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KansasHealthInformationExchange,Inc.
2012AnnualReport
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KHIEVision
ImprovingthehealthofKansansthroughtrustedexchangeofhealthinformation
KHIEMission
Orchestratingtheexchangeofhealthinformationtotransformhealthcare
2012‐2013FocusAreas1) IntegrationwithStateandLocalAgencies/PopulationHealth2) Recognizedqualityoutcomemeasures3) Interoperability4) Infrastructure5) GovernanceandOversight6) ConsumerEducationandEngagement7) Sustainability8) ParticipationandEngagement
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Table of Contents
Executive Summary ....................................................................................................................................... 4
1. Background ........................................................................................................................................... 4
2. Authority ............................................................................................................................................... 5
3. Accomplishments .................................................................................................................................. 5
a. Organizational Activities ............................................................................................................... 5
b. Legislative and Policy Initiatives .................................................................................................... 6
c. Operational activities .................................................................................................................... 6
d. KHIE Financial Status ..................................................................................................................... 8
4. Issues..................................................................................................................................................... 9
a. Confusion with the Health “Insurance” Exchange ........................................................................ 9
b. Role of KHIE ................................................................................................................................... 9
c. Governance ................................................................................................................................. 10
d. Board Composition ..................................................................................................................... 10
e. Conflict of Interest ...................................................................................................................... 10
f. Patient participation in Health Information Exchange (“Opt‐in”/”Opt‐out”) ............................. 10
g. “Break‐the‐glass” ........................................................................................................................ 11
h. Interstate Reciprocity .................................................................................................................. 11
i. Secondary Data Use .................................................................................................................... 11
j. Participation by Ancillary Health Care Providers ........................................................................ 12
k. Status of Federal ARRA ONC Grant Funds .................................................................................. 12
l. Electronic Prescribing .................................................................................................................. 12
5. Summary ............................................................................................................................................. 13
a. Conclusions ................................................................................................................................. 13
b. Recommendations ...................................................................................................................... 14
6. Board of Directors ............................................................................................................................... 14
7. Audit Letter ......................................................................................................................................... 15
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ExecutiveSummaryTheKansasHealthInformationExchangeInc.(KHIE)wasformedinlate2010byExecutiveOrder 10‐06, issued by then Governor Mark Parkinson. KHIE has been instrumental inleadingHealthInformationExchange(HIE)developmentsinthestatesincethattime.KHIEprovidesthisreportonthestatusofHIEdevelopmentsinKansastotheGovernorandtheLegislatureasrequiredunderEO10‐06.
1. BackgroundHIE goals were established by the Bush Administration in 2004 including thecreation of an Electronic Medical Record (EMR) for every American by the year2014andthecreationofanationalHealthInformationExchangeinfrastructurethatwould facilitate the exchange of EMRs among medical providers involved in thediagnosisandtreatmentofpatients.
Wide‐ranginginterestintheuseofHealthInformationTechnology(HIT)andHIEastoolswhichcanhelpKansasachievebettermedicaloutcomesandreducetherateofincreaseofhealthcareservicecostshasexistedsinceGovernorSebeliusformedtheHealth Care Cost Containment Commission (H4C) in 2004 under Executive Order04‐14. The H4C, the HIT/HIE Policy Initiative, the Kansas Health InformationExchange Commission and the e‐Health Advisory Commission (eHAC) thatsucceeded H4C all recognized the necessity for widespread public/privatecollaboration inpolicymakinganddirectionsetting forHITandHIEtosucceed inKansas. Thus, eHAC stakeholders recommended, and the Kansas Department ofHealthandEnvironment(KDHE)endorsed,thecreationofanindependentnot‐for‐profit corporation to guide the creation and development of Electronic HealthInformationExchangeinKansas.
Similarities in terminology have created confusion regarding Kansas Health“Information”ExchangeinitiativeandtheHealth“Insurance”Exchange.WhilebotharesupportedbyFederalgrantfunding,KHIEisnotacomponentoftheAffordableCareActandthetwoconceptsareunrelated.
Kansas is well‐positioned to participate in HIE. The Kansas Regional ExtensionCenter (REC) reports that asof July2012,1,462physiciansand95hospitalshaveagreedtoinstallElectronicMedicalRecord(EMR)systemsasaresultofthefederalincentive programs falling under the American Reconstruction and Recovery Act(ARRA).Fourhundredsixtythree(463)professionalprovidersandthirtyone(31)hospitals are known to be active participants in the stateMedicaid Program, andhave received incentive funds under ARRA to assist with the installation of EMRsoftware. HIE services will allow these EMR systems to be connected, therebyallowing medical providers to improve their ability to diagnose, treat and
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coordinate care for those patients who seek care across a continuum of medicalserviceproviders.
2. AuthorityKHIEwas formed as a result of Executive Order 10‐06 issued by GovernorMarkParkinson.KHIEisapublic/privatecollaborative,andtakesthecorporateformofanot‐for‐profit501c(3)Corporation.KHIEwasformedinlate2010forthepurposeofassuring statewide HIE in Kansas. Executive Order 10‐06 and the Kansas HealthInformation Technology Exchange Act (KSA 65‐6821 through 65‐6834, “KHITE”),delegatedcertainresponsibilitiesandconferredthefollowingpowerstoKHIE:
ExecutiveOrder10‐06 KHITE(KSA65‐6821et.Seq)Acceptgrants,gifts,money
Establishaccountingprocedures
Paycostsofoperationofcommittees
Enterintocontracts
Employstaff
PromulgatestandardsforHIE’s EstablishstandardsforapprovalandoperationofHIEs
AssurethatstatewideHIEiscreated/maintained
Exerciseotherpowersasnecessary EstablishHIEparticipationagreementrequirements
FacilitateimplementationofStatePlan Participationinoutreachactivities
ApproveHIEs EstablishHIOreview/approvalprocess
Provideaccesstoaggregated/de‐identifieddata
AsspecifiedbyEO10‐06,KHIEhasa17memberBoardofDirectors,appointedbytheGovernor, representing state and local agencies andmajor stakeholders in thedeliveryandfinancingofhealthcareservicesinKansas.Intheshorttimesinceithasbeeninexistence,KHIEhasfulfilledthemajorgoalssetforitbytheExecutiveOrder10‐06andKHITE.Specificaccomplishmentsaredetailedinthefollowingsection.
3. Accomplishments
a. OrganizationalActivitiesTheBoardappointedby theGovernorheld its first organizationalmeeting onOctober 18, 2010 and selected temporary officers. Pursuant to EO 10‐06,Articlesof Incorporationwere filedby theSecretaryofKDHEonNovember5,2010. InitialBylawswere approvedby theBoardonDecember17, 2010, andBoardofficersandstandingcommitteeswereselected. AmendedandRestatedArticles of Incorporation were filed by the Secretary of State on January 5,2011.TheCorporateGovernance,RiskManagement, andComplianceProgramwas adopted by the Board on September 20, 2011. Revised Bylaws wereapprovedbytheBoardonNovember9,2011.AnExecutiveDirectorwashired
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onOctober 12, 2011, and a Program Manager and Executive Assistant werehiredinJanuaryandFebruary,2012respectively.
b. LegislativeandPolicyInitiativesTheKHIEBoard,committeemembersandstakeholderslobbiedtogetthedraftKansas Health Information Technology Exchange Act introduced to, andacceptedbythe2011KansasLegislature.TheKHITEactharmonizedKansaslawwith Federal law pertaining to the electronic exchange of patient healthinformation and superseded numerous anachronistic Kansas laws, many ofwhich conflicted with each other. KHITE legislation established that healthinformationrelatedtopatientswhoreceivedservicesfromhealthcareproviderswhoparticipateinanapprovedHealthInformationOrganization(HIO)wouldbeincluded in the exchange unless a patient took action to “opt‐out” of theexchange.
Pursuant to EO 10‐06 and KHITE, the KHIE Board of Directors developedpolicies related to the review, approval and oversight of the HIOs. A total ofeleven(11)policieswerecreatedforthispurposeandarereadilyaccessibleontheKHIEwebsiteathttp://www.khie.org.
c. OperationalactivitiesUnderKHIEpolicies,KHIEisrequiredtoaccept,vetandconveypatientopt‐outdecisions to approved HIOs that operate HIEs in Kansas. KHIE is furtherrequiredunderEO10‐06andKHITEtodevelopaprocessforacceptingconcernsand complaints. KHIE has developed computerized data bases that implementthese requirements. Because these data bases contain personal identifyinginformation (PII) and because a concern could contain personal healthinformation(PHI),KHIEstaffdevelopedandimplementedanadditionaltwelve(12) policies to safeguard this data pursuant to federal HIPAA privacy andsecuritylaws.
UnderKHIEpolicies,specificproceduresweresetforthdocumentingtheprocessthatmustbefollowedforthesubmissionofapplicationstobecomeanapprovedHIO in Kansas. Two such applications have been received, reviewed andapprovedonatemporarybasisbyKHIE.Temporarycertificatesofauthoritytoprovide HIE services have been awarded to the Kansas Health InformationNetwork (KHIN) and the Lewis and Clark Information Exchange (LACIE). It isespecially gratifying that these organizations are local, with KHIN beingsponsoredby theKansasMedical Society and theKansasHospitalAssociation,andLACIEbeingsponsoredbyHeartlandHealth,aSt.JosephMissouriintegratedhealth services delivery organization. Since becoming operational in the 3rdquarterof2012,approvedHIOshaveenrolledover2,400medicalprovidersand55 hospitals in HIO services. Initial enrollment and implementation efforts
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focused on the center and southeast portions of the state as indicated by thefollowingmap.Over100,000patientrecordshavebeenregisteredintheKHINdatabaseintheWichitaareaalone.Inlate2012effortsareexpectedtoshifttothewesternKansasandtheKansasCitymetropolitanareas.
BothHIOshavesubmittedfinancialplansthatshowthattheyareself‐sustaining,primarily through membership fees with some funding occurring throughphilanthropicgrants.Inlate2012andinto2013bothHIOsareexpectedtoapplyfor and receive federal ONC HIE grant funding which will augment theirrecurringrevenuesandstrengthentheirabilitytoachieveandmaintainfinancialsustainability.
KHIEhas also assistedKDHEwith its administrationof amulti‐year StateHIEgrantprovidedbytheOfficeoftheNationalCoordinator(ONC)oftheHealthandHumanServices(HHS)Administration.InFebruaryof2010,ONCawardedKHDEa grant of $9,010,066 to assist in the establishment of HIE services andregulatory functions related thereto.Specificactivities involvingKHIEstaff areassistingintheupdatingoftheKansasStrategicandOperationalPlan;reviewofthe HIE Grant Request for Proposal (RFP); assisting in the preparation ofprogressreportsrequiredbytheONC;attendingmeetingswithONCstaff,etc.
KHIE staff have also been responsible for developing and conducting publicoutreachactivitiesaimedatinformingthepublicandtheprovidercommunityofthe availability ofHIE services, and in somecases, how toparticipate in thoseservices.
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d. KHIEFinancialStatusThe financial status as of June30, 2012 canbe found in theBerberichTrahanFinancialStatementsReport(seeAppendixA).
Additionally,KHIEstaffhaspreparedthefollowingbudgetforCY2013operations:
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4. IssuesIt isreasonable toexpect theemergenceofsignificant issues inanyendeavorascomplex as the creation of statewide HIE capability; particularly when no suchservices or relevant policies existed previously. That has certainly been KHIE’sexperienceas issues suchasduplicationof technical services, lackof services inrural areas, conflicting interstate reciprocity policies, immaturity of technology,evolving rolesand responsibilitieshave surfaced, toname just a few.Key issuesconfrontingKHIEareasfollows:
a. ConfusionwiththeHealth“Insurance”ExchangeDue to similar terminology and the fact that both are supported by Federalgrant funding, somehaveconfused theKansasHealth “Information”Exchangeinitiative with the Health “Insurance” Exchange component of the AffordableCare Act. The similarities in the terminology is indeed unfortunate andconfusing,however,thetwoconceptsaretotallyunrelated.
Health Information Exchange goals were established by the BushAdministrationin2004.Thesegoalsincludethecreationofanelectronichealthrecord (EHR) for every American by the year 2014, and the creation of anational Health Information Exchange infrastructure thatwould facilitate theexchangeofelectronichealthrecordsamongmedicalprovidersinvolvedinthediagnosisandtreatmentofpatients.Theabilityofamedicalprovidertocreateanelectronichealthrecordforapatientandtoexchangethatrecordwithotherproviders involved in the treatmentof that samepatient are two criticalpre‐requisites to a provider’s achieving the status of “meaningful use” of healthinformation technology.Theachievementofameaningfuluse status iskey totheattainmentofimprovedqualityandtreatmentoutcomesforallKansans.
b. RoleofKHIEInitiallythoseinvolvedwiththeformativestagesofKHIEexpectedthatKHIEwouldassumetheroleofregulatorandasupplierofsharedstatewidetechnicalservices.LateritbecameapparentthatmostofthesharedtechnicalservicesneededforstatewideHIEwerereadilyavailablefromlocalserviceproviders,therebyobviatingtheneedforKHIEtoprovidetheseservices.TheBoardofDirectors,therefore,decidedtoscalebackKHIE’sroletothatofaregulator,whichultimatelyraisedconcernswhetherKHIE’soperationalcostscouldbesustainedasanindependentregulatoryagency.Facedwithcostpressures,theKHIEBoardofDirectorsvotedonSeptember12,2012tosupportarecommendationtotransitionregulatoryandoperationalresponsibilitiestoKDHE.
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c. GovernanceThe eventual transfer of regulatory and operational responsibilities to KDHEwill maintain the diverse public‐private composition of the Board but willtransition the authority of theBoard to that of an advisory versus a decisionmakingrole.
d. BoardCompositionSinceitsinceptiontheKHIEBoardhasbeenextremelyactive,holdingmonthlyBoardmeetingswithmorefrequentcommitteemeetings.ThishasplacedtimepressuresuponBoardmembersandasaresultsix(6)oftheoriginalseventeen(17)Boardmembershaveresigned.RequeststotheGovernortoreplacethoseBoardmembershavegoneunanswered.
e. ConflictofInterestOneof theKHIEBoardmembers isalso theChairmanofoneof theapprovedHIOs.WhilethisindividualhasrecusedhimselffromvotingondecisionswhichmightaffecthisHIO,somestakeholdersperceivethis individual’spresenceontheBoardasapotentialconflict‐of‐interest.
f. PatientparticipationinHealthInformationExchange(“Opt‐in”/”Opt‐out”)KHITElegislationiswidelyregardedasforwardthinkingandapre‐requisitetothe creation andoperationof a robust statewideHIE capability. Early on, thelegislaturerecognizedthatthedecisiontorequirepatientstoeitherconsciously“opt‐out”or“opt‐in”inordertohavetheirhealthrecordsincludedinaHIEwasa critical element that would significantly influence the adoption rate andacceptanceofHIEinKansas.TheKansaslegislaturecraftedKHITElanguagetoinclude health records within approved HIEs for those patients who arediagnosedand/ortreatedbyhealthcareproviderswhoparticipateinapprovedHIEs unless those patients consciously “opt‐out”. Therefore, Kansas isconsideredan“opt‐out”state.Thisconceptappearstobewell‐receivedbythepublic owing to the fact that to‐date only two hundred eleven (211) patientshavechosentoopt‐outofHIEservices.
However, thereare two issueswith thecurrent “opt‐out”provision inKHITE:First,aswritten,KHITElanguageindicatesthathealthrecordsforapatientwhohasoptedoutwillnotbeincludedinanHIE.However,currenttechnologydoesnotallowforthis,sothelanguageinKHITEneedstobechangedtoindicatethatanexchangewillnotallowathirdpartytoaccessapatient’srecordswithintheexchangeifhe/shehasoptedoutofHIE.Second,KHIEhasreceivedahandfuloflettersfrompatientswhoobjecttotheobligationplaceduponthembyKHITEto “opt‐out” if they do not want to have their records included in a healthinformation exchange. These patients believe the appropriate public policy
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would be that patients records would be excluded from an HIE unless thepatienttakesactiontoexplicitly“opt‐in”.
g. “Break‐the‐glass”KHITE legislation allows providers to “break‐the‐glass” to access a patient’shealthrecordswhenthereissuspicionofabuseortheexistenceofareportablemedical condition (e.g. aids, TB, etc.). However, KHITE does not permit aprovidertobreak‐the‐glassifapatientisnon‐responsiveandthereislegitimateconcernthatapatienthasalifethreateningcondition.Considerationshouldbegiven to extending break‐the‐glass situations allowed under KHITE to covernon‐responsivepatients.
h. InterstateReciprocityThere are a considerable number of patients who receive care across stateborders.Intheabsenceofastandardizednationwideapproach,statesarelefttopromulgate their own laws and policies related to HIE. It is common to seeconflicting laws and policies adopted in adjacent stateswhich complicate thefree exchangeof patienthealth records. Inmany casespatient health recordsare stored in a single computer system that supports provider facilitiesoperating on both sides of a state line. A patient who receives care in aprovider’sfacilityinonestatemaynothavetotakeactiontohavetheirrecordsincludedinanexchange(Kansas)butmayhavetoexplicitlyopt‐intohavetheirrecords included in another exchange (Missouri). This creates an untenablesituationforprovidersandpatientswhohavetocomplywithconflictingstatelawsandpolicies.
Likewise, thereareconflictingapproachesamongvariousHIEs inotherstatesregardingwhether fees should be charged for the exchange of patient healthrecords between exchanges located within those states and across stateborders.
The KHIE Policy Committee has adopted principles stating that Kansas HIEsshould not have to pay to send or receive patient records between approvedKansas HIOs or between Kansas HIOs and exchanges that operate in otherstates.
i. SecondaryDataUseThere is keen interest among stakeholders in the extent to which HIEs canprovidemeaningful information thatwould improve public health. Currently,technologyavailablefromapprovedHIOslimittheretrievalofhealthrecordstorecordsbelongingtoanindividualpatient.Thusitiscurrentlynotpossibleforeither of the approved HIOs to aggregate data across patients who sharecommon clinical and/or demographic circumstances. Both of the approved
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HIOsacknowledgethatthecapabilityofprovidingaggregateddataisvitaltothegoal of improving public health and are engaged in conversations with theirtechnologyvendorsaimedatfulfillingtheseneeds.
However,therearenumerouspolicychallengesthataccompanythesubjectofsecondary data use: For example, does current Kansas state law require thatuniversities be given access to patient record for research purposes? Shouldthat access be free or come at a price? Should patients be required to giveconsenttotheuseoftheirdataforresearchpurposesasaby‐productoftheirrecords being included in as HIE? Should commercial organizations beprohibited fromaccessing this information,orshould theyberequired topayfor the data if they are permitted to access it? Who owns aggregatedinformationthatisderivedfrompatientdata?Allofthesequestions,andothers,haveyettobeaddressed.
j. ParticipationbyAncillaryHealthCareProvidersInitialenrollmentofprovidersbythetwoapprovedKansasHIOshasfocusedondoctors (including osteopaths, nurse practitioners, etc.) and hospitals in bothrural and urban settings. These efforts are viewed as essential, and haveenabledtheHIOstoachievetheminimumscalenecessarytoensurecontinuityof services.However theHIE financialmodels are still somewhat speculative,and will be considerably strengthened once ancillary medical providers(pharmacies,long‐termcarefacilities,diagnosticimagingcenters,labs,etc.)areenrolled.
k. StatusofFederalARRAONCGrantFundsTheoriginalONCgrantfundsintheamountof$9,010,066havebeenspentasfollows:
Planning……………….……………………………..$471,182.12KHIE……………………………………………………$704,082.50Other……………………………….…………………$230,280.94RemainingONCFunds……….………………$7,604,520.44
l. ElectronicPrescribingDespite best efforts to promote electronic prescribing (“e‐Rx”, or “e‐prescribing”) inallareasof thestate,aplateauappearstohavebeenreached.Several pharmacies in underserved areas of the state have the ability toparticipateinelectronicprescribingbutto‐datehaveresistedmarketpressuresto do so. Thus, according to Surescripts data supplied by the FederalGovernment,Kansasonly88%ofpharmaciesacceptelectronicprescriptions.E‐prescribingsystemshavetheabilitytoensurethatmedicationsprescribedforthepatientarecompatiblewiththepatient’sallergies,othermedicalconditions
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andothermedications that thepatientmightbereceiving.Thus, theability toaccept electronic prescriptions is a key tool in the quest to reduce avoidableadverse drug events related expenses which arise as a result of medication“errors”. It is possible that policymakersmay need to considermeasures toincent or require pharmacies that do not accept electronic prescriptions toparticipateintheseprograms.
5. Summary
a. Conclusionsi. HIE has gotten off to a good start in Kansas. Over 2,400 medicalprofessionals and 55 hospitals are currently enrolled and beginning toexchangepatientinformationthroughtwoHIOswhichhavebeenapprovedbyKHIEtoprovideHIEservicesinKansas.TheHIOsthatprovidetheseHIEservices are working cooperatively to develop interfaces which willfacilitatethefreeexchangeofinformationbetweenthem.
ii. Collaborativepublic‐privateHIEgovernancehasbeensuccessfulto‐date,but theconsensusof theKHIEBoardandstakeholders is thatgovernance,regulatory and operational functions should be transferred from KHIE toKDHE.
iii. KHIE policies are considered leading‐edge and should be maintained,improvedandeventuallyincorporatedwithinKDHErulesandregulations
iv. KHITElegislationisalsoviewedasleading‐edge,butneedstobeamendedtoprovidefor:
a. transfer of HIE governance responsibilities from KHIEtoKDHE
b. the continuation of public‐private input to HIEgovernance through the establishment of a permanentadvisorycommitteereportingtoKDHE
c. expansion of circumstances under which medicalproviderscan“break‐the‐glass”
d. therecognitionthathealthrecordsfor individualswho“opt‐out”ofanexchangemaybecontainedwithin thatexchange as long as the exchange does not allow 3rdpartiestoviewthoserecords.
v. The lack of nationwide laws, policies and standards around theexchange of information across state borders hinders the adoption ofHIEonthepartofprovidersthathavefacilitiesinmultiplestates.
vi. Thestate’sability tomonitorand improvepublichealthhasbeenenhanced by early HIE efforts. Automated immunization reportingthrough HIEs is already occurring. Further efforts are underway toautomate patient registration within selected disease registries (e.g.
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cancer, diabetes); to improve automated syndromic disease reporting;andtointegratethePrescriptionManagementProgram(PMP)withtheapprovedHIOs.
However, the immaturity of current HIE technologies to aggregateinformation across patientswith common clinical and/or demographiccharacteristics,theirlimitedabilitytogeneratesecondarydataresearch,and lack of relevant policieswill impede the ability of HIEs to furtherenhance the state’s efforts to improve population health outcomes forsometimetocome.
vii. FinancialsustainabilityisanissuetotheHIOs.Futureeffortstoenrollancillary care providers are expected to reduce risks of financialinsolvency.
b. Recommendationsi. KHIEresponsibilitiesshouldbetransferredtoKDHEforthepurposeofreducingadministrativecostsassociatedwithrunninganindependentregulatoryagency.
ii. TheGovernorshouldacttoreplacecurrentBoardvacancies.iii. Consider providing grant funds to technology providers that can
providemeaningfulsecondarydataquerycapabilities.iv. ConsiderprovidinggrantfundstoHIOsthatcanenrollancillaryhealth
careprovidersasparticipantsinHIEs.v. Considerpolicymeasuresthatwillincreasethenumberofpharmacies
whoparticipateine‐prescribing.
6. BoardofDirectors Dr.JoeDavison,M.D. WestWichitaFamilyPhysicians
Dr.MichaelAtwood,M.D. ChiefMedicalOfficer,BCBSofKansas
Dr.RobertMoser,M.D. Secretary,KDHE
Dr.JenBrull,M.D. PrairieStarFamilyPractice
HelenConnors,R.N.,P.H.D. Director,KUSchoolofInformatics
KarenBraman,RPh,M.S. ExpressScripts
JonalanSmith,PharmD GenoaHealthcare
KennethMishler,PharmD,RPh KansasFoundationforMedicalCare
CindyChrisman‐Smith,R.N. KingmanCountyHealthDepartment
JerrySlaughter,Exec.Director KansasMedicalSociety
JackieJohn,VicePresident GreatPlainsHealthAlliance ConsumerRepresentative Vacant ConsumerRepresentative Vacant MedicaidDirector Vacant HospitalRepresentative Vacant
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HospitalRepresentative Vacant EmployerRepresentative Vacant
7. AuditLetterSeeAppendixB
