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• Participation agreements – development of agreements to be signed by participants using the exchange that takes into consideration the various and at times con- fl icting interests of stakeholders within a community, region or state.

• Data use and reciprocal support agreements (DURSA) – similarly, development of agreements to be signed by data source providers (e.g. commercial reference laboratories, hospitals, health systems and diagnostic imaging centers).

Where to start

Creating an HIE generally starts with a planning exer- cise, followed by defi ning business, technical and functional requirements of the HIE and EHR capabilities. As in the business world, the planning phase is also essential to secure early funding to jumpstart the initiative and identify future funding sources to sustain operations.

Success of the HIE will largely depend on balancing the need to plan and execute all of the “soft” as well as the technical aspects of an HIE. The key is to be sure many of those softer items are addressed simultaneously with the selection of technology. Absent from that approach, the soft items will very likely bog down the deployment of the technology, features and functions – and certainly its adoption and the long-term viability of the HIE entity.

Synergies with EHRs For providers looking to integrate EHRs into HIEs, there are a few things to consider. Since the advent of the American Recovery and Reinvestment Act (ARRA) and the funding it appropriated via the Offi ce for the National Coordinator of Health Information Technology (ONC) to eligible providers for adoption of EHR applications, there was the need to agree upon a standard defi nition for EHRs and meaningful use. The ONC settled on an EHR defi ni- tion and selected several fi rms to confer ONC certifi cation to vendors’ EHR application suites.

In order for eligible providers to avail themselves of ONC funding derived from the ARRA program, they need to acquire a certifi ed EHR. ARRA funds are meant to defray a portion of the investment necessary to acquire and deploy an EHR solution suite. Providers also need to demonstrate meaningful use of the EHR they acquire. The criteria for meaningful use necessitates that the EHR is electronically interconnected with other healthcare enti- ties in order to share information among caregivers, order diagnostic services (such as laboratory tests and radiology exams) review the results of those diagnostic tests and exams, and order prescriptions.

This has led to the need to interconnect any number of provider organizations and other healthcare entities, such as reference labs and public health entities, via HIEs. These HIEs must be capable of integrating with both

ONC-certifi ed EHRs and other nonstandard healthcare applications.

Help through outsourcing

It often makes sense for an organization pursuing an HIE implementation to engage a strategic partner to support its planning effort and assist in identifying opportunities for HIE alignment with the interests of its community. A good partner provides support in selecting and managing HIE vendor selection. It can assist in establishing a governance model for the HIE and provide a baseline of best practices associated with other successful HIE initiatives. While partners help in these areas, it is prudent for an organization to work directly with a vendor on the creation of an operating model, adoption programs and development of an economic sustainability model. The best vendors are very experienced in the provision and deployment of an HIE, as well as the ongoing operation of information technologies that underlie and comprise an HIE and EHR program. The vendor selected should be experienced in the rigors of establishing policies, de- veloping participation agreements and DURSA, creating and supporting provider outreach and adoption (including meaningful use) programs. Successful vendors also have the collective knowledge of best practices in establishing various economic sustainability models.

Case in point: Kentucky The Commonwealth of Kentucky has been integrating various data source providers, such as large integrated delivery networks, into its HIE framework. The common- wealth’s Cabinet for Health and Family Services, which sponsors a statewide HIE across Kentucky, has outsourced to ACS, a Xerox company, the design, deployment and maintenance of the technical and application foundation of the statewide HIE and “EHR Lite” program. What sets Kentucky apart from many states across the nation undertaking such complex initiatives is the attention to detail in matters only indirectly related to information technology. Kentucky took steps very early in the planning and

execution of its statewide HIE to address many consider- ations, including: • Determining the governance and operating models of the HIE;

• How it would be sustained over time; and • Socialization and development of the many policies and procedures, including areas such opt-in/opt-out, the development of stakeholder and user agreements and alignment of state legislation to the strategic direction of the HIE.

These early steps have signifi cantly enhanced the pace with which the HIE is embraced and adopted by the com- monwealth’s stakeholders, participants and users. HMT


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