Developing a Technical Infrastructure Plan

This module presents a myriad of considerations and options for states, HIOs, and organizations participating in HIE. Although there are emerging models or more so, commonalities, among HIEs, each HIE is unique. Each organization will have different priorities and stakeholders that will drive decisions for the technology approach, HIE architecture, data architecture, interoperability, and applications.

In making decisions, HIEs should seek to understand the rationale and decision-making processes from similar efforts. This information should be used as a guide and educational resource, not a recipe for HIE implementation. A key factor in developing a technical infrastructure plan, is understanding the functional requirements and the privacy and security requirements of the HIE. Often the input of those people who represent these interests is left out of the design of the technical infrastructure. A planning process needs to be developed that incorporates these interests and is reflected in the technical infrastructure plan. A common mistake is that an HIE planning committee consists primarily of technical resources, IT directors, and CIOs of stakeholders of the HIE. Another common mistake is that HIEs have multiple planning committees involving multi-stakeholder representation in governance and development of strategic and operational plans, but then “hand off” the technical infrastructure planning, leaving it to technical stakeholders. HIE is a tool to support business, operational, and clinical effectiveness – these stakeholders have important input and insight that should drive technical infrastructure for HIE.

This section presents key questions related to each section of this module that an HIE should answer during the development of a Technical Infrastructure Plan:

Elements to Consider
State Role in HIE	Which State model or models apply to my State? Which States are implementing or considering these models? In reviewing initial information about these States, which States should we contact to learn more?
State Information Models	What model is in place or emerging in my State? What services are or should be a priority? What are the technology architecture implications based upon my State’s information model?
Standards	How can HIE efforts support required (and planned) standards for Meaningful Use? What standards needs to be prioritized for the HIE to support stakeholder business, clinical, operational, and technical goals? What options will be available for organizations with standards gaps or a longer roadmap for standards adoption?
Data Storage Architecture	Are there any precedents among stakeholders that will drive data storage architecture? What are the priorities, privacy considerations of data senders? What options are offered by infrastructure vendors in place or being considered?
Supporting HIE Services Developed and Ready for Implementation
Hospitals and Health Systems	Has a catalog of EHR and HIE efforts led by hospitals and health systems been conducted? What are the infrastructure or connectivity challenges that can be supported by enterprise, regional, or state-level HIE? Does the planned technical infrastructure support or compete with existing efforts? Has the value proposition to these stakeholders been defined and how can the HIE meet these needs?
Regional Extension Centers (RECs)	What EHRs are being supported or implemented by the RECs? Are the RECs encouraging or educating providers in including HIE interfaces in their vendor quotes or budget? Are vendors charging multiple providers for the same HIE interfaces? How can HIEs educate RECs in streamlining costs for providers? What solutions are RECs supporting (or advising) for providers who are not ready to adopt EHRs? How can the HIE and the REC collaborate to better support providers in meeting MU requirements?
Supporting Providers without Electronic Health Records	Does the selected/planned HIE vendor(s) offer an EHR or “EHR-lite” portal? Is it a function of the HIE to support clinical messaging or results delivery? What are the needs of these providers and do they plan to implement an EHR? What are the barriers to EHR adoption and how can HIE stakeholders support these providers?
Laboratory Results Delivery	Are regional/national labs supporting providers in the cost and implementation of EHR-lab interfaces? What is the role of the HIE in managing or subsidizing EHR integration with labs, other data exchange? What is the timeline for hospitals labs and local labs to support standards? How can or might the HIE support this effort? Can the state or HIE require use of standards for labs licensed in the state?
Electronic Prescribing	Does the selected/planned HIE vendor(s) offer an electronic prescribing solution? Is there value in seeking stand-alone e-Prescribing solutions for providers who are not ready to adopt EHRs? What is the ability of pharmacies in the State/region to accept electronic prescriptions? What is the role of the HIE in supporting e-Prescribing
Patient Care Summaries	What information is contained in electronic summary records available through EHRs and HIEs in the state/region/enterprise? What standards are being used? Should the HIE set a bar for “minimum data set” for a summary record? Have clinical and technical stakeholders been convened? Is there consensus on what the summary record should contain and what’s standardized? Are data transformation/translation/mapping services offered by the HIE? Is there variation in summary record exchange with providers vs. patients?
Infrastructure to Integrate with Regional HIEs (Shared Services)
Master Patient (or Person) Index	What level of MPI infrastructure is needed to support information exchange between organizations or HIEs? Is a state-level MPI needed or beneficial to stakeholders? What level of matching and sophistication for MPI functionality is needed or desired by stakeholders? Is any HIE in the region or state currently providing this same level of capability that can be leveraged?
Record Locator Service	Are health records stored locally within organizations data centers? Is this information accessible? Is an RLS in place or needed to support cross-entity or cross-organization exchange?
Trust Broker	How are roles and patient authorization/consent managed in the HIE? What auditing functions are needed at the HIE-level? How is compliance with policies and procedures monitored and managed?
Provider Directories	What master provider/clinician indexes or directories are available for the region served by the exchange? What vendors and companies support this area or region? How reliable is this information? Is there an index of individual clinicians and an index of individual entities (organizations)?
Integrating with State Medicaid
	What are the current capabilities vs. planned capabilities for data exchange by the State Medicaid agency? What are the goals of Medicaid and how can the HIE achieve these goals? Are there goal conflicts between Medicaid and the HIE and how can they be resolved? Are State Medicaid representatives represented in HIE governance and technical infrastructure planning? For enterprise or regional HIE, what percentage of the population is served by Medicaid? How does this affect the level of coordination needed with Medicaid?
Integrating with Payers
	What payers serve the population covered by the HIE? Are they involved in HIE planning and governance? What are the payer priorities for provider electronic adoption? What information or outcomes will generate payer support in the HIE (e.g. funding)? What information is sought by payers or can be contributed by payers to the exchange? What are the technical infrastructure implications of these information needs? What are the patient privacy and consent issues that may need to be addressed with regard to health plans having access to and/or contributing data to the HIE?
Using Nationwide Health Information Network Standards
Using CONNECT	Are existing organizations or entities within the state or region implementing CONNECT gateways? What is the plan for this? Do you have entities in the state or region such as VA Hospitals and Military bases that can benefit from CONNECT gateways? What are the plans for the HIE vendors in consideration in supporting CONNECT? How does the availability or readiness to implement exchange via CONNECT affect other infrastructure priorities?
Point-to-Point Exchange via the Direct Project	What is the appropriate application of Direct? What is the current HIE functionality in the state and to what extent does is include secure messaging? Are the EHR vendors supported by the area’s REC supporting exchange via Direct? Are there organizations such as small practices that are paper-based or have non-accredited EMRs, that can benefit from Direct? Are there HISPs available for your region? Can your organization serve as a HISP? Have hospitals been involved in discussions surrounding use of Direct protocols for exchange? What is their readiness to support Direct vs. other more advanced specifications for exchange?
Patient Access to HIE Data
	What is the patient interest in the community for having access to their PHI? What is the priority of stakeholders to provide patient access to HIE information? Do the vendors in consideration support patient access via a portal or mechanism for CCD/CCR exchange or access via “Blue Button”? Do stakeholders want patients to manage consent and authorization via a portal? Is this supported by vendors in consideration? Is there benefit to the community in providing a more robust PHR by the HIE, not just a portal or CDDCCR exchange or access via “Blue Button”?

818 Connecticut Avenue, N.W., Suite 500
Washington, D.C. 20006
Tel: 202-624-3270 | Fax: 202-429-5553