Date : July 13, 2010 Time : 1:00 pm – 3:30 pm Location : NC Institute of Medicine

1. Date: July 13, 2010 Time: 1:00 pm – 3:30 pm Location: NC Institute of Medicine Dial in: 1-866-922-3257 Participant Code: 654 032 36#

2. Agenda Discussion Document – Not for Distribution

3. Objectives of Today’s Meeting • Review Operational Plan components and drafting process and schedule • Define vision for statewide HIE in North Carolina • Understand range of options for statewide HIE service offerings and value propositions • Affirm, reject or modify workgroup recommendations to date for inclusion in Operational Plan Discussion Document – Not for Distribution

4. New NC Health IT Website Launched www.healthit.nc.gov Discussion Document – Not for Distribution 4

5. NC Statewide HIE Cooperative Agreement Timeline Strategic Plan Operational Plan Stakeholder Outreach & Begin Transition Biweekly+ Workgroup Meetings with Monthly Board Meetings Strategic Plan Submitted to HHS LaunchPhase 2 Publish Draft Operational Plan for Review/ Comment NC HIE Formed Workgroups Formed & Begin Meeting State HIE Grant App. • Convene Advisory Board & Workgroups • Draft Operational Plan • Publish Draft Operational Plan for Review • Engage and educate stakeholders Aug. 31Submit Operational Plan to HHS Funding Announcement Letter of Intent Submitted Discussion Document – Not for Distribution 5 5

6. NC Statewide HIE Operational Plan Development Timeline Operational Plan Consensus Recommendations Drafting of Operational Plan Governance WG: Confirm governance model, advise on scope of governance, craft recommendations on bylaws and board structure for new entity; develop recommendation for consumer engagement plan approach Clinical/Technical WG: Recommendations on technical architecture approach for statewide HE, begin prioritization of core and value-added services, begin landscape assessment Governance WG: Participation policies and enforcement mechanisms for the statewide HIE; develop recommendations on roles of State in public/private partnershipprocesses for coordination with other ARRA funded programs in the state Clinical/Technical WG: Development of clinical and business use cases, prioritization for core and value-added services, technical approach May 14 – initial NC HIE Board Meeting Master project planning, develop WG charters and workplans; stakeholder meetings, Legal/Policy WG meetings Aug. 31: Submit Operational Plan to HHS Legal/Policy WG: Conduct legal scan for NC laws related to consent for treatment purposes; draft legal principles; conduct legal scan for NC laws related to health information data security; develop recommendations on approach to 4As; develop initial consent approach recommendation under existing law Finance WG: Develop financial model assumptions; data collection to inform financial models. Legal/Policy WG: Develop recommendations for an “ideal” consent policy not restricted by current law and approach to changing the law; develop recommendations on breach policy principles and role based access principles; develop security recommendations beyond access; review emerging consent policies in neighboring states and identify barriers. Finance WG: Develop 2-3 financial models based on modeling assumptions and develop process for sustainability planning. • Compile NC HIE Board & Workgroup recommendations and decisions • Draft Operational Plan – iterative process with WG review • Publish Draft Operational Plan for Public Review Workgroups formed Workgroups formed Discussion Document – Not for Distribution 6 6

7. Workgroup Deliverables for Operational Plan Discussion Document – Not for Distribution Discussion Document – Not for Distribution

8. Operational Plan Outline • NC HIE • Combined Strategic & Operational Plan • I. Introduction • NC HIE Initiative Background • Collaborative Stakeholder Process • Timeline and Next Steps • II. Strategic Plan • Guiding Principles by Domain • Vision • III. Operational Plan • Approach to Statewide HIE • Meaningful Use • A. Governance • Overview • Public/Private Partnership, Articles of Incorporation and Founding Board • Bylaws • Board Nomination Process Moving Forward • Authority and Involvement of the State • Ongoing Development of Governance and Policy Structures • Next Steps • B. Technical Infrastructure • Overview • Planned Technical Architecture • Planned Core Infrastructure • Standards • Technology Deployment • Next Steps • C. Business & Technical Operations • Overview • Core Services • Value-Add Services • Leveraging HIE Capacity in NC • Implementation Timeline • Next Steps • D. Legal & Policy • Overview • Consent, including: • State law scan - consent for TPO • Pathways 1 & 2 • Authorization, Authentication, Access, Audit and Breach • CIA – Confidentiality, Integrity, Availability • Next Steps Discussion Document – Not for Distribution

9. E. Finance • Overview • Financial Model Methodology • Financial Model Key Assumptions • Environmental Data Collection • Cost and Revenue Models • Sustainability Planning • Next Steps (including Controls and Reporting) • IV. Coordination • Overview • Medicaid • ARRA Programs • Veterans Affairs • V. Development of Stakeholder Communication Plan • Appendices Discussion Document – Not for Distribution

10. NC HIE Operational Plan Stakeholder Collaboration Calendar Governance, Clinical/Technical Ops, Finance WG Meetings Legal/Policy WG Meetings Legal/Policy Subcommittee Meetings NC HIE Board Meetings Operational Plan due to ONC WG conference calls as needed Discussion Document – Not for Distribution

11. Proposed Operational Plan Drafting Schedule July 13 Board Meeting • Review Operational Plan structure • Approve, reject or modify Workgroup recommendations July 14 – August 2 • Draft Operational Plan components by Domain including decisions endorsed through July 13 Board meeting. • Meaningful Use final rules expected in mid-July. Educational webinar for Board and all workgroups on final regs. August 2 – August 6 • Core project team and co-chair review of working draft • August 6 Workgroup final meetings prior to Operational Plan August 9 – August 12 • Updates and revisions to Operational Plan draft to include August 6 August 17 • Board meeting to review July and August recommendations and preliminary Operational Plan draft August 19– August 25 • Board and public review of revised Operational Plan draft (revisions based on direction in August 17 board meeting) August 27 • SUGGESTED BOARD CALL ON AUGUST 27 (MORNING) August 27 – August 30 • Prepare final draft for submission to ONC by August 31 Discussion Document – Not for Distribution

12. NC HIE Management Transition

13. Vision for Statewide HIE in North Carolina

14. North Carolina Vision Statement From Oct. 2009 Strategic Plan Discussion Document – Not for Distribution

15. NC HIE Board – Key Objectives for Statewide HIE Key Areas of Focus Identified for NC HIE: • Outcomes & Care Coordination • Cost Reduction • Real Time Access • Individual and Population • Privacy and Security Discussion Document – Not for Distribution

16. Suggested New Vision Statement The NC HIE, a public/private collaboration, will create a secure, sustainable technology infrastructure to support the real time exchange of health information to improve medical decision-making and the coordination of care to improve health outcomes and control health care costs for all residents of North Carolina. Discussion Document – Not for Distribution

17. Defining Value for Statewide HIE: Core & Value-Add Services

18. Statewide Health Information Exchange “What” and “How” Step 1: Define the Clinical Functions - What do we want to achieve? - What activities have be proven to improve outcomes/control costs? Step 2: Determine the Enabling Services - What “value-added” services will help achieve the clinical functions? - What are the “core” services needed to facilitate value-added services? Discussion Document – Not for Distribution

19. Statewide Health Information Exchange Defining Key Clinical Functions Discussion Document – Not for Distribution

20. Statewide Health Information Exchange Clinical Functions and Data Movement National Labs eRx Networks Local Labs Public Health Agencies Gov’t Agencies Payers Care Setting Patients and Caregivers 1. Incorporate essential data 2. Facilitate effective coordination 3. Automate Reporting, Registry Access Med Info Referrals Public health reporting Engage Patients Quality reporting Lab result Discussion Document – Not for Distribution

21. Statewide Health Information Exchange Clinical Functions & Value-Added Services Discussion Document – Not for Distribution

22. Service Access Layer: Transport, Orchestration, Audit, Reporting Statewide Health Information Exchange Accessing Value-Added Services thru Core Services Participating Organizations: With gateways to access Core Infrastructure ClinicNetwork HIO Hospital-Provider Fed Agency Core Services: Security Services Master Patient Index Master Facilities Index Master Clinician Index NHIN Gateway Candidate Value-Added Services: Immunization Registry Patient Access Decision Support Routing of Labs for Required Reporting Quality Reporting Lab Translation Medication Management Eligibility Checking eRx Discussion Document – Not for Distribution

23. Statewide Health Information Exchange Referral to Specialist - (Example of “Push”) 6. Specialist receives referral request and sends response to referring physician through the NC HIE Network 7. Specialist sees patient Hospital Clinic Labs Hospital System 4. Referring provider sends referral and reference clinical documents to the specialist system 5. NC HIE Network documents access to Network in audit log NC HIE Master Facilities Index Master Clinician Index Security Services Translation Transformation 3. Provider’s EHR system looks up specialist practices in NC HIE’s provider directory RHIO 2. Provider uses EHR to initiate referral message and search for specialists 1. Patient visits primary care provider; provider needs to refer patient to a specialist Lab FQHC RHC Discussion Document – Not for Distribution

24. Statewide Health Information Exchange Retrieval of Patient Information - (Example of “Pull”) Lab FQHC RHC Hospital Clinic Labs RHIO Hospital System 4. Statewide HIO uses its record locator service (RLS) to locate and retrieve information on identified patient from connected Qualified Organizations 5. NC HIE documents access to Network in audit log NC HIE Master Patient Index Security Services Translation Transformation 3. Provider’s EHR system looks up patient using the NC HIE’s master patient index (MPI), validates patient consent Hospital RHIO 1. New patient visits primary care provider; provider wants to learn about patient’s medical history 2. Provider uses EHR to initiate search for patient health information Lab FQHC RHC 6. Aggregated patient health information is returned to provider and information is incorporated into the provider’s EHR - Patient information Discussion Document – Not for Distribution

25. Statewide Health Information Exchange Value-Added Services and Prioritizing Implementation (Relative Attractiveness of Value-Added Service as a Statewide Service) HIGH MEDIUM LOW Discussion Document – Not for Distribution

26. Workgroup Updates

27. Clinical / Technical Operations WorkgroupCo-Chairs:Allen Dobson, NC Health Quality AllianceJ.P. Kichak, UNC Hospital

28. Statewide HIE Approach 3. Hosted, Shared HIE Services 1. Specification of Standards 2. Statewide Technical Architecture 4. Single Statewide HIE Facilitate Operate Discussion Document – Not for Distribution

29. Technical Architecture vs. Hosted Shared HIE Services 2. Statewide Technical Architecture 3. Hosted, Shared HIE Services Context of an Existing System • Statewide process defines architectural requirements and implementation guidelines • Describes how an entity will perform a function; doesn’t create the function • Existing implementations connect to a specific shared service which provides an implementation endpoint to organizations that do not have their own implementation and connects to existing deployments • Defines who participates and deploys an operational service Key Distinction Example Locate a patient record • A statewide service orchestrates across existing indexes and provides a consolidated response • Systems may connect directly to a hosted service for identity resolution or link their own index to the statewide system • Existing MPIs allow for patient discovery and respond with patient identifiers • Each index must connect to each other and applications are left to resolve multiple identity responses Discussion Document – Not for Distribution

30. Recommendations Related to Technical Approach Discussion Document – Not for Distribution

31. Recommendations Related to Development of a Core and Value-Add Service Structure Discussion Document – Not for Distribution

32. Recommended Principles for Statewide HIE - Clinical Discussion Document – Not for Distribution

33. Recommended Principles for Statewide HIE - Clinical Discussion Document – Not for Distribution

34. Recommended Principles for Statewide HIE - Clinical Discussion Document – Not for Distribution

35. Recommended Principles for Statewide HIE - Technical Discussion Document – Not for Distribution

36. Recommended Principles for Statewide HIE - Technical Discussion Document – Not for Distribution

37. Governance WorkgroupCo-Chairs:Ben Money, NC Community Health Assoc.Tom Bacon, UNC School of Medicine

38. Recommendations Related to Bylaws Discussion Document – Not for Distribution

39. Recommendations Related to Consumer Engagement Discussion Document – Not for Distribution

40. Strategic Approaches for North Carolina Statewide HIE Structure Regional HIEs given Exclusive Territories – Statewide HIE Provides Governance, Outreach Statewide Network Comprised of Diverse Qualified Organizations Market Determines Structure – Statewide HIE Backfills Statewide HIE is the Market • Abandon core services focus, leaving the private market to address interoperability • Provide backfills where market fails to assure ‘No provider left behind’ • Focus on education, convening, and statewide policy guidance • Clinical/Technical Operations Workgroup advised against this option • Range of “qualified organizations” pursuing regional or localized exchange are core structure • Statewide HIE provides statewide policy guidance, core services to enable interoperability • Statewide HIE may provide value-added services that benefit a range of participants to support sustainability. • Divide North Carolina into markets/territories assigned to existing HIEs, new HIEs or the Statewide HIE • Statewide HIE provides governance, manages monopolies for public good • Statewide HIE works with regional HIEs to develop service matrix to avoid duplication and to support joint sustainability. • Statewide HIE is primary vehicle for HIE • Statewide HIE builds infrastructure, consolidates HIEs for economies of scale • NC HIEs focus on local governance, adoption • Clinical/Technical Operations Workgroup advised against this option Discussion Document – Not for Distribution

41. Considerations for Qualified Organization and Territory-Based HIE Models Territory-Based / Regional HIEs Qualified Organizations • Allows for greater level of control – limited number of “on ramps.” • Potential cost savings due to fewer “on ramps.” • Could present higher level of risk – failure of one regional entity will impact many providers. • Requires significant stakeholder education and outreach. • Requires developing geographic boundaries and potentially close collaboration among competitors. • Responsibilities for service offerings more readily defined (some owned by Statewide HIE, others by RHIOs). • Allows for a greater level of flexibility – wider range of entities can participate / serve as “on-ramps.” • Complexity could present need for greater level of administrative and technical support. • Policies and procedures would need to be adopted by and monitored across a larger and more diverse participant body. • Potential for more variation in core and value-added service needs. Discussion Document – Not for Distribution

42. Statewide Network Comprised of Diverse Qualified Organizations and Participants NHIN Gateway Interstate Connectivity Hospitals Physician Groups Clinics Clinic Clinic Labs Hospital System Public Health Lab Enterprise Private Network Payers Long Term Care EHR Light One Example: Statewide Health Information Exchange Network FQHC Providers Hospital RHC Labs RHIO Medicaid RHIO Clinical Lab Lab MMIS Eligibility Paid Claims Hospital RHC Hospital RHC FQHC Discussion Document – Not for Distribution

43. Complex HIE Landscape in North Carolina • Multiple efforts and investments made across state in electronic exchange of health information. • NC HIE Workgroup members have expressed a commitment to leveraging existing efforts to the extent possible. • Many entities that could serve as data aggregators, for example: • Regional HIEs (WNCHN Datalink, CCHIE, Sandhills, Southern Piedmont) • Statewide Exchange Services (Public Health Surveillance, NCHEX) • Academic Medical Centers with Faculty Practices • Large, Complex Health Systems • Community Care of North Carolina (CCNC) • Others Discussion Document – Not for Distribution

44. What is a Qualified Organization? A Qualified Organization is a health care organization or aggregator of organizations that is capable of fulfilling the technical, legal, policy, and procedural obligations defined by the Statewide HIE, and willing to enter a binding contract with the Statewide HIE that specifies these requirements and the legal consequences entailed therein. Qualified Organizations may be, but are not limited to: Provider Networks Hospitals Health systems Integrated delivery networks (IDNs) Provider groups Consortia of providers FQHCs/RHCs Public Health Regional HIOs • Private Networks • Clearinghouses • Pharmacy • Vendor • Lab enterprise • Medicaid Network • Payors Discussion Document – Not for Distribution

45. Recommendations Related to Governing Participation in the Statewide HIE Discussion Document – Not for Distribution

46. Recommendations Related to Governing Participation in the Statewide HIE Discussion Document – Not for Distribution

47. Legal/Policy WorkgroupCo-Chairs: Linda Attarian, NC DHHSJill Moore, UNC School of Government

48. Legal Framework for Consent • Federal and state laws regulating the disclosure of patient health information provide a framework for the development of a consent policy for statewide HIE in North Carolina. Discussion Document – Not for Distribution

49. Recommendation on Next Steps Discussion Document – Not for Distribution

50. Recommended Breach Principles for Statewide HIE Discussion Document – Not for Distribution 50