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Creating a Roadmap Toward Powered By Docstoc
					August 25, 2008




                  South Dakota eHealth Collaborative:
                  Creating a Roadmap Toward Health
                  Information Exchange
Members of the eHealth Collaborative

                 We would like to acknowledge the contribution of all members of the
                 eHealth Collaborative, both those who facilitated the four workgroups
                 and those who contributed material and expertise to this report. The
                 members of the group are as follows:

FACILITATORS            • Kevin DeWald, Compliance Officer, South Dakota Department
                            of Health
                        •   Dan Friedrich, DSU, Project Coordinator
                        •   Dorine Bennett, Provider Education and Outreach Workgroup
                        •   Joyce Havlik, MSIS, RHIA - Provider and Payer Data Consen-
                            sus Workgroup
                        •   Richard D. Puetz, J.D., C.P.A., Legal and Patient Consent
                            Workgroup
                        •    Steven Graham, DSU,Technical Issues Workgroup



MEMBERS AND             • Holly Arends, Department of Human Services
CONTRIBUTORS
                        • Nancy Beaumont, SD Foundation for Medical Care
                        • Arlyn Broekhuis, Sanford Health
                        • Jacque Cole, DAKOTACARE
                        • Rebekah Cradduck, South Dakota Association of Healthcare
                            Organizations (SDAHO)
                        •   Roy Denis, Wellmark Blue Cross Blue Shield
                        •   Mary DeVany, Telehealth Resource and Assistance Ctr
                        •   Mark East, South Dakota State Medical Assocation (SDSMA)
                        •   Jennifer Gholson, RHIT - Rapid City Regional Hospital
                        •   Laurie Gill, Department of Health
                        •   Scot Graff, Community HealthCare Association of the Dakotas
                            (CHAD)
                        •   Paula Hallberg, Community HealthCare Association of the
                            Dakotas (CHAD)
                        •   Dianne Halverson - DSU
                        •   Wendy Hanson - Department of Social Services
                        •   Tom Hoy, Senior Health Information and Insurance Educa-
                            tion (SHIINE),
                        •   Dennis Kaufman, Good Samaritan Society
                        •   Marsha Kucker of www.HealthEdventure.com
Members of the eHealth Collaborative




         • Dick Latuchie, Regional Health
         • Dennis Laughlin, Rapid City Regional Health
         • LaVonne Linneman, Community HealthCare Association of
             the Dakotas (CHAD)
         •   Linda Maas, Avera St. Benedict Hospital
         •   Cindy Matson, Sanford Health
         •   Randy Moses, Division of Insurance
         •   Mary Nelson, Sanford Health
         •   Kent Norland, South Dakota Foundation for Medical Care
         •   Dawn Reinicke, Avera Health
         •   Jim Vachal, R.Ph. - Administrator Brown Clinic
         •   Gayle Varty, St. Mary’s Healthcare Center
         •   Jim Veline, Avera Health
         •   Sam Wilson, AARP
         •   Don Zimmerman, BIT
Table of Contents
         Executive Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
         Background . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
The Patient and Provider Education and Outreach Workgroup                                       .......................... 5
     Members . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .      .   ............. 5
     Rationale . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .      .   ............. 5
     Core Messages . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .          .   ............. 6
     Audiences . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .      .   ............. 7
     Recommendations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .            .   ............. 8
     Evaluation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .     .   . . . . . . . . . . . . 11
Provider and Payer Data Consensus Workgroup................................................. 12
      Members . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
      Project Scope . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
      Project Outcomes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
      Current Situation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
      Proposed Recommendations: Health Information Exchange in South Dakota. . . 14
      Recommendations: Promoting Quality and Efficiency of Care . . . . . . . . . . . . . 15
      Approach . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
Legal and Patient Consent Workgroup                       ............................................................. 17
      Members . . . . . . . . . . . . . . . . . . .      . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
      Overview . . . . . . . . . . . . . . . . . .       . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
      Recommendations . . . . . . . . . . . .            . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
      Research Results . . . . . . . . . . . . .         . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
Technical Issues Workgroup .............................................................................. 25
      Members . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25
      Overview . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25
      Challenges . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25
      Challenges that require further study . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26
      Research Results: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27
Appendix A: The Action Plan............................................................................... 41
      Primary Objective . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41
             Three Primary Goals - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - 41
             Three Primary Strategies - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - 41

             Strategy 1: Generate awareness of the HIE/EHR/PHR story - - - - - - -                     -   -   -   -   -   -   -   -   - 42
             Tactic 1: Create a unified, identifiable brand- - - - - - - - - - - - - - - - - -         -   -   -   -   -   -   -   -   - 42
             Tactic 2: Develop a comprehensive press kit - - - - - - - - - - - - - - - - -             -   -   -   -   -   -   -   -   - 42
             Tactic 3: Conduct media outreach and pitch the EHR story - - - - - - - -                  -   -   -   -   -   -   -   -   - 43
             Tactic 4: Submit guest editorials for statewide publication - - - - - - - -               -   -   -   -   -   -   -   -   - 43
             Tactic 5: Schedule editorial board meetings - - - - - - - - - - - - - - - - -             -   -   -   -   -   -   -   -   - 43
             Tactic 6: Schedule appearances on important local talk radio programs                     -   -   -   -   -   -   -   -   - 44
             Tactic 7: Produce local Public Service Announcements (PSAs) - - - - - -                   -   -   -   -   -   -   -   -   - 44
             Tactic 8: Create a speakers bureau and schedule appearances - - - - -                     -   -   -   -   -   -   -   -   - 44

             Strategy 2: Launch a targeted outreach effort for healthcare providers - - - - - - - - - 44
             Tactic 1: Work with local professional provider organizations - - - - - - - - - - - - - - - - 44
             Tactic 2: Meet with individual providers- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - 46



                                                                                                                                              i
                      Table of Contents




Tactic   3: Create a volunteer advisory group - - - - - - - - - - - - - - - - - - -         -   -   -   -   -   -   - - 47
Tactic   4: Create marketing materials designed for providers - - - - - - - - -             -   -   -   -   -   -   - 47
Tactic   5a: Develop communication tools for rural stakeholders - - - - - - -               -   -   -   -   -   -   - - 48
Tactic   5b: Develop communication tools for urban stakeholders- - - - - - -                -   -   -   -   -   -   - - 49
Tactic   6a: Develop communication tools for technologically
             sophisticated stakeholders - - - - - - - - - - - - - - - - - - - - - - -       - - - - - - - - 50
Tactic   6b: Develop communication tools for stakeholders
             who lack access to, or have a limited interest in technology - -               -   -   -   -   -   -   -   - 50
Tactic   7a: Conduct targeted outreach geared for chronic disease patients                  -   -   -   -   -   -   -   - 51
Tactic   7b: Conduct targeted outreach for healthy patients - - - - - - - - - -             -   -   -   -   -   -   -   - 52
Tactic   8: Conduct outreach to appropriate local consumer groups - - - - -                 -   -   -   -   -   -   -   - 53
Tactic   9: Conduct outreach to federal groups - - - - - - - - - - - - - - - - - -          -   -   -   -   -   -   -   - 54

Strategy 3: Conduct targeted outreach to payers/insurers and employers -                        -   -   -   -   -   -   - 55
Tactic 1: Enlist support from the state government - - - - - - - - - - - - - - -                -   -   -   -   -   -   - 55
Tactic 2: Conduct outreach to large employers - - - - - - - - - - - - - - - - -                 -   -   -   -   -   -   - 56
Tactic 3: Conduct outreach to insurance companies - - - - - - - - - - - - - -                   -   -   -   -   -   -   - 57

Evaluation       - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - 58




                                                                                                                               ii
EXECUTIVE SUMMARY   In order to successfully move South Dakota toward widespread
                    Electronic Health Record (EHR) adoption and Health Information
                    Exchange (HIE), the following tasks must be completed. Some of these
                    tasks, e.g. a public relations education campaign, can be accomplished
                    by eHealth Collaborative members; some tasks, e.g. staff training, must
                    be accomplished by care providers and payers; other tasks, e.g.
                    legislation specific to the EHR and HIE, must be accomplished by the
                    South Dakota Legislature.

                    Adoption of EHR and HIE involves inherent challenges. While these
                    challenges are manageable and can mostly be mitigated with proper
                    education and training, issues of privacy and security stand at the
                    forefront of both patient and provider concerns. In addition, providers
                    question the cost and resources required to transition to Electronic
                    Health Records and Health Information Exchange, and patients may
                    wonder how such a system works and how difficult and time-consuming
                    it will be for them to participate in it.

                    There are several tasks in the areas of access and participation that need
                    to be addressed. First and foremost is a need to identify who should have
                    access to a health information exchange and to determine the minimal
                    content of the health information to be shared with a Health Information
                    Exchange entity. There must also be a mechanism to establish some kind
                    of opt out provisions for consumers and health care providers and to
                    recommend an incentive plan to encourage practitioner participation in
                    a Health Information Exchange.

                    The eHealth Collaborative also identified the following technical issues
                    that need further exploration: approaches to patient identification/
                    matching; a method of determining the various categories of
                    stakeholders; the kinds of data that need to be collected, maintained, and
                    distributed; and technical issues related to privacy policies.

                    But perhaps the biggest obstacle to widespread EHR adoption is the lack
                    of legislation specific to EHR, PHR, and HIE. The initial review of
                    Chapter 1-43 (Department of Health) and Title 34 (Public Health and
                    Safety) and analysis indicates that we probably do NOT currently have
                    the necessary legal statutes in place. SDCL 1-43-19 does not give the
                    Department of Health authority to deal with issues related to a patient
                    identifier or require provider ID/participation or require providers to
                    develop an Electronic Health Record (EHR) or an exchange. §1-43-24
                    would indicate that legislative intent was to develop a data system that
                    would report general health care information (i.e., pricing, quality, etc.)
                    but does not include a system that would regulate a health information
                    exchange.




                                                                                              1
BACKGROUND   South Dakota, like the rest of the United States, faces challenges in
             addressing increasing health care costs, improving access to medical
             care, and ensuring and improving quality medical care for patients.
             Timely access to essential medical information by providers at the point
             of care is critical to good patient outcomes. The South Dakota eHealth
             Collaborative is working to develop a long range plan to facilitate
             implementing interoperable information technology to improve the
             quality, safety, and efficiency of healthcare in South Dakota. Toward that
             end, the South Dakota eHealth Collaborative established by the
             Governor’s Health Care Commission, has active members from several
             key groups, including physicians, patients, insurance companies and
             other payers, state and local government officials, health information
             managers, lawyers and project administrators.

             Beginning in October 2006, the South Dakota Departments of Health,
             Human Services and Social Services funded the South Dakota Electronic
             Health Record Assessment (SDEHRA) project to investigate the usage of
             electronic health records in the state, as well as the perceptions of
             providers and consumers in relation to electronic health records and
             health information exchange. The goals of SDERHA were to assess
             variations in organization-level business policies and state laws that
             affect health information exchange (HIE), identify barriers and best
             practices relating to HIE, identify privacy and security issues relating to
             HIE, and investigate HIE possibilities for South Dakota and surrounding
             region. The project utilized a two-pronged approach to gathering data,
             including online surveys for payers, providers, and consumers as well as
             four regional focus groups with a variety of participants and
             stakeholders. The results of the project were reported to the Governor’s
             Health Care Commission whose members served as the steering
             committee and shared with the general public at the SD Health
             Information Technology (HIT) Summit in the Fall of 2007.

             Also during 2007, the Zaniya Project Task Force was enacted to develop
             a plan to provide access to affordable, comprehensive health insurance
             to all South Dakota residents. This task force also utilized surveys and
             focus groups as data collection methods and included a diverse
             membership of employers, health care providers, the insurance industry,
             tribal health representatives, consumers, trade association
             representatives, and state government officials.

             The SD eHealth Collaborative will work to address both the barriers
             found in the SDEHRA assessment phase and the recommendations from
             the Zaniya Taskforce related to health information technology. The
             following assumptions guide the eHealth Collaborative and the four
             workgroups: people will continue to seek and receive healthcare;
             documentation of that healthcare will continue to be needed; health



                                                                                       2
information exchange will continue to be needed; electronic health
records and electronic data exchange are happening and evolving; and
single data entry is ideal.

The work groups involved with this phase of the project included the
Patient and Provider Education and Outreach Workgroup, the Provider
and Payer Data Consensus Work Group, the Legal and Patient Consent
Work Group, and the Technical Issues Workgroup.

The Patient and Provider Education and Outreach Workgroup was
tasked with examining the educational and outreach efforts necessary to
move South Dakota forward toward electronic health record use and
electronic health information exchange. The focus of the group is
consumers and healthcare providers.

The Provider and Payer Data Consensus Work Group sought to further
the understanding and provide vision and direction in creating an
environment of key stakeholders who are committed to providing
ongoing, safe, high quality health care services supported by the
electronic exchange of health information.

The focus of the Legal and Patient Consent Work Group was to review
South Dakota’s statutes in order to determine if current legal authority
exists to establish and operate a health information exchange.

The Technical Issues Workgroup has focused on technical issues related
to matters such as privacy, security and standards. The goal has been to
determine key issues and requirements from a technical standpoint
which will be necessary for implementing an electronic health
information exchange in South Dakota. The key challenge is how to
provide interoperability while preserving privacy and security.

Three key terms used in this report first need to be defined.

The Electronic Health Record (EHR) is an electronic record of health-
related information on an individual that conforms to nationally
recognized interoperability standards and that can be created, managed,
and consulted by authorized clinicians and staff across more than one
health care organization.

The Personal Health Record (PHR) is an electronic record of health-
related information on an individual that conforms to nationally
recognized interoperability standards and that can be drawn from
multiple sources while being managed, shared, and controlled by the
individual.




                                                                           3
Health Information Exchange (HIE) is the term used to describe the
electronic movement of health-related information among organizations
according to nationally recognized standards.

EHRs and PHRs are already used to some degree in the state, usually in
larger group practices. Several factors have slowed their large-scale
adoption, however, the most notable being prohibitive cost and a lack of
resources. A recent unfunded federal mandate that stipulates that EHRs
be in use by the year 2014 has created an additional sense of urgency.




                                                                       4
The Patient and Provider Education and Outreach Workgroup

MEMBERS         Members of the Patient and Provider Education and Outreach
                Workgroup included:
                       • Dorine Bennett, DSU, Facilitator
                       • Rebekah Cradduck, South Dakota Association of Healthcare
                           Organizations (SDAHO)
                       •   Mark East, South Dakota State Medical Assocation (SDSMA)
                       •   Roy Denis, Wellmark Blue Cross Blue Shield
                       •   Scot Graff, Community HealthCare Association of the Dakotas
                           (CHAD)
                       •   LaVonne Linneman, Community HealthCare Association of
                           the Dakotas (CHAD)
                       •   Linda Maas, Avera St. Benedict Hospital
                       •   Sam Wilson, AARP
                       •   Kent Norland, South Dakota Foundation for Medical Care
                       •   Valuable input was provided by Tom Hoy of Senior Health
                           Information and Insurance Education (SHIINE), Paula Hall-
                           berg of Community HealthCare Association of the Dakotas
                           (CHAD), Marsha Kucker of www.HealthEdventure.com, and
                           the Alaska Health Information Security and Privacy Collabo-
                           ration

RATIONALE       Widespread EHR adoption in South Dakota offers numerous
                advantages. In broad terms, HIE and EHRs provide better quality health
                care by facilitating the timely and efficient exchange of appropriate
                information to patients and providers in a secure and private manner. In
                specific terms, this gives providers one standard mechanism for
                accessing any patient’s health information, and gives patients an active
                role in managing their health care.

                Adoption of EHR and HIE involves inherent challenges. While these
                challenges are manageable and can mostly be mitigated with proper
                education and training, providers and patients will understandably ask
                questions related to the adoption of EHRs. Issues of privacy and security
                stand at the forefront of both patient and provider concerns. In addition,
                providers question the cost and resources required to transition to EHRs
                and HIE, and patients may wonder how the system works and how
                difficult and time-consuming it will be for them to participate in it.

                Strong public support exists for EHRs and HIE when they are
                thoroughly explained to stakeholders. For example an October 2005
                public opinion survey, conducted by Public Opinion Strategies, revealed


                                                                                         5
                The Patient and Provider Education and Outreach Workgroup




                that seven out of ten Americans support EHRs once the issues of privacy
                and security were properly addressed.

                Results from the same survey revealed that it is important when defining
                Health Information Exchange to focus on the following issues: how it
                works, how patients allow access, who has access, and how the electronic
                Health Information Exchange benefits both the patient and the
                physician.

                Clearly, the opportunity for wider EHR and PHR adoption in South
                Dakota is improved when the benefits and risks are communicated in a
                simple and compelling manner. It is important to establish trust with
                consumers and providers through education and outreach. Therefore, all
                aspects of these recommendations address engaging the public to build
                confidence in the EHR process, especially as it relates to privacy and
                security. Once this trust is established, consumers and providers will be
                more likely to support and participate in an EHR effort. We must
                persuade South Dakota stakeholders, via various educational and
                outreach efforts, that EHRs, PHRs and HIE are safe and desirable
                developments in improving medical care.

CORE MESSAGES   Every element of the recommendations will incorporate the following
                core messages highlighting the key benefits of Electronic Health Records
                and Health Information Exchange:
                        • Improve quality of care: A network of Electronic Health
                            Records ensures secure and timely provider access to essential
                            medical information when needed.
                        •   Improve health safety: Electronic Health Records and their
                            exchange will reduce medical errors and unnecessary dupli-
                            cate tests.
                        •   Reduce healthcare costs: EHRs will increase efficiencies
                            through electronic charts and billing transmittals thereby
                            decreasing paperwork and administrative costs.
                        •   Provide access to care: An electronic health record network
                            will be a strong physician recruitment tool, which will increase
                            patient access to medical providers in South Dakota.
                        •   Improve health of South Dakotans: Through a Personal
                            Health Record, patients can choose to take an ownership role
                            in their health care.
                        •   Increase patient privacy and security in exchanging medical
                            records: The following safeguards will ensure greater privacy
                            and security:
                            a. Patient’s personal medical information will be shared
                               through the network only with their permission.


                                                                                           6
            The Patient and Provider Education and Outreach Workgroup




                        b. Prior to releasing any personal information, the identity of
                           anyone using the EHR system will be carefully confirmed to
                           prevent unauthorized access or cases of mistaken identity.
                        c. Patients will have Internet access to review their own health
                           and medical history via a secure account.
                        d. Patients will be able to review who has accessed their per-
                           sonal medical information through the Personal Health
                           Record.
                        e. Employers will not have access to the secure network used
                           to exchange information between healthcare providers.
                        f. Special selected categories of the medical record will be
                           protected from exchange.

            Realizing the importance of identifying tangible, relevant benefits of
            EHRs to the patient, core messages also should emphasize the following
            real-life situations:
                    • Allowing healthcare providers access to current information in
                        an emergency medical situation
                    •   Making it possible for patients to access their medical records
                        when they are traveling out of state
                    •   Allowing patients access to their medical records when they
                        visit their provider
                    •   Maintaining access to medical records during or after natural
                        disasters when paper records may be lost or destroyed
                    •   Identifying other tangible relevant benefits for the primary
                        audiences (patients, healthcare providers, and payers/insur-
                        ers and employers) will be beneficial in developing core mes-
                        sages that emphasize real-life situations. These will be
                        developed when the recommendations are enacted.

AUDIENCES   In order for any EHR initiative to succeed, key identified groups must be
            educated about the effort, and, ideally, be willing to lend their support or
            intensify their involvement in the process. The following key audiences
            are targeted in our recommendations:
                    • General public, with emphasis on its members’ role as patients
                    • Healthcare providers, including physicians, physician assis-
                      tants, nurse practitioners and pharmacists
                    • Payers, insurers and employers

            Because the general public audience is broad, it is further segmented to
            focus on the following subgroups:
                    • Patients in rural and urban areas



                                                                                       7
                  The Patient and Provider Education and Outreach Workgroup




                          • Patients with access to technology and those who lack or don’t
                            utilize it
                          • Patients with chronic conditions and those considered essen-
                            tially healthy
                          • Federal groups including tribal, military, and veterans

RECOMMENDATIONS   Realizing the importance of positioning EHRs as beneficial to all
                  residents, these recommendations aim to increase awareness and build
                  support among the public at large, healthcare providers, and other
                  identified stakeholders. The strategies and tactics outlined herein are
                  designed to reach out to these groups.

                  Because of the perceived complexity of the EHR/HIE issue these
                  recommendations take a “back to basics” approach: only fundamental,
                  tried-and-true public relations strategies and tactics are recommended.

                  Our recommendations offer a method of achieving results that, if
                  implemented, should further the goals of the South Dakota eHealth
                  Collaborative. The recommendations in this phase are not meant to
                  contain an exhaustive list of specific ideas for each strategy; rather, they
                  provide options for the eHealth Collaborative to review and select for
                  further exploration and refinement.

                  The primary objective of our workgroup recommendations is to convey
                  to South Dakotans the features, benefits and overall advantages of secure
                  Electronic Health Records, Health Information Exchange, and Personal
                  Health Records in order to generate support for their widespread
                  adoption in the state. In order to accomplish this objective, three
                  primary goals must be achieved:
                          1. To educate South Dakota consumers about what Electronic
                             Health Records mean to them on a personal level and how
                             their healthcare can improve as a result,
                          2. To communicate to healthcare providers how a broader use of
                             Electronic Health Records can make their practices and insti-
                             tutions more time and cost efficient and improve the care
                             they provide to patients, and
                          3. To communicate to employers and insurers/payers the value
                             of an Electronic Health Record network to improve the qual-
                             ity of healthcare and increase employee productivity while
                             realizing cost savings in healthcare delivery.

                  Three primary strategies to achieve these goals were identified with a
                  number of related tactics:




                                                                                             8
The Patient and Provider Education and Outreach Workgroup




The first strategy is to generate awareness of the Electronic Health
Record/ Health Information Exchange/Personal Health Record story via
editorial coverage. In working on this strategy, it will be important to
create a unified, identifiable brand for the South Dakota EHR effort.
Several entities in the state are working toward EHR adoption, which
can cause confusion among the media and the public as to who is the
primary authority on the subject. A unified brand will streamline
communications and improve understanding of the issue. Other tactics
include developing a comprehensive press kit and impactful marketing
materials, conducting media outreach and pitching the EHR story,
submitting guest editorials for statewide publication, scheduling
editorial board meetings, scheduling appearances on important local
talk radio programs, producing local Public Service Announcements
(PSAs), and creating a speakers bureau and scheduling appearances.

A second strategy is to launch a targeted outreach effort geared toward
healthcare providers and other crucial stakeholders. Providers stand to
benefit from widespread EHR adoption in several important ways,
including:
        1.     Patient care/satisfaction will be improved.
        2.     Critical electronic information and alerts to aid in diagnosis
               and treatment decisions will
               be provided.
        3.     The chance of medical errors will be reduced.
        4.     Essential clinical trials will be facilitated.
        5.     Standards of care will be promoted.
        6.     Billing accuracy and office efficiency will be improved.
        7.     Practice/clinic profitability will be improved.
        8.     Duplicate services and tests will be reduced.
        9.     Safety in hospitals/in-patient setting will be improved.
        10.    Compliance with HIPAA requirements will be ensured.
        11.    Quick access to back-up documentation for insurance claim
               inquiries, audits, and malpractice allegations will be pro-
               vided.

However, providers have been slow to adopt EHRs due to several
overriding concerns. A number of efforts are underway to mitigate these
concerns, including the following:
        • The cost of EHR adoption could be reduced through a grant
          program for qualified providers (program and amounts
          dependent upon securing funding).
        • The difficulty of selecting an EHR system will be lessened by
          the South Dakota eHealth Collaborative program since all


                                                                            9
The Patient and Provider Education and Outreach Workgroup




            stakeholders are participating in the process. Technology
            adopted must have sustainable EHR suppliers that meet fed-
            eral certification and other national standards for providers.
            This will ensure that the provider does not invest in outdated
            technology or short-lived companies.

It is expected that the eHealth Collaborative organization will provide
guidance in the technology and agreements to allow the secure exchange
of Electronic Health Records between providers, labs, hospitals, payers,
and other medical entities involved in the delivery of patient care.

As part of the targeted outreach efforts, it is recommended to work with
local professional provider organizations to enlist the support of their
members, to meet with individual providers, including those in small
and private practices, to explain the EHR effort and garner support, to
create a volunteer advisory group made up of a broad spectrum of
healthcare providers, and to create marketing materials designed for
provider use.

As mentioned earlier, the South Dakota eHealth Collaborative
recommendations relate to a wide variety of stakeholders.
Communication tools must be designed to reach stakeholders in rural
markets as well as urban markets, technologically sophisticated
stakeholders as well as stakeholders who either do not have access to, or
have a limited interest in technology. There should be targeted outreach
geared specifically toward chronic disease patients as well as targeted
outreach geared specifically toward healthy patients. Another tactic will
be to conduct outreach to appropriate local consumer groups (such as
the American Association of Retired Persons, or AARP) and federal
groups (such as tribal, military, and VA) and ask them to encourage their
members to support a South Dakota eHealth Collaborative effort.

The third strategy is to conduct targeted outreach to payers/insurers and
employers with appropriate emphasis on the benefits of utilizing the
Personal Health Record. In order to do this, it will be necessary to enlist
support from the state, including the South Dakota Legislature and the
Governor’s office/administration and conduct outreach to large
employers and insurance companies.

Appendix A provides a more detailed view of the tactics and action steps
included in our workgroup’s recommendations.




                                                                        10
             The Patient and Provider Education and Outreach Workgroup




EVALUATION   In order to judge whether the recommendations are successful, some
             form of measurement is necessary. Ideally, polling would be conducted
             before and after the recommendations are implemented to see how
             public attitudes about EHR/HIE/PHRs change as a result of the
             outreach effort. Barring that, several other methods may be used to
             monitor progress:
                     • Increased number of providers willing to explore using EHRs
                     • Increased number of providers willing to speak up in favor of
                         the EHR effort
                     •   Increased number of visitors to any Web sites created for the
                         EHR communications effort
                     •   Noticeable amount of correspondence from constituents to
                         their legislators in support of EHRs
                     •   Substantial, positive media coverage across the state with a
                         positive return-on-investment dollar amount
                     •   Inclusion of the EHR pilot program in the state budget
                     •   Increased use of PHRs in the state
                     •   Payer participation in an EHR program




                                                                                     11
Provider and Payer Data Consensus Workgroup

MEMBERS            Members of the Provider and Payer Data Consensus Workgroup
                   included:
                          • Joyce Havlik, MSIS, RHIA - Group Facilitator
                          • Nancy Beaumont, SD Foundation for Medical Care
                          • Jacque Cole, DAKOTACARE
                          • Jennifer Gholson, RHIT - Rapid City Regional Hospital
                          • Dianne Halverson - DSU
                          • Wendy Hanson - Department of Social Services
                          • Jim Vachal, R.Ph. - Administrator Brown Clinic

                   The Provider and Payer Data Consensus Workgroup consisted of a group
                   of community thought leaders who are committed to advancing high-
                   quality, patient-centered, cost effective health care services.

                   The consensus of the work group is that there is much to be learned
                   about the environment and culture surrounding the transparency of
                   quality information, the adoption of interoperable health information
                   standards, and the use of positive incentives that reward value in health
                   care.

PROJECT SCOPE      The objective for the workgroup was to further the understanding and
                   provide vision and direction in creating an environment of key
                   stakeholders who are committed to providing ongoing, safe, high quality
                   health care services supported by the electronic exchange of health
                   information. Information specific to the objective accumulated from the
                   2007 SDEHRA survey. The workgroup also sought input, lessons
                   learned, and experiences from a number of key decision makers and
                   health care leaders internal and external to the SD eHealth Collaborative.

PROJECT OUTCOMES   The workgroup identified the following six tasks that need to be
                   accomplished.
                          1. Identify who should have access to a health information
                             exchange.
                          2. Determine the minimal content of the health information to
                             be shared with a Health Information Exchange entity.
                          3. Establish the need for opt out provisions for consumers and
                             health care providers.
                          4. Recommend an incentive plan to encourage practitioner par-
                             ticipation in a Health Information Exchange.



                                                                                          12
                    Provider and Payer Data Consensus Workgroup




                            5. Explore incentive models to encourage South Dakota partici-
                               pants (providers, payers, patients, others) to use standard
                               performance information.
                            6. Explore incentive models promoting quality and efficiency of
                               care.

CURRENT SITUATION   Clinical practitioners and allied professionals need to have access to the
                    most current clinical information in a timely manner in order to deliver
                    effective health care especially in an emergency setting when a patient
                    may be in a state that does not permit him to speak for himself. Much
                    work has been done to create a scenario where there would be a national
                    health information technology infrastructure to provide for health
                    information exchange for every person in the country, which could be
                    accessed by any care provider, emergency, or not. In order to realize
                    such an exchange, an electronic medical record would be required. This
                    record would contain information regarding every type of medical
                    service a person has encountered along the continuum of his lifetime,
                    beginning with his birth record: in essence, one life-long longitudinal
                    record. When a person arrives at any health care facility at any location
                    within the national infrastructure, the care providers would be able to
                    access his medical record for any pertinent information.

                    The access to health information by third party payers will be viewed as
                    an added benefit: having access to clinical information from a
                    centralized source will provide efficiencies and support treatment,
                    payment and operational requirements between contracted network
                    providers, health plans, and health plan members.

                    The dilemma lies in how to create such a scenario within an environment
                    of perceived barriers. Various surveys have proven that the expenses
                    related to purchasing and implementing an electronic medical record are
                    the number one barrier. Most practitioners do not have resources
                    allocated or available to fund information technology (IT) departments
                    or staff.

                    Re-engineering the workflow is another concern for practitioners, as well
                    as prolonged implementation periods.

                    The ability to share medical information is another potential barrier.
                    Providers wish to maintain ownership of healthcare information created
                    within their entity, but they also realize the importance of sharing the
                    information with other healthcare providers. When a point is reached
                    where EHRs are a prevalent method of recording patient information,
                    the problem then becomes, how do all of the various systems
                    communicate with each other? There is no adopted uniform standard



                                                                                           13
                     Provider and Payer Data Consensus Workgroup




                     required for healthcare records, and interfaces built between systems for
                     communication are expensive and time consuming to build.

PROPOSED             In order to facilitate the electronic exchange of health information in
RECOMMENDATIONS:     South Dakota our recommendations are based on the following
HEALTH INFORMATION   assumptions:
EXCHANGE IN SOUTH
DAKOTA                       • A voluntary, statewide multi-stakeholder consortium of health
                               care providers, consumers, community purchasers and health
                               plans will come together to work on shared health-related
                               community priorities. The stakeholder consortium is commit-
                               ted to improving the health and safety of all individuals resid-
                               ing in and accessing healthcare services within the state of
                               South Dakota.
                             • The strategic clinical guidance and standardization for quality
                               reporting shall be under the auspices of the South Dakota Phy-
                               sician Collaborative for Performance Improvement.

                     The model for South Dakota may be
                             • Built on national standards—with local controls;
                             • Transparently designed to provide ease in consumer decision-
                                 making;
                             •   Supportive of the ongoing promotion of effective payment pol-
                                 icies and consumer incentives;
                             •   An environment to facilitate the sharing of best practices and
                                 lessons learned within the community;
                             •   Modeled to engage providers through standardized perfor-
                                 mance information;
                             •   Collaborative within the local public-private sector.

                     Furthermore, this model should provide
                             • Peer to peer learning through facilitated meetings.
                             • Tools and access to experts, such as a shared web based
                               knowledge management system.
                             • A channel for raising issues to be addressed by national con-
                               sensus-building organizations.
                             • Clear access both to allow and encourage sharing information
                               and to participate in national goal setting for quality improve-
                               ment initiatives.

                     In order to make health care information available in a timely manner
                     we need to promote the exchange of health information as a mechanism
                     to drive both quality improvement and patient safety. Practitioners and
                     allied professionals who provide direct patient care need access to


                                                                                               14
                    Provider and Payer Data Consensus Workgroup




                    accurate medical information. However control processes need to be in
                    place to meet consumer requests for non-disclosure. For example,
                    urgent and emergent care providers could have their access limited to
                    allergies, drug lists, and significant medical history.

RECOMMENDATIONS:    Our recommendations are based on the following assumptions:
PROMOTING QUALITY
AND EFFICIENCY OF   All parties—providers, payers (private and public) and patients—are
CARE                encouraged through a variety of quality driven incentives (financial and
                    non-financial) to participate in arrangements that reward individuals
                    who choose to purchase high quality, competitively priced health care.
                    An example could be health savings accounts to assist consumers in their
                    decision-making by enabling them to do cost comparisons and to also
                    view performance criteria regarding different procedures and services.
                    Possible rewards could include lower premiums and high-quality
                    healthcare services performed in an efficient manner.

                    It is possible to measure increased patient satisfaction at the point of
                    service for those entities who support health information exchange.
                    Efficiencies of care, decreased adverse events and eliminated service
                    duplication are all positive indicators to measure service excellence.

                    Further, the practitioners’ ability to report quality data may lend itself to
                    more favorable provider network contracting, as well as meeting care
                    management goals in managing patients with chronic disease,
                    specifically those who may be considering moving to a medical home
                    model of care or joining other existing incentive and reward initiatives.

                    We therefore make the following five recommendations:
                            1. Establish a Health Information Exchange partnering with a
                               Record Locator Service provider. Minimal data, e.g. demo-
                               graphic information, will be stored in the early development
                               stages but the data will evolve and expand as confidence
                               builds among key stakeholders.
                            2. Adopt standardized, unique patient identifying numbers for
                               use by all parties exchanging data with the RLS.
                            3. Establish access limitations to those practitioners needing to
                               provide emergent and urgent care and organizations who
                               have accountability for patient safety and population health
                               within the state of South Dakota (Department of Health).
                            4. Align with reference guidelines that describe the require-
                               ments of state law and any known regional or local consent
                               policies and practices in place to support future interstate
                               electronic health information exchange.



                                                                                               15
           Provider and Payer Data Consensus Workgroup




                   5. Encourage community stakeholders to come together to cre-
                      ate and implement incentive based activities and initiatives
                      between providers, payers, consumers, and purchasers that
                      promote population health improvement, quality of care
                      delivery, and patient safety.

           The South Dakota eHealth Collaborative is prepared to offer support to
           those practices who are eligible and who wish to submit applications to
           the 2008 EHR demonstration project. Supporting activities will include
           information and links to websites offering decision support tools.

APPROACH   The recommendation above can be accomplished in four phases, as
           follows:
                   1. Establish a Record Locator Service (RLS) containing demo-
                      graphic information. Phase 1 involves establishing a Record
                      Locator Service; however prior to the release of an RFP for an
                      RLS the following key issues will need to be addressed :
                      a. What is the desired business model of the Record Locator
                           Service; shall it be organized as a Public or Private entity?
                      b. Who will be responsible to oversee the RLS —e.g. monitor
                           its operational and regulatory compliance?
                      c. Are there legislative requirements or actions needed to
                           operate a RLS within the State of South Dakota?
                      d. Are Business Associate Agreements required between
                           entities?
                      e. Further discussion of the specific minimal data elements/
                           clinical informatics to be stored – patient name, date of
                           birth, medical encounters, medical home (primary care
                           provider)
                      f. Does the South Dakota model align with the aims being
                           addressed by the Health Information Security & Privacy
                           Collaboration (HISPC) participants?
                   2. Add data that would be contained in a health record problem
                      list, e.g. pertinent clinical data, vaccination history, medica-
                      tions, allergies, etc.
                   3. Add the next generation of information, which would include
                      what is referred to as a continuity of care record with actual
                      medical reports. e.g. discharge summary, history and physi-
                      cal, and any other pertinent clinical information needed to
                      provide emergent care.
                   4. The evolution of the health information exchange would
                      reach fruition when there would be access to actual electronic
                      health records from a centrally located data base service.


                                                                                     16
Legal and Patient Consent Workgroup

MEMBERS           Members of the Legal and Patient Consent Workgroup included:
                         • Holly Arends, Department of Human Services
                         • Laurie Gill, Department of Health
                         • Dennis Laughlin, Rapid City Regional Health
                         • Cindy Matson, Sanford Health
                         • Randy Moses, Division of Insurance
                         • Dawn Reinicke, Avera Health
                         • Richard D. Puetz, J.D., C.P.A., Group Facilitator

OVERVIEW          South Dakota’s statutes were reviewed to determine if there is legal
                  authority to establish and operate a health information exchange. The
                  initial review of Chapter 1-43 (Department of Health) and Title 34
                  (Public Health and Safety) and analysis indicates that we probably do
                  NOT have the necessary legal authority. SDCL 1-43-19 does not give the
                  Department of Health authority to deal with issues related to a patient
                  identifier or require provider ID/participation or require providers to
                  develop an Electronic Health Record (EHR) or an exchange. §1-43-24
                  would indicate that legislative intent was to develop a data system that
                  would report general health care information (i.e., pricing, quality, etc.)
                  but does not include a system that would regulate a health information
                  exchange.

RECOMMENDATIONS   There are several models for the administration of a health information
                  exchange. It is recommended that the Collaborative consider how such
                  an exchange would be governed and administered.

                  It is recommended that the Collaborative consider having legislation
                  drafted to address the establishment and operation of a health
                  information exchange. Specific legislation would:
                         1. establish immunity and/or liability,
                         2. require patient participation in a health information
                            exchange and provide a method for patients to “opt out,”
                         3. authorize a unique patient identifier,
                         4. require a health care provider ID and health care provider
                            participation,
                         5. require providers to develop an electronic health record by a
                            certain date,
                         6. establish a definition of “health care provider” for these pur-
                            poses,


                                                                                           17
                   Legal and Patient Consent Workgroup




                           7. authorize a state Master Person Index (MPI) and data sharing
                              (a data exchange).

                   Privacy issues were also researched. Presently, HIPPA appears to be the
                   foundation for the majority of health records in South Dakota. It is
                   recommended that the Collaborative consider whether HIPPA is
                   sufficient or if additional privacy safeguards are appropriate.

                   This legislation is needed before South Dakota can move forward with
                   both an electronic health record and health information exchange.

RESEARCH RESULTS   The following results were obtained from our research:
                           1. Immunity Legislation (from prosecution or suit due to shar-
                              ing or use of data): Research other States’ statutes and pro-
                              posed legislation concerning immunity and liability
                              exposure. (Related issues: Liability-Inaccuracies, Penalties-
                              Misuse, Liability-data short comings, Liability- inappropriate
                              access.)

                   There is a general lack of case law and state statutes concerning
                   immunity for use of health IT and electronic health information
                   exchange.

                   West Virginia provides immunity to anyone who participates or
                   subscribes to the state health information network resulting solely from
                   that participant’s use or failure to use network information or data that
                   was imputed or retrieved in accordance with HIPAA standards and other
                   applicable state laws. (W. Va. Code § 16-29G-5)

                   In a 2007 Health Care Practice Task-Force Report to the State Alliance
                   for E-Health, the Taskforce heard testimony from providers that are
                   reluctant to engage in an e-health exchange because unknown liabilities
                   have been associated with health IT and the electronic storage of health
                   information. (Second Report From the Health Care Practice Task-Force
                   to the State Alliance for E-Health, October 3, 2007.)

                    Courts have ruled that providers have an obligation to treat the
                   electronic health record the same as a paper record when utilizing
                   information that resides within the record. (Breeden v. Anesthesia West,
                   656 NW2d 913 (Neb. 2003); Oklahoma Case Johnson v. Hillcrest
                   Health Center, 70 P.3d 811 (Ok. 2003).

                   It would also be prudent that participating health care providers and
                   health plans take all necessary steps to ensure employees are trained on
                   HIPAA requirements.




                                                                                          18
Legal and Patient Consent Workgroup




        2. Access: Research and Indentify need for Legislation to per-
           mit or require participation in the exchange for patients. (opt
           in/opt out).

There isn't anything in Title 34 that would permit or require
participation in an exchange for patients. In addition, there is nothing in
Title 58 (Insurance) that would provide the authority to require any of
the possible action items; the closest authority is limited to standardizing
claim forms.

As far as an “opt out or opt in” provision, the only area in Title 34 that
discusses refusal to participate in a system is references to the South
Dakota Immunization Information System (SDIIS). SDCL 34-22-12.5
states as follows:

“34-22-12.5. Sharing of certain immunization records without consent
permitted – Violation as a misdemeanor. A patient's immunization
record, even if the immunization was received prior to July 1, 1996, may
be shared among health care providers, health care facilities, federal or
state health agencies, child welfare agencies, schools, or family day care
facilities, without the consent of the patient or the person acting on the
patient's behalf unless the patient's signed refusal to release
immunization information is part of the patient's medical record. If the
patient is a minor, the refusal to release immunization information may
be signed by the patient's parent or guardian on behalf of the minor
patient. Any person who receives immunization data pursuant to this
section and knowingly or intentionally discloses or fails to protect the
confidentiality of the data is guilty of a Class 1 misdemeanor.”

In general it appears to be preferable to have "opt out" language as
opposed to "opt in": in this way individuals are in the system unless they
specifically say they do not want to be included.
        3. Patient Identifier: Research and Identify need for Legislation
           to authorize a unique patient identifier.

There doesn’t appear to be anything in statute regarding patient
identifiers.
        4. Required Provider Participation and ID: Research & Iden-
           tify need for Legislation to require provider ID and participa-
           tion.

Again, we have several statutes that require providers to participate in
various activities (e.g. cancer reporting, disease reporting, price
reporting) but those requirements are specific to the activity being
addressed in statute. To require a provider ID and participation would
require its own statute.


                                                                             19
Legal and Patient Consent Workgroup




        5. Electronic Health Record: Research & Identify need for Leg-
           islation to require providers to develop an electronic health
           record by certain date.

This would require its own statute.
        6. Consent Process: Design of consent process.

The design of the consent process is contingent upon the decision of the
Collaborative on whether to make patients opt-out of the exchange or to
have patients opt-in to the exchange. Legislation may be required in
either case.
        7. Organizational Structure: Evaluation and recommendation
           for organizational structure.

A number of organizational structures are possible. Governmental
models that could be used are: the South Dakota Risk Pool (SDCL §§ 58-
17-116, 117, 118), and the SD Housing Development Authority (SDCL §§
11-11-2, 3, 4, 10). A separate non-profit corporation could be formed, as
is done in Montana. South Dakota has a model for these in Education.
(SDCL §§ 13-3-76 to 13-3-82).
        8. Data Ownership: Research Ownership of the data.

Generally, patients own the data while the health providers own the
medical record. Software vendors contract away any liability and have
no ownership.

An issue for the future will be how the Collaborative or exchange entity
will deal with corrupt data.
        9. Definitions: Define “health care providers,” etc.

There is not one definition for “health care provider” that was applicable
to all of Title 34. Individual chapters within Title 34 have varying degrees
of definitions of health care providers that would include any
combination of the following: health care facilities licensed pursuant to
§34-12 (i.e., hospitals, nursing facilities, ambulatory surgery centers,
CAH, etc.) and health care professionals licensed pursuant to Title 36.
Depending on what the chapter is regulating, “health care professional”
may simply be a physician licensed pursuant to chapter 36-4 or may be
the laundry list of health professions regulated by Title 36. The same
would hold true for health care facilities.
        10. Privacy Policies: Privacy policy issues.

HIPAA applies to covered entities, including health care providers and
health plans.



                                                                         20
Legal and Patient Consent Workgroup




While SD law is largely silent on this issue, HIPAA provides regulation
and guidance. Regulation in this area is governed by two Federal Rules
(1) “Standards for Privacy of Individually Identifiable Health
Information” (Privacy Rule) (45 CFR Part 160 and Part 164), and (2)
“Security Standards for the Protection of Electronic Protected Health
Information,” (Security Standards).(45 CFR Part 160, 162, 164). These
rules were adopted to implement provisions of HIPAA.

The HIPAA Privacy Rule governs the use and disclosure of protected
health information. The Privacy Rule requires covered entities to have in
place appropriate administrative, physical, and technical safeguards and
to implement reasonable safeguards. (45 CFR § 160.300). The Security
Rule sets standards for ensuring that only those who should have access
to Electronically Protected Health Information (EPHI) will actually have
access.

Electronic vs. oral and paper: The Privacy Rule applies to all forms of
patients’ protected health information in any form, whether electronic,
written, or oral.

In contrast, the Security Rule covers only protected health information
that is in electronic form. (45 CFR § 164.302). This includes EPHI that
is created, received, maintained or transmitted. For example, EPHI may
be transmitted over the Internet, stored on a computer, a CD, a disk,
magnetic tape, or other related means. The Security Rule does not cover
PHI that is transmitted or stored on paper or provided orally.

“Safeguard” requirement in Privacy Rule: The Privacy Rule contains
provisions at 45 CFR § 164.530(c) that currently require covered entities
to adopt certain safeguards for PHI. (Specifically, 45 CFR § 164.530 (c)
of the Privacy Rule states:

“(c)    (1) Standard: safeguards. A covered entity must have in place
appropriate administrative, technical, and physical safeguards to protect
the privacy of protected health information.

        (2) Implementation specification: safeguards.

                (i) A covered entity must reasonably safeguard protected
health information from any intentional or unintentional use or
disclosure that is in violation of the standards, implementation
specifications or other requirements of this subpart.

               (ii) A covered entity must reasonably safeguard protected
health information to limit incidental uses or disclosures made pursuant
to an otherwise permitted or required use or disclosure.)”



                                                                       21
Legal and Patient Consent Workgroup




The Security Rule provides for far more comprehensive security
requirements in 45 CFR 164.306. (45 CFR 164.306.

“(a) General requirements. Covered entities must do the following:

       (1) Ensure the confidentiality, integrity, and availability of all
electronic protected health information the covered entity creates,
receives, maintains, or transmits.

        (2) Protect against any reasonably anticipated threats or hazards
        to the security or integrity of such information.

        (3) Protect against any reasonably anticipated uses or disclosures
        of such information that are not permitted or required under
        subpart E of this part.

        (4) Ensure compliance with this subpart by its workforce.

“(b) Flexibility of approach.

        (1) Covered entities may use any security measures that allow the
        covered entity to reasonably and appropriately implement the
        standards and implementation specifications as specified in this
        subpart.

        (2) In deciding which security measures to use, a covered entity
        must take into account the following factors:

                 (i) The size, complexity, and capabilities of the covered
                 entity.

                 (ii) The covered entity’s technical infrastructure,
                 hardware, and software security capabilities.

                 (iii) The costs of security measures.

                 (iv) The probability and criticality of potential risks to
                 electronic protected health information.

“(c) Standards. A covered entity must comply with the standards as
provided in this section and in § 164.308, § 164.310, § 164.312, § 164.314,
and § 164.316 with respect to all electronic protected health information.

“(d) Implementation specifications. In this subpart:

        (1) Implementation specifications are required or addressable. If
        an implementation specification is required, the word “Required”
        appears in parentheses after the title of the implementation


                                                                              22
Legal and Patient Consent Workgroup




        specification. If an implementation specification is addressable,
        the word “Addressable” appears in parentheses after the title of
        the implementation specification.

        (2) When a standard adopted in § 164.308, § 164.310, § 164.312, §
        164.314, or § 164.316 includes required implementation
        specifications, a covered entity must implement the
        implementation specifications.

        (3) When a standard adopted in § 164.308, § 164.310, § 164.312, §
        164.314, or § 164.316 includes addressable implementation
        specifications, a covered entity must—

                 (i) Assess whether each implementation specification is a
                 reasonable and appropriate safeguard in its environment,
                 when analyzed with reference to the likely contribution to
                 protecting the entity’s electronic protected health
                 information; and

                 (ii) As applicable to the entity—

                         (A) Implement the implementation specification if
                         reasonable and appropriate; or

                          (B) If implementing the implementation
                          specification is not reasonable and appropriate—

                                  (1) Document why it would not be
                                  reasonable and appropriate to implement
                                  the implementation specification; and

                                  (2) Implement an equivalent alternative
                                  measure if reasonable and appropriate.

“(e) Maintenance. Security measures implemented to comply with
standards and implementation specifications adopted under § 164.105
and this subpart must be reviewed and modified as needed to continue
provision of reasonable and appropriate protection of electronic
protected health information as described at § 164.316.)”

In particular, a covered entity must comply with the administrative,
physical, and technical safeguards and other standards as provided in §
164.308, § 164.310, § 164.312, § 164.314, and § 164.316 with respect to all
EPHI.

Covered entities must develop and implement policies and procedures
for authorizing EPHI access in accordance with the Security Rule. (45
CFR § 164.308(a)(4)) and the Privacy Rule. (45 CFR § 164.508).


                                                                            23
Legal and Patient Consent Workgroup




It is important that all personnel who have been granted access to EPHI/
E-Health Portal have been properly trained on the requirements of the
Security and Privacy Rules.

            11. Legislation for state MPI and Data: Research and
                identify the need for legislation to establish a state MPI
                and data sharing (a data exchange).

There is no current authority for a state MPI. A new statute granting
authorization will be required.




                                                                             24
Technical Issues Workgroup

MEMBERS                • Arlyn Broekhuis, Sanford Health
                       • Mary DeVany, Great Plains Telehealth Resource and
                         Assistance Center
                       • Gary Goeden, BIT
                       •   Dennis Kaufman, Good Sam
                       • Dick Latuchie, Regional Health
                       • Mary Nelson, Sanford Health
                       • Steve Graham, DSU, Group Facilitator
                       • Gayle Varty, St. Mary’s Healthcare Center
                       • Jim Veline, Avera Health
                       • Don Zimmerman, BIT

OVERVIEW        This workgroup has focused on technical issues related to matters such
                as privacy, security and standards. The goal has been to determine key
                issues and requirements from a technical standpoint which will be
                necessary for implementing an electronic health information exchange
                in South Dakota. The key challenge is how to provide interoperability
                while preserving privacy and security. Standards, formats, conventions,
                and application programming interfaces (APIs), both formal and
                informal, are essential elements. The technical issues group focuses on
                the technical elements essential for successful implementation. This
                group has not been concerned with the content of the shared data, except
                to the extent that we identify standards, conventions, metadata, etc.
                along with resource requirements and issues such as data storage
                capacities, network bandwidth requirements, update frequencies, and
                processing requirements.

CHALLENGES      Perhaps the central challenge is simply the need to accurately identify
                which patient is associated with which record, so that the data can be
                shared from multiple sources. Once a patient has been accurately
                matched across two or more records, an EHR exchange would need to
                maintain the associations between those records (e.g. through a
                community master patient index) or re-compute the matches as needed.
                Repeated record matching on this scale is infeasible. Current matching
                approaches require human intervention for difficult cases. Once such
                matching has been achieved, it will be necessary to maintain and update
                it over time so that wholesale matching is not required again. Similarly,
                huge quantities of legacy data/records cannot be expected to be
                completely entered and matched as part of such a system initially. The
                scope of legacy data incorporated will be limited by processing resources.



                                                                                       25
                  Technical Issues Workgroup




                  Other particular technical challenges include:
                          • Providing support for patients’ ability to opt-in/opt-out of the
                              system
                          •   Opting-in/opting-out could be at the system level or the pro-
                              vider level
                          •   Providing a single point of access for users
                          •   Distributing the data to/through that point, presumably via a
                              pull mechanism for content data and a push mechanism for
                              patient identification, demographics, and record locator infor-
                              mation
                          •   Providing access control
                          •   Different categories of users (patients, providers, payers,
                              researchers, etc.)
                          •   Different levels of access

                  A variety of different information gathering tasks arose related to these
                  challenges or as prerequisites for them. For example: identifying the
                  different categories of stakeholders/users who will be involved in such a
                  system; considering how other systems have addressed issues such as
                  the need to accurately and uniquely identify patients for effective
                  matching; determining what sorts of data, in what formats, and in what
                  quantities will be needed to support an EHR exchange system.

CHALLENGES THAT   The following topics were identified by the Technical Issues Workgroup
REQUIRE FURTHER   as important to explore. This report includes initial answers which
STUDY             address some of these issues and questions.
                          1. Approaches to patient identification/matching.
                          2. Determining categories of stakeholders.
                          3. Technical issues and their impacts on education needs, for
                             the public and for system users, both entry and access.
                          4. What (specific) data need to be collected, maintained, and
                             distributed to meet the objectives of the system? For patient
                             identification and record location? For content delivery?
                             What size and quantity of records will need to be stored and
                             distributed? What processing may be required on the data?
                          5. Approaches to uniquely identifying/matching records with
                             organizations or entities (e.g. providers).
                          6. Technical issues related to privacy policies.
                          7. ePrescribing’s relation to EHR exchange development.




                                                                                          26
                    Technical Issues Workgroup




RESEARCH RESULTS:   The following section presents the results of our research.
                    First is a consideration of the options and approaches taken to patient
                    identification. In determining the Patient ID to be used we must first
                    consider the types of databases used by RHIOs. These databases fall into
                    three types, centralized, decentralized and hybrid.
                            • Centralized: All databases are combined into one repository,
                              and a new identifier is assigned. This method allows for dupli-
                              cation of data and works well for participants of like entities.
                            • Decentralized: Data are physically stored at the originating
                              organization. The electronic Master Patient Index (MPI) con-
                              strains minimal demographic data and points to where
                              records are held. No PHI is shared. Updates are controlled at
                              each participant site. It is the preferred model for participants
                              who hold records for extraordinary privacy concerns (HIV,
                              mental illness, etc), and it allows a patient to opt out.
                            • Hybrid: Must determine what data are centralized and what
                              are decentralized, as well as patient ID.

                    Source: AHIMA Website-FORE BOK "HIM Principles in Health
                    Information Exchange: RHIO Checklist

                    The Unique Patient Identifier of the RHIO seems to depend upon the
                    database model chosen to be used. In my research, I saw nothing
                    speaking of using the social security #, and am under the impression that
                    if the patient identifers are centralized, a unique (RHIO) number is
                    created

                    Next, we must consider who manages the Master Patient Index (MPI).
                    There are six distinct management types to consider
                            • Federated model with shared repositories: Uses a system of
                              networks connected through the Internet. Participants submit
                              clinical data to a centralized regional repository responsible
                              for the management of patient identification data, storage,
                              system management, security, and privacy. The regional
                              repositories are interconnected via a centralized Master
                              Patient Index (MPI) or Record Locator Service (RLS).
                            • Federated model with peer-to-peer network + real-time,
                              request/delivery of clinical data: Employs a peer-to-peer net-
                              work of participant networks connected through the Internet.
                              Participants maintain their own health information network
                              with no centralized repositories. A national or regional entity
                              maintains a RHIO master patient index for the HIE. Using
                              this index, participating providers (authenticated within their
                              participating organization's system) search and find a patient


                                                                                            27
Technical Issues Workgroup




            in the electronic MPI. When the correct patient is found, the
            provider selects the patient. This selection sends an auto-
            mated request for clinical data to all HIE participating organi-
            zations
        •   Federated model with peer-to-peer network + clinical data
            pushed from the sending organization: Employs a peer-to-
            peer network of participant networks connected through the
            Internet. Participants maintain their own health information
            network with no centralized repositories; however clinical
            data are pushed from the sending organization. The HIE
            maintains a master patient index and previously associated
            providers to patient.
        •   Federated model with peer-to-peer network–no real-time
            clinical data sharing: Employs a peer-to-peer network of par-
            ticipant networks connected through the Internet. Partici-
            pants maintain their own health information network with no
            centralized repositories. A national or regional entity main-
            tains a master patient index (typically an RLS) for the HIE.
            Participants search the index, find a patient and identify all
            participating organizations where the patient has been
            treated. The participant then requests clinical data/medical
            records from the other participating providers via a separate
            request for information.
        •   Non-federated peer-to-peer network (co-op model): Uses a
            peer-to-peer network of participant networks connected
            through the Internet. Participants maintain their own health
            information network, and there is no centralized repository.
            All communications are direct from participant to participant.
            There is no national or regional entity maintaining a master
            patient index for the HIE, so a mechanism to identify the loca-
            tion of records (i.e., ascertain which participating provider has
            the medical records for the patient) is required
        •   Health data bank: PHR-type repository where patients can
            load clinical and results information and can authorize release
            of this information to specified, authorized providers. These
            repositories could be managed by IDNs, insurance companies,
            professional associations, or private companies

Source: AHIMA website - FORE BOK “ Clinical Data Exchange Models”
9/2/07




                                                                          28
Technical Issues Workgroup




Once the RHIO database has been established we must determine who
has ownership of the data. We really could not find an answer for this
question. We did find the various types of entities that the RHIO could
become, such as not-for-profit or a state agency, but we can not really tell
who owns the actual database.

Please see the “http://www.staterhio.org/conference/documents/
workbook_v1.0_071206.pdf” It begins talking about Governance and
entity formation on pages 15-16 and has different options on page 17.

We next considered ways of funding the RHIO. Funding types were
broken down into Initial Funding Sources and Ongoing Funding
Sources. Both types are necessary to initiate and continue the RHIO.

Initial Funding Sources would include the following:
        • Federal grant/contract
        • State
            a.   matching grant
            b.   bond issue
            c.   contract
            d.   tobacco funds
            e.   BC/BS insurance demutualization fund
            f.    Medicaid waiver savings
            g.   State contribution
            h.   Stakeholder contribution
            i.   Foundation grant
            j.   Prepayment of subscription/use fees
            k.   Membership Fees
            l.   Revolving loan fund
            m.   Fee for a Board seat

Ongoing Funding Sources would include the following:
        • Membership Fee model: stakeholders pay to support shared
            services for all
        •   HIE Transaction Fee model: a state level RHIO which charges
            transaction fees for its HIE services/products
        •   Program & Service Fee model: charges stakeholders for partic-
            ipation in, or outcomes from participation in, program-related
            activities undergone by the state level RHIO
        •   A combination of the above models
        •   Grants and contracts administration services



                                                                         29
Technical Issues Workgroup




        • Implementation support for local HIE effort
        • Educational Services and Materials

Source: http://www.staterhio.org/conference/documents/
workbook_v1.0_071206.pdf. The funding section begins on page 23, #5.
In our research through the COP and state sites, state and federal grants
are by far the most common source of initial funding.

One model to consider for managing South Dakota’s RHIO can be found
in the State of Rhode Island. Rhode Island Summary.

Organization and Governance: Rhode Island Quality Institute (RIQI)
was founded in 2002. The State Department of Health is the grantee and
helps with the decisions, but the RIQI is the lead on decisions related to
HIE. RIQI has a board that meets monthly and a committee that meets
every 2-6 weeks.

Operations and Technology: Their initial planned model includes an
MPI and data storage model that stores the data by type of data rather
than by data source. For example, lab results from all data sources
would be stored in a lab file, while medication history would be stored in
a medication history file.

Please see the “staterhio.org” source above in the Funding section.
Rhode Island's Executive Summary is on page 63. The other state
RHIOs participating in the study also include executive summaries. The
website “http://www.staterhio.org/” has lots of information, including
some updated reports that were just released in March 2008. The Links:
Organizations section has links to the individual state RHIO websites.
Rhode Island's RHIO website is http://www.riqi.org/matriarch/
default.asp

Our second major consideration was to compile a list of stakeholders for
an EHR Exchange System and whether or not they will be primarily
producers of records (column labeled “input”) or consumers (column
lagbeled “retrieve”), or both




                                                                        30
                        Technical Issues Workgroup




                        HIT Global Stake-holders Listing


                   Stake-holders                                     Input   Retrieve
                                                         Consumers
•   Patients
•   Family members

                           Healthcare Providers (in network & out of network)
•   Physicians (MD, DO)
•   Physician-extenders (PA, CNP, CRNA, etc.)
•   Nurses
•   Dentists
•   Mental Health Professionals (Psychologists, Counselors)
•   Optometrists
•   Chiropractors
•   Therapists (OT, ST, PT, RT)
•   Pharmacists
•   Ancillary Service Providers (Lab, X-Ray, Dietary, SW)
                                                     Healthcare Facilities
•   Hospitals (tertiary, CAH, etc.)
•   LTC facilities / Assisted Living
•   Clinics (primary care, FQHC, specialty, therapy, etc.)
•   Health systems
•   Homehealth agencies/Hospice/DME
•   Federal facilities (VA, IHS, Prisons, etc.)
•   State facilities (State Hospital, Prisons, Other Services)
•   Telehealth Networks
                                                           Payers
•   Commercial payers
•   Medicaid/Medicare
•   VA/IHS/Etc.
•   Others
                                       Government/Others(in aggregate?)
•   SD DOH
•   SD Public Safety
•   County Governments
•   City Health Officials
•   CDC
•   Health-related Research efforts (aggregated)
•   Veterinarians (avian flu?)


                                                                                        31
                     Technical Issues Workgroup




•   Licensing Boards
•   Employers/Businesses
                            Regulatory/Oversight Entities (regarding HIT)
•   SD Dept. of Health
•   DHHS/CMS (federal)
•   Accrediting Organizations (JCAHO, etc)
•   AMA (allowable billing codes)


                     Our third major consideration was technical issues with impacts on the
                     education of the public and users of an EHR Exchange System:
                                 a. Patient identification is critical - the more entities that are
                                    connected, the greater the hurdle to make sure that when
                                    information is being shared that we have identified the
                                    proper patient. Do we invest in a Master Patient Index
                                    (MPI), and if not, we need to maintain resources for the
                                    purpose of resolving the inevitable patient identification
                                    problems.
                                 b. Unusable data come most readily with the availability of
                                    discrete data elements, which can be difficult if providers
                                    use dictation rather than data templates. Will we take any
                                    sort of unified stand in this issue?
                                 c. Consumers will need reassurances about the security of
                                    their data.
                                 d. Providers will need to understand the limitations of the
                                    data, and the need to verify and augment it.

                     Next, we needed to consider specific data requirements. What (specific)
                     data need to be collected, maintained, and distributed to meet the
                     objectives of the system?

                     The following required data will drive the technical requirements
                             1. Need what data to share from data consensus group
                             2. Develop vs. purchase
                             3. Detailed specifications for all data elements, e.g. the master
                                patient index
                             4. Central vs. decentralized storage
                             5. Data viewing vs. data sharing
                             6. Interface specifications and requirements
                             7. Hardware specifications and data communications




                                                                                                 32
Technical Issues Workgroup




        8.    Data access methods
              a. Web based
              b. Internet
              c. Private lines
        9.    Volume estimates that will drive storage needs
        10.   Security requirements for both encryption and privacy
        11.   System maintenance
        12.   Operating system
        13.   Database
        14.   Retention requirements
        15.   Estimated numbers of active users
        16.   Disaster recovery and reliability requirements
        17.   Other



Our next concern was how to uniquely identifying/matching records
with organizations or entities (e.g. providers) participating in a Health
Information Exchange.

The primary purpose of a health information exchange (HIE) is to
facilitate the exchange of health information between health care entities
in an efficient, secure and stable manner. The term HIE is often used
interchangeably with sub-network organization (SNO) or Regional
Health Interoperability Organization (RHIO). A contemporary HIE
should be, by design, a component part of the Nationwide Health
Information Network (NHIN). This ability to participate in the NHIN is
possible through the consistent and disciplined application of policies
and procedures defined through national standards. A HIE should have
the flexibility in its design to meet the needs of its regional health
organizations while maintaining compatibility with the NHIN through
the application of the NHIN design requirements.

Published Standards. The Healthcare Information Technology
Standards Panel (HITSP) is developing the standards that will define
and govern the NHIN which will be published at http://www.hitsp.org.
The published standards as of July, 2008 are limited to work defining
the electronic delivery of lab results to a clinician, data networks for the
early detection and rapid response to a public health threat, and patient
management and control of their registration and medication histories.
In addition HITSP has defined security and privacy specifications to
provide data in areas relating to medication workflow and quality.1




                                                                          33
Technical Issues Workgroup




HIE Membership Requirements. “An important core competency of
the HIE is to maintain a trusting and supportive relationship with the
organizations that provide data to, and retrieve data from, one another
through the HIE. The trust requirement is met through a combination of
legal agreements, advocacy and technology for ensuring meaningful
information interchange in a way that has appropriate protections.”2

Entity Identifiers. Entities that are participating members of the HIE
have already established a federation of trust and only need to provide
authentication credentials to the HIE when accessing information. Due
to the possibility of a user ID being duplicated, the HIE must establish a
method to combine the participating entity’s credentials with the
identity of the HIE user. The selected methodology depends upon the
architectural design of the HIE data model: the use of an entity
identifier may not be necessary within the context of the HIE although it
would be required to participate in the NHIN.

Analysis of Entity ID Requirements for Members of a Health Infor-
mation Exchange. The need to identify each entity participating in a
shared health information network depends upon the type of data model
that is selected by the exchange network. There are three different data
models that our HIE could engage:
         • Centralized where the patient data are stored in a central
           repository
         • Decentralized where the patient data are only stored at its
           original source (e.g. the hospital, clinic, lab, etc.)
         • Hybrid where the patient data are mostly decentralized but a
           subset of personal health data (e.g. immunization records,
           prescriptions, diagnosis info, etc.) are stored in a central
           repository

Decentralizing the data requires the use of a Resource Locater Service
(RLS) to verify the identity of the patient and provide the location of the
record that would satisfy an inquiry. Once a record has been located the
inquiring entity and the entity holding the record would then transact
the data according to the policies in place at that locality.

The decentralized model appears to be favored at this time because the
participating entities have already established their own privacy and


1. “HITSP and Healthcare Providers”, American National Standards Institute,
   http://hitsp.org/healthcare_providers.aspx, July 2008.
2. Wes Rishel, Virginia Riehl and Cathleen Blanton, “Summary of the NHIN Prototype Architec-
   ture Contracts”, http://www.hhs.gov/healthit/healthnetwork/resources/summary_report_
   on_nhin_Prototype_architectures.pdf, 31 May 2007, p.25.



                                                                                        34
Technical Issues Workgroup




disclosure agreements with their patients and a decentralized data
model allows simple compliance with those agreements to be
maintained. Conversely, it would be very difficult to effectively enforce
multiple privacy agreements against a single, centralized record.

The decentralized model also eliminates the need for a unique entity
identifier since the querying party would become aware of the provider
entity's identity through the RLS and resolve the location of the record
with the information provided.

The decentralized model requires that all participants of the HIE be
comfortable with the process of disambiguation required to identify a
patient record. Disambiguation is the process used to identify whether
Pat Smith is Patrick Smith of 123 Summit Ave, Sioux Falls SD or Patricia
Smith of 456 3rd St., Madision SD.

If it is a requirement, the decentralized model could be hybridized so a
subset of patient data could be still centrally hosted and managed
through a common privacy release form that granted access to a
standardized and limited data subset. This method could introduce
issues of data validity if conflicting values are introduced by separate
provider entities and care would need to be taken to resolve those issues.
This method also would require the storage of Protected Health
Information within the HIE.

Analysis of Entity ID Requirements for Nationwide Health Informa-
tion Network Membership. A HIE participating in the NHIN will need
to provide a set of services referred to as the “NHIN Operational
Services” that were developed as the result of four prototype projects
that had been commissioned by the Office of the National Coordinator
for Health IT. Among the core services and capabilities defined were the
following “User and Subject Identity Management Services” :3
         • User identity proofing and/or attestation of third-party iden-
           tity proofing for those connected through that HIE
         • User authentication and/or attestation of third-party authen-
           tication for those connected through that HIE
         • Subject and user identity arbitration with like identities from
           other HIEs
         • Management of user credentialing information (including
           medical credentials as needed to inform network roles)



3. Wes Rishel, Virginia Riehl and Cathleen Blanton, “Summary of the NHIN Prototype Architec-
   ture Contracts”, http://www.hhs.gov/healthit/healthnetwork/resources/
   summary_report_on_nhin_Prototype_architectures.pdf, 31 May 2007, p.37-38.



                                                                                        35
Technical Issues Workgroup




         • Support of an HIE-level, non-redundant methodology for
             managed identities

Example of User Identity Proofing and Attestation. 4

5.3.2 Authentication (Person)
All participating systems shall authenticate the user that is the direct
user of a system before permitting access to NHIN functions or data
retrieved via the NHIN. Acceptable authentication strength will be
determined in the future.

To be meaningful, user authentication depends on the organization that
operates the authenticated system to do an effective job of proofing the
identity of the users. In transactions to the NHIE, the user is identified
without ambiguity and the user ID is identified with the organization
providing the authentication. This attestation might be transitive, as
described in this scenario:
         • In building an NHIE, the Northern District HIE signs the nec-
             essary agreements to support health interchange with Memo-
             rial General Hospital.
         •   The process of establishing this business relationship is robust
             enough that the Northern District Health Information
             Exchange can say that it has verified the corporate identity of
             Memorial General Hospital and can attest to the fact that it is
             a legitimate hospital with reasonable policies, procedures and
             technological safeguards to ensure that its users are properly
             identified and authenticated.
         •   Memorial General Hospital grants attending privileges to Dr.
             Alfred Newby.
         •   Memorial General’s credentialing and attending intake
             includes verifying (proofing) the identity of Dr. Newby and
             assigning the passwords, tokens or other means of authenti-
             cating Dr. Newby as a system user.
         •   Big Hospital Chain, Inc. operates a Long-Term Care (LTC)
             facility in the same city. Big Hospital Chain chooses to operate
             as a self-contained NHIE, meaning that its procedures for
             proofing user identities and authenticating users directly meet
             the standards for being an NHIE.
         •   Dr. Newby makes a query about a patient that can be fulfilled
             by providing records from the LTC facility of Big Hospital


4. The following example is taken from Wes Rishel, Virginia Riehl and Cathleen Blanton, “Sum-
   mary of the NHIN Prototype Architecture Contracts”, http://www.hhs.gov/healthit/healthnet-
   work/resources/summary_report_on_nhin_Prototype_architectures.pdf, 31 May 2007, p.42.



                                                                                         36
Technical Issues Workgroup




             Chain. The chain of trust that allows the LTC facility to pro-
             vide the information is as follows: Big Hospital Chain trusts
             Northern District HIE because of its status as an NHIE;
             Northern District trusts Memorial General to vouch for Dr.
             Newby.

NHIN Requirements to Eliminate Ambiguity of User or Patient Iden-
tities5.

5.3.12 Transmit Disambiguated Identities
Messages that will be initiated because of the actions of users of a
participating system shall contain sufficient information identifying the
user such that it can be unambiguously traced to the user by the
participating organization.

In support of this feature, NHIEs will need to establish schemes to
unambiguously scope subject IDs.

The messages supporting actions that contain information about a
patient shall, where practical, contain sufficient identifying information
that the NHIE could match the patient with other patients being tracked
by the NHIE or perform inter-NHIE subject adjudication.

It is possible that some of the identifying information transmitted about
healthcare providers could include a subset of information that is
collected as part of provider credentialing, in the sense of determining
the professional qualifications of a provider to work in a specific
healthcare setting.

NHIN Additional Requirements for Authentication. 6

5.4 Ensuring Authorization
Authorization is the granting of rights, which includes the granting of
access, based on permissions. It is not listed as a common transaction
feature, but it is nonetheless an important characteristic that ties
together several features and transaction packages. This section brings
the concepts together for discussion. Authorization cannot be reliably
performed unless identity proofing and authentication has been
performed on the user. See Section 5.3.2.



5. Wes Rishel, Virginia Riehl and Cathleen Blanton, “Summary of the NHIN Prototype Architec-
   ture Contracts”, http://www.hhs.gov/healthit/healthnetwork/resources/
   summary_report_on_nhin_Prototype_architectures.pdf, 31 May 2007, p.4
6. Wes Rishel, Virginia Riehl and Cathleen Blanton, “Summary of the NHIN Prototype Architec-
   ture Contracts”, http://www.hhs.gov/healthit/healthnetwork/resources/summary_report_
   on_nhin_Prototype_architectures.pdf, 31 May 2007, p.45.



                                                                                        37
Technical Issues Workgroup




Information about a patient may reach various users (people or
organizations) via the NHIN through various interchange capabilities as
described in the annexes to this report. This information sharing can
only happen consistent with the policies in place in each NHIE that is
involved in a specific information flow. NHIEs may have different
policies based on the preferences of participants in the NHIE and the
laws or regulations of the specific jurisdictions in which the participants
operate. This includes federal laws and regulations.

Ensuring compliance with specified policies on information flow
requires several common capabilities as described below. Where this
material describes the requirement of a participating organization that
operates an EHR, PHR or other system, those requirements also apply to
the NHIE itself, to the extent that it has direct users through a portal.
Note that system authentication and user authentication are co-requisite
capabilities which are both required, as illustrated in the steps below, to
ensure that authorization is meaningful.
        • Participating organizations will take responsibility for accu-
            rately confirming the identity of all persons who use systems
            that can send and receive information through an NHIE.
        •   They may take actions themselves to confirm identity or they
            may advisedly trust another organization for that. For exam-
            ple, a hospital may directly confirm the identity of users. It
            may participate in an HIE that relies on identifications made
            by the hospital. The HIE may participate in the NHIN through
            an NHIE which relies on the HIE.
        •   Participating organizations will authenticate each user that
            can send or receive information through the NHIE with a level
            of certainty at least as strong as that specified by the NHIE
        •   User IDs are not necessarily unique to a participating organi-
            zation. Each NHIE will establish with its participants a man-
            ner of providing scope information so that a fully scoped user
            ID will be unique in the NHIN.
        •   Not all NHIEs will maintain a registry of users. No such regis-
            try is specified in this document. (They will have a registry of
            providers and be able to identify providers with one or more
            organizations’ systems for routing, but the set of all registered
            providers is not the same as the set of all users.)
        •   Standards that enable information flows through NHIEs will
            support the transmission of the disambiguated user ID for all
            transactions performed on behalf of a user. They will also sup-
            port the transmission of a disambiguated organization ID for
            all transactions.




                                                                           38
Technical Issues Workgroup




        • Standards will also support transmitting a description of the
            roles of users along with their disambiguated identities. This
            role information may include some level of information about
            the professional orientation of a user that is a provider.
        •   The systems of participating organizations that provide infor-
            mation in response to requests from the systems of other orga-
            nizations may use the user and organizational identity and
            role information to enforce local restrictions on providing
            information.
        •   The NHIEs will maintain registries of the permissions that
            consumers give to organizations or providers to receive a con-
            sumer’s data.
        •   An NHIE will support a declaration that the privileges of a
            provider to use the NHIN have been suspended.
        •   Consistent with policy determinations the NHIE will enforce
            the restrictions specified by consumer permissions or sus-
            pended privileges while passing transactions from one system
            to another.
        •   An NHIE will support the declaration of a need to override the
            restrictions that support consumer preferences in an emergent
            situation. This is referred to as a break-the-glass capability.
            When a break-the-glass situation has been declared, the NHIE
            will not interfere with the flow of information, although it will
            retain a complete audit trail of how information flowed. The
            implementation of break-the-glass functionality may be differ-
            ent in different NHIEs to account for differences in policy
            associated with their participants.
        •   Describing the requirement to use protocols that permit
            break-the-glass in this report is not meant to imply that the
            function must always be implemented in the same way, or at
            all. That is a policy issue.




                                                                          39
Appendix A: The Action Plan

                    Plan Elements Realizing the importance of positioning EHRs as
                    beneficial to all residents, the plan aims to increase awareness and build
                    support among the public at large, healthcare providers, and other
                    identified stakeholders. The strategies and tactics outlined herein are
                    designed to reach out to these groups. It is because of the perceived
                    complexity of the EHR/HIE issue that this communications plan takes a
                    ‘back to basics’ approach; only fundamental, tried-and-true public
                    relations strategies and tactics are recommended. The steps outlined
                    below offer a budget-conscious method of achieving results that, if
                    implemented, should further the goals of the South Dakota eHealth
                    Collaborative. The plan in this phase is not meant to contain an
                    exhaustive list of specific ideas for each strategy; rather, it provides
                    options for the eHealth Collaborative to review and select for further
                    exploration and refinement. At that point, specific budgets will be
                    assigned to each task.

PRIMARY OBJECTIVE   To convey to South Dakotans the features, benefits and overall
                    advantages of secure Electronic Health Records, Health Information
                    Exchange, and Personal Health Records in order to generate support for
                    their widespread adoption in the state.

                    Three Primary Goals
                           • Goal 1: To educate South Dakota consumers about what Elec-
                             tronic Health Records mean to them on a personal level and
                             how their healthcare can improve as a result
                           • Goal 2: To communicate to healthcare providers how broader
                             use of Electronic Health Records can make their practices and
                             institutions more time and cost efficient and improve the care
                             they provide to patients
                           • Goal 3: To communicate to employers and insurers/payers
                             the value of an Electronic Health Record network to improve
                             the quality of healthcare and increase employee productivity
                             while realizing cost savings in healthcare delivery

                    Three Primary Strategies

                    This action plan uses three primary strategies, as follows. Strategy 1:
                    Generate awareness of the Electronic Health Record/ Health
                    Information Exchange/Personal Health Record story via editorial
                    coverage. Strategy 2: Launch a targeted outreach effort geared toward
                    healthcare providers and other crucial stakeholders. Strategy 3: Conduct
                    a targeted outreach to payers/insurers and employers with appropriate
                    emphasis on the benefits of utilizing the Personal Health Record.


                                                                                           41
Appendix A: The Action Plan




Strategy 1: Generate awareness of the HIE/EHR/PHR story
via editorial coverage


Tactic 1: Create a unified, identifiable brand for the South
Dakota EHR effort

Rationale: Several entities in the state are working toward EHR
adoption, which can cause confusion among the media and the public as
to who is the primary authority on the subject. A unified brand will
streamline communications and improve understanding of the issue.

Audience: General public, local media

Message: The proponents of EHR in South Dakota are organized and
united in their efforts to improve healthcare in South Dakota

Action Steps:
        1. Retain the services of an advertising agency/graphic designer
           and identify participants in the branding process
        2. Convene participants either in-person or electronically and
           clarify the process and goals for the new identity
        3. Work with the selected designer to develop a brand/logo/
           tagline based on members’ suggestions

Tactic 2: Develop a comprehensive press kit and impactful
marketing materials

Action Steps:
        1. Once the new brand is finalized, assemble the following:
        •   Press release announcing the new brand and providing
            updates on the EHR effort in South Dakota
        •   Fact sheet specific to EHRs and HIE, including how the
            technology works
        •   FAQs related to privacy and security concerns with compre-
            hensive information addressing each issue
        •   History of the various groups’ work toward EHR adoption
        •   EHR implementation timeline
        •   Lists and biographic information for committee members/
            key stakeholders
        •   Story ideas, including the Personal Health Record concept
        •   Case studies from other states already utilizing EHRs suc-
            cessfully
        •   Contact information


                                                                     42
Appendix A: The Action Plan




        2. Distribute press kit to South Dakota media and use the distri-
           bution as an opportunity for a top-line, informal briefing with
           reporters
        3. Update the kit when necessary and post to a designated Web
           site
        4. Determine which marketing materials e.g. brochures, Web
           site, leave-behinds, etc.) are critical to the local effort’s suc-
           cess and establish a timeline and budget for their creation.

Tactic 3: Conduct media outreach and pitch the EHR story

Action Steps:
        1. Armed with the new press kit, aggressively pursue coverage
           of the EHR story in the state’s’s most influential media.
        2. Periodically identify fresh story angles and pitch reporters on
           providing updates to their readers/viewers/listeners.
        3. Position EHR spokespeople as local sources of expertise on
           electronic privacy.

Tactic 4: Submit guest editorials for statewide publication

Action Steps:
        1. Once the press kit is complete, designate stakeholders who
           can pen opinion pieces.
        2. Pitch editors of key publications on running an EHR edito-
           rial.
        3. Work with agency to polish and edit pieces written by desig-
           nated stakeholders. Submit editorials for publication.

Tactic 5: Schedule editorial board meetings

Action Steps:
        1. Once the new identity is finalized, designate stakeholders
           who can speak about the EHR effort with editors.
        2. Schedule and conduct editorial briefings.
        3. Conduct any follow up (with promised information) that
           results from meetings.
        4. Pitch editors on penning a favorable editorial as a result of
           these meetings.
        5. Schedule follow-up meetings as necessary.




                                                                           43
Appendix A: The Action Plan




Tactic 6: Schedule appearances on important local talk radio
programs

Action Steps:
        1. Designate stakeholders who can speak about the EHR effort
           with local talk radio hosts.
        2. Schedule and conduct appearances on local shows.

Tactic 7: Produce local Public Service Announcements (PSAs)

Action Steps:
        1. Decide which messages to incorporate into PSAs for radio
           and TV.
        2. Work with a design team to produce and distribute PSAs
           statewide.
           (Note: The eHealth Initiative’s Web site offers broadcast-
           ready radio PSAs free to its members. If the team elects to use
           them, it will represent a substantial cost savings.)

Tactic 8: Create a speakers bureau and schedule appearances

Action Steps:
        1. Incorporate key messages into a PowerPoint presentation.
        2. Schedule speaking engagements with influential groups and
           organizations, i.e. the Chamber of Commerce, Rotary clubs,
           legislative committees, etc.

Strategy 2: Launch a targeted outreach effort geared toward
healthcare providers, including private and smaller practices,
and other crucial stakeholders


Tactic 1: Work with local professional provider organizations
to enlist the support of their members

Rationale: The South Dakota medical community is active in various
professional organizations

Audience: Physicians, physician assistants, nurse practitioners,
pharmacists, medical office managers

Message: Providers can be assured that adopting Electronic Health
Records will increase office efficiencies, and improve healthcare
outcomes through having critical information at the point of care. More
detailed benefits are outlined under Tactic 2.


                                                                       44
Appendix A: The Action Plan




Providers have been slow to adopt EHRs due to several overriding
concerns. A number of efforts are underway to mitigate these concerns,
including the following:

The cost of EHR adoption could be reduced through a grant program for
qualified providers. (program and amounts dependent upon securing
funding) The difficulty of selecting an EHR system will be lessened by
The South Dakota eHealth Collaborative program since all stakeholders
are participating in the process. Technology adopted must have
sustainable EHR suppliers that meet federal certification and other
national standards, for providers. This will ensure that the provider does
not invest in outdated technology or short-lived companies. It is
expected that the eHealth Collaborative organization will provide
guidance in the technology and agreements to allow the secure exchange
of Electronic Health Records between providers, labs, hospitals, payers,
and other medical entities involved in the delivery of patient care.

Action Steps:
        1. Identify local professional provider organizations to target,
           • South Dakota State Medical Association (SDSMA)
           • South Dakota Academy of Physician Assistants
           • South Dakota Nurse Practitioners Association
           • South Dakota Pharmacists Association
           • South Dakota Medical Group Management Association
           • South Dakota Chapter of the American Academy of Family
             Practice
           • South Dakota Association of Healthcare Organizations.
           • Others to be identified.
        2. Arrange meetings with key representatives from each group
           and establish speaking opportunities at each organization’s
           annual meeting.
        3. Purchase display space at each organization’s annual meet-
           ing.
        4. Explore additional partnership opportunities and identify
           champions in each organization.
        5. Pursue inclusion of the local EHR effort in each organiza-
           tion’s publication, Web site or electronic correspondence
           with its members.
        6. For groups with a legislative agenda, work with designated
           members to encourage them to include the South Dakota
           eHealth Collaborative in their lobbying efforts.




                                                                       45
Appendix A: The Action Plan




        7. For groups that already support the legislative effort, identify
           methods of intensifying their involvement, e.g. ask their
           members to write letters/emails to their lawmakers asking
           them to support the effort, or request to be included in legis-
           lative receptions, etc.
        8. Identify local providers who can write op-ed pieces for state-
           wide publication.

Tactic 2: Meet with individual providers, including those in
small and private practices, to explain the EHR effort and
garner support

Rationale: One-on-one meetings with providers will provide the
opportunity to explain the benefits of EHR and uncover any concerns,
giving providers a voice in the process.

Audience: Health care providers, especially those in small and private
practices.

Message: Providers stand to benefit from widespread EHR adoption in
several important ways, including:
        • Better patient care/satisfaction.
        • Critical electronic information and alerts to aid in diagnosis
            and treatment decisions.
        •   Less chance of medical errors.
        •   Facilitation of essential clinical trials.
        •   Promotion of standards of care.
        •   Improved billing accuracy and office efficiency.
        •   Improved practice/clinic profitability.
        •   Reduction in duplicate services and tests.
        •   Improved safety in hospitals/in-patient setting.
        •   Compliance with HIPAA requirements.
        •   Quick access to back-up documentation for insurance claim
            inquiries, audits, and malpractice allegations.

Action Steps:
        1. Identify key providers/practices and schedule one-on-one
           meetings with them, via either scheduled appointments,
           lunchtime presentations or, in the case of rural providers,
           phone or email correspondence.
        2. Gather feedback from these meetings and incorporate rele-
           vant messages into marketing materials.



                                                                         46
Appendix A: The Action Plan




Tactic 3: Create a volunteer advisory group made up of a
broad spectrum of healthcare providers

Rationale: The local medical community will be more likely to support a
local EHR effort if its opinions and ideas are being incorporated into the
process AudienceHealth care providers

Message: The EHR effort is being advised by a group of credible peers
who support the Initiative

Action Steps:
        1. Identify key providers, including any outspoken critics of
           EHRs, and approach them with the idea of serving on a pro-
           vider advisory group.
        2. Hold meetings on an as-needed basis to provide updates on
           EHR’s progress in South Dakota while asking for suggestions
           and feedback.
        3. Incorporate appropriate ideas into the EHR effort’s strategic
           plan and publicize newsworthy results to the media and the
           local medical community.

Tactic 4: Create marketing materials designed for provider
use

Rationale: Research shows that patients overwhelmingly say they trust
doctors the most for information about secure electronic Health
Information Exchange: physician support is critical to success.

Audience: Doctors and their patients

Message: Physicians are delivering the EHR message because they
believe in its importance to their patients’ healthcare

Action Steps:
        1. Develop talking points for physicians to use when explaining
           EHR/HIE to their patients.
        2. Once developed, design and produce convenient laminated
           talking points cards for physicians to keep for easy reference.
        3. Design and produce posters detailing the benefits of EHR/
           HIE for display in clinics, exam rooms or other appropriate
           venues.
        4. Make other marketing materials available to physician offices
           to use at their discretion, e.g. brochures explaining the bene-
           fits of EHR/HIE in their waiting/exam rooms, etc.



                                                                       47
Appendix A: The Action Plan




Tactic 5a: Develop communication tools designed to reach
stakeholders in rural markets

Rationale: The South Dakota eHealth Collaborative effort is statewide,
including rural areas; some messages aimed at a rural audience will
differ from those targeting urban populations.

Audience: Health care providers, general public, media

Message: Rural patients have specific interests related to their
healthcare. EHRs, PHRs and HIE offer advantages to all patients as
outlined in the core benefits, on page 5, and the general messages for
both urban and rural stakeholders under Tactic 5b. In addition, the
following, more specific messages offer these advantages:
        • Improve the quality of care by making Electronic Health
            Records available to providers in multiple locations and/or
            specialties.
        •   Facilitate secure provider-patient interactions when it is not
            feasible to visit a provider in person.
        •   Provide comprehensive personal health information, included
            in the patient’s PHR, whether care is received at the clinic, or
            the hospital.
        •   Provide specialty medical knowledge and diagnostic or medi-
            cal services at local or remote locations through important
            information in the EHR and quicker contact with specialists in
            other locations.
        •   Reduce paperwork burden associated with patients receiving
            care from various medical facilities and providers. Increase
            security of records and allow patient to monitor access.

Action Steps:
        1. Work with the various stakeholders to streamline efforts
           already underway at moving to an EHR system.
        2. Target rural publications for coverage of the EHR issue or
           submit editorial pieces for publication.
        3. Work with the identified community organizations to develop
           a presence at their annual meetings.
        4. Approach the state with the idea of promoting an effort to
           make every clinic/provider location wireless by 2011. Pitch
           the idea of promoting EHRs/PHRs as an ideal platform from
           which to announce its commitment to rural parts of the state.
        5. Make a concerted effort to meet in-person with legislators
           representing rural parts of the state to make sure they under-



                                                                         48
Appendix A: The Action Plan




           stand the issue and can explain its benefits to their constitu-
           ents.
        6. Identify and approach key rural leaders with the idea of serv-
           ing as ambassadors to their communities.
        7. Hire professionals with expertise in communicating effec-
           tively with rural populations to further develop strategies for
           reaching these markets with appropriate messages.
        8. Hold community meetings to educate residents about EHRs,
           PHRs, and HIE.

Tactic 5b: Develop communication tools designed to reach
stakeholders in urban markets

Rationale: The South Dakota eHealth Collaborative effort is statewide,
and messages aimed at major population centers will be broader in scope
than those aimed at rural residents

Audience: General public

Message: Patients in urban areas stand to benefit from Electronic Health
Records in specific ways, including the core benefits, plus the following
general messages for both urban and rural stakeholders:
        • Greater access to and control over their own health records
            through Personal Health Records will:
            a. Allow the ability to ask more informed questions of their
                physicians.
            b. Confirm information provided by a physician/nurse dur-
                ing a visit or phone call.
            c. Help them better understand choices in treatment
                options.

Providers will have quick access to complete medical information about
the patient, which will result in better diagnoses and outcomes for the
patient. The paperwork burdens for patients and providers will be
reduced, and duplicate, unnecessary testing eliminated.

Action Steps:
        1. Develop displays using the new brand/logo/tagline and dis-
           play them at health fairs across the state.
        2. Distribute marketing materials designed for a mass consumer
           audience (perhaps the same brochures available in providers’
           waiting rooms) at these events.
        3. Create displays at other large-scale gatherings or events, e.g.
           the South Dakota State Fair, etc.


                                                                        49
Appendix A: The Action Plan




        4. Produce bus signs for display on the back/side of buses.
        5. Develop branded java jackets (cardboard latte holders) for
           use at local coffee shops.
        6. Explore the possibility of utilizing print advertising when
           camera-ready art is available (the e-Health Initiative’s Web
           site makes print ads of various sizes and colors available free
           to its members).

Tactic 6a: Develop communication tools designed to reach
technologically sophisticated stakeholders

Rationale: Patients most likely to first adopt EHRs and PHRs will likely
be tech savvy

Audience: General public, media

Action Steps (most or all of this may be in place at the DSU site ? so
review for correct language):
        1. Develop a professional, comprehensive Web site where mem-
           bers of the public and the media can access information on
           the South Dakota eHealth Collaborative effort. Ideally, the
           Web site would include:
        •    History and background information on the South Dakota
             eHealth Collaborative
        •    Basic definition of EHR/HIE/PHRs and how they work,
             including graphics and/or flow charts.
        •    FAQs addressing the most common questions and con-
             cerns.
        •    An image of a sample EHR juxtaposed with a photo of an
             overstuffed paper-chart storage room to illustrate the sim-
             plicity of the EHR system
        •    Testimonials from key healthcare providers explaining how
             their patients’ care is improved with EHRs.
        •    Sections specific to providers, the general public and media
             with information on each group’s main issues. Links to
             other relevant Web sites.
        •    Contact information and ‘how to get involved’ information.

Tactic 6b: Develop communication tools designed to reach
stakeholders who either do not have access to, or have a
limited interest in technology

Rationale: Some critical stakeholders either do not have access to the
Internet or do not use it


                                                                         50
Appendix A: The Action Plan




Audience: General public

Message: Even if patients are not enthusiastic about the improved
technology offered by Electronic Health Records, their wider use can
benefit them in the following ways:
        • Reduced medical errors.
        • Reduced out-of-pocket healthcare costs.
        • Easier, more accurate pharmacy transactions. Improved cor-
          respondence with healthcare agencies like Medicare or Medic-
          aid.
        • Reduced paperwork burdens associated with visiting new pro-
          viders.

Action Steps:
        1. Develop a direct mail campaign targeting specific demo-
           graphics (e.g. the elderly) to educate them about the EHR
           effort, especially PHR, and how they stand to benefit from it.
        2. Create informational displays for use in community centers,
           libraries, public health clinics and other high-traffic areas
           where people tend to gather.
        3. Identify demographic groups who tend not to have access to
           or don?t trust technology and enlist the help of their leaders
           to communicate effectively with their members.
        4. Produce an insert for distribution in statewide publications.

Tactic 7a: Conduct targeted outreach geared specifically
toward chronic disease patients

Rationale: Patients with chronic conditions stand to benefit greatly
from improved health record accuracy, and may also desire to manage
their own healthcare more actively via PHRs

Audience: General public, media

Message: Patients with chronic conditions stand to benefit from wider
use of EHRs and particularly in the use of PHRs in the following ways:
        • Organized personal health information in the Personal Health
          Record will reduce or eliminate the individual’s burden of
          facilitating the exchange of information between providers.
        • Better access to health records will allow patients to monitor
          their progress and check for errors, including potential medi-
          cation interactions and contraindications.




                                                                       51
Appendix A: The Action Plan




        • Patients’ access to their Personal Health Records will improve
            their ability to manage their own medical conditions through
            seeing and recognizing trends in their Personal Health
            Record, being able to ask better questions of their providers,
            and having access to all of their providers’ instructions and
            recommendations in one place.

Action Steps:
        1. Partner with the local chapters of organizations affiliated with
           chronic conditions (e.g. the American Diabetes Association,
           the American Heart Association, the American Cancer Soci-
           ety, etc.) to reach their members with the EHR/HIE/PHR
           message. For example, ask to include information with an
           emphasis on how their members’ healthcare can improve in
           any electronic communication, newsletters, etc.
        2. Identify methods for creating a presence at these organiza-
           tions’ large-scale events and fundraisers, e.g. auctions, bike
           rides, formal dinners, etc.
        3. Once the South Dakota eHealth Collaborative Web site is
           launched, ask these organizations to link to the site from their
           own.
        4. Partner with providers, clinics and practices that serve
           patients with chronic conditions (e.g. diabetes, heart disease,
           AIDS, mental illness, cancer, etc.) and identify ways of involv-
           ing their patients in the EHR effort.

Tactic 7b: Conduct targeted outreach geared specifically
toward healthy patients

Rationale: Healthy patients may not consider EHRs to be very useful to
them because of their overall good health

Audience: General public

Message: EHRs benefit everyone, including patients who require only an
annual check-up, in the following ways:
        • Ensuring the safety/accuracy of health records in an emer-
          gency
        • Allowing access to medical information while traveling Pro-
          viding easy refills of prescription medications
        • Ensuring survival of records during a natural disaster or other
          catastrophe
        • Allowing caregivers (who have been given permission) to
          access medical records, and monitor them for accuracy


                                                                        52
Appendix A: The Action Plan




        • Allowing patients to monitor their records for billing errors or
            identity theft issues.

Action Steps:
        1. Create marketing tools (brochures, posters, etc.) designed to
           address issues of universal interest.
        2. Distribute these materials in primary care provider offices,
           clinics and practices.
        3. Dedicate a portion of the Web site to address this issue, e.g. a
           “Why EHRs benefit everyone” section.

Tactic 8: Conduct outreach to appropriate local consumer
groups (AARP) and ask them to encourage their members to
support a South Dakota eHealth Collaborative effort

Rationale: Consumer groups are credible providers of information to
their members

Audience: Members of respective groups

Message: The South Dakota eHealth Collaborative enjoys broad support
from a range of consumer groups who promote the rights and interests
of their members, which include the desire for improved, more efficient
healthcare delivery and better access to providers.

Action Steps:
        1. Work with current supporters (e.g. AARP) to develop addi-
           tional strategies for getting their membership to support a
           South Dakota EHR effort, e.g. write letters to the editor in
           support of EHR’s widespread adoption, or include a news
           item with a call-to-action component in the AARP Bulletin’s
           Regional News.
        2. Approach other identified groups and ask for their support.
           Once secured, take advantage of their media muscle to pitch a
           story on how EHRs and PHRs benefit South Dakota consum-
           ers.
        3. Identify other consumer groups (e.g. AAA relative to the issue
           of accessibility of records while traveling) whose participation
           in an EHR initiative would be appropriate, and approach
           them for strategies of how best to marshal their member-
           ships’ resources.
        4. Include letters of support from willing consumer groups in
           media and legislative materials.




                                                                        53
Appendix A: The Action Plan




        5. Add links on consumer groups’s’ websites to the South
           Dakota eHealth Collaborative website and to the other con-
           sumer groups’ websites.

Tactic 9: Conduct outreach to federal groups (e.g. tribal,
military, VA)

Rationale: Many South Dakota federal groups are responsible for the
healthcare of their members

Audience: Members of respective groups and their administrators

Message: It is in the best interest of federal groups to support an
Electronic Health Record effort because:
        • Their members’ health will improve through use of the Per-
          sonal Health Record by giving them an active role in their care
          and to provide access to health information when away from
          home.
        • A more efficient system will reduce healthcare costs for both
          the federal groups and their members.
        • Federal group members are more likely to hold their respec-
          tive healthcare organizations in high regard if they perceive
          that steps are being taken to improve their care and quality of
          life.
        • Frequent moves make electronic access to records very valu-
          able.

Action Steps:
        1. Work with various federal groups’ healthcare administrators
           to identify how the South Dakota eHealth Collaborative can
           meet their members’ needs.
        2. Identify champions within each organization that can assist
           in delivering the EHR message to their respective decision
           and policy-makers.
        3. Ask that information about the features and benefits of the
           Electronic Health Record, Personal Health Record and secure
           Health Information Exchange be included in each federal
           group’s communication with its members, e.g. newsletters,
           emails, etc.




                                                                      54
Appendix A: The Action Plan




Strategy 3: Conduct targeted outreach to payers/insurers and
employers with appropriate emphasis on the benefits of
utilizing the Personal Health Record


Tactic 1: Enlist support from the state, including the South
Dakota Legislature and the Governor’s office/administration

Rationale: The South Dakota eHealth Collaborative effort requires
funding, which the state can help provide. As a major payer, the state has
a vested interest in the benefits provided by Electronic Health Records
and Personal Health Records

Audience: Legislators, the Governor, and her administration

Message: The South Dakota eHealth Collaborative is worth supporting
financially for the following reasons:
        • It will reduce costs associated with inefficiencies in adminis-
          tering and delivering medical care.
        • It will improve the healthcare and quality of life for all South
          Dakotans by reducing medical errors and improving medical
          outcomes.
        • It will help recruit and attract new healthcare providers to the
          state, thereby increasing access to providers.
        • It will allow employees (through PHRs) more control over
          their own healthcare resulting in improved overall health.

Action Steps:
        1. Designate one or two stakeholders as the primary contacts on
           the EHR issue and register as lobbyists in Pierre.
        2. Travel to Pierre during the session on an as-needed basis and
           meet with legislators and/or staff to provide information on
           and promote the EHR effort.
        3. Write and distribute to legislators and the Governor’s admin-
           istration a monthly (or some other time interval) email news-
           letter with updates on the South Dakota EHR effort.
        4. Work with legislative champions to develop strategies for
           communicating effectively with the legislature and the
           administration.
        5. Continue working with all stakeholders and encourage their
           members to ask for support for the South Dakota eHealth
           Collaborative from their respective constituencies.




                                                                       55
Appendix A: The Action Plan




Tactic 2: Conduct outreach to large employers

Rationale: Support from large employers is critical to the EHR effort’s
success

Audience: Human resource administrators at major employers and
employees at those companies

Message: Electronic Health Records and Personal Health Records are
worth investing in for the following reasons:
        • Patient care will improve and ultimately create healthier
            employees.
        •   Productivity will improve as a result of healthier, happier
            employees who miss fewer days of work.
        •   Morale will receive a boost from employees who feel as if their
            company is genuinely interested in providing them with the
            most advanced tools available to improve their health and the
            health of their families.
        •   Employees with chronic health conditions are apt to stay on
            the job longer and file for disability less often when their
            healthcare is being managed effectively.
        •   Employees with Personal Health Records become more active
            in managing their health, which translates to healthier, hap-
            pier employees, and reduced healthcare costs.
        •   Potential reduction in insurance costs due primarily to
            increased efficiencies and elimination of duplicate or unneces-
            sary tests or procedures.

Action Steps:
        1. Create marketing materials designed to sell the benefits of
           EHRs and PHRs to employers, e.g. brochures and leave-
           behinds containing messages about improved patient and
           employee health, fewer sick days, etc.
        2. Schedule appointments with the HR administrators of major
           employers and lobby their support for statewide EHR adop-
           tion.
        3. Participate in any large employer’s ?Benefits Day? or fairs
           when employees visit booths from various vendors to learn
           about their healthcare plan.
        4. Create an animated computer demonstration showing how
           an average employee/patient might navigate a PHR and
           become more engaged in his/her healthcare as a result.
        5. Post it to the Web site and use it for presentations and meet-
           ings.


                                                                        56
Appendix A: The Action Plan




        6. Include testimonials from patients/employees/providers who
           have used PHRs and can speak to their convenience and
           effectiveness in any meetings with payers and employers.
        7. Post to the Web site. Pitch business media on covering the
           PHR story with the angle of employers using innovative new
           methods to keep employees healthy.

Tactic 3: Conduct outreach to insurance companies

Rationale: Support from insurance companies is critical to the South
Dakota eHealth Collaborative’s success

Audience: Administrators of major insurance companies

Message: EHRs and PHRs will improve patient care and ultimately
reduce healthcare costs by:
        • Streamlining communication between providers’ offices and
          insurance companies including timely processing of insurance
          claims through standardized claim reporting
        • Eliminating manual and cumbersome claims processing that
          is costly to the whole system Increasing ease and efficiency of
          access to records when appropriate
        • Ensuring that practitioners and patients know in advance
          what will be covered by a patient’s insurance plan.
        • Giving patients the tools to help manage and monitor their
          own healthcare, resulting in healthier patients and, subse-
          quently, lower medical costs Reduced Cost of Care:
          a. Decrease in long-term care costs resulting from a healthier
               population utilizing screening reminders and best practice
               alerts for wellness management
          b. Reduction in duplicate clinical tests
          c. Fewer medication errors and poor outcomes resulting
               from poor access to patient clinical data
          d. Reduction in numbers of appeals from patients to insurers

Action Steps:
        1. Create marketing materials designed to sell the benefits of
           EHRs and PHRs to payers, e.g. brochures and leave-behinds
           containing messages about improved patient and employee
           health, reduced paperwork, etc.
        2. Compile any existing research findings and/or statistics
           showing how use of EHRs and PHRs can reduce expensive




                                                                       57
Appendix A: The Action Plan




           medical errors, streamline administrative work and, ulti-
           mately, reduce healthcare costs.
        3. Conduct one-on-one meetings with major insurance compa-
           nies’ HR administrators and sell the benefits of widespread
           EHR adoption. Use these meetings to assess what the compa-
           nies need in order to support the local effort.
        4. Create a section of the Web site designed for payers with
           information (graphs, charts, etc.) showing improved patient
           outcomes and cost savings realized by EHR/PHR use.
        5. Include payers in all aspects of the outreach effort, including
           pitches to the media, workgroups and meetings, lobbying the
           state legislature, etc.

Evaluation

In order to judge whether the plan is successful, some form of
measurement is necessary. Ideally, polling would be conducted before
and after the plan is implemented to see how public attitudes about
EHR/HIE/PHRs change as a result of the outreach effort. Barring that,
several other methods may be used to monitor progress:
        1. Increase in the number of providers willing to explore using
           EHRs
        2. Increase in the number of providers willing to speak up in
           favor of the EHR effort
        3. Increase in the number of visitors to any Web sites created for
           the EHR communications effort
        4. Noticeable amount of correspondence from constituents to
           their legislators in support of EHRs
        5. Substantial, positive media coverage across the state with a
           positive return-on-investment dollar amount
        6. Inclusion of the EHR pilot program in the state budget
        7. Increased use of PHRs in the state
        8. Increased payer participation in an EHR program




                                                                       58

				
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