Commonwealth of Massachusetts Executive Office of Health and Human Services   

Health Information Technology Council  Meeting 
December 7, 2015 

1.Welcome  [5 minutes] – Alice Moore 
2.Direct Messaging [15 minutes] -  David Whitham   
a)Summary of November HIT Council meeting    
b)Discussion    
3.Phase 2 HIway Services [60 minutes] - Ipek Demirsoy  
a)Summary of November HIT Council meeting  
b)Discussion  
4.Conclusion  [5 minutes] – Alice Moore   

Appendix: 
–Consent Workgroup Recommendations 
–Near-term Initiatives 
–ENS Initiative 
–Fast Initiative 
–Operations Update    
–Background information 

2 
Agenda 

 
Direct Messaging 
David Whitham 
3 

4 
•Definition of Direct Messaging:   
–Direct Messaging Services are defined as Mass HIway technical services to enable private and secure transport of health information from one User to another.    
–The HIway does not open or store any of the information that gets transported via Direct Messaging. 

Direct Messaging:  Definition 

•At the November HIT Council meeting, the recommendations from the Consent Work Group were shared.  There was some understandable confusion between consent for Direct Messaging vs. consent for Phase 2 HIway services. 
•Direct Messaging is functionally equivalent to faxing or emailing but much more secure. 
–Yet, HIway Direct Messaging imposes consent requirements not required by HIPAA and not required by other competitive Direct Messaging services 
•HIway Consent requirement on Direct Messaging has the unintended consequence of keeping providers on less secure modes of exchange (fax, mail, phone, etc.). 
•Direct messaging transactions on the HIway are encrypted end-to-end -- HIway does not store or have access to ANY patient information contained in Direct messages. 
•Making HIPAA the basis for HIway Direct Messaging would align it with other consent requirements in the market and increase adoption. 
•All consent requirements that supersede HIPAA (e.g., HIV test results, substance abuse, etc.) would still apply to HIway Direct Messaging, just as they do with any type of electronic or non-electronic exchange. 

5 
Direct Messaging:  Summary of November HIT Council Meeting 

Recommendations from the Consent Work Group: 
1.Removal of consent for Direct Messaging:  Mass HIway Direct Messaging should not have a consent requirement that goes above and beyond HIPAA 
2.Education for Providers:  Mass HIway should provide additional education, clarification, and guidance to providers about health information exchange generally as well key consent requirements related to the HIway specifically 
3.Educations for Patients:  Mass HIway should provide education and guidance to patients about the HIway including a statewide education and outreach campaign   

See Appendix for more information about recommendations. 
6 
Direct Messaging: Recommendations 

 
Phase 2 HIway Services 
Ipek Demirsoy 
7 

8 
•Definition of “Phase 2 HIway Services”: 
–Phase 2 HIway services include the current Relationship Listing Service (RLS) and Medical Record Request service. 
–If implemented by the HIway, an Event Notification Service (ENS) would be a Phase 2 service.  
•Definition of the Relationship Listing Service (RLS):  
–The RLS is a HIway registry that can display a list of Participants that have published a consented relationship with a selected Patient.  
–The RLS is populated by Participants who transmit Patient demographic information with Patient consent and is accessible by Participants with an existing relationship to the selected Patient, or in an emergency situation. 
–Participants may use the RLS to identify other organizations that have a patient’s record and initiate a request for those records in whatever way works best for them (outside the HIway).  The HIway currently does not support automated query & retrieve capabilities. 
•Definition of an Event Notification System (ENS): 
–An ENS can alert Participants regarding patient events such as hospital admissions/discharges/transfers as well as scheduled and fulfilled appointments. 
–ENS provides real-time awareness of where patients are receiving care and can aid providers with care coordination. 

Phase 2 Services:  Definitions 

•At the November HIT Council meeting, the topic of possible changes to the HIway’s consent model for Phase 2 services was introduced, emphasizing that no decisions had been made yet. 
•Any HIway-delivered Phase 2 services (e.g., ENS, RLS)  that require retention of patient information trigger different consent considerations than Direct Messaging. 
•RLS and ENS require creation of a HIway ADT registry which would store patient demographics, Participants that provided care to the patient, and limited event information (e.g., Hospital Discharge date and time). No clinical data would be stored by HIway. 
•Key consent considerations relate to the HIway creating and managing such a statewide ADT repository, and who has access to information in the repository. 
•As a Business Associate to all participants, HIPAA allows the HIway to collect and store patient encounter information, but Chapter 118i requires an opt-in consent, which has been difficult to implement. 
•Moving forward, consent options currently being considered are opt-in (status quo), federated opt-out, or centralized opt-out. 

9 
Phase 2 Services:   Summary of November HIT Council Meeting 

Discussion topics: 
1.Impact of consent model on patient privacy 
2.Impact of consent model on scale 
3.Impact of consent model on operationalization  

10 
We now would like to hear from Council members and guests for additional input regarding Phase 2 Services, and the HIway’s consent model for Phase 2 Services. Phase 2 Services: Discussion 

11 
†  On this slide, “Provider Organizations” include the 29 large hospitals, 40 small hospitals, 9 Health Plans, and over 6,000 ambulatory practices in the state. Participation statistics for all organization types may be found in the appendix. 
††  “Active use” refers to any transaction on the HIway, whether public health reporting, provider-to-provider communication, or other purposes. 
†††   The "Not Participating" organizations include many that are connected to the Mass HIway via their HISP but have not started sending or receiving messages. They may be exchanging within their own HISPs or with other HISPs, which is activity that is invisible to the HIway. 

1% 5% 
3% 
Which provider organizations† are using the HIway? 9 28 16 12 9 4 11 2 5 
5,206 27 1 4 
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Small ambulatory practices
FQHCs
Small Hospitals
Large Hospitals
Active use
Connected
Signed On
Not ParticipatingProvider Organization Participation 
•Direct use of the HIway is much more prevalent among larger provider organizations than smaller provider organizations. 
•Smaller provider organizations may either be using another HISP to connect to HIway or are not yet connected 

† † 

Please note that “Active use” refers to any transaction on the HIway, whether public health reporting or provider-to-provider communication.   
† † † 

12 
Why are Participants using the HIway? 
•Although there were almost 3 million production transactions via the HIway during the month of November 2015, only 5% of these transactions were from one Provider Organization to another.1  
•~ 90% of the current transactions via the HIway are not subject to opt-in consent above HIPAA requirements, following current HIway Policies & Procedures. 
(87%)  (7%)  (1%)  (5%)  
 -
 1
 2
 3
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Number of Transactions (Millions) 
Public Health Reporting
Quality Data Reporting
Payer Case Management
Provider Org to Provider Org
1Mass HIway data and analysis; 2Michigan Health Information Technology Commission, Presentation from Nov 19th 2015 Meeting 
Current Transactions over the HIway 

13 
 13 Month RLS Growth – Cumulative Unique Patients Count1 
Note: Starting 12/20/2014, reporting cycle is through the 20th of each month. 
Since launching the Relationship Listing Service (RLS) with four pilot sites in January 2014:  
•A total of ~32,500 unique patients have been added to the RLS (less than 1% of the state’s population)1. 
•Only 1 of the 4 pilot sites is actively populating the RLS with patient information. 
•All four pilot sites needed at least one year to refine their existing HIway consent process to include the RLS. 
•One site is still deciding how to manage consent.  Merging the HI-way’s opt-in consent with the local HIE opt-out is difficult since their EMR is currently designed to have only one consent flag 

•Phase 2 services such as the proposed ENS depend on a well-populated RLS. 
•Consent for the pilot sites has been a barrier to rapid, robust HIway utilization, and indicates that opt-in consent will be a major barrier for other providers, especially smaller providers. 

HIway RLS - Unique Patients 
 -
 5,000
 10,000
 15,000
 20,000
 25,000
 30,000
 35,000
Nov
Dec
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
2014
2014
2015
2015
2015
2015
2015
2015
2015
2015
2015
2015
2015
Unique Patients
1,989
2,080
2,111
2,138
2,176
2,209
2,211
8,408
14,739
20,050
24,126
28,557
32,466
% Change
5%
1%
1%
2%
2%
0%
280%
75%
36%
20%
18%
14%
1Mass HIway data and analysis 

 
Conclusion  
Alice Moore 
14 

•Next steps 
–EOHHS will continue to engage stakeholders around the three strategic initiatives:  FAST,  ENS, Consent 
–The next HIT Council meeting:   February 1, 2016  

15 Next Steps 

16 HIT Council - Meeting Schedule:* 
•2016:  The 1st Monday of every other month, starting February 1, 2016  Advisory Group Schedule: 
•January 12, 2016 
•April 12, 2016  Consent Workgroup Schedule: 
• TBD     *All HIT Council meetings to be held from 3:30-5:00 pm at One Ashburton Place, 21st floor, Boston 

2016 Schedule  

Commonwealth of Massachusetts Executive Office of Health and Human Services   

Thank you! 

 
Appendix:  Consent Workgroup Recommendations 18 

Recommendation 1:  Mass HIway Direct Messaging should not have a consent requirement that goes above and beyond HIPAA (please see inventory of existing protections for Personal Health Information on following pages) 
 
Discussion: 
•Protection of personal health information is already covered by HIPAA and sensitive information is already covered by other federal and state laws regardless of mode of exchange (e.g., Mail, fax, direct messaging) 
•Direct Messaging is functionally equivalent to faxing or emailing but much more secure. The current Mass HIway Consent requirement on Direct Messaging has the unintended consequence of keeping providers on less secure modes of exchange (i.e., when a patient does not provide consent for the HIway, then their provider can still send the same information via fax without explicit consent). 
•Mass HIway consent requirement for Direct Messaging is inherently confusing 
–Consumers confuse consent to send over HIway with consent to disclose their information 
–Out-of-step with other functionally equivalent and heavily used modes such as faxing 
–At odds with all known public and private direct messaging services in the country 
•Consent is a barrier to provider adoption and use of Mass HIway Direct Messaging services 
Recommendation 1 - Consent 19 

Recommendation 2:   Mass HIway should provide additional education, clarification, and guidance to providers about health information exchange generally as well key consent requirements related to the HIway specifically 
 
Discussion: 
•Though Mass HIway consent was originally cited as a major “barrier to exchange,” the Consent Advisory Group has discovered that the challenges are much broader 
–The HIway is the first significant entrée to electronic exchange for many providers, so they have to adjust all of their consent (and other) processes 
–HIway consent is one of many consents required in clinical practice and must be aligned with other consent processes 
•Provider organizations must navigate a complex web of state and federal information disclosure laws when they modernize information exchange processes – this includes HIPAA as well as laws designed to protect sensitive information 
•Navigation of PHI disclosure laws and regulation may be done more efficiently and effectively with additional clarification from the HIway and by organizations working together, sharing legal and policy expertise, and developing best practices conventions to share with all 

Recommendation 2 – Provider Education 
20 

Recommendation 3:  Mass HIway should provide education and guidance to patients about the HIway including a statewide education and outreach campaign 
 
Discussion: 
•Patients are generally uninformed of or confused by the many laws and regulations governing release and disclosure of their health information 
•Many patients do not understand how their information is collected, stored, exchanged, and used by healthcare organizations 
•Patients can be a driver of adoption if they are included and engaged in the discussion – Misunderstanding and mistrust by patients can undermine the benefits Mass HIway is trying to bring to patients and providers 
•By introducing patients to the Mass HIway through a broad outreach campaign, patient conversations with providers about information exchange can be better informed, more targeted, and more meaningful to patients 
•Patient education may be done more consistently and efficiently by the state government than by thousands of individual provider organizations 
Recommendation 3 – Patient Awareness 21 

 
Appendix:  Near-term Initiatives 22 

The Cross-agency Workgroup is planning three near-term initiatives to address key challenges 

Complexity of Connection 
Functionality to Support Care Delivery Goals Consent Management FAST Initiative 
•Standardize available methods of connecting to the HIway 
•Provide expected time-to-connection for each method 
•Streamline connection process and ensure expected timelines are met 
Consent Initiative 
•Evaluate feasibility of consent workgroup recommendations and pursue potential policy and procedure improvements 
•Educate providers and consumers about current consent requirements and potential changes 
Event Notification Service Initiative 
•Identify, develop and launch new functionality to facilitate new or third-party tools that support care delivery goals  
•Event Notifications Service (ENS) identified as a priority tool to facilitate in the near-term 
Key Challenge Potential Near-Term Initiative 

23 

 
Appendix:  Event Notification Service (ENS) Initiative 24 

25  The HIway has heard the demand for a state-wide ENS 
Programs, Services, Initiatives that were considered by the Cross-Agency Workgroup: 
•New Technical Support Programs – For example: 
–Care Transitions Support Program 
–New Provider types Connectivity Program 
•Continue Buildout of Mass HIway Services – For example: 
–Query & Retrieve Service 
–Event Notifications Service 
–Patient credentialing and RLS access 
•Possible MassHealth Edge Services – For example: 
–Clinical Quality Measure Data Registry 
–CDR for case management support 
•Possible Future Commercially Provided Edge Services – For example: 
–Advance Directives Service 
•Possible Management & Process Initiatives – For example: 
–“Simplify” Initiative 

•In summer 2015, the Cross-Agency Workgroup considered multiple programs, services, and initiative to improve eHealth in the state. 
•A state-wide Event Notification Service (ENS) was identified one of the top priorities that providers in the state were looking for the HIway to provide 
•Private ENS services are already being used and introduced, but none of them provide the state-wide scope that is needed to support payment reform and delivery system improvements 

26 
Event Notification Service:  what is an ENS? 

ADT notifications provide a basic level of interoperability that increases efficiency in the healthcare system, while improving health outcomes for the patient.  
ENS is a notification system that alerts providers and health plans when a patient is admitted, discharged, or transferred in a clinical setting. ENS provides real-time awareness of where patients are receiving care serves as a backbone to help providers ensure patients are receiving the appropriate level of care 

 
Who the patient is 
Where the patient is 
What is happening to the patient (ADT) 
ADTs are lightweight data messages that communicate 
ENS  
•In health level 7 (HL7) - the data interchange standard that supports the processing of messages - ADT messages are considered it’s most commonly used messaging type. In total there are 51 different types of ADT messages that represent real case scenarios for a patient.   
•ADT messages are often created through a clinical (e.g. an EHR) or administrative (billing data) information system. In any setting where an update occurs to a patient’s health record, an ADT message is sent to all ancillary systems to keep the patient’s information in sync.   
•State HIEs are using trigger events with information contained in ADT messages (e.g. patient demographics) combined with a notification system (that uses rules) to indicate where the alert should go and who should receive it.  

27 
ENS: How does it work? 
1.Patient event (admission, discharge, or transfer) triggers ADT message from participating provider organizations – usually hospitals – that provide an ADT feed to the HIE  
2.Subscribers  (e.g. provider organizations and or health plans) and their terms of use may vary based on the HIE’s policy decisions. In a typical scenario, the subscriber provides the HIE with a list of active patients for whom they want notifications.   
3.ENS tool compares hospital notices to the provider organization or health plan’s patient lists; if a match is made, notice of the patient’s hospital encounter is securely delivered to the provider organization or health plan.  

Payer Roster 
2 
3 
ACO Roster 
Notification 
Roster / ADT Matching 
1 
1 
2 
3 

28 
  What is the benefit of a state-wide ENS? 
•An ENS is a key tool for providers and clinicians since they need to know where their patients are seeking care, in order to be successful in coordinating care. 
•The value and need for an ENS is expected to increase as providers are increasingly managing risk in alternative payment methodologies. 
•A state-wide ENS is needed because many patients do not stay within one provider organization: 
oApproximately 18% of hospital readmissions in the state goes to a different hospital 
oAmong potential MassHealth ACOs, an average of ~50% of acute inpatient hospital spend is out-of-network (see next slide for more details) 

29 

0%
25%
50%
75%
100%
A
B
C
D
E
F
G
H
I
J
K
M
N
O
In Network
Out of Network 
 Acute Inpatient Hospital Spending (Calculated from claims) 
•Recent analysis by MassHealth shows that without a statewide ENS, potential MassHealth ACOs will receive only part of the information needed to effectively manage utilization.  
•Among potential MassHealth ACOs, an average of ~50% of acute inpatient hospital spend is out-of-network. 

Potential MassHealth ACOs 
Why is a statewide ENS needed? 

Discussion questions :  
•Do you agree with the need for a state-wide ENS provided by the HIway? 
•Do you agree that the HIway should pursue launching an ENS in 2016?     
Discussion about ENS 
30 

 
Appendix:  FAST Initiative  
31 

1. Engage clinical, business, and IT leaders with streamlined content 	2. Simplify sign-on 	3. Simplify connecting 	4. Support Active Use 	5. Support Expansion of HIway Use 	

•Update of core content  
•Website update and redesign 
•Sales packet refresh 
•Outreach campaign 
	
•Connection type decision tree 
•Outreach meeting improvement 
•Streamline Contractual Agreements for Participants 
	
•Vendor relationship management 
•Provider Directory 2.0 
•Connection type simplification and reduction in time to connect 
•Customized end user technical onboarding documentation 
	
•Trading Partner matchmaking 
•Post and maintain trading partners and their readiness 
•Technical support for clinical workflow improvement 
	
•RLS Early Adopter Recruitment and Expansion 

32 
FAST Initiative Projects 

Why focus resources and time to the FAST Initiative? 
–Rapid on-boarding is key to HIway success 
–On-boarding is a complex process with multiple dependencies and interdependencies 
–Though on-boarding time has improved dramatically since the inception of the HIway there are still areas with ample opportunity for improvement 
–Some improvements are under direct control of HIway but most require collaboration with multiple parties (e.g., Customers, vendors, HISPs, integrators) 
33 Introduction to the FAST Initiative 

34 

Initiative 	Status 	
New Core Content 	New streamlined content, including FAQ’s,  has been created 	
Improved Connection Type Decision Tree 	Outreach team is using a new decision tree that helps guide participants through the onboarding process, eliminating redundant and unnecessary steps 	
Participation Agreement Consolidation 	Outreach team is now presenting the “minimum necessary” set of contractual agreements to participants in an effort to reduce administrative complexity and confusion during onboarding 	
Improvements to the Provider Directory 	The number of required fields on the Provider Directory spreadsheet has been reduced  
significantly to ease the administrative burden on  
the participants onboarding to the HIway. 	
Creation of Participant Onboarding Documentation and Checklists by Vendor 	Query and Retrieve onboarding checklist/documentation is under internal review.  Documentation customized by all major vendors will be the final output of this project. 	

FAST Current Status – Simplify Sign On/Onboarding Accomplishments 

35 
1.Sunset of the cross-onboarding approach for testing has been completed.  
•Approach eliminates stress on the production systems by separating test transactions during public health message validation and simplifies new Participant configuration.  
•Testing is improved by providing the same MDN responses that are seen in Production.  
2.Migration of XDR connections to the more widely-used XPL connection method as started with success at Emerson PHO using Qvera.  
•This implementation will be the template for migrating the other 11 Qvera sites. 
•Work is also underway with Iatric to implement a similar migration at Emerson Hospital, to be followed by 2 other Iatric sites.   
•Following those migrations, plans will be made for migration of the 2 sites using SMART ‘s XDR connection  
•End goal is to retire XDR connection method, eliminating support requirements for a seldom-used connection method. 

FAST Current Status – Simplify Connectivity Accomplishments 

Notes: 
•Calendar days, calendar years 
•Days from PA to Connected includes Participants with “Connected” and “Actively Using” status 
•Days from PA to Actively Using includes Participants with “Actively Using” status (excludes Participants that are “Connected” but not yet “Actively Using”)  
Days to Connectivity and Days to Actively Using (2012-2015) N=13 
N=11 
N=92 
N=62 N=107 
N=56 N=61 N=36 2012 
2013 
2014  
2015 36 
FAST – Days to Connectivity and Days to Active Use Have Been Declining Steadily 

•Holyoke MC migrated to the XPL solution 
•PVIX went live using the XPL solution 
•CHA went live using the XPL solution - the first Epic site to connect directly 
•Emerson PHO migrated to XPL solution - the first of 12 for GE/Qvera 
•CareConnect, MaxMD, eCW Direct Plus, and Updox HISPs connected 
•Sturdy Memorial, Tufts MC, Health Alliance, Steward, Southcoast, and BID-Plymouth all went live on Syndromic Surveillance 
•Southcoast Ambulatory went live on MIIS for Immunizations 
•Dartmouth Dermatology went live on the Mass Cancer Registry 
•Family Health Center of Worcester and HealthLeads went live on e-Referrals 
•23 new webmail sites have been implemented for Childhood Lead Poison Prevention Program submissions, with about 40 more in progress. 
•New webmail accounts and LAND installations continue every week. 
37 FAST – Onboarding Accomplishments September through November 2015 

Appendix:   Operations Update 
38 

39                HIway Participation 
New Participation Agreements   (Oct 21 to Nov 20) 
•As of November 20, 2015, the HIway has a total of 478 agreements with Participants. 
•In the last quarter (i.e., Sept– Nov 2015) the HIway made agreements with 37 new Participants. 
•This list can be used to identify organizations that are ready to start the connection process with the HIway.   These organizations may also be ready to discuss possible use cases with their trading partners. 

Chelmsford Pediatrics 
Dracut Family Healthcare 
Pediatric Associates Inc. of Brockton 
Primary Care Family Center (Mathur Manorama) 
Wareham Pediatric Associates 
Newburyport Pediatrics 
Dartmouth Dermatology 
Pediatrics Healthcare at Newton Wellesley 
Bolton Street Pediatrics P.C. 
East Elm Pediatrics 
Abington Pediatrics 
Associates of South Shore Dermatology LLC 
Pediatric Associates of Fall River, Inc.  

Rainbow Pediatrics / Northend Medical Associates 
Merrimack Valley Pediatrics 
Milton Orthopedic & Sports Physical Therapy PC 
Ludlow Medical Center(Gino Mercandante, MD, PC) 
Weston Pediatric Physicians 
Washington Square Dermatology 
Vicki Smith, M.D. 
Northeast Dermatology Associates 
Amherst Pediatrics  
Fairview Pediatrics 
Massachusetts Dermatology Associates, PC 
One Medical Group P.C 
Blue Hills Medical Associates (HermesIQ) 

40 
               HIway Participation 
New Connection Activity   (Oct 21 to Nov 20) 
•As of November 20, 2015, the HIway has a total of 583 connected organizations. 
•In the last quarter (i.e., Sept– Nov 2015) 30 new participants connected to the HIway. 
•This list (and the full list available at MassHiway.net under “Resources”) can be used to identify organizations that are able to exchange Direct Messages via the HIway with their trading partners. 

Baystate Franklin Medical 
Baystate Mary Lane Hospital 
Pioneer Valley Information Exchange 
Riverbend Medical Group 
Noble Medical Group - Southwick 
Lakeville Family Medicine P.C 
Health Leads National 
Michael C Zaslow, MD PC 
Dartmouth Dermatology 
East Elm Pediatrics 
Weston Pediatric Physicians 
Massachusetts Dermatology Associates, PC      

41 Customer Status Dashboard 

42 
 13 Month HIway Transaction Activity HIway Transaction Activity * Note: Includes all transactions over Mass HIway, both production and  test ** Note: Starting 12/20/2014, reporting cycle is through the 20th of each month.   3,889,748  Transactions* exchanged in November (10/21 to 11/20/2015**) 31,248,655  Total Transactions* exchanged inception to date  

•The number of HIway transactions has increased steadily, to well over 3 million transactions per month. 

 -

 500
 1,000
 1,500
 2,000
 2,500
 3,000
 3,500
 4,000
Nov
Dec
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
2014
2014
2015
2015
2015
2015
2015
2015
2015
2015
2015
2015
2015
Transactions (000's)
655
623
1,129
1,412
1,626
1,815
1,964
2,148
2,293
2,888
2,713
3,217
3,890
% Change
-5%
81%
25%
15%
12%
8%
9%
7%
26%
-6%
19%
21%
Transactions (thousands) 

HISP to HISP Connectivity 
43 
•The HIway currently connects with over 20 Health Information Service Providers (HISPs), including those used by the major EHR systems in Massachusetts for sending and receiving Direct Messages. 
•In November 2015, there were 106 organizations that used one of the HISPs to communicate with a HIway Participant. 
•Only 10,742 HIway transactions were sent or received via these HISPs (which is less than 1% of all HIway transactions), but the number of users connecting via these HISPs is growing.     

# 	HISP Vendor 	Kickoff 	Onboarding 	Testing 	HIway Prod Readiness 	Live/Target Date 	
1 	eLINC 	  	  	  	  	  2014-May 	
2 	DataMotion 	  	  	  	  	  2014-Jun 	
3 	Wellport (By Lumira) 	  	  	  	  	  2014-Jul 	
4 	Inpriva 	  	  	  	  	  2014-Aug 	
5 	Surescripts 	  	  	  	  	  2014-Oct 	
6 	eClinicalWorks 	  	  	  	  	  2014-Oct 	
7 	McKesson(RelayHealth) 	  	  	  		 2014-Dec 	
8 	Allscripts(MedAllies) 	  	  	  	  	 2014-Jan 	
9 	EMR Direct 			  	  	 2015-Mar 	
10 	SES 					 2015-Mar 	
11 	Medicity 					 2015-Apr 	
12 	NHHIO 	  	  	  	  	 2015-May 	
13 	MyHealthProvider(Mercy Hospital) 	  	  	  	  	 2015-May 	
14 	NextGen Share 		  	  		 2015-Jun 	
15 	Athenahealth 	  	  	  	  	 2015-Jun 	
16 	Aprima 	  	  	  	  	 2015-Jun 	
17 	Cerner 	  	  	  	  	 2015-Jun 	
18 	Medicity 	  	  	  	  	 2015-Aug 	
19 	CareConnect (NetSmart HISP) 	  	  	  	  	 2015-Oct 	
20 	UpDox 	  	  			 2015-Nov 	
21 	MaxMD 					 2015-Nov 	
22 	eClinicalWorks Plus 	  	  	  	  	2015-Dec 	
23 	CareAccord 					2015-Dec 	

Connection Status –  State Registries and Applications 44 
•This table lists the different state registries and applications that are connected to the HIway 
•This table can assist organizations that are considering new or additional use cases for sending data to the state’s registries and applications. 

Registry/Application 	Status 	Acceptable Message Types 	
Massachusetts Immunization Information System (MIIS) 	Connected 	HL7 	
Electronic Lab Reporting  (ELR) 	Connected 	HL7 	
Syndromic Surveillance (SS) 	Connected 	HL7 	
Massachusetts Cancer Registry (MCR) 	Connected 	CDA HL7 R2 	
Opioid Treatment Program (OTP) 	Connected 	XML (only for A01s), HL7 ADT (A01, A03, A08); QRY_19 	
Childhood Lead Poisoning Prevention Program (CLPPP) 	Connected 	.CSV, .TXT (All txt files are fixed length files)  	
E-Referral 	Connected 	CCD, HL7  	
Adult Lead 	Connected 	HL7 	
Prescription Monitoring Program (PMP) 	Testing 	HL7 	

EHR Vendor 	MIIS [1] 	Opioid Treatment Program 	E-Referral 	Syndromic  Surveillance [2] 	Cancer Registry 	
SMART 		Live 				
Netsmart 		Live 				
eClinicalWorks 	Live 		Live 			
GE Qvera 	Live 					
Cerner 	Live 			Live 		
Allscripts 	Live 					
athenahealth 	Live 				Testing 	
Aprima 					Initiated 	
Surescripts 	Live 					

Connection Status By Vendor – State Registries and Applications 
45 
•This table can be used by organizations that are using some of the popular EHR systems as they  determine the system’s readiness for reporting to various state registries and applications.  

[1] MIIS is the Massachusetts Immunization Information System 
[2] Syndromic Surveillance program reports data collected from Mass EDs for the CDC’s BioSense program 

HIway Availability Trends 46 
•HIway availability has improved significantly as a result of the Stabilization program earlier in 2015. 
•In months where the target 99.9% up-time has been missed, the cause can be traced to infrastructure issues outside the HIway, such as the state-wide IT outage on October 28th. 

Metric Targets:  
•“Total Monthly Availability” – no lower than 99.9% (downtime no more than ~44 minutes/month)  
•In the month of November, we had 2 days when Severity 2 incidents occurred and 2 days when Severity 3 incidents occurred.  

47 

2015 Mass HIway Incident Summary Dashboard 
November 2015 Sev 1 -   All / Most Mass HIway components impacted as a result of outage. For example: LAND, Webmail, Direct XDR, and DPH nodes are all down Sev 2 -   Multiple Mass HIway components  impacted as a result of outage in one of the shared service. For example: LAND and Webmail are down but Direct XDR and DPH nodes are up. Sev3 – One Mass HIway component impacted  as a result of outage. For example: Webmail is down but all other services are up and running.   
•In November 2015, most days the HIway was available 100% for all 24 hours (shown in green). 

0
200
400
600
800
1000
1200
1400
1600
11/1/2015
11/2/2015
11/3/2015
11/4/2015
11/5/2015
11/6/2015
11/7/2015
11/8/2015
11/9/2015
11/10/2015
11/11/2015
11/12/2015
11/13/2015
11/14/2015
11/15/2015
11/16/2015
11/17/2015
11/18/2015
11/19/2015
11/20/2015
11/21/2015
11/22/2015
11/23/2015
11/24/2015
11/25/2015
11/26/2015
11/27/2015
11/28/2015
11/29/2015
11/30/2015
Sev1 and Sev2
Sev3
Uptime

48 2015 Mass HIway Incident Summary Dashboard November 2015 Details Sev 1 -   All / Most Mass HIway components impacted as a result of outage. For example: LAND, Webmail, Direct XDR, and DPH nodes are all down Sev 2 -   Multiple Mass HIway components  impacted as a result of outage in one of the shared service. For example: LAND and Webmail are down but Direct XDR and DPH nodes are up. Sev3 – One Mass HIway component impacted  as a result of outage. For example: Webmail is down but all other services are up and running.   
•These specific details about each incident impacting the HIway’s availability are used by the HIway team to analyze and address root causes, and by Participants to gain additional understanding. 

Date 	Time frame 	Downtime in Minutes 	Severity 	Incident Overview 	Areas addressed or impacted 	
11/15/2015 	9:46 am to 10:27 am 	41 	Sev 3 	Syndromic Node causing error queues to grow and needing restart 	Syndromic CG Node 	
11/17/2015 	8:45 am to 9:36 am 	51 	Sev 3 	Syndromic Node causing error queues to grow and needing restart 	Syndromic CG Node 	
11/17/2015 11/18/2015 	10:47 pm to 1:00 am 	73 on 11/17 60 on 11/18 Total of 133 	Sev 2 	PROD1/2 - Direct Gateways had polling and communication issues needing a restart 	Webmail Restart Tomcat/Trust GW Restart James Restart 	

Appendix:   Background information 
49 

Background - Inventory of privacy protections for personal health information in Massachusetts (1 of 2) 

Topic 
(Law/Reg.) 	Fed/ 
MA/ Private 	Description 	Applicability 	Type of Consent 	Frequency of Consent 	
PHI disclosure 
(HIPAA) 	Fed 	
•Broadly protects privacy and security of PHI and ePHI 
•Establishes rules for disclosure for purposes of treatment, payment, and operations as well as public health reporting  
	
•Defines PHI and regulates PHI exchange 
•Self Pay disclosure to health plans 
	
•No consent required for TPO 
•Notification of Privacy Practices (NPP) required 
	
•No set time limit on NPP though most are refreshed annually 
	
Psych Notes 
(HIPAA) 	Fed 	
•Protects psychotherapy notes  
	
•Only notes, not other parts of record  
	
•Written consent to disclose psych notes for any reason (including TPO) 
	? 	
Substance Abuse Treatment 
(CFR Title 42 Part 2) 	Fed 	
•Protects privacy of substance abuse treatment provided by federally funded facilities 
	
•Any information in record 
	
•Written consent to disclose 
	
•At each disclosure 
•At each redisclosure 
	
HIV Testing 
(MA Ch. 111 Sec 70F) 	MA 	
•Protects privacy of HIV test results 
	
•HIV test results 
	
•Verbal consent to test 
•Written consent to disclose 
	
•One time to test 
•At each disclosure 

50 

Law/Reg. 	Fed/ 
MA/ Private 	Description 	Applicability 	Type of Consent 	Frequency of Consent 	
Genetic Testing 
(MA Ch. 111 Sec 70G) 	MA 	
•Protects privacy of Genetic test results 
	
•Genetic test results 
	
•Written consent to test 
•Written consent to disclose 
	
•One time to test 
•At each disclosure 
	
MIIS 
(MA Ch. 111 Sec 24M and CMR 222.105) 	MA 	
•Protects privacy of immunization information 
	
•Immunization reporting to DPH 
	
•Written opt-out for sharing with other providers 
•Opt-out form either to provider or DPH* 
	
•Not defined 
	
Age of majority (MA Ch. 231 Sec 85P) 	MA 	
•18 is the age of majority in but MA does recognize mature minor rule 
	
•Generally, for regular doctor visits, in non-emergency situations, a minor must obtain parental consent 
	
•Informed consent may be verbal or written 
	
•Once 
	
Mass HIway consent 
(Chapter 118i Sec 13) 	MA 	
•Provides patient choice to send information via Mass HIway 
•Provides patient choice to have data stored by HIway 
	
•Sending PHI via Mass HIway 
•Storing and sharing information in RLS 
	
•Written consent 
•Level of detail varies with type of HIE service 
	
•One time with refresh at age of majority 
	
Surescripts 	Private 	
•Protects access to med history information maintained by Surescripts 
	
•Any provider access to med history 
	
•Provider attestation of verbal consent 
	
•Not defined 

*Added considerations if bi-directional  is enabled  51 Background - Inventory of privacy protections for personal health information in Massachusetts (2 of 2) 

Query + Retrieve     Query & retrieve may be transacted between the parties through a variety of means inside and outside of the HIway 
•Fax/Phone/Mail 
•Direct Message 
•“Magic Button” 
•Synchronous query/retrieve 

Patient name Local name Institution MRN Last event date    # events  
 
Jones, Jennifer L Jones, Jennifer Hospital A 1234 Dec 3, 2012          3 
Jones, Jennifer L Jones, Jenny PCP 5678 Jul 8, 2010          12 

Relationship Listing Service 

Specialist Hospital A Jennifer L Jones 

PCP Y Y 
N 

2.  Send demographics to RLS Hospital A 
Jennifer L Jones 

4.Request patient record  

5.Send patient record  

3.  View Patient Relationships (limited to patients with established relationships) Current model: Opt-in for Phase 2 services 
52 
1.  HIway Opt-in Consent  
•This slide shows the current opt-in consent model for the HIway’s Phase 2 services 
•The RLS is at the core of Phase 2 services, and is necessary for Query & Retrieve, and for an ENS  

3. Opt-out to share      with the RLS & ENS     (i.e., “Centralized Opt-out”)       Consent is managed by the HIway Provider A 
Patient Consent? (default “no”) 

Provider A 

Provider A 

Statewide ADT 
Repository 

Statewide ADT 
Repository 
Statewide ADT Repository 
RLS & ENS 

Consent is assumed, but an opt-out choice is collected by the HIway once and applies to all Participants.  If a person opts-out , then they are “invisible” to any Participant viewing the RLS.  Thirty states have implemented a complete opt-out model.1 Consent is required to disclose any data, and is collected separately at each Participant that a person interacts with.  Six states have implemented opt-in1 (two originally implemented opt-in but moved to opt-out). 
Consent is assumed, but any opt-out choices are collected separately at each Participant that a person interacts with.  Seven states have implemented an opt-out with exceptions model.1 2. Opt-out to disclose     to the HIway       Consent is managed by Participant 
1. Opt-in to disclose  
    to the HIway 
    (This is the current model)        Consent is managed by Participant 

RLS & ENS 
RLS & ENS Yes No Patient Consent? (default “yes”) 

Yes No 
Patient 
Consent? 
(default “yes”) 

Yes No 53 1Office of the National Coordinator for Health Information Technology (ONC). State HIE Grantee Lab Strategy Inventory. September 2013 
Consent Options Under Consideration