 700 non-hospital providers with EHR
receiving electronic results, 50-60% of which receive from both labs and 40% which
submit electronic orders to one and/or both labs.

Physicians can access and look up lab results in real time within their respective EHR
systems. To address this gap, the Hawai‘i HIE will work with the leading labs to enable
the other 30 percent of labs in the market to participate. These labs will need to
monitor numerous gateways and maintain upgrades and patches, which can multiply
when the EHR vendor sends an upgrade notification. An additional challenge to be
addressed is the duplication of lab tests experienced by patients (as they move from
general practitioner, to specialist, back to the primary care provider) and by the Health
Management Organization (HMO)—these duplications drive up average overall health
care costs. Hawai‘i HIE is participating in national meetings encouraging collaboration in


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a standard library of lab interfaces based on EHR vendors. Discussions to explore portal
expansion are beginning, and outcomes of this effort are pending.

4.1.1     Meeting Gaps - Laboratory

Hawai’i HIE, as a single organizational entity, will be able to manage a single point of
entry for laboratory interfacing with CLH and DLS. It will also be the technical voice and
provider of information for national guidelines to affected stakeholders, which will lead
to communication efficiencies between local and national groups. Part of the guidelines
is to promote collaboration with other state HIEs in developing specification
requirements for technical and operational categories such as electronic master patient
index (e-MPI or MPI), alignment to ONC’s recent Meaningful Use (MU) requirements,
and claim reconciliation auditing. The Hawai‘i HIE will also be the portal for the
exchange of clinical reporting to reduce the need for duplication of laboratory diagnosis.

CIOs of both labs are voting board members of the Hawai‘i HIE and are eager to lead
efforts to contribute to the health exchange effort. In some concept this is already
occurring in 2010; however, Hawai’i HIE will be the facilitator in defining the next step.

Table 12: Lab Adoption Metrics
 Category                                                Year 1         Year 2     Year 3      Year 4
 Capability to send structured lab data (HL7)            70%            75%        85%         85%
 Capability to send structured lab data with             15%            70%        85%         85%
 LOINC*(for prioritized tests)
 EHR received structured lab data (LOINC* if             16%            32%        74%         95%
 applicable)



4.1.2     HDOH Activities

The Hawai’i Department of Health (HDOH) proposes to enhance and improve its health
information technology infrastructure through focus on the public health system
development and best practice implementation. This application focuses on three
specific areas of electronic laboratory reporting, vital statistics infrastructure
enhancements, enhancements to the Hawai’i Immunization Registry.

The objectives in these three areas include replacing and updating critical electronic
laboratory software and technology, enhancing Hawai’i’s electronic birth and death
system towards national vital statistics standards with the advanced objective to share
and implement its system with Pacific Rim federation partners, and then adapting the
vital statistics system to capture and share specific birth and death data for the
augmentation and maintenance of the Hawai’i Immunization Registry.



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The methods that will be employed to meet the objectives shall include the
establishment of a pilot project to properly ensure conversion of the HDOH electronic
laboratory reporting translators, the incorporation and implementation of technical and
functional specifications into the Hawai’i vital statistics system database enhancements,
and then creating a link to the Hawai’i Immunization Registry by standardizing the
necessary demographic and immunization information.

The table below reflects the effort required for the leading labs to transmit standardized
data (year 1, 70%), with incremental adoption by the remaining 30% of labs in
subsequent years.

Table 7: Lab Adoption Metrics
 Category                                                Year 1       Year 2      Year 3       Year 4
 Capability to send structured lab data (HL7)            70%          75%         85%          85%
 Capability to send structured lab data with             15%          70%         85%          85%
 LOINC*(for prioritized tests)
 EHR received structured lab data (LOINC* if             16%          32%         74%          95%
 applicable)


4.2      e-Prescribing

Individual physicians with EHRs are working with Hawai‘i pharmacies. The two largest
are CVS (Long’s Drugs) and Walgreens, both of which utilize the clearinghouse,
Surescripts. As mentioned in the Strategic Plan, an estimated 975 in-state active
providers currently use or have an e-prescribing system. However, current data reflects
that only 10 percent of eligible prescriptions in Hawai‘i are transmitted electronically,
while 85 percent of pharmacies are enabled to receive these prescriptions28.

Table 13: E-Prescribing in Hawai’i
                             E-Prescription Utilization: State of Hawai‘i
 Year                                                2007             2008              2009
 Total Prescriptions Routed Electronically           14,974           53,946            558,880
 Percent of Total Prescriptions Represented          0.51 percent     1.12 percent      3.11 percent
 by Renewal Response


The gaps that require acknowledgment are the large percentage of scripts that may be
transmitted electronically by Hawai‘i prescribers, and the 15% of pharmacies that must
be connected to Surescripts in order to receive electronic prescriptions. In addition,

28
     Surescripts 2009 Report
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there is little to no loop-back mechanism to address the dispensing of the prescription
or an electronic means to trigger a refill (both pharmacies are currently employing refill
by phone notification). Although Hawai‘i is unique in that it has been awarded a HIE,
REC and Beacon grant, all three efforts have the potential of creating electronic chaos as
providers increase the numbers of electronic prescriptions they transmit, and various
EHR vendors and HCBCC implementations attempt to migrate their data in an
unstructured data warehouse. This will create difficulties as patients obtain drugs from
various dispensing locations, i.e. hospitals, large drug chains multiple corner drugstores,
and physician’s offices. Over the next four years, the frequency of transmission of
electronic scripts and related processes are expected to increase as follows.

Table 14: Anticipated Increases in E-Prescribing Functionality Use
 Category                               Year 1             Year 2            Year 3            Year 4
 E-Prescribing Use                      20%                40%               80%               80%
 Refill Request/Approval                15%                50%               85%               80%
 Medication History Availability*       70%                70%               70%               70%
 Medication History Lookup*             100%               100%              100%              100%
 Medication Management**                0%                 0%                50%               80%
 Retail Pharmacy Capability             85%                90%               95%               100%

* Medication History lookup for all except Kaiser and VA beneficiaries is estimated at 100%; however,
matching is not occurring at a consistent rate. The 70% reflects all systems except Kaiser and the VA –
these encompass 30% of the Hawai‘i population.
** Currently there is no data to definitively measure decision support or co-payment amounts, but it is a
measure we will create.

4.2.1     Meeting Gaps – E-Prescribing

Hawai’i HIE will participate in national best data practices to collaborate with pharmacy
organizations, private and public, to create a HIE Drug Table that can synchronize to
each system to transmit drug information through Hawai’i HIE, thereby notifying the
physician of dosage dispensed, drug-drug interaction alerts, allergy alerts, and refill
notifications. For billing, a national standard drug table will be provided, requiring EHR
vendors to update, or align to, this table. Hawai’i HIE will also participate in statewide
and national reporting to identify specialized drugs and quantities related to diagnosis,
such as hypertension (high blood pressure), oncology, and epidemiology reports, which
can assist studies regarding public health. Currently, Hawai‘i laboratories are passing
HL7 messages to the Department of Health and similar types of pharmacy reports can
assist in research activities.

Aligned with the Strategic Plan’s Environmental Scan, it is anticipated that CVS (formerly
Long’s Drugs) and Walgreens will soon represent approximately 80 percent of the
Hawai‘i retail prescription market. In part as a result of Walgreens arrival into the
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Hawai‘i market, both entities have made significant investments in their prescription
processing and recordkeeping systems, which are currently accepting and processing e-
prescriptions, thereby providing additional incentives for EHR vendors and adopters to
make greater use of this capability.

Hawai‘i HIE will be collaborating with these two main retail chains and other
pharmacies, such as Wal-Mart, Target, and Costco, to develop the inclusion of
prescription drug information into the Hawai‘i HIE. Medication Management
components are being incorporated into the Hawai‘i HIE proposal, and opportunities for
collaboration with other organizations are being pursued, as these organizations are
open to assisting HHIE in developing pharmacy partnerships. There will also be a
partnership with the HCBCC program, University of Hawai‘i, Hilo College of Pharmacy, to
determine clinical needs assessment, define technical requirements and develop the
information transports, and negotiate how the two grants can create deliverables
jointly.

An additional adoption approach is to work with the Hawai‘i Pharmacists Association to
further hone the definition of controlled substances that may be dispensed
electronically. These are not currently allowed by statute revision (HRS 329: Uniform
Controlled Substances Act). The goal will be to clarify Hawai‘i rules and seek to bring
them into alignment with national practices. With recent statutory revision, authorized
prescribers may transmit all, except controlled substances, of their prescriptions
electronically and maximize the number of e-prescriptions being conveyed to
pharmacies.

If Hawai‘i HIE can assist in this change, the non-electronic prescribers identified by
Surescripts and other clearinghouses, could receive education models from Hawai’i HIE
that will allow their staff workflow modification to be minimally disrupted by the
implementation of an electronic system. In addition, other companies have expressed
interest in allocating resources to provide assistance, best practices and lessons learned
from across their national network.

4.3     Summary of Care Across Unaffiliated Organizations

The major goal for HIE is the sharing of information from provider to provider. As
mentioned in the Environmental Scan, Hawai‘i is predominately hospital-centric. In the
most ideal case, requesting providers will be able to share Patient Health Information
(PHI) with other providers outside of their business environments. Epic EHR is currently
utilized in six large hospital facilities: The Queen’s Medical Center, HPH’s Corporations
(Straub Clinic and Hospital, Kapi‘olani Medical Center, Wilcox Memorial Hospital, Pali
Momi Medical Center), and Kaiser Permanente Hawai‘i. Although each affiliated
organization implemented their respective EHR systems independently, the potential for
clinical exchange is technically possible. A meeting will be scheduled for late October,
2010, to discuss the mechanisms of creating a demonstration of clinical data exchange
with two major hospital entities.
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This type of collaboration has already been done in an earlier data exchange effort.
However, the gap still exists that 20% of organizations are not able to share CCR/CCD
information outside of their walls. Each unaffiliated organization has privacy policies and
business practices that restrict the sharing of electronic patient records. Hawai‘i HIE is
respectful of businesses’ bottom-line and proprietary data; however, in the spirit of
maintaining the patient’s health and decreasing duplicate International Statistical
Classification of Diseases and Related Health Problems (ICD-10) codes, it is imperative
that collaboration with legal and policy departments must occur. Although this is not a
technical problem, the issue is identified as a gap that will need to be addressed as PHI
that is under the responsibility of the source organization. Prudent policies that legally
bind CCR/CCD to each organization will need to be considered in developing
corresponding internal policies that revolve around sharing of health information. As
other states (e.g. New Mexico and Utah) are also in the process of developing these
policies, Hawai‘i will follow their examples.

Hawai‘i HIE is setting the strategy to meet gaps in HIE capabilities for Meaningful Use to
gain a better understanding of how unaffiliated organizations can exchange patient
information data. Ongoing collaboration with the REC and HCBCC programs, along with
lessons learned from previous initiatives, will direct interim plans to meet ONC
requirements


4.4     PIN Requirements and Meaningful Use

Hawai’i HIE has its Board of Directors, individual stakeholders within each health care
organization, and public representatives that share the informational exchange concept.
These stakeholders realize the need for sharing vital information as a means to
streamlining the health care process for the patient and driving health care costs down.
Hawai’i HIE will promote change in policies by organizing special working sessions,
obtaining specialized experts, and collaborating with other states to create open policies
to share PHI while protecting it.

Currently, the Environmental Scan indicates that, although clinical portability is being
conducted within organizational health systems, it does not indicate that interoperable
clinical information is being transmitted. The only instance in which clinical data sharing
does occur is at TAMC and the VAPIHCS, where the Janus application is accessed
through a browser-based dual provider view. This application, displaying CHCS data
from the DoD and CPRS-VistA data, will be explored as a possible data exchange
application.

Exportability to the civilian arena and exchange among others providers will require
data elements to be mapped according to the PIN and MU definitions, as displayed
below:



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Table 15: Executing Strategy for Supporting Meaningful Use
                     Description*                                            EP 1 Viable Option
 Laboratory          Hawai‘i HIE and the two major Hawai‘i labs will         Meeting MU Core
 Results             develop standard message conformity for                 Objectives 1, 3, 5,6, & 8.
                     complete laboratory data exchange.                      Menu Set: 2, 8, and
                     Discussions to explore portal expansion are             possibly 10.
                     beginning, and outcomes of this effort are
                     pending.
 Electronic          Coordinating with Surescripts, those already e-         Meeting MU Core Obj: 1,
 Prescribing         prescribing (e.g. HPH), local corporate                 2, 4, 5, 6, 7, 10, 11, & 14.
                     representation, the REC program, and                    Menu Set: 1, 3, 4, 6, 7, &
                     legislators on implementation of e-prescribing          8.
                     systems & education outreach programs.
 Sharing Patient     Transparency and collaboration will be                  Business Associate
 Care                essential in building and maintaining trust             Agreement will be
 Summaries           between unaffiliated organizations. Policies and        created to outline the
                     technical security collaboration will need              protection and security
                     consent between partnerships as secured                 of PHI.
                     messaging translation services will be
                     transmitting data.
*Selected Meaningful Use requirements will overlap for specific services. Hawai‘i HIE will meet all Core
MU requirements.




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     Table 16: Meaningful Use Requirements Matrix
     Eligible Professionals –15 CORE Objectives                               Eligible Professionals: 10 MENU Set (must choose 5 to implement in 2011-2012)
1    Computerized physician order entry (CPOE)                            1   Drug-formulary checks
2    E-Prescribing (eRx)                                                  2   Incorporate clinical lab test results as structured data
3    Report ambulatory clinical quality measures to CMS/States            3   Generate lists of patients by specific conditions
4    Implement one clinical decision support rule                         4   Send reminders to patients per patient preference for preventive/follow up care


5    Provide patients with an electronic copy of their health             5   Provide patients with timely electronic access to their health information
     information, upon request
6    Provide clinical summaries for patients for each office visit        6   Use certified EHR technology to identify patient-specific education resources and provide
                                                                              to patient, if appropriate
7    Drug-drug and drug-allergy interaction checks                        7   Medication reconciliation
8    Record demographics                                                  8   Summary of care record for each transition of care/referrals
9    Maintain an up-to-date problem list of current and active            9   Capability to submit electronic data to immunization registries/systems*
     diagnoses
10   Maintain active medication list                                     10   Capability to provide electronic syndromic surveillance data to public health agencies*
11   Maintain active medication allergy list
12   Record and chart changes in vital signs                                  *At least 1 public health objective must be selected
13   Record smoking status for patients 13 years or older
14   Capability to exchange key clinical information among providers
     of care and patient-authorized entities electronically
15   Protect electronic health information




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      Eligible Hospitals –14 CORE Objectives                               Eligible Hospitals: MENU SET (must choose 5 to implement in 2011-2012)
  1   Drug-drug and drug-allergy interaction checks                    1   Drug-formulary checks
  2   CPOE                                                             2   Record advanced directives for patients 65 years or older
  3   Record demographics                                              3   Incorporate clinical lab test results as structured data
  4   Implement one clinical decision support rule                     4   Generate lists of patients by specific conditions
  5   Maintain up-to-date problem list of current and active           5   Use certified EHR technology to identify patient-specific education resources and
      diagnoses                                                            provide to patient, if appropriate
  6   Maintain active medication list                                  6   Medication reconciliation
  7   Maintain active medication allergy list                          7   Summary of care record for each transition of care/referrals
  8   Record and chart changes in vital signs                          8   Capability to submit electronic data to immunization registries/systems*
  9   Record smoking status for patients 13 years or older             9   Capability to provide electronic submission of reportable lab results to public health
                                                                           agencies*
 10   Report hospital clinical quality measures to CMS or States      10   Capability to provide electronic syndromic surveillance data to public health agencies*


 11   Provide patients with an electronic copy of their health
      information, upon request
 12   Provide patients with an electronic copy of their discharge          *At least 1 public health objective must be selected
      instructions at time of discharge, upon request
 13   Capability to exchange key clinical information among
      providers of care and patient-authorized entities
      electronically
 14   Protect electronic health information
      NOTE: Hospital-based EPs are NOT eligible for incentives
      DEFINITION: 90 percent or more of their covered professional services in either an inpatient (POS 21) or emergency room (POS 23) of a hospital
      •Definition of hospital-based determined in law. Incentives are based on the individual, not the practice
      CMS Medicare and Medicaid Incentive EHR Program: www.cms.gov/EHRIncentivePrograms




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Table 16: Meaningful Use Requirements Matrix (Cont’d)
 Stage 1 Core Objective – Final Rule                                Stage 1 Measure – Final Rule
 Use CPOE                                                           At least one medication order entered for
                                                                    30% of patients (includes ED for Eligible
                                                                    Hospitals (EHs))
 Implement drug to drug and drug allergy interaction checks         Functionality Enabled

 E-Prescribing (Eligible Providers (EPs) only)                      40% of permissible prescriptions
 Record demographics                                                50%
 Maintain an up-to-date problem list                                80%
 Maintain active medication list                                    80%
 Maintain active medication allergy list                            80%
 Record and chart changes in vital signs                            50%
 Record smoking status                                              50%
 Implement one clinical decision support rule                       1 rule (not required to track compliance
                                                                    with rule)
 Capability to exchange key clinical information (e.g.,             1 test
 problem list, med list, med allergies, diagnostic test results),
 among care providers and patient authorized entities
 electronically

 Provide patients with an electronic copy of their health           50% of those who request electronic
 information upon request                                           copy, within 3 business days
 Provide patients with an electronic copy of their discharge        50% of those who request electronic
 instructions upon request (EH Only)                                copy

 Provide clinical summaries for patients for each office visit      50% of all office visits within 3 business
 (EP Only)                                                          days
 Protect electronic health information created or maintained        Conduct or review a security risk analysis
 by certified EHR                                                   and implement updates as necessary
 Report clinical quality measures as specified by the               2011 – report via attestation
 Secretary                                                          2012 – report electronically


The plan for 2011 is to provide clinician access to the Hawai‘i HIE Web Portal in January
with 300 physicians in the state’s two largest medical groups. Hawai‘i HIE will interact
with the CHCs that have exchanged data in the past. As CHCs have developed an MPI
system coordinating with other health facilities, Hawai‘i HIE will build from those
experiences from and lessons learned by creating a new MPI. The MPI will consist of a
patient matching algorithm identifying common data elements to validate the accuracy
of the match. Social Security numbers will not be used. Currently, patient consent is
being discussed acknowledging other states’ use of existing HIPAA guidelines amended
to include the sharing of patient information within the exchange. Patients will be able
to opt out of having their information exchanged with other healthcare organizations.

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Hawai‘i HIE will reach out to additional centers in the other rural areas as they
implement their EHRs to provide referral care and clinical summaries to their patient
population. Hawai‘i HIE will also expand to rural hospitals and South Pacific medical
practices. The expansion of Hawai‘i HIE network services across the state will be focused
on Hawai’i HIE acting as the as technology infrastructure hub, or pass-through of data
extracting that which is reflected in federal requirements. Our intent is to leverage
hospitals to host the technology required to support physicians across that community.
Formal business agreements are pending, however, resource allocations are being
committed to the exchange and will ramp-up when the agreements are finalized. Given
our role as the key entity centrally located in the Pacific Basin, we will have the
opportunity to assist Medically Underserved Populations (MUP) in the American
Territories and Commonwealth of the Northern Mariana Islands where physicians are
deploying EHR systems in a manner that will integrate centrally with the statewide HIE.

Coordination between the Hawai‘i Med-QUEST (Medicaid program) of the Hawai‘i
Department of Human Services (DHS) and Hawai‘i HIE has already begun. The
coordination will continue to take place in several areas, including governance, finance,
and expansion of network services. An important element of this coordination will be
access to Medicaid’s claim and encounter information over the Hawai‘i HIE network to
support Meaningful Use of Medicaid providers as early as 2011. Hawai‘i HIE is also
communicating with additional payers that fall under Medicare to develop EHR
implementation programs to assist the facilities in receiving their reimbursements
expeditiously. The benefit is that by facilitating these payments, the physicians will
continue to serve the elderly, disabled and those with targeted conditions such as End-
Stage Renal Disease. As this particular patient population utilizes multiple facilities, the
electronic transfer of current health information is vital for their overall health.

The plan for 2011 also includes establishing care coordination through NHIN CONNECT
to local Veterans Administration (VA) Health facilities, and the military health system of
the Department of Defense (DoD). This will close a major gap in coordination of care for
patients flowing between the VA, DoD, and private sector health facilities within the
Pacific region.

With respect to improving compliance with HHS Standards and Implementation
Specifications, Hawai‘i has demonstrated the adoption of HHS standards through its
participation with the NHIN project. Also, Hawai‘i has been involved extensively in the
NHIN Testing Workgroup, which is defining the process for testing compliance with
NHIN standards. We anticipate that when a NHIN certification program exists, the state
will be in a position to achieve that certification. As soon as ONC establishes the criteria
for HIE certification, selects an organization to perform the certification, and the
certification process is tested and approved, Hawai‘i HIE will apply for certification.




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Hawai‘i has ongoing plans to continue its practice of sharing information and
coordinating with the HIE initiatives in other states, as well as the national initiatives to
support and coordinate the development of HIEs nationwide.

5.      Technical Infrastructure
The architectural framework for Hawai‘i HIE was developed through its committee
structure in three successive stages of discussion. In the first, the relative merits of a
truly federated, hybrid, and centralized model of exchange were discussed. By
consensus, the Technical Infrastructure Committee opted to pursue a hybrid model.
That was followed by extensive discussion of the kinds of functionalities the system
should possess. Within this discussion, several simple, but pragmatic principles were
adopted to focus attention on developing a workable system of exchange within limited
cost parameters and as soon as possible. From this discussion, a discrete set of functions
was prioritized from a much longer list and then further condensed into a first and a
second stage of development. These functions, along with an appropriate set of relevant
data elements, establish the basis on which an initial and subsequent request for
proposal (RFP) will be developed by staff and vetted through the appropriate
procurement mechanisms. Throughout the process, the committee has been guided by
the ONC Toolkit and PIN requirements.

The existing Technical Infrastructure Committee will begin to establish specific
guidelines and identify technical polices in September 2010. These will continue to
evolve as the formal ONC approval process of the Strategic and Operational Plans moves
forward. The Definition Tasks List will not significantly affect the planned Technical
goals. The Technical Infrastructure Committee will undertake the creation of the
preliminary schematic blueprint to specify the mechanical architecture and
infrastructure interoperability requirements of the Hawai’i HIE (such as interoperability
with the State’s immunization database and biosurveillance alerts), as it aligns to the
ONC PIN requirements and addresses the elements of the Meaningful Use objectives.
These linkages are portrayed in the following diagram:




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Figure 5: Sample Technical Diagram




5.1     HIE Services

The statewide HIE architecture enables connections between Hawai‘i’s approximately
six major acute care hospitals and approximately 1,000 physician practices. The
statewide HIE provides a mechanism that enables authorized individuals to perform
select analytical reporting. The statewide HIE also allows secondary uses of data for
public health, bio-surveillance, and other appropriate secondary uses of data. Below is a


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brief discussion regarding the statewide HIE’s implementation schedule for the required
use cases.

a.      Electronic Eligibility and Claims Transactions

Certified EHRs are required to be certified by the Hawai‘i HIE to operate in Hawai‘i.
Select vendors are in discussions with the statewide HIE to implement this exchange.
Preliminary discussions are underway between the statewide HIE and a network that is
used by one of the state’s largest payers, HMSA.

b.      Electronic Prescribing and Refill Requests

According to Surescripts®, in 2009, 3.11 percent of the 558,880 electronic prescriptions
routed electronically were represented by a renewal response.

The total number of eligible prescriptions does not include controlled substances as
they are not eligible for e-prescribing under current DEA regulations. The total number
of eligible prescriptions also excludes preauthorized refills on existing prescriptions
because they do not require communication between a physician and a pharmacist. It is
possible to work with the pharmacy companies to develop mechanisms for dual
financial benefits.

c.      Electronic Clinical Laboratory Ordering and Results Delivery

DLS has been providing online reporting via DLSLAB.com since 2002 with state-of-the-
art technology and up-to-the-minute lab order status and result updates. The site was
launched “softly” with seminars for physicians hosted by DLS and its co-marketing
partners. Aeos, Clinical Laboratories of Hawai‘i’s online reporting system, provides
physicians and their staff with the next generation of patient laboratory reporting.

d.      Electronic Public Health Reporting

Hawai‘i has specific regulations governing public health reporting for a number of
infectious or communicable diseases, such as meningitis, measles, mumps, and
smallpox, to name a few. Currently, providers are required to submit information to
public health officials for monitoring and reporting purposes with variable requirements
on the reporting timeframe. Initial discussions regarding grant opportunities and the
implementation process for collaboration have occurred.

e.      Quality Reporting Capabilities

Quality reporting is essential to inform and educate stakeholders, and it is an important
component for achieving Meaningful Use. Interest in quality reporting continues to
grow; however, a consistent mechanism for reporting does not exist. The statewide HIE
is expected to make available quality reporting, as deemed appropriate, for use by
authorized stakeholders.

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f.      Clinical Summary Exchange

The Clinical Summary Exchange Use Case allows for the sharing of summary clinical
data, such as a discharge summary, Continuity of Care Document (CCD) or Continuity of
Care Record (CCR), to assure that health information is shared among authorized
providers. This exchange will ensure that data, or an appropriate image, is available to
participating providers.

5.2     Data Access and Management

The operational requirements of this section elaborate upon the outreach endeavors
that launched Hawai‘i HIE, that underlie the stakeholder character of its governing
board, and that allow it to leverage many of the outreach features of the Regional
Extension Center Grant. In addition, both the short- and longer-term business
operational efforts rely considerably on the principles that are embodied in the
proposed long-term sustainability financing mechanism presented in the Strategic Plan.
They also rely on the ability to gain fully-reliable operational and technical services from
our federal fiscal intermediary, PICHTR, which has an outstanding reputation for the
careful fiscal management of federal grants.

As the SDE, Hawai‘i HIE is required to plan and coordinate the development of HIE
network services statewide. The network will create a community master patient index
(MPI) with unique identities within a state population of 1.3 million people. It is
anticipated that the MPI will grow to equal nearly the full state population before the
end of the second year of the project. Initial data sources will be extracted from the
major hospitals in the state. As the patients are queried through the exchange over
time, and as the REC providers begin to exchange data, growth is expected to reach
project goals. HHIE will be working with the sources of information for patient/provider
resources for matching reconciliation.

Similarly, in Q2 2011, a provider index will be created that will identify providers and
match them based on name, NPI, facility, and other identifiers. This index will be
audited along with their authentication keys to verify security and privacy, protecting
health information.

HHIC also has been processing transactions from the largest delivery system and the
two laboratories in the state and has processed over one million HL7 messages from
those systems from April 2008 through December 2009. These volumes represent
approximately half of the health care provided in Hawai‘i. A yet-to-be-determined
organization will partner with Hawai‘i HIE to network to the large integrated health
delivery systems and laboratory companies and several other key support services. In
addition, this neutral data aggregating organization will connect with communities
across the state where information sharing and exchanges exists at any of multiple
levels (i.e. disease registries, tumor registries, immunizations). In the summer of 2011,
the expectation is that the MPI and data available in the HIE will represent more than 60

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percent of the physicians practicing in the state and, at a minimum, half the state's
population.

Table 17: Data Access and Management Requirements
 Requirement                         Description
 Meaningful Use Federal              Technical schematic blueprint will included a filtered
 Standards                           transactional scrubber model in the initial stage one
                                     implementation. By using a scrubber application, Hawai’i HIE
                                     will only receive data that has been authenticated by the
                                     Meaningful Use guidelines determined by the Data Access
                                     and Management Committee. Within the exchange
                                     application, rules will be determined by the Data Access and
                                     Management Committee that will permit the gates of specific
                                     information to be allowed from the exchange to the
                                     requesting provider. These gates can be adjusted pertaining
                                     to various policies from competing organizations and the
                                     evolution of health information need. If the fields do not
                                     contain the specific format that is required by the exchange
                                     scrubber, it could send a message back to the source
                                     notifying the incompatibility. This will ensure the proper
                                     message transaction to occur and for efficient vital health
                                     information to be understood. Adherence to the MU federal
                                     requirements will guide the technical design.
 Direct Services                     Hawai‘i HIE is open to participating in the services offered by
                                     NHIN as we develop our technical architecture that will follow
                                     an updated Notice of Award. Hawai‘i HIE is interested in the
                                     following subgroups.
     •   Authoritative               By having access to available standards and services, Hawai‘i
         Directories                 HIE would be in a better position to align our data reporting
                                     for provider, health plans, and clinical labs to the NHIN, local
                                     stakeholders and ONC.
     •   Identity Assurance and      Hawai‘i HIE will be using industry standards for
         Authorization Service       authentication of sending and receiving of information, and
                                     will incorporate the NHIN standard for data synchronization.
     •   Secure Routing              Hawai‘i HIE will implement network and data accessibility
                                     protocol to ensure improper network connection is identified
                                     and denied.
     •   Interoperability            Data Access and Management stakeholders will review and
         Specifications              integrate the NHIN data standards and develop a
                                     specification design policy that will designate technical data
                                     specifications and evolution guidelines for data refinement.
     •   Exchange Services           NHIN exchange services will be a component of the basic
                                     Hawai‘i HIE data structure. Elements of MPI, Patient Locator,
                                     and Document Referral Management will be incorporated
                                     into the data integrity standard.

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6.      Business and Technical Operations
Hawai‘i HIE will be creating a modular and flexible infrastructure to provide practical
and secured portals for core health information sharing, as well as Value-Added Services
that would entice organizations to become members of the exchange. The
infrastructure requirements must be scalable to allow for the changing technology
industry and for additional applications that may need to be required due to federal
measurement standards that have yet to be announced.

Although Hawai‘i HIE will be announcing a RFP to create these core services, the
Technical Infrastructure and Data Access & Management Committee’s will drive the
guidelines and policies for the exchange. It is known that the timeline for these activities
are aggressive, but it is the Hawai‘i HIE’s believe that the core services that reside in the
Hub have already been to market and standard federal specifications have already been
accomplished.

Customizations should be discouraged and under strict criteria, only to address minor
deviations from a very robust data standard established by Hawai’i HIE. As a general
rule, the EHR product should be customized where necessary to conform to the Hawai’i
HIE standard. Hawai‘i HIE and vendors are evaluating entities that have already
accomplished this effort and will work with a security officer and audit processes to
safeguard the proprietary code from each entity.

As outlined in the strategic plan, services have been split into Infrastructure components
and Functional features.

6.1     Infrastructure

The Hawai‘i HIE infrastructure will be the foundation of Hawai‘i health sharing services.
As part of the Core Service, the foundation will need to address the basic necessary
functions of any data exchange:

           Data Transformation Services
            • Master Clinician Index (name, NPI, facility, and other identifiers)
            • Patient identifier Services
            • Clinical Portals
            • Audit Trail Services
               o Privacy and Security

             Functional Features
             • Lab Results Exchange
             • Medication History Exchange
             • Medical Encounter Notes (medical history, allergies, medication list, vital
                signs, etc.)
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             • Radiology results Exchange
             • Population Health Services
             • Patient Notification and Consent

Once the foundation of the infrastructure is approved, the application model is designed
to be a secured component-based interface design that is driven from a singular
product. These components will switch levels of interchange based on rules set forth by
the Data & Access Management Committee. Each organization will maintained their
individual data sources and the hub will be allowed tunneling access based on firewall
permissions between the source site and the exchange. The application will run user
security authentication checks and a patient identification verification algorithm to
obtain specific information based on the user’s request. Request will be real-time and
will be monitored for sub-second relays and confirmation receipt messages.

6.2     Auditing and Data Repository

The storage layer will be a de-identified partition that will store and aggregate data for
analysis, like immunization, bio-surveillance, and other epidemiology/public health
reporting. As the patient information is exchanged, identifiers will be tagged to create
statistical categories aligned with Medicaid, public health and other government
programs. Stakeholders have signed off on the State HIE Plan, acknowledging that de-
identification will take place within the HIE.

6.3     Scalability

As mentioned in the Strategic plan, our immediate goal is to create an environment that
utilizes what is already in existence. Once the interchange of data is introduced at a
smaller scale, needs assessment will be planned for scaling up to the next level.
Aforementioned agreements with the two major hospital systems will be discussed at
the end of October. As exchange begins, incremental steps will be taken to avoid
catastrophic events. Once trust and data validation is affirmed, then incorporation of
scaling to the next phase will appropriate. These levels will be assessed by user
adoption, business agreements, and collaboration with other health care initiatives that
will be facilitated and driven by the ONC timelines.

7.      Legal and Policy

7.1     Requirements

The primary approach to meeting the requirements of the Legal and Policy Domain has
been to use what is already established and render it appropriate to the task. In
practice, this has been building off agreements developed in the past for health
information exchange, making use of inventories of relevant policies, statutes, and rules
developed by stakeholders. An inventory of relevant laws and rules provided by the

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Department of Health, and the expertise of national organizations and individual
persons who have worked in this area for many years, particularly in the hospital
environment, have also been reviewed. The Legal and Policy Committee has been the
center of this activity, and at the appropriate initiative of its chair, it was consensually
agreed to recommend to the Executive Director that an RFP be extended that could
bring focused legal expertise to create a comprehensive analysis from which the
requirements listed in this domain section can be met. The committee will, through this
process, develop a set of relevant policies and related documents for Board approval.
The plan is to have these in place in time to initiate data exchange within six months of
approval of these plans.

7.1.1     Opt In/Opt Out as the Baseline Consent Process

The Privacy and Security enforcement, building on the practices of the existing HIOs,
recognizes that statewide policy is an evolutionary process. As appropriate and secure
HIE is available to health care providers for care coordination, there will need to be
revisions to existing new patient notification policies and the patient’s right to “opt out”
of sharing information for treatment purposes. The Legal and Policy Committee will
conduct forums, targeted to start in Winter 2010/Spring 2011, to begin to draft policies
to address authorization, access, audit, authentication, and breach notification. The next
policies to be addressed are related to sensitive data, secondary use, and minors. After
these policies have been drafted, the Committee has agreed to re-visit and possibly
revise the patient notification/opt-in/opt-out policy.

7.1.2     Privacy and Security

In analyzing state laws affecting in-state and out-of-state disclosures of electronic health
information through a health information exchange, in assisting in the passage of the
Hawai‘i HIE, and in collaborating with stakeholders across the state in the development
of the Hawai‘i HIE, a significant increase in the stakeholders’ understanding of privacy
and security requirements will be required. While there is no quantifiable data available
to support the conclusion, Hawai‘i HIE believes that the efforts to establish an electronic
health information exchange have resulted in a re-examination by stakeholders of their
existing policies and procedures, both with respect to compliance with the HIPAA
Regulations and with respect to more stringent state legal requirements related to
specially-protected health information such as HIV/AIDS and mental health information.
Consequently, Hawai‘i HIE believes that the level of awareness of privacy and security
issues by stakeholders statewide has already been significantly improved and, in
addition, that the policies and procedures of the stakeholders are becoming more
standardized across stakeholders. Informal conversations with key legislators are taking
place to keep them apprised of developments in this area.

It is proposed that each participant in the Hawai‘i HIE will be required to execute a
standardized Hawai‘i HIE Subscription Agreement. Under this Agreement, health care


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providers utilizing the Hawai’i HIE would have to comply with HIPAA, federal and state
laws. With the privacy and security agreement in place, there will be no unauthorized
access to the exchange. As more participants become a part of the HIE, awareness of
and compliance with privacy and security requirements will become more standardized.

Hawai‘i HIE proposes to include provisions in the Hawai‘i HIE Subscription Agreement
and to adopt policies and procedures that will foster standardization of privacy and
security policies across participants. For example, as a result of comments received at
recent stakeholder meetings, Hawai‘i is considering requiring that all participants meet
HIPAA rules and federal encryption standards with respect to their electronic health
information. If a requirement such as this is mandated by ONC, the subscription fee may
increase due to added government regulation. With respect to coordination and
consistency on an interstate basis, Hawai‘i stakeholders intend to continue to
participate in the development of the Hawai‘i HIE. The plan acknowledges privacy and
security requirements as follows.

Table 18: Patient/Provider Privacy and Security Requirements
Requirement          Description
Individual Access    Within each participating group, specific definition will define individuals’
                     ability to access their personal information.
Correction           Within each participant group, a correction of information process will be
                     explained.
Openness and         Agreements between Hawai‘i HIE and the participating groups will have a
Transparency         clause that will indicate how to access privacy and security information.
Individual Choice    Section 2.5 describes an initial statement of the Opt-In/Opt-Out policy. With
                     the ability to access their PHI from their providers, individuals will be able to
                     correct their records and have control over their use.
Collection, Use,     Hawai‘i HIE will disclose individual identifiable health to the public only when it
and Disclosure       is for a specified purpose and never to discriminate inappropriately. The
Limitation           current intended design of Hawai‘i HIE to not retail PHI, but to be utilized as a
                     gateway of individual information to cache information and purge once the
                     transaction has been complete.
Data Quality and     Policies and procedures within participating groups have reasonable
Integrity            mechanisms to ensure PHI is complete, accurate and up-to-date. Our Business
                     Associate Agreement will stipulate that information that enters the Hawai‘i HIE
                     port will have gone through their Data Quality and Integrity process.
Safeguards           Technical security measures will be developed using industry standards and
                     will be guided by designated Committees. Specific safety measures will be
                     safeguarded and tested for integrity.
Accountability       Auditing reports and unscheduled integrity testing will be conducted and
                     reported through appropriate mechanisms.




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             • Creation of a five-year financial model that allows the comparison of
                 sources and uses of financial resources and alternate case scenarios;
             •   Development of scenarios based on alternative strategies and timelines;
             •   Estimation of contributions from recurring and non-recurring revenue
                 sources to permit sensitivity analyses based on graduated charges to
                 specified participants in the health care economy;
             •   Analysis of costs of core services which may be equitably supported by all
                 users versus value-added services that may be charged only to users of
                 the service; and
             •   Identification of policy and regulatory mechanisms to accelerate demand
                 for and participation in HIE.

The Finance Committee is engaged in discussions of various revenue streams for Hawai‘i
HIE’s Sustaining Model that will be communicated to ONC. Legislative actions, user fees,
private sector donations, and/or a combination of all, are potential avenues that are
under consideration. Research fee-for-service may also be a potentially viable revenue
stream. As collaborations with other national HIEs are evolving, quantifiable and
quantitative data on a national scale, as it compares to each local state, can potentially
be an asset that can be marketed. As data is also imported from the Pacific region,
specialized ethnic populations can be subject to research focused on these population
groups.

Building on the assumptions and principles outlined in the Sustainability/Business Model
section of the Strategic Plan, Hawai’i HIE’s Finance Committee is currently in the process
of developing scenarios that model the costs and funding mechanisms expected. The
models will be built based on the existing environmental scan data and current adoption
assumptions. The Finance Committee will continue to work with Medicaid and the
other stakeholders to update and refine the assumptions and environmental data.

The Finance Committee will apply expected upfront and ongoing costs to the
environment data and adoption assumptions to develop the expected “all-in” costs for
the development and operations of the Hawai’i HIE for the next five years. Initial cost
estimates will be based on publicly available information from other RFI and RFP efforts
as well as information from consultants assisting in the process. These cost will be
updated and refined with input from Hawai’i HIE’s own RFP process.

Upfront funding mechanisms will be identified to offset upfront costs identified in the
previous modeling steps. It is expected that these upfront funding mechanisms will not
be enough to support a full build out and operations of the entire HIE infrastructure
being planned. However, this initial gap will be identified to determine the minimal
additional upfront and ongoing funding necessary to sustain Hawai’i HIE.

Ongoing funding mechanism will be defined based on the generation of value to various
stakeholder groups. Pricing will be applied to these mechanisms and market tested with

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workgroup participants and stakeholders. The need for bridge funding will also be
analyzed because a critical mass of participation may be required before pricing is able
to reach a palatable level for participants.

This model will be continually harmonized with refined environment, adoption rates and
cost data. The Finance Committee of the Hawai’i HIE expects to have a draft Plan for
Sustainability written and iterated with stakeholders and the board by the end of Q1
2011 with a goal of finalizing the plan by the end of Q2 2011.

9.1     Creation of Demand for HIE Products and Services

Hawai‘i HIE stakeholders share the view of ONC that HIE funding will be instrumental in
creating the demand for future products and services that will, in turn, create a vibrant
HIE marketplace. The following table reflects Hawai‘i HIE’s current consideration of out-
year budget possibilities:




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Table 25: Hawai‘i HIE Budget Considerations




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With these budget projections before it, Hawai‘i HIE’s strategy for developing a plan for
sustainable financing for HIE will take into account its rapid development over the next
five years. It will also recognize that bridge financing mechanisms are likely to be
required to support development and implementation of statewide HIE until the time at
which there is sufficient marketplace demand to support a permanent financing
mechanism.

10.     Risk Assessments
As these plans were developed by Hawai‘i HIE, specific risks were identified and risk
mitigation activities were developed. Risks will continue to be monitored over time.
Summaries of risks and mitigation strategies are outlined below.

Table 26: Risks and Mitigation Strategies
 Category            Risk                      Risk Level      Mitigation
 Business            The use of                Low / 10%       The Hawai‘i HIE has three full-time
 Operations          contractors poses                         employee (FTE)positions and relies
                     challenges related to                     upon contractors to meet its
                     meeting the                               deliverables. The contractors are
                     milestones of the                         required to provide the statewide HIE
                     State Plan.                               with a Scope of Work document that
                                                               identifies the deliverables due from
                                                               the contractor and are required to
                                                               meet with the Executive Director of
                                                               the Hawai‘i HIE on a weekly basis to
                                                               ensure completion of the work. The
                                                               designated contractor providing
                                                               human capital support is located in
                                                               Hawai‘i.
 Contingency         Disruption in the         Low / 25%       The Hawai‘i HIE will continue to have
 Planning            statewide HIE’s                           open and trusting relationships with
                     ability to meet its                       other health organizations within our
                     deliverables in the                       state. Representatives from
                     event of a severed                        organizations participate on a
                     relationship with                         voluntary basis in a number of
                     supporting                                planning and implementation
                     organization(s).                          activities and Hawai‘i HIE is conscious
                                                               of the in-kind services these
                                                               organizations have contributed.
 Vendor              Improper oversight        Med / 40%       The Project Management Office
 Oversight           of contractor could                       (PMO) of the statewide HIE will
                     negatively impact the                     manage vendor relations. The PMO
                     workflow and build                        Director reports to the Executive
                     out of the statewide                      Director and is responsible for
                     HIE.                                      implementing the HIE technology and

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 Category            Risk                      Risk Level      Mitigation
                                                               leading various project teams to
                                                               ensure effective and efficient roll out
                                                               of use cases. The PMO Director is
                                                               responsible for monitoring the
                                                               projects and preparing reports that
                                                               track the performance of the Hawai‘i
                                                               HIE.
 Participant Risk    Unpredictable             Low/ 15 %       Services of the statewide HIE will be
 Management          demand for services                       regionally deployed and clustered by
                     from the statewide                        location around the state. The work
                     HIE.                                      of the Regional Extension Center is
                                                               structured to target high
                                                               concentration medical trading areas.
                                                               The Hawai‘i HIE has established a
                                                               plan to work with the Mountain
                                                               Pacific Quality Health Foundation and
                                                               TIPG to leverage their support in
                                                               getting providers to participate in the
                                                               Hawai‘i HIE.
 Health System  Uncertainty as to the          Med / 33%       The effective exchange of electronic
 Implementation period of time that                            health information largely depends
                the health system                              on the various health systems
                will connect to the                            participating in the statewide HIE.
                statewide HIE.                                 These health systems constitute
                                                               approximately 90 percent of all
                                                               hospitals in Hawai‘i and are
                                                               associated with the vast majority of
                                                               the physicians that would be
                                                               participating in the HIE. The Hawai‘i
                                                               HIE has been working with the CIOs
                                                               and leadership of the leading health
                                                               systems to encourage early adoption
                                                               of the HIE services.
 Payers              Payers may delay          Low / 30%       One payer in the state has
 Participation       implementation due                        approximately 68 percent of the
                     to concerns over                          privately insured market. The payer
                     value and services.                       sits on the Hawai‘i HIE Board of
                                                               Directors and has a key leadership
                                                               role in the implementation of the
                                                               Hawai‘i HIE.
 Technical Risk      Staggered                 Low / 15%       Identifying technology partners and
 Management          implementation of                         resolving issues related to
                     component                                 functionality and contracting are
                     technology may                            critical in keeping with the

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 Category            Risk                      Risk Level      Mitigation
                     impact the overall                        established timeline. As a hybrid
                     functionality of the                      model HIE, the system is built using
                     statewide HIE.                            components from different vendors.
                                                               Adhering closely to the timeline is
                                                               critical to ensuring that services are
                                                               deployed as scheduled. The Hawai‘i
                                                               HIE is monitoring vendor activities
                                                               and limits the time that potential
                                                               vendor solutions have to overview
                                                               products, address questions, and
                                                               complete contract negotiations.
                                                               Hawai’i HIE will review other states’
                                                               contracts and incorporate language
                                                               to protect milestones.
 Sustaining the      Disruption in services    Low / 10%       Maintaining the functionality of the
 Functionality of    due to hybrid model,                      system as additional components are
 the Core            resources, and                            added to the system and as new
 Infrastructure      increased utilization.                    providers begin to participate with
                                                               the Hawai‘i HIE can have an impact
                                                               on the ability to adequately maintain
                                                               network availability and reliability,
                                                               and recover quickly from any
                                                               unforeseen disruption to the system.
                                                               The Operational Plan anticipates
                                                               growth in services and in capacity.
                                                               The Hawai‘i HIE will monitor capacity
                                                               on a monthly basis to determine if
                                                               additional technology and human
                                                               resources are needed to sustain the
                                                               core infrastructure. The technical
                                                               staff of the core infrastructure that is
                                                               being deployed will also monitor
                                                               capacity and assist in capacity
                                                               planning and evaluation.
 User Education      Improperly trained        Low / 10%       Every new user that participates with
                     users can create                          the Hawai‘i HIE will require
                     system disruptions                        authorization, authentication,
                     and breaches to best                      education, and technical support. The
                     practices.                                Regional Extension Center staff is
                                                               funded and responsible for ensuring
                                                               that large provider groups with more
                                                               than ten providers follow specific
                                                               training guidelines for instructing
                                                               users of the system on best practices.
                                                               For practices with less than ten

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 Category            Risk                      Risk Level      Mitigation
                                                               providers, the Regional Extension
                                                               Center staff will conduct an on-site
                                                               visit to train users how to access the
                                                               system.
 Integrating         Community data            Med/ 45%        Leadership from the statewide HIE
 Community           sharing initiatives                       will routinely meet with Hospital CIOs
 Data Sharing        may not make clear                        to discuss the value of participating in
 Initiatives         the benefit in                            the statewide HIE and technology
                     participating with the                    requirements to connect to Hawai’i
                     Hawai‘i HIE.                              HIE. Providing CIOs with critical
                                                               information regarding connectivity
                                                               and their participation prior to
                                                               implementing the Hawai‘i HIE helps
                                                               the hospitals align their technology
                                                               deployment plans with the
                                                               Operational Plan. A key assumption is
                                                               that the more hospitals that
                                                               participate in Hawai’i HIE, the more
                                                               independent physician providers will
                                                               come to appreciate the value of their
                                                               own participation. Priority will be:
                                                               Lab orders/results;
                                                               medication/allergy list; HL7
                                                               summary/MU requirements.
 Financial Risk      Improperly setting        Med / 35%       The statewide HIE’s Finance
 Management          user participation                        Committee is charged with identifying
                     fees at a threshold                       the appropriate costs of HIE services.
                     where providers are                       The work of this group includes
                     willing to pay for                        provider surveys and the review of
                     value                                     national efforts to determine price
                                                               points for services provided by the
                                                               Hawai‘i HIE.
 Cost                Improper pricing of       Low/ 20%        The Finance Committee is tasked with
 Containment         services in                               developing unity costs for each
                     comparison of value                       service provided by the Hawai‘i HIE.
                     and the cost of the                       The evaluation includes assessing
                     services could                            central processing unit (CPU) usage,
                     negatively impact                         human capital, and potential support
                     participation, thus                       from technology partners. Each
                     increasing cost to                        service will have the base amount as
                     those that are                            well as a fee required by the provider
                     participating                             type to manage cost in the most
                                                               appropriate manner. The outcome of
                                                               this process is used in determining


Hawai‘i Health Information Exchange
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 Category            Risk                      Risk Level      Mitigation
                                                               standardized user fees for
                                                               participation in the Hawai‘i HIE.
 Legal Risk          Developing a              Low / 10%       The Hawai‘i HIE will engaged an
 Management          participant                               outside legal resource to create
                     agreement that is                         mutual agreements. The legal counsel
                     enormously complex                        will seek feedback from the provider
                     or too simplistic to                      community in the modifications
                     appropriately                             proposed to the agreement. Hawai’i
                     address participant                       HIE is working with organizations that
                     requirements.                             will review the national legal
                                                               landscape.
 Liability           Insufficient insurance    Low / 10%       The Hawai‘i HIE recognizes the risks
 Insurance           to cover risks                            associated with exchanging electronic
                     associated with                           health information. The Hawai‘i HIE
                     potential civil suits                     has retained liability insurance to
                     that could emerge as                      counter any litigation that could
                     a result of electronic                    materialize. Feedback from the Board
                     health information.                       of Directors and outside legal counsel
                                                               will routinely be sought to ensure
                                                               adequate liability coverage of the
                                                               organization and its’ officers.
 Competitive         Acute care hospitals      Low / 10%       The Hawai‘i HIE is working with all of
 Risk                may choose to                             the hospitals to ensure that they will
 Management          implement                                 participate with the Hawai‘i HIE.
                     community-sharing                         Engaging the hospitals early in their
                     initiatives in their                      technology planning processes will
                     service area and                          help ensure that independent efforts
                     bypass the Hawai‘i                        to connect physicians to hospitals will
                     HIE.                                      not affect the community from
                                                               participating in the Hawai‘i HIE.
 Payers              Payers may choose to Med / 45%            Hawai‘i HIE engages the Hawai‘i
 Establishing        implement data                            Medical Service Association and other
 Their Own HIE       sharing initiatives for                   payers in the design and service
                     their provider                            deployment of the statewide HIE. The
                     network.                                  goal is to identify payer value for
                                                               participation and implementing select
                                                               services (i.e., electronic claims,
                                                               eligibility verification, etc.) in the
                                                               early stages to keep payers engaged
                                                               in developing a statewide HIE. HMSA
                                                               sits as the Chair of the Hawai‘i HIE
                                                               Legal Policy committee and formal
                                                               agreements are pending.



Hawai‘i Health Information Exchange
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11.     Communications Plan
Hawai’i HIE is in process of developing a comprehensive communications plan to engage
all stakeholders in health information exchange. Deliverables and timelines are as
follows.

Table 27: Hawai’i HIE Communications Plan Components
Deliverable            Activities                                                          Timeline
Hawai’i HIE Web        Add “Programs” tab to include information on the REC                September
Site                   Program and the State HIE Program                                   2010
                       Add “Events Calendar”                                               (complete)
                       Add form to collect leads
                       Choose web design firm
                       Prepare web layout
                       Prepare content
Branding               Create a logo                                                       Summer
                       Create letterhead and envelopes                                     2010
                       Create style guide (to include proper spelling and                  (complete)
                       abbreviations, house font, house colors, house style)
Email Marketing        Choose email marketing software                                     Completed
                       Create branded template for enewsletters                            and
                       Send monthly updates                                                Ongoing
Print Collateral      Fliers                                                               To be
                           •     Hawai’i HIE                                               completed
                           •     REC Program                                               in October
                                                                                           2010
                           •     EHR Incentives
                      Tri-fold
                           •     Meaningful Use
                           •     Hawai’i HIE folder
                           •     Postcards
                           •     State HIE Program
                           •     REC Program
PR and Social          Create a Facebook account                                           Completed
Media Marketing        Create a Twitter account                                            and
                       Write press releases (one/month)                                    Ongoing
                       Create ning for Hawai’i HIE
                       Create a LinkedIn account
                       Design branded webinars for the website and for
                       presentations
Advertising            Create Google AdWords account                                       Completed
                       Create Yahoo Search Solutions account                               and


Hawai‘i Health Information Exchange
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Deliverable            Activities                                                          Timeline
                       Make a print and online marketing plan for future use               Ongoing
                       Prepare posters and signage for events as needed
CRM                    Participate in Salesforce training and prepare setup                Completed
                       materials                                                           and
                       Train users                                                         Ongoing
                       Track progress and run reports
 REC Recruitment      •    Conferences                                                         October
 Campaign                      o Oct 2—HMA Ola Pono Ike Fundraiser                             2010 and
                               o Oct 3—National REC & HIE Summit West                          Ongoing
                               o Oct 4—HAPA, Annual Aloha Medical
                                   Conference
                               o Oct 7—HPCA Annual Conference
                               o Oct 14—ACOG Annual District Meeting
                               o Nov 4—AAP Pediatrics Island Style
                      •    Presentations
                               o Late-October or early-November
                                            Updates to the Neighbor Islands and
                                            Oahu on the HPREC
                      •    eNewsletter Updates
                               o include info on the MU presentations posted on
                                   the ning, invitation to join the ning, incentive to
                                   sign with the REC, featured physician, contact
                                   info
                      •    Postcard (mail in early to mid-Oct)
                               o To members of:
                                            Hawai’i IPA
                                            HPCA (or CHC staff)
                                            HPH
                                            Queen’s Health Systems
                                             HMA
                                            HHSC
                                            AAPH
                                            ACOG
                                            HAOPS
                               o Include info on:
                                            Incentives
                                            Invite to October/November
                                            presentations
                      •    Design and print HPREC folders
                      •    Set up interviews with PR contacts and C Suenaga



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Appendices
A-1 ONC Submission Letter




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A-2 Hawai‘i HIE State HIE Award 4-year Program Budget submitted to ONC

             Hawai‘i HIE State HIE planning and implementation grant 4-year Program Budget submitted to ONC

             Total Grant Budget = $5,602,000
             Revised: 07-30-2010

             Budget Categories                        Year 1        Year 2       Year 3        Year 4      4 YR       4 YR     4 YR
                                                                                                         Program    Program   Comb
                                                      Budget       Budget        Budget        Budget      Total     Match    Budget
             PERSONNEL
                                 Total Personnel      385,500       709,499      723,149       737,072 2,554,808     54,000 2,608,808
                                                                                                                          0         0
             TRAVEL                                                                                                       0         0
             National                                                                                                     0         0
             Airfare:                                   12,000       12,000        12,000       12,000     48,000         0    48,000
             Lodging:                                   12,000       12,000        12,000       12,000     48,000         0    48,000
             Per diem                                    2,600        2,600         2,600        2,600     10,400         0    10,400
             Ground Transportation                         480          480           480          480      1,920         0     1,920
             Local                                                                                              0         0         0
             Airfare: $250 x 19 trips                    4,750        4,750         4,750        4,750     19,000         0    19,000
             Per diem                                      893          893           893          893      3,572         0     3,572
             Ground Transportation                         950          950           950          950      3,800         0     3,800
             Parking: $10/day x 19 trips                   190          190           190          190        760         0       760
                                    Total Travel        33,863       33,863        33,863       33,863    135,452         0   135,452




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             Budget Categories                        Year 1        Year 2       Year 3        Year 4      4 YR       4 YR     4 YR
                                                                                                         Program    Program   Comb
                                                      Budget       Budget        Budget        Budget      Total     Match    Budget
             CONSULTANT COSTS
             Fiscal Agent                          72,000            72,000        72,000       72,000    288,000         0   288,000
             State HIE Planning Costs                                                                                     0         0
             HIE subject matter expert             48,000            24,000         9,600        9,600     91,200         0    91,200
             Strategic Facilitator                100,000            10,000        10,000       10,000    130,000         0   130,000
             Legal Council                         60,000            60,000         6,000        6,000    132,000    36,000   168,000
             Business Analyst                           0                                                                 0         0
             HIE technical subject matter          48,000            48,000         9,600        9,600    115,200         0   115,200
             expert
             Subtotal State HIE Planning Costs    328,000           214,000      107,200       107,200    756,400        0    756,400
             HIE development costs
             HIE IT network development           385,000           100,000         5,000        5,000    495,000   253,475   748,475
             HIE software purchase &              400,000           100,000         5,000        5,000    510,000   232,930   742,930
             development
             HIE interface development             90,000            60,000                               150,000         0   150,000
             HIE annual user licenses                                              25,000       25,000     50,000    50,000   100,000
             HIE annual software licenses &             0            10,000         5,000       10,000      5,000    10,000    15,000
             support
             HIE annual hosting & security              0            35,000        17,500       17,500     70,000    35,000   105,000
             services
             HIE cyber insurance                        0            30,000        30,000       30,000     90,000        0     90,000
             User/Transitional Care Support             0             2,500         2,500        2,500      7,500        0      7,500
             Doc
             Research & Evaluation Director             0            10,000       20,000        20,000    50,000         0    50,000
             Research Activities                        0             5,000       10,000        10,000    25,000         0    25,000
             Subtotal HIE Dev & Implem costs      875,000           352,500      120,000       125,000 1,472,500         0 1,472,500
                         Total Consultant Costs 1,203,000           566,500      227,200       232,200 2,228,900         0 2,228,900

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             Budget Categories                        Year 1        Year 2       Year 3        Year 4         4 YR       4 YR     4 YR
                                                                                                            Program    Program   Comb
                                                      Budget       Budget        Budget        Budget         Total     Match    Budget
             EQUIPMENT
             HIE network equipment                    100,000                                                100,000    44,000   144,000
             Staff computers and printers               7,000                0            0             0      7,000         0     7,000
                             Total Equipment          107,000                0            0             0    107,000         0   107,000
                                                                                                                             0         0
             SUPPLIES                                                                                                        0         0
             Project related supplies                    2,500         2,000        2,000        2,000         8,500         0     8,500

             OTHER EXPENSES
             (STANDARD OPERATIONS)                                                                                          0             0
             INDIRECT COSTS
             Insurance - D&O                             4,250        8,500         8,500        8,500        29,750        0     29,750
             Insurance - General Liability               2,500        5,000         5,000        5,000        17,500        0     17,500
             Website development & hosting              21,500          150           150          150        21,950        0     21,950
             Telecommunication: Phone &                  8,400       16,800        16,800       16,800        58,800        0     58,800
             Email
             Rent                                       25,200       25,200        25,200       25,200       100,800        0    100,800
             Fed/State Tax filing                        4,000        8,000         8,000        8,000        28,000        0     28,000
             Audit & accounting fees                    17,500       17,500        17,500       17,500        70,000        0     70,000
             Vehicle Mileage                               198          198           198          198           792        0        792
             Advertising/Marketing/outreach             23,448       20,000        20,000       20,000        83,448        0     83,448
             Visitor Parking                             6,000        6,000         6,000        6,000        24,000        0     24,000




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             Budget Categories                        Year 1        Year 2       Year 3        Year 4      4 YR    4 YR      4 YR
                                                                                                         Program Program    Comb
                                                      Budget       Budget        Budget        Budget      Total   Match    Budget
             Meetings                                                                                            0      0          0
             HHIE Board regular meetings.                1,500         1,500        1,500        1,500       6,000      0      6,000
             HHIE Board strategic planning               2,250                                               2,250      0      2,250
             mtgs
             Public planning committee                  15,750       10,500        10,500       10,500    47,250        0     47,250
             meetings
             Meeting space                               4,200         4,200        4,200        4,200    16,800         0    16,800
             Other                                                                                             0         0         0
                                                                                                               0         0         0
             Conference, seminars, training            15,000        15,000       15,000        15,000    60,000         0    60,000
                      Total OTHER EXPENSES            151,696       138,548      138,548       138,548   567,340   715,405 1,282,745
                                                                                                                         0         0
                         TOTAL DIRECT COSTS 1,883,147 1,450,410 1,124,760 1,143,683 5,602,000                            0 5,602,000
                             Required In-kind  44000    101,041   160,680   381,228   686,949                            0   686,949
                     TOTAL INCLUDING MATCH 1,927,147 1,551,451 1,285,440 1,524,911 6,288,949                             0 6,288,949
                               REQUIREMENT




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A-3 Bylaws of the Hawai‘i Health Information Exchange
                      DATE OF ADOPTION: NOVEMBER 17, 2009

Amended and Restated By-laws of the Hawai‘i Health Information Exchange

ARTICLE V

COMMITTEES

SECTION 5.1. Committees. The Board of Directors may create and appoint standing or
ad hoc committees of any kind as the business of the Corporation may require and
define the authority and duties of such committees, except that such committees shall
not have such powers as are reserved to the Board of Directors by statute or otherwise.
The President shall appoint all committee chairs and members of the committees
subject to confirmation by the Board of Directors, unless otherwise provided in this
Article.

SECTION 5.2. Committee Membership and Terms. Membership on Permanent
Committees of the Corporation shall be limited to the then serving Directors.
Membership on Ad Hoc Committees of the Corporation shall be chaired by a then
serving Director and made up of then serving Directors. Each committee, whether
Permanent or Ad Hoc, shall be composed of at least three members, including the chair
person. Members appointed to each committee shall serve a term of three years with
the terms of committee members staggered to the extent feasible. A Director shall not
serve more than two consecutive terms on any committee. If a Director misses two
consecutive committee meetings without an approved excuse, then the President may
remove that Director from that Committee and appoint a replacement.

SECTION 5.3. Committee Meetings. The committees of the Board of Directors shall
hold public meetings and keep meeting minutes to conduct the business of such
committees to the extent feasible and in keeping with the purposes of the Corporation
and the requirements of State and Federal law.

SECTION 5.4. Executive Committee. The Officers, Chairpersons of the Permanent
Committees, Chairpersons of the Ad Hoc Committees and Immediate Past President
shall serve as the members of the Executive Committee. The President of the Board of
Directors shall serve as the chair of the Executive Committee. The Executive Director
shall also serve as a non-voting member of the Executive Committee. The Executive
Committee shall perform such functions and duties and shall have such powers and
authority as determined from time to time by the Board of Directors. The Executive
Committee shall oversee and be responsible for issues relating to finance, governance
and human resources. The Executive Committee, unless otherwise directed by the
Board, shall meet at least monthly.



Hawai‘i Health Information Exchange
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SECTION 5.5. Technical Infrastructure and Standards Committee. There shall be a
permanent Technical Infrastructure Committee consisting of at least three (3) members,
all of whom shall be Directors of the Corporation. The President of the Corporation shall
appoint the chair of the Committee. The duties of the Committee shall include
development of the technical infrastructure and HIT plan for the statewide Hawai‘i
health information exchange; development of data exchange standards; development
of a plan to interface the Hawai‘i Health Information Exchange with the federal health
information exchange or other governmental or private exchanges; coordination with
the State HIT coordinator; participation in the development of the State HIT Strategic
Plan under ARRA; and other technical issues relating to the purpose of the Hawaii
Health Information Exchange. The Executive Director shall be an ex-officio, non-voting
member of the Committee.

SECTION 5.6. Audit Committee. If there is an annual audit, then there shall be a
permanent Audit Committee consisting of three (3) members, all of whom shall be
Directors of the Corporation. The President of the Corporation shall appoint the chair of
the Committee. The duties of the Audit Committee shall include review of the annual
audit of the Corporation, review of the annual audit, selection of the auditor, and other
matters relating to the audit of the Corporation. The Board may assign such other duties
to the Audit Committee.

SECTION 5.7. Governance Committee. There shall be a permanent Governance
Committee consisting of at least three (3) members, all of whom shall be Directors of
the Corporation. The President of the Corporation shall appoint the chair of the
Committee. The duties of the Governance Committee shall the include nomination of
new officers and directors; recommendations regarding the removal of any Officer or
Director of the Corporation; periodic review and proposal of amendments of the By-
Laws and Articles of Incorporation; periodic review and proposal of amendments of the
policies and procedures of the Board; periodic self-assessments of the Board and
Corporation; developing and reviewing a compliance plan and policies; developing and
maintaining a continuing education program for the Board; periodic review and revision
of the conflicts policy of the Corporation; periodic review and revision of the
organizational chart of the Corporation; planning of Board retreats; conducting the
annual appraisal of the performance of the Executive Director and reporting the results
of such appraisal to the Board; and such other duties as are assigned by the Board to the
Committee. The Governance Committee shall serve as the Board designated entity to
receive any compliance complaints. The Executive Director shall be an ex-officio, non-
voting member of the Committee.

SECTION 5.8. Legal Policy Committee. There shall be a permanent Legal Policy
Committee consisting of at least three (3) members, all of whom shall be Directors of
the Corporation. The President of the Corporation shall appoint the chair of the
Committee. The duties of the Legal Policy Committee shall include developing and
reviewing contract and grant procedures and policies; coordinating the monitoring of all

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contracts and grants with the Executive Director and staff of the Corporation;
negotiating and analyzing contracts and grants in coordination with the Executive
Director and staff; investigating and reporting any contract breaches or grant violations
to the Board and negotiating any resolution of such breaches or violations; and such
other duties as are assigned by the Board to the Committee. The Executive Director shall
be an ex-officio, non-voting member of the Committee.

SECTION 5.9. Finance Committee. There shall be a permanent Finance Committee
consisting of at least three (3) members, all of whom shall be Directors of the
Corporation. The Treasurer of the Corporation shall serve as Chair of the Finance
Committee. The duties of the Finance Committee shall include developing and reviewing
fiscal procedures and policies; reviewing the annual budget of the Corporation and
making recommendations about the budget to the Board; developing a plan to
transition from federal and/or state funding to other funding sources to sustain the
Corporation; and reporting periodically on the financial status of the Corporation to the
Board. The Board may assign such other duties from time to time to the Finance
Committee. The Executive Director shall be an ex-officio, non-voting member of the
Committee.

SECTION 5.10. Data Access and Management Committee. There shall be a permanent
Data Access and Management Committee consisting of at least three (3) members, all of
whom shall be Directors of the Corporation. The President of the Corporation shall
appoint the chair of the Committee. The duties of the Data Access and Management
Committee shall include developing and reviewing all legal policies including but not
limited to the privacy policy, security policy, and the data access policy of the
Corporation; developing, negotiating and approving data trust agreements, such as data
sharing or data use agreements and policies and procedures that pertain to such
agreements; developing and reviewing data breach procedures and policies; developing
and reviewing records management and electronic content management policies and
procedures; serving as the data access committee to handle requests for access to the
Corporation’s health care data and information through data trust agreements;
coordination with the State HIT coordinator; participation in the development of the
State HIT Strategic Plan under ARRA; and reporting to the Board any data breaches. The
Board may from time to time assign such other duties and functions to the Data Access
and Management Committee as deemed appropriate. The Executive Director shall be an
ex-officio, non-voting member of the Committee




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A-4 Current Functionalities for Data Exchanged Within the Major Hospitals & EHR Vendors in Hawai‘i
                                                                                       Hawaii Pacific Health: 25%                                                                                                                                       TOTAL
         Percent of Hawaii's Inpatient Discharges CY 2008
                    (proxity for level of hospital adoption)             4%           4%           3%             14%                                  19%          18%        11%          9%          5%     5%            2%        <1%               94%
                                                                                                        Kapi`olani                                                                     Kaiser                          North
                                                                 Kapi`olani                               Medical                                                The        Tripler    Medical                        Hawaii
                                                                  Medical       Straub      Wilcox       Center for Kauai          Kap`iolani                   Queens       Army      Center      Kuakini           Commun Rehabilitation
                                                                 Center at    Clinic and   Memorial     Women and Medical           Medical       HHSC- 13      Medical     Medical     and        Medical              ity   Hospital of the                   Team
                                                                 Pali Momi     Hospital    Hospital       Children  Clinic         Specialists    hospitals     Center      Center     Clinics     Center     Castle Hospital Pacific                           Praxis
CURRENT FUNCTIONALITIES FOR DATA EXCHANGE
Results Delivery (e.g. laboratory or diagnostic study results)       X            X            X              X            X            X              X            X           X          X          X          X       X               X                         X
Connectivity to electronic health records                            X            X            X              X            X            X                           X           X          X          X          X       X          3/1/2011                       X
Clincial documentation                                               X            X                           X            X            X                           X           X          X          X          X       X    Partial (full 3/1/2011)              X
Alerts to Providers                                                  X            X                           X            X            X                           X           X          X          X          X            Limited (full 3/1/2011)              X
Electronic Prescribing                                                                                                                                              X                      X                     X       X          3/1/2011                       X
Enrollment or eligibility checking                                   X            X            X              X            X            X              X            X           X          X          X          X       X               X                         X
Electronic referral processing                                       X            X            X              X            X            X              X                        X          X          X          X       X
Consultation/referral                                                X            X                           X            X            X                           X           X          X          X          X       X                                         X
Clinical Decision Support                                            X            X                           X            X            X                                       X          X          X                  X          3/1/2011                       X
Disease or Chronic Care Management                                   X            X                           X            X            X                           X           X          X          X          X       X                                         X
Quality Improvement reporting to Clnicians                           X            X            X              X            X            X                           X           X          X          X          X       X              X                          X
Ambulatory Order Entry                                               X            X            X              X            X            X                           X           X          X                     X       X              X                          X
Inpatient Order Entry                                                X                                        X            X            X                           X           X          X          X          X       X              X
Disease registries                                                                X                                        X                                        X           X          X                             X                                         X
Reminders                                                            X            X            X              X            X            X                           X           X          X          X                  X              X                          X
CCR/CCD summary record exchange                                      X            X            X              X            X            X              X            X                      X          X                                                            X
Public Health: case management                                       X            X            X              X            X            X              X            X           X          X          X
Public Health: surveillance                                                                                                                                         X           X          X          X
Quality perfromance reporting for purchases or payers                X            X            X              X            X            X              X            X                      X          X                  X             X                           X
Connectivty to personal health records                                            X                                        X                                        X                      X                                         Future

DATA CURRENTLY EXCHANGED
Laboratory                                                           X            X            X              X            X            X              X            X           X          X          X          X       X              X                          X
Medication Data (including outpatient prescriptions)                 X            X            X              X            X            X                                       X          X          X          X                                                 X
Outpatient laboratory results                                        X            X            X              X            X            X              X            X           X          X                     X                      X                          X
Outpatient episodes                                                  X            X            X              X            X            X                                       X          X                     X       X                                         X
Radiology results                                                    X            X            X              X            X            X              X            X           X          X          X          X       X              X                          X
Emergency Department Episodes                                        X            X            X              X            X            X              X                        X          X          X          X       X             N/A
Inpatient Diagnosis and procedures                                   X            X            X              X            X            X                                       X          X          X          X       X
Care Summaries                                                       X            X                           X            X            X                                       X          X          X          X       X                                         X
Inpatient Discharge summaries                                        X                                        X            X            X                                       X          X          X          X       X
Pathology                                                            X            X            X              X            X            X                           X           X          X          X          X       X                                         X
Dictation/transcription                                              X            X            X              X            X            X              X            X           X          X                     X       X              X                          X
Cardiology                                                           X            X            X              X            X            X                                       X          X          X          X       X             N/A                         X
Claims: pharmacy, medical, and/or hospital                           X            X            X              X            X            X              X            X           X          X          X          X       X              X                          X
Enrollment/eligibility                                               X            X            X              X            X            X              X            X           X          X          X          X       X              X                          X
Pulmonary                                                            X            X            X              X            X            X                                                  X          X          X       X             N/A                         X

Notes:
Tripler's data exchange is primarily for the DoD facilities on Oahu and to the large central DoD enterprise repository. They do not send data to agencies outside of the DoD other than the HHIC, for example.
While we've had electronic prescription for many years, it goes to our pharmacy and to the VA, not to civilian pharmacies.
Kaisesr's data exchange is within the Kaiser system only. Kaiser is an integrated model. They do not 'exchange' data with anyone else, especially medical/phi type data unless it is for electronic billing. If the
word 'exchange' means passing data between disparate systems but still within Kaiser, then the answer would change to yes because we have extensive integration services.




Hawai‘i Health Information Exchange
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A-5 Basic Data for Hawai‘i Hospitals
(Data source: Individual hospital websites supplemented by HHIC data.)

                                                                                                average
                                                                                                annual
 Hospital                                     # of beds     # employees       # physicians      admittance
 Hawai‘i Health Systems Cooperation
 Maui Memorial Medical Center
 221 Mahalani Street Wailuku, Hawai‘i
 96793-2581                                   231           1200              200               12,193
 Kula Hospital
 100 Keokea Place Kula, Hawai‘i 96790-7450    104           195                                 129
 Lāna‘i Community Hospital
 628 Seventh St Lāna‘i City, HI 96763-0650    14            31                                  37
 Hilo Medical Center
 1190 Waianuenue Ave Hilo, HI 96720-2095      271                                               8,797
 Ka'u Hospital
 1 Kamani St. Pahala, Hawai‘i, 96777          21            46                                  50
 West Kaua‘i Medical Center
 4643 Waimea Canyon Dr. Waimea, Kaua‘i,
 HI 96796                                     45            205                                 1047
 Hale Ho'ola Hamakua
 45-547 Plumeria Street Honokaa, Hawai‘i
 96727-6902                                   50            83                                  85
 Samuel Mahelona Medical Hospital 4800
 Kawaihau Road Kapaa, Hawai‘i 96746           80            135                                 201
 Kona Community Hospital
 79-1019 Haukapila Street Kealakekua,
 Hawai‘i 96750-7920                           94            413               61                3582
 Kohala Hospital
 54-383 Hospital Road Kohala, Hawai‘i
 96755                                        28            54                                  56
 Leahi Hospital
 3675 Kilauea Avenue Honolulu, Hawai‘i
 96816-2398                                   190           151                                 158
 Maluhia Hospital
 1027 Hala Drive Honolulu, HI 96817           158           250                                 205
 Kahuku Medical Center
 56-117 Pualalea Street Kahuku, Hawai‘i
 96731-2052                                   21
 Hawai‘i Pacific Health                       553           5,427             1,342             34,166
 Kapi‘olani Medical Center for Women and
 Children
 1319 Punahou Street Honolulu, Hawai‘i        207 + 90
 96826-1032                                   bassinets     1,328             612               17,968
 Kapi‘olani Medical Center at PaliMomi 98-
 1079 Moanalua Road Aiea, Hawai‘i 96701-
 4713                                         116           905               375               5,863



Hawai‘i Health Information Exchange
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                                                                                                average
                                                                                                annual
 Hospital                                      # of beds    # employees       # physicians      admittance
 Straub Clinic and Hospital
 888 South King Street Honolulu, Hawai‘i
 96813-3083                                    159          1,341             181               6,622
 Wilcox Health
 3-3420 Kuhio Highway Lihue, Hawai‘i
 96766-1099                                    71           565                174              3,992
 Kuakini Health System
 347 North Kuakini Street Honolulu, Hawai‘i
 96817-2381                                    250                            175
 North Hawai‘i Community Hospital
 67-1125 Mamalahoa Highway Kamuela,
 HI96743                                       35
 Rehabilitation Hospital of the Pacific
 226 North Kuakini Street Honolulu, Hawai‘i
 96817-9881                                    100                            16
 Queen’s Medical Center
 1301 Punchbowl Street Honolulu, Hawai‘i
 96813-2499                                    533          3,000             1,200
 Moloka'i General Hospital
 280A Puali Street Kaunakakai, HI 96748        15
 Shriners Hospital
 1310 Punahou Street Honolulu, Hawai‘i
 96826-1099                                    20
 Hawai‘i Medical Center                                                       130
 Hawai‘i Medical Center East
 2226 Liliha St. Honolulu, HI96817             308
 Hawai‘i Medical Center West
 91-2141 Fort Weaver Rd Ewa Beach, HI
 96706                                         102
 Castle Medical Center
 640 Ulukahiki Street Kailua, Hawai‘i 96734-
 4498                                          160          1,000             248
 Hawai‘i State Hospital
 45-710 Keaahala Road Kaneohe, Hawai‘i
 96744-3597                                    194
 Kahi Mohala Behavioral Health
 91-2301 Old Fort Weaver Rd Ewa Beach,
 HI 96706-3602                                 88           16
 Kaiser Permanente Medical Center
 3288 Moanalua Rd Honolulu, HI 96819-
 1469                                          275
 Wahiawa General Hospital
 3-3420 Kuhio Highway Lihue, Hawai‘i
 96766-1099                                    162




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A-6 List of All Stakeholder Meetings as Part of the Strategic and
Operational Planning Process
•   April 14. Meeting with chair of Governance Committee 10a-11a
•   April 15. Data Access and Management Committee Meeting 1:30p-2:30p
•   April 16. Meeting with Chair of Technical Infrastructure Committee 12p-1p
•   April 19. Conference Call Meeting with Chair of Finance Committee 10a-11a
•   April 20. State HIE Leadership Forum Conference 8a-9a
•   April 23. HHIE Stakeholder Day 12p-9p
•   April 26. Finance Committee Meeting 8a-10a
•   April 27. Technical Infrastructure Committee Meeting 12:30p-2p
•   April 28. Data Access and Management Committee Meeting 10:30a-12p
•   April 29. Technical Infrastructure Committee Meeting 9:30a-11a
•   April 30. Governance Committee Meeting 12p-1:30p
•   May 4. HHIE Expert Meeting—Noam Artz Presenting 8a-4p
•   May 14. Legal and Policy Committee Meeting 12p-1:30p
•   May 17. Technical Infrastructure Committee Meeting 1:30p-3p
•   May 19. Data Access and Management Committee Meeting
•   May 19. Finance Committee Meeting 2:30p-4p
•   May 27. Legal and Policy Committee Meeting 11:45a-1p
•   June 1. Data Access and Management Committee Meeting 3:30p-5p
•   June 3. Legal and Policy Committee Meeting 11:45a-1:15p
•   June 4. Governance Committee Meeting 9a-10:30a
•   June 4. Technical Infrastructure Committee Meeting 12:30p-2p
•   June 14. Finance Committee Meeting 9a-10:30a
•   June 15. Technical Infrastructure Committee Meeting 1p-2:30p
•   June 17. Data Access and Management Committee Meeting 2p-3:30p
•   June 21. Governance Committee Meeting 1:30p-3p
•   June 21. Legal and Policy Committee Meeting 3p-4:30p
•   June 24. Lāna‘i Outreach Meeting 9:30a-12:30p
•   June 25. Big Island Outreach Meeting Kona 8a-11a; Hilo 4p-7p
•   June 28. Kaua‘i Outreach Meeting 4:30p-7:30p
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•   June 29. Moloka‘i Outreach Meeting 1:00p-2:30p
•   June 30. Maui Outreach Meeting 7:30a-10:30a
•   July 6. Legal and Policy Committee Meeting 3p-4:30p
•   July 20. Board of Directors Meeting 9a-10:30a




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A-7 Board Membership and Stakeholder Representation
   Hawai‘i HIE Board                           Position                    Stakeholder Interest
       Members
Money Atwal                        CIO/CFO, HHSC East Hawai‘i          Public Hospital-Neighbor
                                   Region (Hilo Medical                Island Representative
                                   Center)
Francis Chan                       CIO, Clinical Laboratories of       Laboratory
                                   Hawai‘i, LLP
Jennifer Diesman                   Vice President Government           Health Plan
                                   Relations, Hawai‘i Medical
                                   Service Association
Susan Forbes, Ph. D                (Ret.) President and CEO,           Health Data Reporting
                                   Hawai‘i Health Information
                                   Corporation
Beth Giesting                      CEO, Hawai‘i Primary Care           Federally Qualified Health
                                   Association                         Centers
Bruce “Skip” Keane                 Retired                             Community Member
Emmanuel Kintu                     Executive Director, Kalihi-         Federally Qualified Health
                                   Pālama Health Center                Centers
Janet Liang                        President, Hawai‘i Region,          Integrated Hospital System
                                   Kaiser Permanente Health
                                   Plan
Wesley Lo                          CEO, Maui Memorial                  Neighbor Island Hospital
                                   Medical Center
Roy Magnusson, M.D.                Associate Dean, Clinical,           University
                                   University of Hawai‘i, John
                                   A. Burns School of Medicine
John McComas                       CEO, Aloha Care                     Health Plan
Gary Okamoto, M.D.                 Past President, Hawai‘i             Independent Physician
                                   Medical Association
Kevin Roberts                      President and CEO, Castle           Hospital System
                                   Medical Center
Steve Robertson                    Executive V.P. and CIO,             Integrated Delivery
                                   Hawai‘i Pacific Health              Network
David Saito, M.D.                  Officer, Hawai‘i                    Independent Physician
                                   Independent Physicians
                                   Association
Barbara Stanton                    Sr. State Director, American        Community Member
                                   Association of Retired
                                   Persons
Jim Tollefson                      President and CEO, Hawai‘i          Business
                                   Chamber of Commerce


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     Hawai‘i HIE Board                         Position                    Stakeholder Interest
        Members
Lisa Wong                          Human Resource Manager,             Business
                                   Society of HR Managers of
                                   Hawai‘i
Raymond Yeung                      Vice President Information          Laboratory
                                   Services, Diagnostic
                                   Laboratory Services, Inc.
Jeffrey Yu, M.D.                   CTO, The Queen’s Health             Hospital System
                                   System

Data in this section were extracted from presentations made to a stakeholder meeting, April 23, 2010.
See bibliography for further information.


A-8 Proposed Nomination Process for Hawai‘i HIE Board
Step One: The board, guided by input from its Governance Committee, should review
the current distribution of board seats to determine a desired distribution.

Recommendation One: Each health care sector that must be represented should be
done so by stating the minimal number of seats that sector should have, e.g. hospitals
(3), independent physicians (3), health care plans (3), ancillary services (2), consumers
(3) etc. It is suggested that other HIEs be considered a sector for this purpose and
provide representation. After that minimal number is established, the remainder should
be designated “at large,” with the understanding that in the main this refers to the
health care community, including consumers. It is also recommended that the chair of
the State of Hawai‘i High Technology Taskforce sit on the board ex officio to ensure
effective communication between the state and Hawai‘i HIE as a SDE.

The task to be done is for the Governance Committee to provide such a plan to the
board for its endorsement, with a given date for implementing the plan as a necessary
step in permitting the current board to serve out its terms.

Step Two: The board, guided by input from its Governance Committee, (a) establishes
the beginning date of the current term cycle, and (b) sets a rotational schedule for
current board seats and occupants, with the assumption that the board refreshes on
average 1/3 per year.

Step Three: The board, guided by input from its Governance Committee, establishes a
limit for individual board positions, e.g. one or two, three-year consecutive terms. A
given individual could return to the board after a break, either to occupy a seat
designated as a sector seat, or in an at-large seat.

Step Four: Key stakeholders review and comment on the process prior to its adoption.


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Step Five: Six months prior to the end of the term-designated year (which should
probably coincide with the fiscal year), the Governance Committee, acting as a
nominating committee, will circulate broadly within the stakeholder community a
request for nominations identifying the sectoral representation of the seats up for
election (which can and probably should include at large seats). Nominations from
throughout the stakeholder community are welcomed and elicited.

Step Six: Nominees are contacted by the Governance Committee, acting as a
nomination committee, and requested to indicate their willingness to stand for the
board (and provided a minimal information packet). If the person is willing, she/he is to
provide a brief résumé to the committee and requested to provide supporting letters if
the candidate so desires.

Step Seven: When the committee has a complete slate of candidates (which needs to
be larger than the number of seats available), publication of the nomination list should
take place, probably on the organization website. Comments are welcomed and
solicited. In compiling the slate, the nominations committee needs to assure both
sufficient sectoral and geographic (neighbor islands) representation will result from the
election.

Step Eight: At the end of the comment period, the nomination committee provides a
slate of nominees to the board with any recommendations that it chooses to make.

Step Nine: The board chooses new members (or renewed terms) for the presented
slate.

Step Ten: At the end of the first and second year cycles of this process, the process will
be formally evaluated by the Executive Committee to assure that it is operating in line
with its explicit or implied principles of inclusivity and transparency.

Recommendation Two: The board, as a board, should submit to its own evaluation on
either an annual or a biennial basis to assure its own effective and efficient functioning.

Note: This process “opens” the board selection process more broadly than most 501
organizations employ. To some extent, it replicates the “comment” period used by
some public or semi-autonomous organizations, such as universities, to allow interested
constituencies to participate.




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A-8 Current Board Charters and Committee Members
Overview
Excerpt from Amended and Restated By-Laws Adopted 11/17/2009:

SECTION 5.1. Committees. The Board of Directors may create and appoint standing or
ad hoc committees of any kind as the business of the Corporation may require and
define the authority and duties of such committees, except that such committees shall
not have such powers as are reserved to the Board of Directors by statute or otherwise.
The President shall appoint all committee chairs and members of the committees
subject to confirmation by the Board of Directors, unless otherwise provided in this
Article.

In addition, the Cooperative Agreement for Health Information Exchange defines six
domains for which Hawai‘i HIE has created working committees:




The charters of the committees defined in our bylaws and in the cooperative agreement
are described in the following tables, along with their membership.




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A-9.1 Executive Committee

                                        Excerpt from By-Laws:

    SECTION 5.4. Executive Committee. The Officers, Chairpersons of the Permanent
    Committees, Chairpersons of the Ad Hoc Committees and Immediate Past President
    shall serve as the members of the Executive Committee. The President of the Board
    of Directors shall serve as the chair of the Executive Committee. The Executive
    Director shall also serve as a non-voting member of the Executive Committee. The
    Executive Committee shall perform such functions and duties and shall have such
    powers and authority as determined from time to time by the Board of Directors.
    The Executive Committee shall oversee and be responsible for issues relating to
    finance, governance and human resources. The Executive Committee, unless
    otherwise directed by the Board, shall meet at least monthly.

    Chair: Steve Robertson, President
    Members:
    Money Atwal, Treasurer
    Jennifer Diesman, Chair, Legal and Policy Committee
    Susan Forbes, Ph.D., Chair, Governance Committee
    Skip Keane, Secretary
    Gary Okamoto, M.D., Vice President
    Christine Sakuda, Executive Director
    Raymond Yeung, Chair, Data Access and Management Committee
    Jeffrey Yu, M.D., Chair, Technical Infrastructure and Standards




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A-9.2 Governance Committee

           Excerpt from By-Laws:                                       HITECH Domain:
SECTION 5.7. Governance Committee.                   Governance
There shall be a permanent Governance                This domain addresses the functions of
Committee consisting of at least three (3)           convening health care stakeholders to create
members, all of whom shall be Directors of           trust and consensus on an approach for
the Corporation. The President of the                statewide HIE and to provide oversight and
Corporation shall appoint the chair of the           accountability of HIE to protect the public
Committee. The duties of the Governance              interest. One of the primary purposes of a
Committee shall the include nomination of            governance entity is to develop and maintain a
new officers and directors;                          multi-stakeholder process to ensure HIE among
recommendations regarding the removal                providers is in compliance with applicable
of any Officer or Director of the                    policies and laws.
Corporation; periodic review and proposal            Key accomplishments to be met by the
of amendments of the By-Laws and                     recipients in the first two years include:
Articles of Incorporation; periodic review           • Establish a governance structure that
and proposal of amendments of the                        achieves       broad-based        stakeholder
policies and procedures of the Board;                    collaboration with transparency, buy-in and
periodic self-assessments of the Board and               trust.
Corporation; develop and review of a
                                                     •   Set goals, objectives and performance
compliance plan and policies;
                                                         measures for the exchange of both health
development and maintenance of a
                                                         information that reflect consensus among
continuing education program for the
                                                         the health care stakeholder groups and that
Board; periodic review and revision of the
                                                         accomplish statewide coverage of all
conflicts policy of the Corporation;
                                                         providers for the HIE requirements related
periodic review and revision of the
                                                         to Meaningful Use criteria to be established
organizational chart of the Corporation;
                                                         by the Secretary through the rulemaking
planning of Board retreats; conducting of
                                                         process.
the annual appraisal of the performance of
the Executive Director and reporting the             •   Ensure the coordination, integration, and
results of such appraisal to the Board; and              alignment of efforts with Medicaid and
such other duties as are assigned by the                 public health programs through efforts of
Board to the Committee. The Governance                   the State Health IT Coordinators.
Committee shall serve as the Board                   •   Establish mechanisms to provide oversight
designated entity to receive any                         and accountability of HIE to protect the
compliance complaints. The Executive                     public interest.
Director shall be an ex-officio, non-voting
member of the Committee.                             •   Account for the flexibility needed to align
                                                         with emerging nationwide HIE governance
                                                         that will be specified in future program
                                                         guidance.

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A-9.3 Finance Committee
            Excerpt from By-Laws:                                    HITECH Domain:
 SECTION 5.9. Finance Committee. There               Finance
 shall be a permanent Finance Committee              This domain encompasses the
 consisting of at least three (3) members,           identification and management of
 all of whom shall be Directors of the               financial resources necessary to fund
 Corporation. The Treasurer of the                   health information exchange. This domain
 Corporation shall serve as Chair of the             includes public and private financing for
 Finance Committee. The duties of the                building HIE capacity and sustainability.
 Finance Committee shall include:                    This also includes, but is not limited to,
 developing and reviewing fiscal                     pricing strategies, market research, public
 procedures and policies; reviewing the              and private financing strategies, financial
 annual budget of the Corporation and                reporting, business planning, audits, and
 making recommendations about the                    controls.
 budget to the Board; developing a plan to           Key accomplishments to be met by the
 transition from federal and/or state                recipients in the first two years include:
 funding to other funding sources to                 • Develop the capability to effectively
 sustain the Corporation; and reporting                  manage       funding     necessary     to
 periodically on the financial status of the             implement the state Strategic Plan.
 Corporation to the Board. The Board may                 This     capability    should     include
 assign such other duties from time to                   establishing financial policies and
 time to the Finance Committee. The                      implementing procedures to monitor
 Executive Director shall be an ex-officio,              spending and provide appropriate
 non-voting member of the Committee.                     financial controls.
                                                     •    Develop a path to sustainability
                                                          including a business plan with feasible
                                                          public/private financing mechanisms
                                                          for ongoing information exchange
                                                          among health care providers and with
                                                          those offering services for patient
                                                          engagement and information access.




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A-9.4 Audit Committee
           Excerpt from By-Laws:                                     HITECH Domain:
 SECTION 5.6. Audit Committee. If there
 is an annual audit, then there shall be a
 permanent Audit Committee consisting of
 three (3) members, all of whom shall be
 Directors of the Corporation. The
 President of the Corporation shall appoint
 the chair of the Committee. The duties of
 the Audit Committee shall include review
 of the annual audit of the Corporation,
 review of the annual audit, selection of
 the auditor, and other matters relating to
 the audit of the Corporation. The Board
 may assign such other duties to the Audit
 Committee.




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A-9.5 Legal and Policy Committee
            Excerpt from By-Laws:                                  HITECH Domain:
 SECTION 5.8. Legal Policy Committee.                Legal and Policy
 There shall be a permanent Legal Policy             The mechanisms and structures in this
 Committee consisting of at least three (3)          domain address legal and policy barriers
 members, all of whom shall be Directors             and enablers related to the electronic use
 of the Corporation. The President of the            and exchange of health information. These
 Corporation shall appoint the chair of the          mechanisms and structures include but are
 Committee. The duties of the Legal Policy           not limited to: policy frameworks, privacy
 Committee shall include: developing and             and security requirements for system
 reviewing contract and grant procedures             development and use, data sharing
 and policies; coordinating the monitoring           agreements, laws, regulations, and multi-
 of all contracts and grants with the                state policy harmonization activities. The
 Executive Director and staff of the                 primary purpose of the Legal and Policy
 Corporation; negotiating and analyzing              domain is to create a common set of rules
 contracts and grants in coordination with           to enable inter-organizational and
 the Executive Director and staff;                   eventually interstate health information
 investigating and reporting any contract            exchange, while protecting consumer
 breaches or grant violations to the Board           interests.
 and negotiating any resolution of such              Key accomplishments to be met by the
 breaches or violations; and such other              recipients in the first two years include:
 duties as are assigned by the Board to the          • Identify and harmonize the federal and
 Committee. The Executive Director shall                 state legal and policy requirements
 be an ex-officio, non-voting member of                  that enable appropriate health
 the Committee.                                          information exchange services that will
                                                         be developed in the first two years.
                                                     •   Establish a statewide policy framework
                                                         that allows incremental development
                                                         of HIE policies over time, enables
                                                         appropriate,        inter-organizational
                                                         health information exchange, and
                                                         meets other important state policy
                                                         requirements such as those related to
                                                         public     health    and      vulnerable
                                                         populations.
                                                     •   Implement enforcement mechanisms
                                                         that ensure those implementing and
                                                         maintaining      health    information
                                                         exchange services have appropriate
                                                         safeguards in place and adhere to legal
                                                         and policy requirements that protect
                                                         health information, thus engendering

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            Excerpt from By-Laws:                                 HITECH Domain:
                                                         trust among HIE participants.
                                                     •   Minimize obstacles in data sharing
                                                         agreements, though, for example,
                                                         developing accommodations to share
                                                         risk and liability of HIE operations fairly
                                                         among all trading partners.
                                                     •   Ensure policies and legal agreements
                                                         needed to guide technical services
                                                         prioritized by the state or SDE are
                                                         implemented and evaluated as a part
                                                         of annual program evaluation.




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A-9.6 Technical Infrastructure Committee
              Excerpt from By-Laws:                                        HITECH Domain:
 SECTION 5.5. Technical Infrastructure and                 Technical Infrastructure
 Standards Committee. There shall be a                     This domain includes the architecture,
 permanent Technical Infrastructure Committee              hardware, software, applications, network
 consisting of at least three (3) members, all of          configurations and other technical aspects
 whom shall be Directors of the Corporation.               that physically enable the technical services
 The President of the Corporation shall appoint            for HIE in a secure and appropriate manner.
 the chair of the Committee. The duties of the             Business and Technical Operations
 Committee shall include: development of the               The activities in this domain include but are
 technical infrastructure and HIT plan for the             not limited to procurement, identifying
 statewide Hawai‘i Health Information                      requirements, process design, functionality
 Exchange; development of data exchange                    development, project management, help
 standards; development of a plan to interface             desk, systems maintenance, change control,
 the Hawai‘i health information exchange with              program evaluation and reporting. Some of
 the federal health information exchange or                these activities and processes are the
 other governmental or private exchanges;                  responsibility of the entity or entities that
 coordination with the State HIT coordinator;              are implementing the technical services
 participation in the development of the State             needed for health information exchange;
 HIT Strategic Plan under ARRA; and other                  there may be different models for
 technical issues relating to the purpose of the           distributing operational responsibilities.
 Hawai‘i Health Information Exchange. The                  Key accomplishments to be met by the
 Executive Director shall be an ex-officio, non-           recipients in the first two years include:
 voting member of the Committee.                           • Develop or facilitate the creation of a
                                                               statewide technical infrastructure that
                                                               supports statewide HIE. While states
                                                               may prioritize among these Hawai‘i HIE
                                                               services according to their needs,
                                                               Hawai‘i HIE services to be developed
                                                               include:
                                                           •    Electronic prescribing and refill requests
                                                           •    Electronic clinical laboratory ordering
                                                                and results delivery
                                                           •    Electronic public health reporting (i.e.,
                                                                immunizations, notifiable laboratory
                                                                results)
                                                           •    Quality reporting
                                                           •    Prescription fill status and/or medication
                                                                fill history
                                                           •    Clinical summary exchange for care


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               Excerpt from By-Laws:                                      HITECH Domain:
                                                                coordination and patient engagement
                                                           •    Leverage existing regional and state level
                                                                efforts and resources that can advance
                                                                HIE, such as master patient indexes,
                                                                health information organizations (ex:
                                                                HHIC), and Medicaid Management
                                                                Information System (MMIS).
                                                           •    Develop and facilitate the creation and
                                                                use of shared directories and technical
                                                                services, as applicable for the state’s
                                                                approach for statewide HIE. Directories
                                                                may include, but are not limited to:
                                                                Providers (e.g., with practice location(s),
                                                                specialties, health plan participation,
                                                                disciplinary actions, etc.); laboratory
                                                                service providers, radiology service
                                                                providers, health plans (e.g., with
                                                                contact     and      claim     submission
                                                                information, required laboratory or
                                                                diagnostic imaging service providers,
                                                                etc.). Share services may include, but
                                                                are not limited to: patient matching,
                                                                provider     authentication,      consent
                                                                management, secure routing, advance
                                                                directives and messaging.




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A-9.7 Data Access and Management Committee
         Excerpt from By-Laws:                                    HITECH Domain:
 SECTION 5.10. Data Access and                 Data Access and Management
 Management Committee.                         This domain primarily sets and administers rules
 There shall be a permanent Data               and user agreements around the practices of
 Access and Management Committee               accessing, sharing and using of patient health data
 consisting of at least three (3)              that are originated from the HIE infrastructure.
 members, all of whom shall be                 These rules and agreements align with the high
 Directors of the Corporation. The             level privacy and security policies established by
 duties of the Data Access and                 the Legal and Policy Domain. The Data Access and
 Management Committee shall                    Management Domain also sets prerequisites on
 include developing and reviewing all          data accessibility, availability and privacy that the
 legal policies including, but not             Technical Infrastructure Domain incorporates into
 limited to: the privacy policy,               the HIE technical design. As part of operations, the
 security policy, and the data access          Data Access and Management Domain administers
 policy of the Corporation;                    requests for data access and monitors and audits
 developing, negotiating and                   data exchanged via the HIE infrastructure.
 approving data trust agreements,              Key accomplishments to be met by the recipients
 such as data sharing or data use              in the first two years include:
 agreements and policies and                   • Develop State level policies and procedures
 procedures that pertain to such                   including, but not limited to, the access, sharing
 agreements; developing and                        and use of patient health data originating from
 reviewing data breach procedures                  the HIE infrastructure.
 and policies; developing and
                                               •   Develop and implement State level data trust
 reviewing records management and
                                                   agreements including those pertaining to the
 electronic content management
                                                   access, sharing and use of health data that
 policies and procedures; serving as
                                                   contains identifiable patient(s) originating from
 the data access committee to handle
                                                   the HIE infrastructure.
 requests for access to the
 Corporation’s health care data and            •   Develop and implement State level data trust
 information through data trust                    agreements including those pertaining to the
 agreements; coordination with the                 access, sharing and use of discrete or aggregate
 State HIT coordinator; participation              health data that do not contain identifiable
 in the development of the State HIT               patient(s)    originating    from     the    HIE
 Strategic Plan under ARRA; and                    infrastructure.
 reporting to the Board any data               •   Develop and implement a mechanism to handle
 breaches. The Board may from time                 requests to activate, update and remove user
 to time assign such other duties and              access in a timely manner.
 functions to the Data Access and
 Management Committee as deemed                •   Develop the mechanism to monitor and audit
 appropriate. The Executive Director               the level of compliance with the data trust
 shall be an ex-officio, non-voting                agreements.
 member of the Committee.                      •   Develop and implement an efficient reporting

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                                                   mechanism on data breaches to the Board.




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A-10 Hawai’i HIE Privacy and Security Policy
Hawai‘i Island Health Information Exchange (HHIE) Project Privacy and
Security Policy
Goal: The primary goal is to enhance medical care available to Hawai‘i Island patients by
providing patient information to those who need it for treatment, payment and health
care operations (including quality improvement), while adhering to all state and federal
patient privacy protections.

A secondary goal is to enhance the efficiency of public health surveillance and research,
which benefits the local and global community.

Definitions: All terms used in this policy that are defined in HIPAA regulations are
italicized, and abbreviated definitions for these terms are provided below for
convenience only. For purposes of policy application and interpretation, definitions used
in the HIPAA regulations apply:

http://www.hhs.gov/ocr/privacy/hipaa/administrative/privacyrule/index.html

Authorized Representative: A person who has the legal authority to consent to release of
another person’s Protected Health Information.

Business Associate: A vendor who is performing services for a Covered Entity and in the
course of performing the services will use Protected Health Information. Business
Associates enter into written agreements with Covered Entities to protect and secure
the Protected Health Information and use it only for purposes agreed upon.

Covered Entity: The term includes but is not limited to physicians, hospitals, health plans
and clinics.

Data User: An entity that signs a data use agreement with HHIE for purposes other than
payment, treatment and health care operations.

End User: The employee or agent of a Covered Entity or Business Associate.

Hawai‘i Island Health Information Exchange (HHIE): An entity to which Protected Health
Information is transferred and then shared electronically among physicians, clinics,
health plans, hospitals and others according to agreed upon standards and protocols.

DRAFT 5/18/2010 9:08 PM

HIPAA (The Health Insurance Portability and Accountability Act): Except when states
provide stricter protections, it allows the free exchange of Protected Health Information
between Covered Entities and their Business Associates for the purposes of treatment,
payment and health care operations.

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Participant: A Covered Entity that signs a Participant Agreement with the HHIE.

Protected Health Information: Patient identifiable information about the past, present,
or future physical or mental health or condition of an individual.

Research: A systematic investigation designed to develop or contribute to generalizable
knowledge.

Parameters:

1.      HHIE recognizes that Protected Health Information can be exchanged under
certain circumstances without specific consent. HHIE will not participate in the exchange
of protected health information except in a medical emergency situation where the
patient or their authorized representative is unable to provide consent, in accordance
with state law unless a patient's consent is on file. Once consent is obtained, HHIE will
enhance the flow of information by making it electronically available to participants and
data users, while always adhering to HIPAA standards.

2.      With respect to information in the HHIE that requires consent:

a.      Consent needs to be obtained by only one Participant to apply to all Participants.

b.    Participants should seek to obtain consent whenever in contact with a patient
who does not have a valid consent on file.

c.      Consent will be for release of Protected Health Information by the HHIE to
Participants or their Business Associates for the purposes of treatment, payment or
health care operations.

d.     Participants may access Protected Health Information only for their own
patients. DRAFT 5/18/2010 9:08 PM

e.     Consent does not imply release to Data Users. Data Users must comply with
additional requirements under state and federal human research subject regulations.

3.     Consent will be valid for 10 years unless revoked. When consent expires or is
revoked, that patient’s Protected Health Information in the HHIE will be blocked from
release as soon as practical.

4.    Consent cannot be for partial information nor can it exclude Protected Health
Information from a particular Participant.

5.     All Participants, End Users and Data Users must sign agreements promising to
protect and secure Protected Health Information obtained from the HHIE.



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6.     Research and public health surveillance are not included in definitions of
treatment, payment and health care operations. Participants, Data Users and End Users
MAY NOT use Protected Health Information for purposes such as research and public
health surveillance, except in accordance with relevant HIPAA regulations.

7.     Except as set forth in item #8, information which relates to any services provided
to a minor from 14 through 17 years of age shall not be released by the HHIE without
consent of both (a) the minor and (b) the minor's parent or guardian.

8.     An emancipated minor or a minor without support from 14 through 17 years of
age, authorized by statute to consent to treatment, has the exclusive authority to
consent to disclosure of his or her Protected Health Information.




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A 11 - List of Technical Features Considered for Future Inclusion in the
System
The technical infrastructure committee conducted the following exercise to develop its
initial prioritization list for system construction.

For each technical function, please answer the following 3 questions:

                 How important is this function? Select one.
                   1 = Not at all important
                   2 = Somewhat important
                   3 = Very important
                   4 = Critically important
                   5 = Not sure / not applicable

                 What is the relevant time frame for this activity? Select one.
                 (Revised)
                    a—short term
                    b—intermediate
                    c—long-term

                 What entity should provide this service? Check one, both or neither.
                 (Revised)
                    A state-level HIE entity
                    A regional or local HIE entity

                 For example: The response to the first item might be: 4, a, state

                     Connection to a Nationwide Health Information Network (NHIN) – A
                     set of services that allow Hawai‘i stakeholders to connect to data
                     seekers and data providers outside of Hawai‘i by connecting to a
                     national “network of networks,” thereby enabling health information
                     exchange to occur at a national level

                     Patient Identifier Services – A methodology and related services used
                     to uniquely identify an individual person as distinct from other
                     individuals and connect his or her clinical information across multiple
                     providers using an Enterprise Master Patient Index (EMPI)

                     Record Locator Services– A mechanism for identifying and matching
                     multiple patient records together from different data sources

                     Audit Trail Services – A mechanism for tracking when, where and
                     what data was accessed and who accessed the data through an HIE
                     entity


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                     Cross-Enterprise User Authentication Services – A mechanism for
                     identifying and authenticating clinical system users to validate their
                     right to access clinical information based upon privacy rules, patient
                     consent and individual user and organizational roles

                     Clinical Portal – A web-based service offered to providers for
                     accessing, viewing and downloading clinical data available from data
                     sources connected to an HIE

                     Terminology Services – A service that ties together technology,
                     nomenclature, data-element or coding-transaction standards across
                     disparate systems, normalizing (among others) HIPAA-standard
                     transaction sets including HL7 and ANSI, LOINC, SNOMED CT,
                     RxNorm, ICD, NCPDP, HCPCS, CPT, and document terminology

                     Patient Consent Management Services – A process for defining levels
                     of patient consent and for tracking those consents and authorizations
                     to share personal health information through an HIE entity

                     De-identification Services – A mechanism for removing demographic
                     and other person-identifying data from personal health information
                     and other health care data so that they can be used for public health
                     reporting, quality improvement, research, benchmarking and other
                     secondary uses

                     Data Transformation Services – A mechanism for facilitating the
                     intake of data in largely standardized format from multiple disparate
                     sources in real-time or batching through the use of an integration
                     engine, which collates data into consolidated and uniform format for
                     display or exchange.

                     Population Health Services – A set of services that fulfill various state
                     and federal public health and chronic disease management practice
                     requirements – such as biosurveillance, predictive modeling and
                     health risk assessment – by leveraging and aggregating data available
                     through an HIE entity

                     Benchmarking and Reporting Service – A set of services that define
                     and deliver a set of reports that leverage data available through an
                     HIE entity and provide the public and provider organizations with
                     information that can be used to fulfill pay-for-performance or
                     Medicare and Medicaid incentive requirements, facilitate process
                     improvement, etc.



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                     Advance Directives Management Services – A set of services that
                     maintain and exchange a patient’s legal documentation such as a
                     living will, durable power of attorney for health care, etc.

                     Patient Registry Connectivity Services – A set of services that enable
                     providers to connect to multiple existing state and national patient
                     registries (e.g., Hawai‘i immunization registry) using common
                     standards and interfaces

                     Electronic Health Record Provisioning Services – A set of services
                     that establish group purchasing or licensing agreements for, and
                     assist with implementation of EHR applications for interested
                     providers within Hawai‘i

                     Clinical Decision Support Services – A mechanism for distributing
                     standardized clinical rules that can be incorporated into EHR or e-
                     Prescribing systems in support of clinical decision making at the point
                     of care

                     Medication History Exchange – A mechanism for facilitating the
                     delivery of patient prescription history to providers for use in
                     prescribing, clinical care and medication management

                     Lab Results Exchange – A mechanism for facilitating the delivery of
                     patient lab results for use in clinical care

                     Personal Health Record Exchange Services – A mechanism for
                     facilitating the electronic delivery of personal health information to
                     individual patients’ personal health records

                     Support for “Meaningful Use” of EHRs – Assistance and services to
                     providers in support of their efforts to meet the “Meaningful Use”
                     requirements for receiving incentive funding from Medicare and
                     Medicaid under the American Recovery and Reinvestment Act

                     Other – Please define: (Note: the radiology items were suggested in
                     general at the meeting, but amplified in this form by email later. The
                     non-radiological results were added after the meeting and ranked by
                     proposer.)

                     Radiology Results Exchange– A mechanism for facilitating the
                     delivery of patient radiology interpretations for use in clinical care

                     Radiology Image Exchange–A mechanism for facilitating the delivery
                     of patient radiology images for use in clinical care, preferably using


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                     standard DICOM-compliant tools to allow clinical-quality image
                     comparison between images obtained at different sites

                     Medical Encounter Note Exchange–A mechanism for facilitating the
                     delivery of patient medical notes for use in clinical care. This should
                     include the following: hospital discharge summaries, clinical
                     consultations, operative reports, emergency room encounter notes,
                     and ambulatory clinic encounter notes

                     Connection to Regional HIEs – A set of services that enable the bi-
                     directional exchange of health information between the Hawai‘i HIE
                     and regional HIEs inside or outside of Hawai‘i

                     Performance – Ability to provide system response times for
                     interactive transactions that do not have a negative impact on end
                     user productivity

                     System Availability and Reliability – Ability to provide reliable access
                     to critical system functions at a high level of availability on a 24 x 7 x
                     365 basis

                     Eligibility Information–Ability to identify patient eligibility for benefit
                     services

                     Claims/Billing Information–Ability to submit claims electronically and
                     to check their payment status. Ability to bill participating institutions
                     for services rendered.

                     Service Order Entry–Ability to submit and track orders for services
                     requested between participating institutions. Includes pharmacy,
                     laboratory, and other service orders.

                     Provider registry–List of providers and their areas of specialty for
                     information routing and referrals.




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A-12 Listing of Data Elements Developed for Prioritization by Data Access &
Management Committee
The following is a discussion regarding necessary data elements revolved around the
distinction of data necessary for treatment (and therefore necessary for exchange) and
the data necessary for reporting purposes (such as that currently performed by Hawai‘i
Health Information Corporation—HHIC). Data elements for both treatment and
reporting are categorized below. An inventory of data currently collected monthly from
all acute hospitals by HHIC is included as 5.4. Note: data collected by HHIC is available to
qualified users via HHIC’s Online Reports, a web portal that is updated monthly, with the
newest data reflecting discharges or visits 3 months ago.

•   Data Elements needed to identify the patient:
             o Patient demographics - patient information includes names, social
               security number (SSN), gender, race/ethnicity, date of birth, residence,
               marital status, religion, place of birth, occupation and industry, and
               socioeconomic status.
             o Master Patient Index -Master Patient Index (MPI) is a database that
               maintains a unique index (or identifier) for every patient registered at a
               health care organization. The MPI is used by each registration application
               (or process) within the HCO to ensure a patient is logically represented
               only once and with the same set of registration demographic/registration
               data in all systems and at an organizational level.
             o Medical Record Numbers - the current method of identifying a patient
               and patient information by the majority of organizations is based on the
               use of Medical Record Numbers. Each provider organization maintains a
               Master Patient Index (MPI) and the Medical Record Number is issued and
               maintained through this index. The MPI usually contains the patient’s
               demographic information such as name, date of birth, address, mother's
               maiden name, SSN, etc. The Medical Record Number is used to identify
               an individual and his or her medical record/information. It is designed to
               be unique only within the same organization. The numbering system
               including the content and format of the medical record number is usually
               specific to the individual organization. Patients and providers will be
               required to use the respective Medical Record Number when dealing
               with different provider organizations.

•   Data Elements used to identify the provider of care:
             o National Provider ID - A National Provider Identifier or NPI is a unique
               10-digit identification number issued to health care providers in the
               United States by the Centers for Medicare and Medicaid Services (CMS).
               All individual HIPAA covered health care providers must obtain an NPI for
               use in all HIPAA standard transactions, even if a billing agency prepares


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               the transaction. Once assigned, a provider’s NPI is permanent and
               remains with the provider regardless of job or location changes.
             o Medicare Provider Number
             o NCPDP - the National Council for Prescription Drug Programs Provider
               Identification number (NCPDP Provider ID) provides pharmacies with a
               unique, national identifier that would assist pharmacies in their
               interactions with pharmacy payers and claims processors. The NCPDP
               Provider ID is a seven-digit numbering system that is assigned to every
               licensed pharmacy and qualified Non-Pharmacy Dispensing Sites (NPDS)
               in the United States.

•   Data Elements related to diagnosis and treatment:
             o Admissions/Discharges -dates of visit to health care facilities for
               treatment
             o Physician Notes – patient ad hoc physician notes.
             o Diagnoses -Medical diagnosis refers both to the process of attempting to
               determine the identity of a possible disease or disorder and to the
               opinion reached by this process.
             o Diagnosis in Standardized Nomenclature (e.g. ICD-9, SNOMED CT, etc.)
             o Procedures
             o X-Rays (interpretations and images)
             o Clinical Lab Orders and Results – results of medical lab procedures that
               involve testing samples of blood, urine, or other tissues or substances in
               the body.

Point of Care Lab Orders and Results - covers diagnostic tests performed at the point of
care in a health care institution; specimen drawn from the patient by the caregiver,
tested immediately, and then eliminated (no pre or post-processing of the specimen).
The results are produced and displayed at once on the point of care device, and can be
used immediately in the caregiver’s clinical decisions.
            o Medication Dispensing

•   Data Elements Related to Administration of Care:
             o   Insurance information for billing
             o   Financial class “bill-to” category, such as Medicare, Medicaid, etc.
             o   Insurance Payers-cross reference
             o   Admissions/Discharges/Transfers-dates of visit to health care facilities
                 for treatment
             o   Diagnoses
             o   Procedures
             o   Dates of Procedures
             o   Identification of Providers

•   Data Elements related to data management and use:
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             o User authentication profile – the set of properties/credentials that
               control how users are authenticated. Examples of types of credentials
               are passwords, one-time tokens, digital certificates, and phone numbers.
             o User authorization levels – the various levels to which the user is
               authorized to use the system e.g. Administrator, Patient, Clinician, etc.
             o Opt in/opt out agreements –agreement for patient consent to exchange
               personal health information through the HIE, often referred to as “opt-
               in” and “opt-out” (also referred to as patient consent to share health
               data).
             o Patient Record Locator (if applicable) – a Unique Patient Identifier in the
               Record Locator Service (RLS). The RLS holds information authorized by
               the patient about where authorized information can be found, but not
               the actual information the records may contain. It thus enables a
               separation, for reasons of security, privacy, and the preservation of the
               autonomy of the participating entities, of the function of locating
               authorized records from the function of transferring them to authorized
               users.

•   Standardized Coding Schemes for Diagnosis, Treatment, and/or Billing:
             o ICD9/ICD10
             o CPT - CPT (Current Procedural Terminology) codes are numbers assigned
               to every task and service a medical practitioner may provide to a patient
               including medical, surgical and diagnostic services. They are then used by
               insurers to determine the amount of reimbursement that a practitioner
               will receive by an insurer. Since everyone uses the same codes to mean
               the same thing, they ensure uniformity.
             o LOINC – (Logical Observation Identifiers Names and Codes)The purpose
               of LOINC® is to facilitate the exchange and pooling of clinical results for
               clinical care, outcome management, and research by providing a set of
               universal codes and names to identify laboratory and other clinical
               observations. The Regenstrief Institute, Inc., an internationally renowned
               health care and informatics research organization, maintains the LOINC
               database and supporting documentation, and the RELMA mapping
               program.
             o SNOMED CT - SNOMED CT (Systematized Nomenclature of Medicine--
               Clinical Terms) is one of a suite of designated standards for use in U.S.
               Federal Government systems for the electronic exchange of clinical
               health information.
             o RxNorm - RxNorm provides normalized names for clinical drugs and links
               its names to many of the drug vocabularies commonly used in pharmacy
               management and drug interaction software.
               RxNorm now includes the National Drug File - Reference Terminology
               (NDF-RT) from the Veterans Health Administration. NDF-RT is a


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               terminology used to code clinical drug properties, including mechanism
               of action, physiologic effect, and therapeutic category.
             o HCPCS - HCPCS Codes, Healthcare Common Procedure Coding System
               numbers, are the codes used by Medicare. HCPCS Codes are numbers
               assigned to every task and service a medical practitioner may provide to
               a Medicare patient including medical, surgical and diagnostic services.




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A-13 Complete List of Data Elements Currently Collected by HHIC

                             Summary of Data Collected by Hawai‘i Health Information Corporation
                                                    Hospital         Hospital
                                       Hospital                                     Physician
           Data Element                            Emergency        Ambulatory                                            Comments
                                      Inpatient                                     Database
                                                   Department        Surgery
 Medicare Provider Number                  x           x                x                x      Hospital’s Medicare provider number as assigned by CMS.
 Account (Register) Number                                                                      The number assigned to the patient’s visit by the hospital.
                                                                                                The account number is typically used for charge and/or
                                           x             x                x                     billing purposes.
 Medical Record Number                     x             x                x                     The number assigned to the patient’s medical/health record
                                                                                                by the hospital. The medical record number is typically used
                                                                                                to do an audit of the history of treatment.
 Date of Birth                             x             x                x              x      Month, day, and year (including century) of birth of the
                                                                                                patient
 Sex                                       x             x                x                     Sex of patient
 Race                                      x             x                x                     The race or ethnicity with which the patient most closely
                                                                                                identifies (i.e. race/ethnicity is self reported). Standardized
                                                                                                to 34 categories for Hawai‘i.
 Zip Code of Residence                     x             x                x                     U.S. postal zip code for the address of the patient’s current
                                                                                                residence. Use country codes for non-US residents.
 Date of Admission                         x             x                x                     Month, day and year of admission to hospital as an acute
                                                                                                care patient. This field along with discharge date is used to
                                                                                                calculate length of stay. The day of admission is counted,
                                                                                                but not the day of discharge when the length of stay is
                                                                                                generated.
 Hour of Admission                                       x                x
 Date of Discharge                         x             x                x                     Month, day and year the patient left the facility as an acute
                                                                                                care patient.
 Discharge Hour                                          x                x




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                                                    Hospital         Hospital
                                       Hospital                                     Physician
            Data Element                           Emergency        Ambulatory                                           Comments
                                      Inpatient                                     Database
                                                   Department        Surgery
 Principal Source of Payment               x           x                x                       Expected principal source of payment for this hospital
                                                                                                admission (27 options)
 Disposition of Patient                    x             x                x                     Patient disposition or discharge status. Same as UB-04 (form
                                                                                                locator 17) patient status field.
 Disposition of Patient - Specific         x             x                x                     Hospital’s Medicare provider number as assigned by CMS for
 Facility                                                                                       the facility that patient is transferred to by your facility.
                                                                                                When discharge disposition (position 67 - 68) has a value of
                                                                                                02 (transfer to acute hospital), this data element must be
                                                                                                filled in.
 Total Charges                             x             x                x                     Total charges for this stay, including room and board,
                                                                                                pharmacy, laboratory, X-ray and hospital-based physician
                                                                                                charges
 Hospital Based Physician Charges          x             x                x                     Total hospital-based physician charges
 Birth Weight                              x             x                x                     Birth weight in grams for admissions less than 30 days in age

 Attending Physician                       x             x                x                     The number of the licensed physician who would normally
                                                                                                be expected to certify and re-certify the medical necessity of
                                                                                                the services rendered and/or who has primary responsibility
                                                                                                for the patient’s medical care and treatment.

 Principal Diagnosis Code                  x             x                x                     The ICD-9-CM code describing the condition established
                                                                                                after study to be chiefly responsible for causing the
                                                                                                admission of the patient to the hospital for care




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                                                    Hospital         Hospital
                                       Hospital                                     Physician
           Data Element                            Emergency        Ambulatory                                           Comments
                                      Inpatient                                     Database
                                                   Department        Surgery
 Other Diagnosis - 1                       x             x                x
 Other Diagnosis - 2                       x             x                x
 Other Diagnosis - 3                       x             x                x
 Other Diagnosis - 4                       x             x                x
 Other Diagnosis - 5                       x             x                x
 Other Diagnosis - 6                       x             x                x
 Other Diagnosis - 7                       x             x                x
 Other Diagnosis - 8                       x             x                x                     ICD-9-CM diagnosis code(s) corresponding to additional
 Other Diagnosis - 9                                                                            conditions that co-exist at the time of admission or develop
                                           x             x                x
                                                                                                subsequently which affect the treatment received and/or
 Other Diagnosis - 10                      x                                                    the length of stay. Diagnoses that relate to an earlier episode
 Other Diagnosis - 11                      x                                                    which have no bearing on this hospital stay are to be
 Other Diagnosis - 12                      x                                                    excluded
 Other Diagnosis - 13                      x
 Other Diagnosis - 14                      x
 Other Diagnosis - 15                      x
 Other Diagnosis - 16                      x
 Other Diagnosis - 17                      x
 Other Diagnosis - 18                      x
 Other Diagnosis - 19                      x




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                                                    Hospital         Hospital
                                       Hospital                                     Physician
           Data Element                            Emergency        Ambulatory                                          Comments
                                      Inpatient                                     Database
                                                   Department        Surgery
 E-Code                                    x           x                x                       The ICD-9-CM diagnosis code for the external cause of an
                                                                                                injury, poisoning, or adverse effect.
 Principal Procedure                       x             x                x                     The principal procedure is the one performed for definitive
                                                                                                treatment, rather than the one performed for diagnostic or
                                                                                                exploratory purposes or was necessary to take care of a
                                                                                                complication. The principal procedure is most closely related
                                                                                                to the principal diagnosis.
 Other Procedures - 1                      x             x                x
 Other Procedures - 2                      x             x                x
 Other Procedures - 3                      x             x                x
 Other Procedures - 4                      x             x                x
 Other Procedures - 5                      x             x                x
 Other Procedures - 6                      x             x                x
 Other Procedures - 7                      x             x                x
                                                                                                The ICD-9-CM codes identifying all significant procedures
 Other Procedures - 8                      x             x                x                     other than the principal procedure. Report all procedures
 Other Procedures - 9                      x             x                x                     including any therapeutic procedures. Include procedures
 Other Procedures - 10                     x                                                    which carry an operative or anesthetic risk and/or require
 Other Procedures - 11                     x                                                    highly trained personnel as well as special procedures which
 Other Procedures - 12                                                                          require technologically advanced facilities and/or
                                           x                                                    equipment.
 Other Procedures - 13                     x
 Other Procedures - 14                     x
 Other Procedures - 15                     x
 Other Procedures - 16                     x
 Other Procedures - 17                     x
 Other Procedures - 18                     x
 Other Procedures - 19                     x


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                                                    Hospital         Hospital
                                       Hospital                                     Physician
           Data Element                            Emergency        Ambulatory                                         Comments
                                      Inpatient                                     Database
                                                   Department        Surgery
 Principal Surgeon                         x           x                x                       Physician who performed the principal procedure
 Other Surgeon - 1                         x           x                x
 Other Surgeon - 2                         x           x                x
 Other Surgeon - 3                         x           x                x
 Other Surgeon - 4                         x           x                x
 Other Surgeon - 5                         x           x                x
 Other Surgeon - 6                         x           x                x
 Other Surgeon - 7                         x           x                x
 Other Surgeon - 8                         x           x                x
 Other Surgeon - 9                         x           x                x
                                                                                                Physician(s) who performed the corresponding procedure(s)
 Other Surgeon - 10                        x
 Other Surgeon - 11                        x
 Other Surgeon - 13                        x
 Other Surgeon - 14                        x
 Other Surgeon - 15                        x
 Other Surgeon - 16                        x
 Other Surgeon - 17                        x
 Other Surgeon - 18                        x
 Other Surgeon - 19                        x
 Principal Procedure Date                  x             x                x                     Month, day and year when the principal procedure was
                                                                                                performed




Hawai‘i Health Information Exchange
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                                                    Hospital         Hospital
                                       Hospital                                     Physician
           Data Element                            Emergency        Ambulatory                                           Comments
                                      Inpatient                                     Database
                                                   Department        Surgery
 Other Procedure Date - 1                  x           x                x
 Other Procedure Date - 2                  x           x                x
 Other Procedure Date - 3                  x           x                x
 Other Procedure Date - 4                  x           x                x
 Other Procedure Date - 5                  x           x                x
 Other Procedure Date - 6                  x           x                x
 Other Procedure Date - 7                  x           x                x
 Other Procedure Date - 8                  x           x                x
 Other Procedure Date - 9                  x           x                x
 Other Procedure Date - 10                                                                      The date on which the corresponding procedure occurred
 Other Procedure Date - 11
 Other Procedure Date - 12
 Other Procedure Date - 13
 Other Procedure Date - 14
 Other Procedure Date - 15
 Other Procedure Date - 16
 Other Procedure Date - 17
 Other Procedure Date - 18
 Other Procedure Date - 19
 Type of Admission                         x             x                x                     A code indicating the priority of this admission
 Source of Admission                       x             x                x                     A code indicating the source of this admission




Hawai‘i Health Information Exchange
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                                                    Hospital         Hospital
                                       Hospital                                     Physician
           Data Element                            Emergency        Ambulatory                                              Comments
                                      Inpatient                                     Database
                                                   Department        Surgery
 Source of Admission – Specific            x           x                x                       Hospital’s Medicare provider number as assigned by CMS for
 Facility                                                                                       the facility that transferred the patient to your facility.
                                                                                                When source of admission (position 588) has a value of 4
                                                                                                (transfer from a hospital), this data element must be filled in.

 Mother’s Account Number                   x                                                    The number assigned to a newborn patient’s MOTHER’s visit
                                                                                                by the hospital. The mother’s account number will allow
                                                                                                HHIC to correctly match each newborn record with the
                                                                                                mother’s record.
 Social Security Number                    x             x                x                     The number assigned by the Social Security Administration.
 Patient First Name                        x             x                x                     The patient’s first name.
 Patient Last Name                         x             x                x                     The patient’s last name.
 Mailing Address 1                         x             x                x                     Patient’s mailing address. First line.
 Mailing Address 2                         x             x                x                     Second line for apartment complex names or other long
                                                                                                mailing addresses.
 Mailing Address - City                    x             x                x                     City associated with patient’s mailing address.
 Mailing Address - State                   x             x                x                     State associated with patient’s mailing address.
 Mailing Address - Zip Code                x             x                x                     Zip Code associated with patient’s mailing address.
 Patient Phone Number                      x             x                x                     Patient telephone number.
 Admitting Nursing Unit                    x                                                    The name of nursing unit to which the patient was admitted.
 Discharge Nursing Unit                    x                                                    The name of nursing unit from which the patient was
                                                                                                discharged.
 Opt-Out Flag                              x             x                x                     For surveying purposes such as patient satisfaction only. A
                                                                                                code used to designate patients who have requested not to
                                                                                                receive any mailings such as satisfaction surveys, from their
                                                                                                treating hospitals.




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                                                    Hospital         Hospital
                                       Hospital                                     Physician
           Data Element                            Emergency        Ambulatory                                             Comments
                                      Inpatient                                     Database
                                                   Department        Surgery
 POA Principal Diagnosis Code              x
 POA Other Diagnosis - 1                   x
 POA Other Diagnosis - 2                   x
 POA Other Diagnosis - 3                   x
 POA Other Diagnosis - 4                   x
 POA Other Diagnosis - 5                   x
 POA Other Diagnosis - 6                   x
 POA Other Diagnosis - 7                   x                                                    Present on Admission (POA) Indicators
                                                                                                Y = Yes (present at the time of inpatient admission)
 POA Other Diagnosis - 8                   x
                                                                                                 N = No (not present at the time of inpatient admission)
 POA Other Diagnosis - 9                   x                                                     U = Unknown (documentation is insufficient to determine if
 POA Other Diagnosis - 10                  x                                                    condition was present on admission)
 POA Other Diagnosis - 11                  x                                                     W = Clinically Undetermined (provider is unable to
 POA Other Diagnosis - 12                                                                       determine whether condition was present on admission)
                                           x
                                                                                                 1 = Unreported/Not used – Exempt from POA reporting
 POA Other Diagnosis - 13                  x
 POA Other Diagnosis - 14                  x
 POA Other Diagnosis - 15                  x
 POA Other Diagnosis - 16                  x
 POA Other Diagnosis - 17                  x
 POA Other Diagnosis - 18                  x
 POA Other Diagnosis - 19                  x
 POA E-Code                                x
 Patient Middle Initial                    x             x                x                     The patient’s middle initial
 Patient Name Suffix                       x             x                x                     The patient’s name suffix, e.g. JR, SR, III, IV




Hawai‘i Health Information Exchange
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                                                    Hospital         Hospital
                                       Hospital                                     Physician
           Data Element                            Emergency        Ambulatory                        Comments
                                      Inpatient                                     Database
                                                   Department        Surgery
 HCPCS Code 1                                          x                x
 HCPCS Code 1 - Modifier 1                             x                x
 HCPCS Code 1 - Modifier 2                             x                x
 HCPCS Code 1 - Modifier 3                             x                x
 HCPCS Code 2                                          x                x
 HCPCS Code 2 - Modifier 1                             x                x
 HCPCS Code 2 - Modifier 2                             x                x
 HCPCS Code 2 - Modifier 3                             x                x
 HCPCS Code 3                                          x                x
 HCPCS Code 3 - Modifier 1                             x                x
 HCPCS Code 3 - Modifier 2                             x                x
 HCPCS Code 3 - Modifier 3                             x                x
 HCPCS Code 4                                          x                x
 HCPCS Code 4 - Modifier 1                             x                x
 HCPCS Code 4 - Modifier 2                             x                x
 HCPCS Code 4 - Modifier 3                             x                x
 HCPCS Code 5                                          x                x
 HCPCS Code 5 - Modifier 1                             x                x
 HCPCS Code 5 - Modifier 2                             x                x
 HCPCS Code 5 - Modifier 3                             x                x
 HCPCS Code 6                                          x                x
 HCPCS Code 6 - Modifier 1                             x                x
 HCPCS Code 6 - Modifier 2                             x                x
 HCPCS Code 6 - Modifier 3                             x                x



Hawai‘i Health Information Exchange
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                                                    Hospital         Hospital
                                       Hospital                                     Physician
           Data Element                            Emergency        Ambulatory                                           Comments
                                      Inpatient                                     Database
                                                   Department        Surgery
 HCPCS Code 7                                          x                x
 HCPCS Code 7 - Modifier 1                             x                x
 HCPCS Code 7 - Modifier 2                             x                x
 HCPCS Code 7 - Modifier 3                             x                x
 HCPCS Code 8                                          x                x
 HCPCS Code 8 - Modifier 1                             x                x
 HCPCS Code 8 - Modifier 2                             x                x
 HCPCS Code 8 - Modifier 3                             x                x
 HCPCS Code 9                                          x                x                       HCPCS codes level I, II, and III. Enter up to 20 codes for each
 HCPCS Code 9 - Modifier 1                             x                x                       ambulatory surgery and emergency room visit
 HCPCS Code 9 - Modifier 2                             x                x                       Up to three HCPCS modifiers can be reported for each HCPCS
                                                                                                level I, II or III code
 HCPCS Code 9 - Modifier 3                               x                x
 HCPCS Code 10                                           x                x
 HCPCS Code 10 - Modifier 1                              x                x
 HCPCS Code 10 - Modifier 2                              x                x
 HCPCS Code 10 - Modifier 3                              x                x
 HCPCS Code 11                                           x                x
 HCPCS Code 11 - Modifier 1                              x                x
 HCPCS Code 11 - Modifier 2                              x                x
 HCPCS Code 11 - Modifier 3                              x                x
 HCPCS Code 12                                           x                x
 HCPCS Code 12 - Modifier 1                              x                x
 HCPCS Code 12 - Modifier 2                              x                x
 HCPCS Code 12 - Modifier 3                              x                x


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                                                    Hospital         Hospital
                                       Hospital                                     Physician
           Data Element                            Emergency        Ambulatory                        Comments
                                      Inpatient                                     Database
                                                   Department        Surgery
 HCPCS Code 13                                         x                x
 HCPCS Code 13 - Modifier 1                            x                x
 HCPCS Code 13 - Modifier 2                            x                x
 HCPCS Code 13 - Modifier 3                            x                x
 HCPCS Code 14                                         x                x
 HCPCS Code 14 - Modifier 1                            x                x
 HCPCS Code 14 - Modifier 2                            x                x
 HCPCS Code 14 - Modifier 3                            x                x
 HCPCS Code 15                                         x                x
 HCPCS Code 15 - Modifier 1                            x                x
 HCPCS Code 15 - Modifier 2                            x                x
 HCPCS Code 15 - Modifier 3                            x                x
 HCPCS Code 16                                         x                x
 HCPCS Code 16 - Modifier 1                            x                x
 HCPCS Code 16 - Modifier 2                            x                x
 HCPCS Code 16 - Modifier 3                            x                x
 HCPCS Code 17                                         x                x
 HCPCS Code 17 - Modifier 1                            x                x
 HCPCS Code 17 - Modifier 2                            x                x
 HCPCS Code 18                                         x                x
 HCPCS Code 18 - Modifier 1                            x                x
 HCPCS Code 18 - Modifier 2                            x                x
 HCPCS Code 18 - Modifier 3                            x                x




Hawai‘i Health Information Exchange
900 Fort Street Mall | Suite 1300 | Honolulu, HI96813 | Tel: 808-441-1346 | Fax: 808-441-1472   169
                                                    Hospital         Hospital
                                       Hospital                                     Physician
           Data Element                            Emergency        Ambulatory                        Comments
                                      Inpatient                                     Database
                                                   Department        Surgery
 HCPCS Code 19                                         x                x
 HCPCS Code 19 - Modifier 1                            x                x
 HCPCS Code 19 - Modifier 2                            x                x
 HCPCS Code 19 - Modifier 3                            x                x
 HCPCS Code 20                                         x                x
 HCPCS Code 20 - Modifier 1                            x                x
 HCPCS Code 20 - Modifier 2                            x                x
 HCPCS Code 20 - Modifier 3                            x                x
 Physician ID                                                                            x
 Last Name                                                                               x
 First Name                                                                              x
 Middle Initial                                                                          x
 Suffix                                                                                  x
 Specialty No. 1                                                                         x
 Specialty No. 2                                                                         x
 Specialty No. 3                                                                         x
 Hawai‘i State License Number                                                            x
 DEA Number                                                                              x
 UPIN                                                                                    x
 National Provider Identifier (NPI)                                                      x
 Record Type                               x             x                x              x




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A-14 Inventory of Legal and Policy Requirements
This document represents the work of the Legal/Policy committee to gather an inventory of policies, procedures, structural
documents and other related materials that are required for the overall operation of Hawai‘i HIE and to effect the exchange of
health information.

                                                                       List One
#                       Description                           Key Elements/Decisions              Comments                             Timeliness
1-   Privacy Policy     Governs the protection of             •   Patient consent model           •    Leverage with existing          Need to have
a                       Personal Health Information           •   Policy needs to cover issues         documents and make use of       to initiate
                        stored in or transmitted by               of use and disclosure                available templates including   exchanges
                        exchange                                                                       those from other states
                                                                                                       where relevant
1-   Patient Rights     Clearly states and delineates         •   Privacy Protections             •    Need to note exceptions         Need to have
b    Policy             the rights of patients with           •   Redress                              created by state and federal    to initiate
                        respect to the gathering, use,        •   Liability Issues                     class for named classes, e.g.   exchanges
                        and exchange of their personal                                                 mental illness, HIV/AIDS
                        health data
1-   Security Policy    Cover Hawai‘i HIE as an entity                                            •    Leverage with existing          Need to have
c                       regarding rules governing the                                                  documents and make use of       to initiate
                        security of data and other                                                     available templates. NB in      exchanges
                        assets. Required for compliance                                                particular DOH security
                        with federal regulations                                                       regulations
1-   Security           Standards that define in more         •   Physical security               •    Leverage with existing          Need to have
d    Standards          detail elements of the security       •   Infrastructure security              documents and make use of       to initiate
                        policy                                •   Access control                       available templates             exchanges
                                                              •   Application controls            •    Need to create a system of
                                                              •   Business continuity                  periodic audit and review
                                                              •   Network controls-audits
                                                              •   Transmission security



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                                                                       List One
#                       Description                           Key Elements/Decisions              Comments                             Timeliness
1-   Privacy Policy     Governs the protection of             •   Patient consent model           •    Leverage with existing          Need to have
a                       Personal Health Information           •   Policy needs to cover issues         documents and make use of       to initiate
                        stored in or transmitted by               of use and disclosure                available templates including   exchanges
                        exchange                                                                       those from other states
                                                                                                       where relevant
                                                              •   Change Management
                                                              •   Encryption
1-   Data               Defines how data is to be             •   Acceptable Use                  •    Leverage with existing          Need to have
e    Management         managed while it is under the         •   Minimum necessary                    documents and make use of       in place to
     Policy             control of the HIE (Includes              definitions                          available templates.            initiate
                        identification of ownership);         •   Information classification      •    These elements will be partly   exchanges.
                        lined to issues of liability and          (this and other data                 covered in usage agreements
                        liability limitation in event of          domains with issues of who      •    Data domains, types and
                        breaches.                                 is housing data in various           interchange standards are
                                                                  stages of use)                       likely to change as HIE moves
                                                              •   Data domains                         through progressive changes.
                                                              •   Data types                           Need to schedule for review.
                                                              •   Data interchange standards
1-   Legislative        Identify federal and state            •   Need to cover all the areas     •    Useful to conduct               High Priority
f    Analysis           legislation that impacts HIE and          discussed in this section            comparative analysis with
                        ensure that appropriate                                                        the National Council of State
                        compliance is involved.                                                        Legislatures, and the
                                                                                                       National Governors
                                                                                                       Conference to consult
                                                                                                       emerging best practices
                                                                                                       literature.
1-   Breach             Procedures for notifying                                                  •    Refer to applicable state and   Need to have
g    Notification       covered entities about a breach                                                                                in place to


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                                                                       List One
#                       Description                           Key Elements/Decisions              Comments                              Timeliness
1-   Privacy Policy     Governs the protection of             •   Patient consent model           •    Leverage with existing           Need to have
a                       Personal Health Information           •   Policy needs to cover issues         documents and make use of        to initiate
                        stored in or transmitted by               of use and disclosure                available templates including    exchanges
                        exchange                                                                       those from other states
                                                                                                       where relevant
                                                                                                       federal statutes and rules.      initiate
                                                                                                       Link to liability issues         exchanges.
1-   Legal Services     General and specialized counsel       •   Need to review all of the       •    Hawai‘i HIE needs to develop     Need to do
h                       to the HIE                                policies and legal                   an RFP for legal services to     soonest.
                                                                  implications discussed here          conduct full-scale analysis
                                                                  with in this inventory.              and develop necessary
                                                                                                       policies
1-   Participant         Agreement between the HIE            •   Identification of entity        •    Needs to be developed.           High priority
i    agreement          and participants regarding their      •   Compliance with rules of HIE    •    Could include Code of
     (usage)            responsibilities and obligations.     •   Compliance with data usage           Conduct included below.
                        Includes usage and sharing of             terms                           •    Suitable draft language
                        data.
                                                              •   Accountability for data
                                                                  submitted
                                                      •           Effective period
1-   Data Use           Agreement between the HIE and •           Same key elements, but          •    In separating out the two        High Priority
j    Agreement-         the client. May be separated              these elements need to               functions that used to be in
                        from 4 below, which applies to            comply with any and all              this element into privacy and
                        secondary use for analysis                privacy requirements                 later use, it may be useful to
                        purposes after data have been                                                  consider a privacy board that
                        gathered                                                                       meets periodically to review
                                                                                                       policies and audits
                                                                                                       compliance.
1-   Consent            Agreement that the patient            •   Identification of individual    •    This could be a barrier,         Need to


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                                                                       List One
#                       Description                           Key Elements/Decisions              Comments                                Timeliness
1-   Privacy Policy     Governs the protection of             •   Patient consent model           •    Leverage with existing             Need to have
a                       Personal Health Information           •   Policy needs to cover issues         documents and make use of          to initiate
                        stored in or transmitted by               of use and disclosure                available templates including      exchanges
                        exchange                                                                       those from other states
                                                                                                       where relevant
k    Agreement          signs to allow their PHI to be        •   Agreement to share                   especially as it involves opt-in   develop before
                        shared through the exchange.              personal information                 and opt-out issues                 data exchange
                        Minors must also have the             •   Acknowledgement of              •    The op-in, or op-out is            can take place
                        signature of an authorized adult.         sharing federal & state              fundamental and needs to be
                                                                  protected information                settled at the outset and
                                                              •   Acknowledgement of rights            become part of the
                                                              •   Acknowledgement of free              presentation of HHIE to its
                                                                  will                                 stakeholders and the broader
                                                                                                       community
                                                              •   Term of agreement
                                                              •   Right to revoke (See Privacy
                                                                  Rights below).


                                                                       List Two
#    Deliverable        Description                           Key Element/Decision                Comments                           Timeliness
2-   Entity legal       Creation and maintenance of           •   Tax status: non-profit          •    Essentially accomplished      Completed—
a    structure          legal documents related to the                                                 by incorporation of           periodic review
                        HIE as an operational entity                                                   Hawai‘i HIE as a 501 (c)
                                                                                                       (3) entity.
2-   Revenue            Documents regarding financial         •   Terms of sharing                •    Link to model being           Develop within
b    sharing.           arrangements between the HIE          •   Fee schedule                         developed by finance          year one.
                        and other parties.                                                             committee based on



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                                                                       List Two
#    Deliverable        Description                           Key Element/Decision               Comments                          Timeliness
                                                                                                    ideas of value/benefit
                                                                                                    calculations
2-   Code of            Policy defining how employees,                                           • This item may be                Need to have early
c    business           contractors, or vendors are to                                              combined with                  on, but can be
     conduct.           behave when representing the                                                HR/staffing policy for         obtained from
                        HIE. Required by federal law.                                               HHIE staff, which is           standard sources.
                        May also be extended to cover                                               covered within the
                        exchange participants.                                                      business plan domain
2-   Data Use           Agreement between the HIE             •   Identification of entity       • Can find analogies in           First year
d    Agreement          and non-participants who need         •   Compliance with rules of          other non-participant
     (non-              access to the data. Non-                  HIE                               data sharing agreements
     participant)       participants may be research or       •   Compliance with data usage        such as HHIC. Consult
                        public health organizations that          terms as they apply to non-       with DOH on registry
                        seek a legal basis to use the             participants                      issues.
                        data.
                                                              •   Accountability for data
                                                                  submitted
                                                              •   Effective period
2-   Incident           Investigate and report on                                                •    This element can be          Need to have a
e    Management         potential violation of policies                                               viewed within the overall    plan in place in
                                                                                                      context of organizational    anticipation of
                                                                                                      due diligence.               possible instances.
2-   Monitoring         Monitor key controls and                                                 •    See in broader context of    Some version of
f    controls           report weaknesses                                                             overall due diligence,       this should emerge
                                                                                                      however, the ARRA grant      early in the second
                                                                                                      requires regular             year of operation.
                                                                                                      evaluation efforts, and it
                                                                                                      would be wise to
                                                                                                      construct an evaluation



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                                                                       List Two
#    Deliverable        Description                           Key Element/Decision               Comments                           Timeliness
                                                                                                    tool that permits one to
                                                                                                    conduct routine
                                                                                                    monitoring.
2-   Operating          Covers a variety of topics            •   Business process                                                  Begin to develop
g    Procedures         related to the operation of HIE       •   Management                                                        during period
                                                              •   Data interchange                                                  between grant
                                                                                                                                    submission and
                                                              •   Change management
                                                                                                                                    ONC approval.
                                                              •   Access provisioning
                                                              •   Issue management
                                                              •   Information systems
                                                                  management
                                                              •   Quality Assurance
                                                              •   Vendor/Contract
                                                                  management
2-   Inter-HIE          Agreement between HIE’s               •   Mutual identification          •    Initiate conversations        Within first year.
h    agreement          regarding obligations                 •   Intentions of both parties          with Beacon
                        expectation. This will ultimately     •   Data Interchange
                        be needed for regional or
                                                              •   Reference to other policies
                        national information exchange,
                        but could also be needed to
                        assist exchange between
                        Beacon and other Hawai‘i HIEs.
2-   Enforcement        Enforce corrective actions as                                            •    See in the broader            First or second
1                       directed by the Board                                                         context of overall due        year of operation
                                                                                                      diligence. May wish to
                                                                                                      build this function into a
                                                                                                      specific organizational job
                                                                                                      description.


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                                                                       List Two
#    Deliverable        Description                           Key Element/Decision               Comments                        Timeliness
2-   Lobbying           Advance the goals of the HIE by                                          •    Need to be mindful of      First or second
j                       impacting future legislation.                                                 possible limitation of     year as
                                                                                                      funds for such purposes.   appropriate.




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A-15 Inventory of Applicable State and Federal Laws and Rules Regarding Security and Privacy
  Subject (Privacy)         Law/Citation                                Description/Summary                                Consequences of
                                                                                                                           Non-compliance

Applicability            42 CFR Part 2         -A/DA patient records maintained by any federally assisted A/DA        Criminal penalty for
                         A 2.1, 2.2            program.                                                               violation:
                         B 2.12                -Records are confidential, disclosed with patient consent.             -First offense-up to $500.
                                               -Consent not required: Medical emergency, research,                    -Subsequent offense-up to
                                               audit/evaluation, court order, between Armed forces and Veteran’s      $5000
                                               Administration, to report child abuse under state law.                 -Violations may be reported
                                                                                                                      to U.S. Attorney or Food and
                                                                                                                      Drug Administration
                                                                                                                      Regional Office (methadone
                                                                                                                      program).


Confidentiality          42 CFR Part 2         -Records are confidential and may not be disclosed or used in civil,   See above
restrictions             B 2.13                criminal, administrative, legislative proceedings.


Minor patients           42 CFR Part 2         -Only a minor (defined as any person from the age 14 to 17 inclusive) See above
                         B 2.14                can provide written consent


Incompetent and          42 CFR Part 2         -Incompetent-consent may be given by guardian or personal rep.         See above
deceased patients        B 2.15                -Deceased-disclosure to determine cause of death, vital statistics
                                               required by law permitted.




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  Subject (Privacy)         Law/Citation                                Description/Summary                                  Consequences of
                                                                                                                             Non-compliance

Security for written     42 CFR Part 2         -Must be secured in locked file cabinet or safe. Written access          See above
records                  B 2.16                procedures


Restrictions on use      42 CFR Part 2         -Cannot require patient to carry an ID card that identifies pt as A/DA   See above
of ID cards              B 2.18                while off premises.


Disposition of           42 CFR Part 2         -Records must be destroyed unless pt. consents to transfer to            Criminal penalty for
records by               B 2.19                another program.                                                         violation:
discontinued                                   -Follow laws for retention-store in sealed envelopes, labeled.           -First offense-up to $500.
programs                                       Responsible person must destroy at end of retention period.              -Subsequent offense-up to
                                                                                                                        $5000
                                                                                                                        -Violations may be reported
                                                                                                                        to U.S. Attorney or Food and
                                                                                                                        Drug Administration
                                                                                                                        Regional Office (methadone
                                                                                                                        program).


Notice to patient-       42 CFR Part 2         -Required at admission, required elements                                See above
confidentiality          B 2.22
requirements

Consent form             42 CFR Part 2         -Required elements                                                       See above
                         C 2.31




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  Subject (Privacy)         Law/Citation                                Description/Summary                             Consequences of
                                                                                                                        Non-compliance

Re-disclosure            42 CFR Part 2 C       -Written statement to prohibit re-disclosure required on Notice     See above
                         3.32                  -Written consent required for re-disclosure


Prevent multiple         42 CFR Part 2         -Written consent required for limited disclosures between central   See above
enrollments in           C 2.34                registry and detox or maintenance programs. No re-disclosure.
detoxification and
maintenance
programs


Disclosures to           42 CFR Part 2         -Written consent required.                                          See above
criminal justice         C 2.35                -May re-disclose to carry out job duties.
system


Medical                  42 CFR Part 2         -To medical personnel who need information to treat immediate       Criminal penalty for
emergencies              D 2.51                threat to health.                                                   violation:
                                               -Disclosure must be documented in pt. records.                      -First offense-up to $500.
                                                                                                                   -Subsequent offense-up to
                                                                                                                   $5000
                                                                                                                   -Violations may be reported
                                                                                                                   to U.S. Attorney or Food and
                                                                                                                   Drug Administration
                                                                                                                   Regional Office (methadone
                                                                                                                   program).




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  Subject (Privacy)         Law/Citation                                Description/Summary                              Consequences of
                                                                                                                         Non-compliance

Research activities      42 CFR Part 2         -Disclose to qualified researcher with qualifying protocol.          See above
                         D 2.52

Audit and                42 CFR Part 2         -Records not copies or removed                                       See above
evaluation activities    D 2.53                -Records copied or removed
                                               -Medicare/Medicaid audits


Legal effect of order    42 CFR Part 2         -Court order does not compel disclosure                              See above
                         E 2.61                -Subpoena or other legal mandate must be issued to compel
                                               disclosure


Records disclosed        42 CFR Part 2         -Court order does not allow disclosure or use for criminal           See above
without consent to       E 2.62                prosecution against patient.
researchers,
auditors, evaluators


Confidential             42 CFR Part 2         -Court order may authorize disclosure to protect against threat to   See above
Communications           E 2.63                life, serious crime, offered by patient during litigation.




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  Subject (Privacy)         Law/Citation                                Description/Summary                                  Consequences of
                                                                                                                             Non-compliance

Disclosures for          42 CFR Part 2         -Application for court order by any person                               Criminal penalty for
Noncriminal              E 2.64                -Adequate notice to patient and person holding the records.              violation:
purposes                                       -Hearing in judge’s chambers, granted if good cause exists, limited to   -First offense-up to $500.
                                               min necessary.                                                           -Subsequent offense-up to
                                                                                                                        $5000
                                                                                                                        -Violations may be reported
                                                                                                                        to U.S. Attorney or Food and
                                                                                                                        Drug Administration
                                                                                                                        Regional Office (methadone
                                                                                                                        program).


Disclosures and uses     42 CFR Part 2         -Application for court order by person holding records or
to criminally            E 2.65                prosecution/investigation officials.                                     See above
investigate patient                            -Notice and hearing.
                                               -Order must limit disclosure essential parts of record only, to law
                                               enforcement/ prosecutorial officials.


Disclosures and use      42 CFR Part 2         -Application for court order by any entity with jurisdiction over        See above
to investigate or        E 2.66                program’s activities.
prosecute a program                            -Notice not required.
                                               -Patient identifying information must be deleted from any
                                               documents made public.
                                               -Information cannot be used to prosecute a patient.




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                                            Federal Privacy Law – HIPAA Privacy and Security Rules
  Subject (Privacy)         Law/Citation                                Description/Summary                                    Consequences of
                                                                                                                               Non-compliance

Use and Disclosure       45 C.F.R. §           A covered entity may not use or disclose protected health                  See Attachment 1
of PHI                   164.502(a).           information, except either: (1) as the Privacy Rule permits or
                                               requires; or (2) as the individual who is the subject of the
                                               information (or the individual’s personal representative) authorizes
                                               in writing.


Permitted Uses and       45 C.F.R. §           A covered entity is permitted, but not required, to use and disclose       See Attachment 1
Disclosures              164.506               protected health information, without an individual’s authorization,
                         45 C.F.R. §           for the following purposes or situations: (1) To the Individual (unless
                         164.510               required for access or accounting of disclosures); (2) Treatment,
                         45 C.F.R. §           Payment, and Health Care Operations; (3) Opportunity to Agree or
                         164.512               Object; (4) Incident to an otherwise permitted use and disclosure;
                                               (5) Public Interest and Benefit Activities; and (6) Limited Data Set for
                                               the purposes of research, public health or health care operations.


Authorized               45 C.F.R. §           A covered entity must obtain the individual’s written authorization        See Attachment 1
Uses and                 164.508.              for any use or disclosure of protected health information that is not
Disclosures                                    for treatment, payment or health care operations or otherwise
                                               permitted or required by the Privacy Rule.




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  Subject (Privacy)         Law/Citation                                Description/Summary                                   Consequences of
                                                                                                                              Non-compliance

Limiting Uses            45 C.F.R. §§          A covered entity must make reasonable efforts to use, disclose, and       See Attachment 1
and Disclosures to       164.502(b) and        request only the minimum amount of protected health information
the                      164.514 (d)           needed to accomplish the intended purpose of the use, disclosure,
Minimum Necessary                              or request.


Notice of Privacy        45 C.F.R. §§          Each covered entity, with certain exceptions, must provide a notice       See Attachment 1
Practices                164.520(a) and (b)    of its privacy practices. The Privacy Rule requires that the notice
                                               contain certain elements. The notice must describe the ways in
                                               which the covered entity may use and disclose protected health
                                               information. The notice must state the covered entity’s duties to
                                               protect privacy, provide a notice of privacy practices, and abide by
                                               the terms of the current notice. The notice must describe
                                               individuals’ rights, including the right to complain to HHS and to the
                                               covered entity if they believe their privacy rights have been violated.
                                               The notice must include a point of contact for further information
                                               and for making complaints to the covered entity. Covered entities
                                               must act in accordance with their notices. The Rule also contains
                                               specific distribution requirements for direct treatment providers, all
                                               other health care providers, and health plans.


Individual Rights to     45 C.F.R. §           Except in certain circumstances, individuals have the right to review     See Attachment 1
Access                   164.524               and obtain a copy of their protected health information in a covered
                                               entity’s designated record set.




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  Subject (Privacy)         Law/Citation                                Description/Summary                                 Consequences of
                                                                                                                            Non-compliance

Individual Rights to     45 C.F.R. §           The Rule gives individuals the right to have covered entities amend     See Attachment 1
Amendment                164.526               their protected health information in a designated record set when
                                               that information is inaccurate or incomplete.


Individual Rights to     45 C.F.R. §           Individuals have a right to an accounting of the disclosures of their   See Attachment 1
Disclosure of            164.528               protected health information by a covered entity or the covered
Accounting                                     entity’s business associates.


Individual Rights to     45 C.F.R. §           Individuals have the right to request that a covered entity             See Attachment 1
Right to Restrictions    164.522(a)            restrict use or disclosure of protected health information for
                                               treatment, payment or health care operations, disclosure to persons
                                               involved in the individual’s health care or payment for health care,
                                               or disclosure to notify family members or others about the
                                               individual’s general condition, location, or death.


Individual Rights to     45 C.F.R. §           Health plans and covered health care providers must permit              See Attachment 1
Confidential             164.522(b)            individuals to request an alternative means or location for receiving
Communications                                 communications of protected health information by means other
                                               than those that the covered entity typically employs.


Privacy Policies and     45 C.F.R. §           A covered entity must develop and implement written privacy             See Attachment 1
Procedures               164.530(i)            policies and procedures that are consistent with the Privacy Rule.




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  Subject (Privacy)         Law/Citation                                Description/Summary                                 Consequences of
                                                                                                                            Non-compliance

Privacy Personnel        45 C.F.R. §           A covered entity must designate a privacy official responsible for      See Attachment 1
                         164.530(a)            developing and implementing its privacy policies and procedures,
                                               and a contact person or contact office responsible for receiving
                                               complaints and providing individuals with information on the
                                               covered entity’s privacy practices.


Workforce Training       45 C.F.R. §160.103 Workforce members include employees, volunteers, trainees, and             See Attachment 1
and Management.          45 C.F.R. §        may also include other persons whose conduct is under the direct
                         164.530(b)         control of the entity (whether or not they are paid by the entity). 66
                                            A covered entity must train all workforce members on its privacy
                                            policies and procedures, as necessary and appropriate for them to
                                            carry out their functions.


Sanctions                45 C.F.R. §           A covered entity must have and apply appropriate sanctions against      See Attachment 1
                         164.530(e)            workforce members who violate its privacy policies and procedures
                                               or the Privacy Rule.


Mitigation               45 C.F.R. §           A covered entity must mitigate, to the extent practicable, any
                         164.530(f).           harmful effect it learns was caused by use or disclosure of protected   See Attachment 1
                                               health information by its workforce or its business associates in
                                               violation of its privacy policies and procedures or the Privacy Rule.




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  Subject (Privacy)         Law/Citation                                Description/Summary                                    Consequences of
                                                                                                                               Non-compliance

Data Safeguards          45 C.F.R. §           A covered entity must maintain reasonable and appropriate                  See Attachment 1
                         164.530(c).           administrative, technical, and physical safeguards to prevent
                                               intentional or unintentional use or disclosure of protected health
                                               information in violation of the Privacy Rule and to limit its incidental
                                               use and disclosure pursuant to otherwise permitted or required use
                                               or disclosure.


Complaints               45 C.F.R. §           A covered entity must have procedures for individuals to complain          See Attachment 1
                         164.530(d).           about its compliance with its privacy policies and procedures and the
                                               Privacy Rule.
                                               The covered entity must explain those procedures in its privacy
                                               practices notice.


Retaliation              45 C.F.R. §           A covered entity may not retaliate against a person for exercising         See Attachment 1
                         164.530(g)            rights provided by the Privacy Rule, for assisting in an investigation
                                               by HHS or another appropriate authority, or for opposing an act or
                                               practice that the person believes in good faith violates the Privacy
                                               Rule.


Documentation and        45 C.F.R. §           A covered entity must maintain, until six years after the later of the     See Attachment 1
Record Retention         164.530(j)            date of their creation or last effective date, its privacy policies and
                                               procedures, its privacy practices notices, disposition of complaints,
                                               and other actions, activities, and designations that the Privacy Rule
                                               requires to be documented.




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  Subject (Privacy)         Law/Citation                                Description/Summary                                Consequences of
                                                                                                                           Non-compliance

Preemption               45 C.F.R. §160.203 In general, State laws that are contrary to the Privacy Rule are          See Attachment 1
                                            preempted by the federal requirements, which means that the
                                            federal requirements will apply.


Administrative           45 CFR § 164.308      In general, these are the administrative functions that should be      See Attachment 1
safeguards                                     implemented to meet the security standards. These include
                                               assignment or delegation of security responsibility to an individual
                                               and security training requirements.


Physical safeguards      45 CFR § 164.310      In general, these are the mechanisms required to protect electronic    See Attachment 1
                                               systems, equipment and the data they hold, from threats,
                                               environmental hazards and unauthorized intrusion. They include
                                               restricting access to EPHI and retaining off site computer backups.


Technical                45 CFR § 164.312      In general, these are primarily the automated processes used to        See Attachment 1
safeguards                                     protect data and control access to data. They include using
                                               authentication controls to verify that the person signing onto a
                                               computer is authorized to access that EPHI, or encrypting and
                                               decrypting data as it is being stored and/or transmitted.




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                                                                  Hawai‘i State Laws
       Subject               Law/Citation                                 Description/Summary                                   Consequences of
                                                                                                                                Non-compliance

Notice of Security        HRS§ 487N-2            To decrease the risks of identity theft by establishing security breach   No statutory penalty or
Breach                                           notification and reporting policies and guidelines requiring the          civil action may be brought
                                                 notification of an individual(s) whenever the individual’s personal       against a government
                                                 information has been compromised by unauthorized disclosure, and          agency based on HRS§
                                                 to comply with the requirements of Hawai‘i Revised Statutes (“HRS”)       487N-3
                                                 Chapter 487N.


Destruction of            HRS§ 487R-2            To decrease the risks of identity theft by establishing policies and      No statutory penalty or
Personal Information                             guidelines relating to the adequate destruction or proper disposal of     civil action may be brought
Records                                          records containing personal information and to comply with the            against a government
                                                 requirements of Hawai‘i Revised Statutes (”HRS”) Chapter 487R.            agency based on HRS§
                                                                                                                           487R-3


Social Security           HRS§ 487J-2            To decrease the risks of identity theft by establishing Department of     No statutory penalty or
Number Protection                                Health (“DOH”) policies and guidelines relating to the protection of      civil action may be brought
                                                 records containing social security numbers from unauthorized access       against a government
                                                 and to comply with Hawai‘i Revised Statutes (“HRS”) Chapter 487J.         agency based on HRS§
                                                                                                                           487J-3




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       Subject               Law/Citation                                 Description/Summary                                  Consequences of
                                                                                                                               Non-compliance

Contractual                 First Special        Third party personal information use contractual provisions. Any        Silent on statutory fines
                                                                                                 rd
provisions for            Session Laws of        government agency that: 1) Contracts with 3 parties to provide          and penalties
disclosures of            Hawai‘i 2008 –         support services on behalf of the agency that requires access to
personal information       Act 10 Part V,        personal information; or 2) Is requested to provide access to SS#s
to 3rd parties                                   and other personal information by a credit bureau or similar financial
                             Section 8
                                                 reporting organization, shall include, in all new or renewed contracts,
                                                 provisions to protect the use and disclosure of personal information
                                                 administered by the agency.


Minor Patients            HRS § 577A-2, §        Pregnancy, venereal disease, and family planning services
                          577A-3                 Emancipation of certain minors
                          HRS § 577-25           Counseling services related to alcohol or drug abuse
                          HRS § 577-26           Minor without support
                          HRS § 577D-2

In-patient psychiatric    HRS § 334E-            Any patient in a psychiatric facility has a statutory right to
patients                  2(a)(14), HRS §        confidentiality of the patient’s records.
                          334-1

Criminal offender         HRS § 353G-5           Anyone receiving drug test results or assessment results of an
drug test results                                inmate, parolee, or other person released from a correctional center
                                                 or facility shall keep the information confidential in accordance with
                                                 the requirements of 42 USC § 290dd-2. HRS § 353G-5.




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       Subject               Law/Citation                                 Description/Summary                              Consequences of
                                                                                                                           Non-compliance

Mental health,            HRS § 334-5            All records made for the purposes of this chapter (which is for the
mental illness, drug                             Department of Health to establish a mental health, mental illness,
addiction and                                    drug addiction and alcoholism program) that directly or indirectly
alcoholism                                       identify a person subject hereto must be kept confidential and not
                                                 disclosed except :
                                                 (1) with the consent of the individual or individual’s representative;
                                                 (2) as deemed necessary by the Director of Health or by the
                                                 administrator of a private psychiatric or special treatment facility to
                                                 carry out HRS Chapter 334; (3) as directed by a court; (4) as deemed
                                                 necessary under the Federal Protection and Advocacy for Mentally Ill
                                                 Individuals Act of 1986; or (5) for the disclosure to the patient’s
                                                 health insurer to obtain reimbursement for services rendered,
                                                 provided that disclosure shall be made only if the provider informs
                                                 the person that a reimbursement claim will be made to the person's
                                                 payer, the person is afforded an opportunity to pay the
                                                 reimbursement directly, and the person does not pay.


Sterilization of          HRS § 560:5-           Any records relating to the sterilization or proposed sterilization of
Incapacitated person      611(b), HRS §          an incapacitated person (ward), for whom a guardian of the person
                          560:5-601, HRS §       has been appointed and who is at least 18 years old, “shall be
                          560:5-611(d)           confidential and shall not be released to third parties except: (a)
                                                 when the ward or guardian of the ward has signed a written release
                                                 for the specific information; or (b) when the ward or guardian
                                                 designates a payer or co-payer for the sterilization and consents to
                                                 release information which is necessary to establish reimbursement
                                                 eligibility.”




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       Subject               Law/Citation                                 Description/Summary                               Consequences of
                                                                                                                            Non-compliance

Congenital Syphilis       HRS § 325-54           State law requires tests and reports regarding whether congenital
                                                 syphilis is present for every pregnant woman. Any information
                                                 secured from these tests or reports relating to congenital syphilis
                                                 shall be used only in connection with professional medical duties or
                                                 within the scope and course of medical employment, and shall not
                                                 be divulged to others than the doctor and other persons permitted
                                                 by law to attend and attending a pregnant woman, laboratory
                                                 technicians, or the DOH and its duly authorized representatives.


HIV/ARC/AIDS              HRS § 325-101          The records of any person that indicate that a person has a human
                                                 immunodeficiency virus (HIV) infection, AIDS related complex (ARC),
                                                 or acquired immune deficiency syndrome (AIDS), which are held or
                                                 maintained by any state agency, health care provider or facility,
                                                 physician, osteopathic physician, laboratory, clinic, blood bank, third
                                                 party payer, or any other agency, individual, or organization in the
                                                 State shall be strictly confidential. For the purposes of this part, the
                                                 term "records" shall be broadly construed to include all
                                                 communication that identifies any individual who has HIV infection,
                                                 ARC, or AIDS. This information shall not be released or made public
                                                 upon subpoena or any other method of discovery.


Newborn screening         HAR § 11-143-12        All infants born in Hawai‘i must be tested for specific metabolic and
                                                 other diseases, and the newborn’s physician and hospital attendant
                                                 are jointly responsible for assuring this occurs. In this regard, “all
                                                 information, including records, correspondence, and documents,
                                                 specific to individual newborns, shall be confidential and shall be



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       Subject               Law/Citation                                 Description/Summary                              Consequences of
                                                                                                                           Non-compliance
                                                 used solely for the purposes of medical intervention, counseling,
                                                 scientific research, or reporting. The infant's name shall be kept
                                                 confidential.”


Donor registry            HRS § 327-20           Personally identifiable information on a donor registry about a donor
                                                 or prospective donor may not be used or disclosed without the
                                                 express consent of the donor, prospective donor, or the person that
                                                 made the anatomical gift for any purpose other than to determine,
                                                 at or near death of the donor or a prospective donor, whether the
                                                 donor or prospective donor has made, amended, or revoked an
                                                 anatomical gift.


Hospitals                 HAR § 11-93-           All information contained in a patient’s record, including information
                          21(g),                 contained in an automated data bank, shall be considered
                          HAR § 11-93-21(j)      confidential.
                                                 The patient's record shall be the property of the hospital whose
                                                 responsibility shall be to secure the information against loss,
                                                 destruction, defacement, tampering, or use by unauthorized
                                                 persons.
                                                 There shall be written policies prepared by the hospital
                                                 administration which shall govern access to, duplication of, and
                                                 dissemination of information from the patient's record.
                                                 Written consent of the patient, if competent, or otherwise the
                                                 patient’s guardian, shall be required for the release of information to
                                                 persons not otherwise authorized by hospital policy to receive it.




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       Subject               Law/Citation                                 Description/Summary                             Consequences of
                                                                                                                          Non-compliance

EMS                       HAR § 11-72-22         During or immediately after the time of patient care, an ambulance
                                                 patient care report form shall be prepared for each patient. Any data
                                                 recorded, collected, or evaluated for the pre-hospital emergency
                                                 medical data system shall comply with applicable federal and state
                                                 guidelines and statutes relating to the privacy of medical data and a
                                                 patient's condition.


Mental health or          HAR § 11-175-31,       Information in the clinical record of a consumer of mental health or
substance abuse           HRS § 334-5            substance abuse services shall be confidential and shall not be
programs* (if part of                            shared outside the mental health division, outside a contract
a participant group)                             program, or by a private provider.
                                                 "Program" for the purpose of these rules, means the only or smallest
                                                 distinct unit within a service setting offering treatment or care. HAR
                                                 § 11-175-2.


Skilled                  HAR § 11-94-            All information contained in a patient's record, including any
nursing/intermediate 22(h),                      information contained in an automated data bank, shall be
care facilities (if part                         considered confidential.
of a participant         HAR § 11-94-22(i),      The record shall be the property of the facility, whose responsibility
group)                                           shall be to secure the information against loss, destruction,
                         HAR § 11-94-22(j),      defacement, tampering, or use by unauthorized persons.
                                                 There shall be written policies governing access to, duplication of,
                          HAR § 11-94-22(k)      and dissemination of information from the record.
                                                 Written consent of the patient, if competent, or the guardian if
                                                 patient is not competent, shall be required for the release of
                                                 information to persons not otherwise authorized to receive it.



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       Subject               Law/Citation                                 Description/Summary                               Consequences of
                                                                                                                            Non-compliance

Health plans              HRS § 431: 10A-        No insurer may disclose an individual's or a family member's genetic
                          118.                   information without the written consent of the person affected, the
                                                 person's legal guardian, or a person with power of attorney for
                          HRS § 432:1-607        health care for the person affected. This consent shall be required
                                                 for each disclosure and shall include the name of each person or
                          HRS § 432E-            organization to whom the disclosure will be made.
                          10(b)(5).              Mutual benefit societies may not “disclose an individual's or a family
                                                 member's genetic information without the written consent of the
                                                 person affected, the person's legal guardian, or a person with power
                                                 of attorney for health care for the person affected. This consent
                                                 shall be required for each disclosure and shall include the name of
                                                 each person or organization to whom the disclosure will be made.”
                                                 A managed care plan shall ensure confidentiality of records and shall
                                                 not disclose individually identifiable data or information pertaining to
                                                 the diagnosis, treatment, or health of an enrollee, except as provided
                                                 under law.


Laboratories –            HAR § 11-113-          Any information concerning a substance abuse test [ ] shall be strictly
substance abuse           32(a), HRS § 329B-     confidential. Such information shall not be released to anyone
testing                   6,                     without the informed written consent of the individual tested and
                                                 shall not be released or made public upon subpoena or any other
                          HAR § 11-113-          method of discovery, except that information related to a positive
                          32(b)                  test result of an individual shall be disclosed to the individual, the
                                                 third party, or the decision maker in a lawsuit, grievance, or other
                                                 proceeding initiated by or on behalf of the individual tested and
                                                 arising from positive confirmatory test result.
                                                 Any person who receives or comes into possession of any



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       Subject               Law/Citation                                 Description/Summary                       Consequences of
                                                                                                                    Non-compliance
                                                 information protected under this chapter shall be subject to the
                                                 same obligation of confidentiality as the party from whom the
                                                 information was received.




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A-16 Rules for the Board of Pharmacy and Controlled Substances
The current rules for the Board of Pharmacy and Controlled Substances are being
revised as they are out of date. HRS 461 covers Pharmacists and Pharmacies,
administered by the Board of Pharmacy and the corresponding rules are found in
Chapter 95. HRS 328 covers non-controlled substances prescriptions and is
administered by the Department of Health, Food and Drug Branch. HRS 328 has no
rules only statutory language. HRS 329 covers controlled substances prescriptions and is
administered by the Department of Public Safety, Narcotic Enforcement Division and the
corresponding rules is Chapter 200.




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A-17 Memorandum of Agreement State HIT Coordinator and Hawai‘i HIE




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Hawai‘i Health Information Exchange
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Hawai‘i Health Information Exchange
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A 18 DRAFT Request for Information (RFI)




                           REQUEST FOR INFORMATION (RFI)

         IN THE FORM OF WRITTEN AND VENDOR DEMONSTRATIONS

                                                  BY

                 HAWAI‘I HEALTH INFORMATION EXCHANGE (HIE)




                                RFI #: 20101008-1
             REGARDING HEALTH INFORMATION EXCHANGE CORE SERVICES



                                          October 8, 2010




Responses due by: October 31, 2010; 5:00PM Hawai‘i Standard Time
Email notification of intention to submit by: Oct. 21, 2010 to: info@hawaiihie.org




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Contents
INSTRUCTIONS FOR RESPONDING.........................................................................................................204
    TIMELINE OVERVIEW:...................................................................................................................................204
RFI SUMMARY ......................................................................................................................................205
BACKGROUND: .....................................................................................................................................205
1. CORE SERVICES..................................................................................................................................206
    A. DATA TRANSFORMATION SERVICES (REF. STRATEGIC PLAN – TABLE 5: I1).................................. 206
    B. CLINICAL PORTAL (REF. STRATEGIC PLAN – TABLE 5: I2) .............................................................. 207
    C. AUDIT TRAIL SERVICES (REF. STRATEGIC PLAN – TABLE 5: I3) ...................................................... 207
    C-A. PRIVACY AND SECURITY ........................................................................................................... 207
    D. PATIENT IDENTIFIER SERVICES (REF. STRATEGIC PLAN – TABLE 5: I4) .......................................... 208
    E. CROSS-ENTERPRISE USER AUTHENTICATION SERVICES (REF. STRATEGIC PLAN – TABLE 5: I5) ..... 209
    F. LAB RESULTS EXCHANGE (REF. STRATEGIC PLAN – TABLE 5: F1)................................................... 209
    G. MEDICATION HISTORY EXCHANGE (REF. STRATEGIC PLAN – TABLE 5: F2) ................................... 210
    H. MEDICAL ENCOUNTER NOTES (REF. STRATEGIC PLAN – TABLE 5: F3) .......................................... 210
    I. RADIOLOGY RESULTS EXCHANGE (REF. STRATEGIC PLAN – TABLE 5: F4) ...................................... 210
    J. POPULATION HEALTH SERVICES (REF. STRATEGIC PLAN – TABLE 5: F5) ........................................ 210
    K. PATIENT NOTIFICATION AND CONSENT (REF. STRATEGIC PLAN – TABLE 5: F6)............................ 211
    L. DE-IDENTIFICATION SERVICES (REF. STRATEGIC PLAN – TABLE 5: F7) ........................................... 211
2. Valued Added Services......................................................................................................................212
    A. PATIENT ACCESS.......................................................................................................................... 212
    B. ELIGIBILITY CHECKING ................................................................................................................. 212
    C. DECISION SUPPORT AND RESULTS............................................................................................... 212
    D. TRUST BROKER............................................................................................................................ 212
    E. SERVICE ACCESS LAYER ................................................................................................................ 213
    G. NHIN GATEWAY .......................................................................................................................... 213
3. Service Descriptions ..........................................................................................................................213
    A. ADMINISTRATION ....................................................................................................................... 213
    B. COMMUNICATION ...................................................................................................................... 214
    C. DATA PUBLISHING ....................................................................................................................... 214
    D. DATA QUALITY ASSURANCE ........................................................................................................ 214
    E. EXCHANGES ................................................................................................................................. 215
    F. DATA STANDARDS ....................................................................................................................... 215
    G. SENSITIVE DATA .......................................................................................................................... 216
    H. STANDARDS AND PROTOCOLS .................................................................................................... 216
    I. SYSTEM ENVIRONMENTS ............................................................................................................. 216
    J. TRAINING REQUIREMENTS........................................................................................................... 216
4. RESPONSES INSTRUCTIONS: ..............................................................................................................217
    A. COVER LETTER ........................................................................................................................................217
    B. EXECUTIVE SUMMARY ..............................................................................................................................217
    C. ORGANIZATION INFORMATION ...................................................................................................................218
    D. PROPOSAL..............................................................................................................................................218
    F. PRICING INFORMATION.............................................................................................................................219

Hawai‘i Health Information Exchange
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INSTRUCTIONS FOR RESPONDING
Timeline Overview:
        •    Vendors may submit written questions to the Hawai‘i Health Information Exchange
             (HIE) until 5:00 p.m. Hawai‘i Standard Time, October 19, 2010
        •    Answers to written vendor questions will be posted on the Hawai‘i HIE website
             (http://www.hawaiihie.org/) by 5:00 p.m. HST, October 26, 2010
        •    RFI responses are due by 5:00 p.m. HST October 31, 2010


EVENT                                                                            DATE
Release of RFI                                                                   Oct. 8, 2010
Vendor Questions Due                                                             Oct. 19, 2010
Deadline for Notice of Intent to Respond                                         Oct. 21, 2010
Release Clarifications Based on Vendor Questions                                 Oct. 26, 2010
Vendor RFI Responses Due                                                         Oct. 31, 2010
Planning Date for Future Request for Proposal                                    Jan, 2011

RFI Point of Contact
All written questions and RFI responses should be sent to:
Christine Mai‘i Sakuda and Gregory Suenaga
Hawai‘i Health Information Exchange
900 Fort Street Mall, Suite 1300
Honolulu, Hawai‘i 96813
Phone: 808.441.1310; Fax: 808.441.1472
Email: info@hawaiihie.org

Submission Media
To assist vendors in minimizing their costs in providing information, Hawai‘i HIE prefers
that responses to this RFI be submitted either electronically in Microsoft Word 2003-up
or PDF to the email listed. The vendor as an alternative, may choose to submit
information on CD to the postal address above.

Submission Format
The total response to Section 4.D should not exceed a total of 30 pages; the response
should be formatted using Arial font, size 11, with no less than one inch margins.
Vendors may submit references to online material and attach appendices to their
response, but materials beyond the core response (Sections 4.D) may not be read.

Solution Demonstrations
In addition to written submissions, Hawai‘i HIE encourages responses to demonstrate
the use and capabilities of its available solution. The demonstration date/time will be

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coordinated with the vendor’s point of contact provided in the RFI response and should
be a webinar format so that multiple stakeholders may participate.

RFI SUMMARY
The Hawai‘i Health Information Exchange (HIE), a 501(c) (3) non-profit organization and
authorized as the State Designated Entity (SDE), issues this Request for Information for
the purpose of conducting technical research regarding health information exchange
core technologies and services from industry leaders and top performers. These services
will be offered statewide to health care organizations and providers through
coordinated data exchange. Information provided will assist our State in understanding
the current condition of the application marketplace, including commercial/government
best practices, industry capabilities, innovative delivery approaches, commercial market
service levels, and performance strategies and measures.

This market research is not a competition. The information obtained from submitted
written responses and/or oral presentations will be used only to improve Hawai‘i HIE
and their stakeholders’ knowledge of private industry’s capabilities. No evaluation of
participating vendors will occur and your participation is not a promise of future
business with Hawai‘i HIE. Responding or not responding to this RFI does not preclude
the vendor from bidding on any future solicitations. Any pricing information provided in
your information packet must meet the strict guidelines outlined in Section 4.F.

Information obtained through this RFI will be shared among participating organizations
to encourage complimentary development of services across multiple healthcare
efforts. Entities responding to this RFI should be aware that information they provide
will be subject to the public at large. Proprietary information is not to be submitted in
response to this RFI. In addition, Hawai‘i HIE reserves the right to amend, extend, or re-
release this RFI.

After reviewing the information obtained through this RFI, Hawai‘i HIE will determine its
own next steps, including how and when to pursue a Request for Proposal.

Hawai‘i HIE appreciates your cooperation and looks forward to a very meaningful,
productive, and collaborative market research effort.

BACKGROUND:

Hawai‘i HIE will be offering health information exchange services to assist medical
providers in complying with the meaningful use criteria developed by the U.S.
Department of Health and Human Services (HHS). Among these services the States are
specifically interested in gauging the need for and ability for vendor(s) to provide a
health information CORE SERVICES management solution that offers a robust and
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secure technical environment in which to exchange Protected Health Information (PHI).
For further details refer to the Hawai‘i HIE plan located on:
http://www.hawaiihie.org/opportunities.html.

Hawai‘i HIE is seeking information describing demonstrated experience, financial
stability, and a proven product, as well as possessing the ability to outline service
offerings to implement, host and operate Hawai‘i HIE’s CORE SERVICES and potential
information exchange with other state’s HIEs. The yet to be determined solution will
enable the stakeholders of Hawai‘i to facilitate the sharing of health information to
improve the quality of patient care and enhance health benefits for the population.

The CORE SERVICES and access to state HIE will be an internet-based, robust search-
engine, proficient, statewide hybrid modeled network that will integrate health care
communications and data transfer based on federal standards for health information
exchange. CORE SERVICES will facilitate clinical data exchange for the state’s one million
residents among authorized health care professionals in a secure environment.

The CORE SERVICES and access to state HIE will also connect Hawai‘i to the Nationwide
Health Information Network (NHIN).

1. CORE SERVICES

Hawai‘i HIE CORE SERVICES are described in the State HIE Plan located on
www.hawaiihie.org/opportunities.html. The HIE CORE SERVICES consist of the
following:

        A. Data Transformation Services (ref. Strategic Plan – Table 5: I1)
The design, development, testing and loading of a wide variety of information sources
will be critical to the successful population of various parts of the CORE SERVICES. Given
the diverse range of sources and targets, the information should describe the overall
approach:
    1) Data translation/normalization;
    2) Sample DTS Task functionality from other HIEs;
    3) OLE DB wizard logic;
    4) Transmission failure logic;
    5) Global Variable protection; and
    6) SSIS Packages, Extract, Transform, and Load packages (ELT), or other applications
        used.


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        B. Clinical Portal (ref. Strategic Plan – Table 5: I2)
Stand-alone web based service protocols that will allow the transfer of data securely,
will be evaluated and is essential for long-term success. How such an approach is taken
and how the same technologies can enable other means of availability must be
explored. Accordingly, please address your approach for:
    1) Secure web-browsers;
    2) Specialized interfaces (e.g., ED “white boards”);
    3) Support for projects like the ED/Safety Net clinic transitions in care;
    4) Web 2.0 technologies;
    5) Interfaces to PHRs;
    6) Document summaries via CCD or CCR;
    7) Discreet data transfers (e.g. lab results, medications)
    8) Direct integration of codified data into EHRs

        C. Audit Trail Services (ref. Strategic Plan – Table 5: I3)
Ability to historically track back who, what, when, and where health information was
accessed, viewed, and/or downloaded.
RFI must provide efficient and effective means of auditing use of the Exchange’s
services. This remains an area of rapid evolution and uncertainty, but basic, reliable
auditing services are essential. Accordingly, vendor should address:
    1) How auditing services are performed;
    2) How security to audit functions is assured;
    3) How audits can be codified and transmitted “downstream” to other
       exchanges as part of an NHIN effort; and
    4) Disclosure tracking.


        C-A. Privacy and Security
Vendors should describe their approach to:
        1. Limiting access to authorized users and monitoring unauthorized
           access at both the vendor level as well as the Hawai‘i HIE level.
             a. How controls are configured by end user;
             b. How controls are configured by internal staff;
             c. How controls are implemented to monitor and limit access to end
                users, developers and system administrators;



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             d. How data access is limited to sensitive content (i.e.;
                HIV/AIDS/ARC, behavioral medications/health, substance abuse,
                etc.)
        2. Monitoring use, as well as successful and unsuccessful security
           incidents.
        3. Breach notification and other violations of policies:
             a. Notification to Hawai‘i HIE in the event of a suspected successful
                security incident or other unauthorized access, use or disclosure of PHI.
             b. Coordination of a risk analysis and forensic analysis.
             c. Legal analysis of Federal & State breach reporting requirements.
             d. Mitigation techniques including both technical and administrative
                measures to lessen the impact of the breach.
             e. Reporting to Attorney’s General Office of Civil Rights, consumers and
                others as well as any coordination with credit reporting bureaus.
             f. Involvement of Covered Entities who’s PHI has been breached.
        4. Alignment from the HITRUST Common Security. Although Hawai‘i HIE
           is not requiring that the Solution Provider apply for or obtain HITRUST
           certification at this time, it may be required at a later date. The
           vendor should describe their experience with the HITRUST Common
           Security Framework.
        5. Coordinating both privacy and security policies between the vendor’s
           internal staff and operations and those of the Hawai‘i HIE, and
        6. Compliance with applicable federal and state laws.

        D. Patient Identifier Services (ref. Strategic Plan – Table 5: I4)
This component is a reconciliation service that matches records from existing systems to
provide a definitive mechanism for matching all records for a patient. Exchange
performance will depend critically on the ability to reconcile all records appropriate to a
specific individual and to avoid collating records that are from different individuals.
Describe the following approaches to patient record identification and matching:
    9) Probability Scoring parameters by acceptable matched algorithm;
             a. How is the configuration adjusted and the maximum amount of
                adjustments;
    10) Record locator services and patient matching algorithms without the use of
        Social Security Numbers;
    11) Verifying performance characteristics of accurate record matching algorithms;
    12) Resolution of discrepancies and duplicates;
             a. How are unmatched patients resolved and what is the threshold;
             b. How are match patients in error resolved;

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             c. Describe the process of notifying users that information used was
                matched incorrectly and resolved.
    13) How an architecture can leverage or interact with the proposed state-wide
        record locator service;
    14) How architecture can be integrated into a statewide and potentially a
        nationwide network;
    15) Describe the use of phonetic algorithm to address Hawai‘i’s specific geographical
        uniqueness with population names; and
    16) How patient identifier and matching are re-established after patient
        demographic changes (e.g. maiden to married last name).

Note: Clinical records will remain in the source system with explicit data exchanged or
stored into the Exchange’s cached area. It is the intention that only data required to
meet the requirement of the Exchange are held in the Exchange.

        E. Cross-Enterprise User Authentication Services (ref. Strategic Plan
        – Table 5: I5)
This component is an index containing all relevant information on all registered
clinicians and other authorized users (such as payers, labs, State, etc.) within Hawai‘i HIE
that will process additions, deletions, and changes to the master list. Recognizing that
this data will be available from multiple sources, the intention is to partner with these
stakeholders. This information may also be used for routing messages to the right
organization for delivery to the intended user.
    1) Name-Password or other ID –based approaches;
    2) A systematic process that alerts administrators of authorized users inappropriate access
       to restricted data by way of id/pw/facility/IP address/ and other traceable identifiers;
    3) Site-based (e.g., IP zone or through institutional web portal). This component is an index
       of facilities with which the clinician (or other user) registered with the Hawai‘i HIE has an
       affiliation/relationship. Note that clinicians may be affiliated with multiple facilities or
       offices.;
    4) Role-based administration process (e.g., activate/deactivate roles, staff roles,
       location); and
    5) Combinations of approaches such as SSO and two-factor authentication.

        F. Lab Results Exchange (ref. Strategic Plan – Table 5: F1)
A service to impose and apply uniformity to laboratory result and order messages to
conform to the format, coding, and transport requirements between the Hawai’i HIE
and the receiving EHR or public health agency (as mandated by federal and state laws
and in accordance with national standards and specifications). The centralized routing
service is intended to replace the numerous, point-to-point connections among the

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specific Hawai‘i laboratories, EHRs and public health databases with a single routing hub
connected to participating entities. Majority of the clinical laboratories in the State of
Hawaii, including its two largest laboratories supporting hospital and outreach testing,
have not defined or implemented the use of Logical Observation Identifiers Names and
Codes (LOINC), which is vital in the access and management of laboratory information
coming from multiple disparate sources in a HIE environment.

        G. Medication History Exchange (ref. Strategic Plan – Table 5: F2)
This service will allow for the medication summary exchange for care coordination,
prescribing, and medication management. This service could also offer a medication
retrieval and aggregation of prescription (new, refills, etc.) information from identified
sources (e.g., Surescripts, others) to medical providers, including pharmacists. A
medication management solution may also include: (1) medication history, including
analytical services and medication reconciliation, and (2) e-prescribing support,
including prescription management, eligibility, and formulary information.
Specifically this service will allow for the reconciliation of prescription fill status and/or
medication fill history. It enables display of a single record of both medications ordered
and filled.

        H. Medical Encounter Notes (ref. Strategic Plan – Table 5: F3)
This service will offer a centralized hub for transforming clinical summary data among
provider and patient-designated entities. This service would be analogous to the
laboratory-routing clearinghouse, and would enable organizations to exchange clinical
summary data. This service will allow for the clinical summary exchange for care
coordination, capability and capacity for the translation of legacy messaging to
standardized CCD and/or CCR.

        I. Radiology Results Exchange (ref. Strategic Plan – Table 5: F4)
This component is a service that facilitates the delivery of radiology reports and/or
interpretations to providers. It is recommended that future considerations and
scalability be described with an interface to PACS systems.

        J. Population Health Services (ref. Strategic Plan – Table 5: F5)
Hawai‘i HIE will propose to exchange information with the DoH immunization registry to
receive data in a format as required by the final federal rule on standards and
certification. DoH’s Immunization Registry will then be capable of electronically
recording, retrieving, and transmitting immunization information in accordance with
national standards and specifications.30 Initial services may not include aggregate

30
  The State currently uses the following CDC implementation guides for immunization data transmissions:
 (1) IM v2.3.1: Centers for Disease Control and Prevention Implementation Guide for Immunizations Data

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queries over and above those required to manage the system. Long-term viability,
however, will require close interplay between exchange technologies and one or more
of Hawai‘i’s secure databases for the purposes of research. These services may include
more structured queries for public health, population health, quality reporting, financial
planning, and other efforts. Potential vendors should address this issue and consider
some of the following topics:
    1) Are there potential Solution Providers that have any experience with
       other parties doing this category of research;
    2) Ability to co-exist with a secure research database derived from same
       data as obtained through the Exchange’s services;
    3) Approach to quality reporting;
    4) Application for public health; and
    5) Interactions with other sources, and if possible, list programs.

        K. Patient Notification and Consent (ref. Strategic Plan – Table 5: F6)
Under the “opt” model, Hawai‘i HIE intends to exchange health information across
providers with the option for patients to permit or deny consent to the Exchange or
“opt-in or out” for the purpose of treatment. The main implication of the opt-in or out
system is that data exchange will take place and will be governed in conjunction with
HIPAA rules and by individual patient option.
How would Hawai‘i HIE address:
    1) Recording and tracking of patient consents at the qualified organization level and
       at the provider level;
    2) At the HIE level;
    3) Changes in patient consent over time;
    4) Further granularity of consent based on roles, purposes, types of data, etc.; and
    5) Audit logs of all “opt in and opt out” activity.

        L. De-Identification Services (ref. Strategic Plan – Table 5: F7)
A mechanism for removing demographic and other personally identifiable data from
protected health information and other health care data so that they can be used for
public health reporting, quality improvement, research, benchmarking and other
secondary uses.



 Transactions using Version 2.3.1 of the Health Level Seven Standard Protocol Version 2.2 and (2) IM
 v2.5.1: Centers for Disease Control and Prevention Implementation Guide for Immunizations Data
 Transactions using Version 2.5.1 of the Health Level Seven Standard Protocol Version 1.0.

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2. VALUED ADDED SERVICES

Hawai‘i HIE will explore the viability of additional Value-Added Services that provide
specific functions needed for HIE that are not otherwise available to eligible providers
and/or to the counterparties with whom they need to exchange health information.
These services would be layered on top of and accessed through the CORE SERVICES
based on the following criteria:
                 •   Consistent with Meaningful Use or other federal/state requirements,
                 •   Complementary to other states developed CORE SERVICES,
                 •   Aligns with identified clinical priorities,
                 •   Shared access accrues mutual benefit, and
                 •   Contributes to the overall sustainability model.

Value-Added Services currently under consideration include, but are not limited to:

        A. Patient Access
EHR Meaningful Use requires timely patient access to their health information. The
Hawai’i HIE could support this requirement by providing a mechanism for patients to
access their clinical information (e.g. deliver or route to patient’s preferred PHR or view
through a web portal) with built in administrative functions to manage access control of
patients.

        B. Eligibility Checking
A service to provide a central access point for EHRs and practice management systems
to retrieve insurance eligibility information via HIPAAEDI transactions across various
payers specifically for the Hawai‘i provider. This service would demonstrate and
facilitate electronic eligibility checking and the fulfillment of the corresponding
Meaningful Use criteria for the users and vendors of EHR systems in Hawai‘i.

        C. Decision Support and Results
A service to provide expanded functionality for the laboratory-routing clearinghouse, to
include a decision-support component able to automatically determine which test
results can and/or must be transmitted electronically to which
providers/patients/agencies per Hawai‘i statutes and regulations.

        D. Trust Broker
The Trust Broker enables transaction-based routing. The component is an index of
participating entities (or Qualified Organizations) including organizational details. It will
store participating entity rules (based on data sharing agreements) to enable the sharing
of clinical records.

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        E. Service Access Layer
The Service Access Layer is responsible for mediating all access to and from other HIE
CORE SERVICES: the various registries, the trust broker and the NHIN gateway. The
Service Access Layer is based on the NHIN messaging platform standard as approved by
HHS. This uniform interface simplifies interoperability and shields the other CORE
SERVICES components from requestors/receivers/information providers, while also
ensuring proper basic security is enforced.

        G. NHIN Gateway

The NHIN Gateway provides for a single statewide implementation of the NHIN
CONNECT gateway available as a web service for authorized users and entities. This
service is the required standard for interoperability with federal agencies, and the
proposed standard for the exchange of clinical information across the NHIN.

3. SERVICE DESCRIPTIONS
A comprehensive set of services will be required to begin effective use of patient-
centered information in initial care settings. The following sections describe some
expectations surrounding initial use and raises questions that vendors should consider
in describing their approach.
        A. Administration
Administration of the Exchange services requires a complex set of relationships between
individual contributors, various intermediary parties, governing bodies, advisory bodies,
and clinical users. This RFI is not expected to provide unguided “turn-key” operations
but instead should be a participant with other project management, governing, and
stakeholder groups. The RFI should describe how they best balance administrative and
governing relationships. Issues that could be addressed include:
    1) How will the Solution Provider interact with the governing bodies,
       advisory boards, and clients?
    2) What local and remote involvement with the Hawai‘i HIE stakeholders
       will the vendor commit to during development and in subsequent
       operations?
    3) Does the vendor use local sub-contractors for management, technical
       development, or local relationships?
    4) How does the vendor address liability issues?
    5) How might the vendor approach have a positive impact on providers
       seeking compliance with ARRA Meaningful Use provisions?
    6) What types of routine reports are most useful and to whom?


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    7) How does the vendor address issues requiring extensive coordination
       between a vendor at the Hawai‘i HIE such as:
             a. Development of consistent privacy and security policies;
             b. Successful security incident investigation, risk analysis and mitigation?
    8) How would a vendor make notification of data integrity disruptions?
    9) How would a vendor recommend handling patient inquiries both for
       audit logs and later for direct access to some aspects of the services
       provided through HIE?
    10) Describe system recommended requirements; and
    11) Ability to archive, purge and reconfigure archive/purge parameters of the
        system.
        B. Communication
Description on an approach for communication of clinical data and messaging among
providers. These approaches may include point-to-point or through a centralized
resource. Most communication services are not essential to initial deployment.
Solutions could describe:
    1) Their general approach to secure messaging;
    2) Examples of successful messaging deployments;
    3) Factors identified that inhibit successful widespread use of secure messaging;
        C. Data Publishing
Data from large institutions may be published to the Exchange in their native formats in
real-time or in batch feeds. Describe scenarios with:
    1) Establishing demographic feeds for Record Locator Services;
    2) Establishing clinical feeds for exchange;
    3) Demonstration of ability to manage diverse data types;
    4) Incorporation of PHR data;
    5) Incorporation of over-the-counter medication history data.
        D. Data Quality Assurance
Experience in various exchanges suggests that parsing techniques can be challenging,
that data feeds from participants can stop for technical reasons, and that data formats
can change over time. Describe:
    1) Data methods to assure data integrity;
    2) Roles and responsibilities of possible users; and
    3) Issue reporting.



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        E. Exchanges
Describe approaches to data repositories and exchanges. Among the topics that should
be addressed are:
    1) Examples on previous architectures and topologies as it relates to a similar HIE
       environment;
    2) Data representation using, for example, IHE Cross Enterprise Document Sharing
       (XDS) and most commonly used description logic and data flow;
    3) Performance in sub-second response time;
    4) Metadata tagging in a granular level;
    5) Indexing;
    6) Scalability;
    7) Support for general queries, such as statistical CMS Reports and access use
       reporting;
    8) Ability to transmit data to anonymized or other de-identified resources; and
    9) Ability to purge data if an entity withdraws participation.
        F. Data Standards
Although data will be submitted to the Exchange through a variety of standards, efforts
will be made to conform to national standards over time. In-bound data may be in a
variety of formats, but out-bound data should – over time – be made available through
a limited range of consensus standards. Accordingly, describe approach to and support
for:
    1) LOINC;
    2) CCD;
    3) ASC X12N
    4) HL7;
    5) CCR;
    6) IHE;
    7) ICD-9 and ICD-10 (conversion strategy to meet Federal Timeline)
    8) SNOMED CT
    9) RxNORM
    10) NCPDP
    11) Other relevant national standards and certifications.




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        G. Sensitive Data
To date, Hawai‘i HIE is developing policies regarding the exchange of general clinical
information including policies regarding patient notification with the expectation of an
opt-out implemented.
    1) Describe experience with the exchange of sensitive data, tools and procedures that
       address the legal and policy issues surrounding the exchange of sensitive data, including
       the exchange of HIV/AIDS/ARC, mental health and developmental disability records and
       records relating to alcohol and substance abuse treatment protected by 42 CFR part 2.
    2) Describe ability to segregate specific sensitive data that would not be allowed through
       the Exchange but still allow other data attached to the patient to be exchanged (i.e.;
       HIV/AIDS/ARC, behavioral medications/health, substance abuse, etc.).
        H. Standards and Protocols
The recommendation should be compliant with national recognized standards and protocols.
Compliance with these standards and protocols will ensure that users of the statewide HIE will
be able to exchange vital health information with other compliant state and national health care
providers, HIEs, registries, agencies, etc.

        I. System Environments
The Hawai‘i HIE CORE SERVICES is considering options that would establish, host, and
maintain the Exchange and may be expected to be deployed across multiple
environments. As mentioned, clinical records will stay in the existing system with
specific data exchanged or stored into the Exchange’s repository.
Please describe a recommended system environments and migration plans for the
following:
    1) Development and Unit Testing;
    2) Component Integration Testing;
    3) Production staging to be used for System, Stress, and User Acceptance
       Testing (UAT);
    4) Production;
    5) Training;
    6) Technical requirements pertaining to supported platforms, hardware,
       and software;
    7) Conversion; and
    8) Hot site (disaster recovery).
        J. Training Requirements
Appropriate Hawai‘i HIE and qualified organization end-users will need to be trained on
using the Hawai‘i HIE portal and supplied functionality.


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Please describe a training approach, process, staffing and timeframes, including how
you will meet the following requirements:
    1) Provide training plan including proposals for staffing approach;
    2) Provide hard copy and electronic training materials;
    3) Provide state-wide training approach, including super-users;
    4) Provide proposals for both web-based training modules and in-person training;
       and
    5) Provide experience and options for courses and component training.

4. RESPONSE INSTRUCTIONS:
General Note on RFI Responses:
The specific solution capabilities discussed in this RFI describe an ideal system given
current technology and levels of connectivity. In responding to the inquiries, Hawai‘i HIE
welcomes your comments regarding the reasonability of offering the described
capabilities (currently and in the next several months/years) as well as whether a vehicle
other than an HIE Core Service would be more appropriate to provide the solution
capability.

Vendor Point of Contact and RFI Response Labeling
Please provide your point of contact for this RFI response. List the following for contact:
    1)   Name and Title
    2)   Company name
    3)   Address
    4)   Phone number
    5)   Fax number
    6)   Email address

Also, please clearly label the response document with the responding vendor’s
Company name, and include the vendor name and a page number in the footer on each
page of the response.

A. Cover Letter

Please provide a cover letter on the prime organizations’ letterhead. This cover letter
should be signed by a representative of the respondent(s).

B. Executive Summary

Please provide an overall summary of your proposed solution. Include a description of
all contracting relationships, technical approach, cost model and timeline.


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C. Organization Information

If your response requires the collaboration with or inclusion of additional partner(s),
that should be stated, and if you have current formal relationships with contemplated
partner(s). The intent is to have a single inclusive and complete solution proposed from
a single responsible lead entity.

Briefly describe the history of the organization and developing the proposed HIE
services, products or solutions.

Please provide a list of all data interface relationships and a description of the
relationship as related to the proposed solution. Description should include itemized
interfaces with the below healthcare products:

         Epic                    Allscripts           Centricity             NextGen
         eClinicalWorks          WelLogic             VistA/RPMS             MS HealthVault
         Surescripts             Amalga (HIE)         Google Health          Cerner
         McKesson EMR            Meditech             CHCS/AHLTA             others

D. Proposal

Please provide a summary of your proposed solution including the names of products
and version/release you are proposing to use. Provide an overall technical architecture
description and diagram that shows all proposed components and how they related to
each other. Include a high level technical and functional view of the solution and how it
meets the required clinical and technical functions, as well as the associated supporting
CORE SERVICES. The response should not exceed 30 pages and formatted using Arial
Font, size 11 with no less than one inch margins.

Reviewers should be able to clearly understand the technical aspects for each
component and how it is constructed. Essential items:
    •   Technical architectural pattern and approach;
    •   Product name and version for which the function is or will be available;
    •   Number of years/months which the function has been in production & supported
    •   CCHITor Meaningful Use certification if applicable;
    •   Healthcare standards supported for the functional component (please list all applicable,
        and if there are many, how they relate to each other);
    •   Healthcare vocabularies supported – address how your system supports translation to
        specified standards to achieve semantic interoperability;
    •   NHIN capabilities (please distinguish between NHIN gateway, NHIN Direct, and/or other
        NHIN capabilities);


Hawai‘i Health Information Exchange
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    •   Sequence diagram(s), if appropriate, for the function or across functions;
    •   Relationships to other services or functions;
    •   How the component can be configured, extended or modified;
    •   Screenshots and examples of the described functionality; and
    •   Please provide a breakdown and description of how your proposed solution supports
        non-functional requirements. These include:
                     o    Software bug tracking
                     o    Availability
                     o    Testing
                     o    Performance
                     o    Failover
                     o    Disaster Recovery
                     o    Service Level Monitoring
                     o    Pattern for scaling – vertical vs. horizontal, etc.

F. Pricing Information
It is recommended that vendors break out pricing somewhat based on the below model:

    1) CORE SERVICES
    2) VALUE ADDED SERVICES
    3) SERVICES DESCRIPTION
    4) HARDWARE
    5) MAINTENANCE AND SUPPORT
    6) ANNUAL LICENSE FEES, WITH BREAK OUT PRIMARY SOFTWARE AND ANCILLARY
       SOFTWARE PRODUCTS BASED ON END USER AND SMALL / LARGE FACILITY
    7) SUBTOTAL
    8) HAWAI‘I STATE TAX
    9) ESTIMATED TOTAL




Hawai‘i Health Information Exchange
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Resources
Resources:

Reference materials used throughout the strategic and operational plans have been
drawn from a variety of sources, many of them available on line. These are listed below
in terms of the reference category to which they most apply.

Hawai‘i Broadband

1)      Hawai‘i Broadband Task Force Final Report: A Report to the Governor and
Legislature of the State of Hawai‘i prepared by The Auditor State of Hawai‘i and RHD
Consulting, LLC, December 2008, available at:
        www.hbtf.org/files/Hawaii%20Broadband%20TaskForce%20Final%20Report.pdf

2)   Pacific Broadband Telehealth Demonstration Project, University of Hawai‘i,
Mānoa. (Personal Communication, August 3, 2010). Project description available at:
     www.fcc.gov/cgb/rural/rhcp_applications.html.

Stakeholder Presentations, April 23, 2010.

At the beginning of the strategic planning process, a group of fifteen stakeholder groups
was invited to an all-day session at which they were invited to present on information
about their organizations relevant to health information exchange.

    •   Participants (by Organization) included:

•   Hawai‘i Health Information Corporation;
•   Hawai‘i Primary Care Association;
•   Independent Physicians Association,
•   Kaiser Permanente;
•   Honolulu Chamber of Commerce;
•   Yeoh and Muranaka Outpatient Radiology Practice;
•   Castle Medical Center;
•   Hawai‘i Department of Health;
•   Hawai‘i Medical Services Association;
•   John A. Burns, School of Medicine, University of Hawai‘i;
•   VA-DOD Pacific Telehealth and Technology Hui;
•   Hawai‘i Health Systems Corporation (Maui Memorial Hospital);



Hawai‘i Health Information Exchange
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•   Laboratories (Joint presentation by DLS and CLH—supplemented by later
    communications)
General Resources Consulted:

State Health Information Exchange Cooperative Agreement Program- Hawai‘i, Project
Narrative, fall 2009

WI SLHIE Planning Project, WI SLHIE Asset Survey, available at:

dhs.wisconsin.gov/.../SLHIE/WISLHIESteeringCommitteePresentation08.09.09.pdf

Wellogic, Project Summary, North Hawai‘i Health Information Exchange, Fact Paper,
summer 2010.

Privacy and Security Legal Inventories

Hawai‘i State Department of Health, Inventory of Applicable State and Federal Laws and
Rules Regarding Security and Privacy (Reproduced as Appendix 18)

Health Care Insurance Coverage

Gerald Russo, et. al., Hawai‘i’s Uninsured Population: Estimates from the Current
Population Survey 1997-2008. Draft Report Prepared for the Hawai‘i State Department
of Health, Family Services Division, June 30, 2009.

EHR Provision

Welllogic, Project Summary, North Hawai‘i Health Information Exchange, 2010,
distributed by NHHIE

Hawai‘i Hospital Data

Hawai‘i Health Information Corporation

Websites Consulted:

Health Status and Some Health Plan Data:

Health Trends in Hawai‘i: A Profile of the Healthcare System, available at:
www.healthtrends.org/

Kaiser Family Foundation, statehealthfacts.org, available at:
www.statehealthfacts.org/

Hawai‘i Population Data:

hawaii.gov/dbedt/info/economic/databook/
Hawai‘i Health Information Exchange
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Hawai‘i Health Plans:

Aloha Care:
www.alohacare.org/

Hawai‘i Medical Service Association:
www.hmsa.com/

Native Hawaiian Health Care:
www.nativehawaiianhealth.net/history.cfm

Health Information Exchange:

U.S. Department of Health and Human Services, Office of the National Coordinator for
Health Information Technology. Available at:
healthit.hhs.gov/portal/server.pt?open=512&objID=1200&mode=2

Census Information:

U.S. Census Bureau, Population Division, update July 26, 2010, available at:
www.google.com/publicdata?ds=uspopulation&met=population&idim=state:15000&dl=
en&hl=en&q=population+of+Hawaii

Pharmacy:

Letter from Todd Inafuku to Hawai‘i’s pharmacists summarizing state of legal status for
pharmaceuticals, “Electronic Prescriptions Requirements,” July 9, 2009, Hawai‘i
Pharmacists Association, available as PDF from author and through:
www.hipharm.org

Pharmacy:

http://www.surescripts.com/

Kaiser Family Foundation, State Health Facts, Health Costs and Budgets, Pharmacy.
Available at:
www.statehealthfacts.org/profileglance.jsp?rgn=13

Hospitals:

    •   www.theagapecenter.com/Hospitals/Hawaii.htm
    •   www.healthcarehiring.com/general-hospitals/hawaii/0/
    •   www.officialusa.com/stateguides/health/hospitals/hawaii.html
    •   en.wikipedia.org/wiki/List_of_hospitals_in_Hawaii
    •   www.ushospital.info/Hawaii.htm
    •   www.hospitalsworldwide.com/usa_states/hawaii.php

Hawai‘i Health Information Exchange
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    •   www.yellowpages.com/hi/hospitals?g=HI
    •   www.allhospitaljobs.com/hospital/hs-hi.html

Ancillary Facilities:

    •   rds.yahoo.com/_ylt=A0oGdHCxD1FMMfYApaVXNyoA;_ylu=X3oDMTEzMDBmN3ZsBHNlY
        wNzcgRwb3MDMwRjb2xvA3NrMQR2dGlkA0g2MTJfMTM4/SIG=13m8s8jtf/EXP=128046
        7249/**http%3a//ambulatorysurgerycenter.info/index.php%3foption=com_content%2
        6task=view%26id=26%26Itemid=31
    •   honolulucounty.hi.networkofcare.org/mh/links/display_links.cfm?id=85&topic=20
    •   honolulucounty.hi.networkofcare.org/mh/links/display_categories.cfm?id=19
    •   hawaii.gov/health/environmental/water/disability-services/neurotrauma/continuum-
        of-care-MML.html
    •   health.usnews.com/best-
        hospitals/search?city=City&zip=ZIP+Code&state=HI&sort_by=&specialty_id=All&hospita
        l_name=Hospital+name&service_offered=All&page=2
    •   www.yellowpages.com/search?tracks=true&search_terms=urgent+car&geo_location_t
        erms=HI
    •   yellowpages.whowhere.com/search/?C=surgery&L=HI
    •   yellowpages.whowhere.com/search/?C=urgent+care&L=HI
    •   gourgentcare.practicevelocity.com/Hawaii.htm
    •   www.rahawaii.com/html/contact.html#businessoffice
    •   www.hirad.com/contact.html
    •   www.yellowpages.com/search?tracks=true&search_terms=radiology&geo_location_ter
        ms=HI
    •   www.yellowpages.com/search?tracks=true&search_terms=Physicians+%26+Surgeons%
        2C+Radiology&geo_location_terms=HI
    •   www.healthcarehiring.com/radiology-medical-imaging/hawaii/0/
    •   www.healthcarehiring.com/byname/dialysis-clinics/hawaii/1/-/0
    •   www.libertydialysis.com/clinic_locator.html
    •   www.dialysiscenters.org/hi/kamuela/
    •   www.fmcna.com/
    •   https://www.ultracaredialysis.com/gm/map_internal_filter.asp?transaction=search&lan
        guage=en&street=&city=kapaa&state=HI&postalCode=&distance=100&x=79&y=10
    •   www.yellowpages.com/search?tracks=true&search_terms=Dialysis+Services&geo_locati
        on_terms=HI




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