Commonwealth of Massachusetts Executive Office of Health and Human Services   

Health Information Technology Council  Meeting 
November 2, 2015 

1.Welcome  [5 minutes] – Alice Moore, David Whitham 
–Minutes Approval 
–State IT Recognition Award 
2.Consent Workgroup Update  [15 minutes] -   Mark Belanger 
3.Overview of Strategic HIway Initiatives  [5 minutes] – David Whitham  
4.Consent Initiative & Event Notification Service Initiative  [40 minutes]  
•Introduction – Ipek Demirsoy 
•Where we are today with Mass HIway Phase 2 consent  - Mark Belanger 
•Lessons learned from other states – David Seltz 
•Expansion of Query & Retrieve Services (Phase 2) with Event Notifications - Ipek Demirsoy 
•Discussion of consent model options - Ipek Demirsoy 
5.Fast Initiative  [10 minutes, if time permits] – Dave Bowditch, Mark Belanger 
6.Operations Update  [10 minutes, if time permits] – Dave Bowditch 
7.Conclusion  [5 minutes] – Alice Moore     

Agenda 
2 

Discussion Item 1: Welcome 
Alice Moore, David Whitham  
3 

4 
National Recognition for Mass HIway 

 
Discussion Item 2:  Consent Subgroup Recommendations 
Mark Belanger 5 

Consent Workgroup update 
•In late Spring the HIT Council identified consent as a barrier to Mass HIway adoption and use and asked that the multi-stakeholder consent workgroup reconvene to formulate recommendations for the HIT Council 
•The consent workgroup met 5 times over the summer and early fall to discuss consent for Direct Messaging (phase 1), the MA HIV testing law, and electronic information disclosure generally 
•The following 3 recommendations for HIT Council are a result of the discussions of the workgroup 

Consent Workgroup Update 
6 

Consent Work Group recommendations for HIT Council discussion: 
1.Mass HIway Direct Messaging should not have a consent requirement that goes above and beyond HIPAA 
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 
3.Mass HIway should provide education and guidance to patients about the HIway including a statewide education and outreach campaign 

Recommendations 
7 

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 8 

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 

9 

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  
10 
Background - Inventory of privacy protections for personal health information in Massachusetts (2 of 2) 

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 11 

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 12 

 
Discussion Item 3: Overview of Strategic HIway Initiatives  
David Whitham  
13 

Summary of the strategic planning process 
▪The Cross-agency Workgroup reviewed findings from ongoing stakeholder engagement efforts at MeHI, HPC, and MassHealth 
▪The workgroup identified clear areas of growth for the HIway, specifically the ongoing increases in participation and transaction volume 
▪The workgroup also found that participants face ongoing challenges: 
–The complexity of connecting to the HIway can frustrate participants 
–Providers are struggling with consent management 
–Need for the HIway to facilitate functionality to support reform 
▪To address these challenges, we advance three near-term initiatives: 
1.Fast-track Initiative to simplify the onboarding process 
2.Consent Initiative to pursue consent workgroup recommendations 
3.Event Notifications Service as a pilot for enhanced functionality 
▪Additional long-term considerations must be addressed in parallel, including infrastructure capacity and business planning 
14 

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-Track 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 

15 

 
Discussion Item 3:   
Consent Initiative & Event Notification Service Initiative 
 
Ipek Demirsoy, Mark Belanger, David Seltz 
16 

Agenda  
Consent Initiative and Event Notification Service Initiative 
–Introduction:  Ipek Demirsoy 
–Where we are today with Mass HIway Phase 2 consent:   Mark Belanger 
–Lessons learned from other states:  David Seltz 
–Expansion of Query & Retrieve Services with Event Notifications:  Ipek Demirsoy 
–Discussion of consent model options:  Ipek Demirsoy    
17 

Introduction 
–HIway adoption and use has been steadily increasing since inception – yet consent has consistently been raised as a barrier to HIway adoption and use 
–The Health Policy Commission has researched what is happening in other states for HIE and consent to bring in external perspective 
–The Consent workgroup has made recommendations to the HIT Council / EOHHS to simplify consent for Direct Messaging and to provide education to help providers and patients better understand health information disclosure broadly 
–Today, HIway leadership would like input from the HIT Council regarding the consent policy for Mass HIway services above and beyond Direct Messaging – this includes the current Relationship Listing Service (RLS) and new Event Notification Service (ENS) 
–Compared to when the HIway started, there now is an increased need for HIE adoption and Phase 2 services as a result of alternative payment methods.  

18 

Introduction (continued) 
Early conversations with stakeholders (including the Consent Workgroup and Advisory Group) have highlighted a few key considerations for a possible change to a centralized opt-out model: 
•We should address stakeholders’ concerns that the current consent model has been a barrier to adoption. 
•We recognize that stakeholders have participated in past conversations about the HIE consent models since at least 2010. 
•The state and national HIE landscape has changed in recent years (e.g., increased alternative payment methods), and across the nation momentum is building around opt-out consent models. 
•Stakeholders have identified reduced administrative burden, faster adoption of innovative technologies, and simplified patient control over consent preferences as potential benefits of an opt-out model. 
•Stakeholders have raised questions about operational details of a potential centralized opt-out model (e.g., how would identity proofing be implemented?).  
•Some stakeholders have raised the potential need for varied approaches on how to address opt-in/opt-out . 

    19 

Agenda  
Consent Initiative and Event Notification Service Initiative 
–Introduction:  Ipek Demirsoy 
–Where we are today with Mass HIway Phase 2 consent:   Mark Belanger 
–Lessons learned from other states:  David Seltz 
–Expansion of Query & Retrieve Services with Event Notifications:  Ipek Demirsoy 
–Discussion of consent model options:  Ipek Demirsoy    
20 

Current phase 2 consent:  Decentralized Opt-in 
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 Jennifer L Jones 

Y Y N 

1. HIway Opt-in Consent 

2.  Send demographics to RLS Information Sent by Participant to Mass HIway RLS 
•Consent attestation (Yes or No) 
•Patient Identifier (e.g., Organization specific Medical Record Number (MRN)) 
•Patient Name 
•Patient Gender 
•Patient Date of Birth 
•Patient Address 
•Patient Email 
•Patient Phone Number 
•Participant sending the information and the Participant’s Direct address 
•Date message received 

Disclosure of information to RLS is controlled by participant and enforced by HIway  21 Hospital A PCP 

Current phase 2 consent (continued) 

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 Jennifer L Jones 

Y Y N 

1.  HIway Opt-in Consent 

2.  Send demographics to RLS 
Hospital A 
Jennifer L Jones 

3.  View Patient Relationships (constrained to patients with established relationships and “break seal” access for emergency providers) View of RLS is constrained to those with declared patient relationship. “Break the seal” access is permitted for emergency providers 22 Hospital A PCP 

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  
HIway imposes no additional consent requirement on query & retrieve Current phase 2 consent (continued) 
23 1.  HIway Opt-in Consent 

3.  View Patient Relationships (constrained to patients with established relationships and “break seal” access for emergency providers) 

Agenda  
Consent Initiative and Event Notification Service Initiative 
–Introduction:  Ipek Demirsoy 
–Where we are today with Mass HIway Phase 2 consent:   Mark Belanger 
–Lessons learned from other states:  David Seltz 
–Expansion of Query & Retrieve Services with Event Notifications:  Ipek Demirsoy 
–Discussion of consent model options:  Ipek Demirsoy    
24 

Health Policy  Commission | 25 
Multi-state Scan: In order to better understand field-tested approaches to statewide HIE / ADT implementation, the HPC conducted a scan of 8 HIEs 
•8 state HIEs were interviewed from July 21 to August 25, 2015.  
•Use cases were selected through HPC stakeholder engagement, input of MassHealth and MeHI, and priorities seen in the State eHealth Plan. The interviews contributed to understanding the value and relevance of key use cases, and highlighted strengths and weaknesses from interviewed states. 
•Selection criteria were based on these states’ established HIE efforts in defined use cases of interest: Event Notification Services; Advance Directives; Consent Management and Centralized Patient Portals; Continuity of Care Document and Discharge Summaries  

0%
10%
20%
30%
40%
50%
60%
70%
80%
Opt Out
Opt In
Other
Consent Model Selected by HIEs for Query-Based Exchange n=38 n=9 n=9 SOURCE: 2013 Program Data Collected by NORC; HPC interviews 

Health Policy  Commission | 26 Opt-In 
In Rhode Island, the RHIO has prescribed three levels of consent; patient choice-driven: 
•Current and future providers who are participants of the HIE to be authorized access 
•Only named healthcare provider organizations have access 
•Healthcare providers that may care for the patient in emergencies – temporary access  25 percent of RI physicians have signed up for the HIE (2014); 14 percent of these never used the HIE. Opt-in policies were cited as the primary barrier to participation and use.   

No Consent 

In Indiana consent has not been explicitly regulated; Indiana HIE authorities reported that they believe opt-in consent would have been a barrier to the HIE flourishing. Patients must be granted permission by their health care providers to opt-out of the exchange. The number of opt-outs are very low. Indiana authorities note that a more robust opt-out policy would be unlikely to have a detrimental impact on participation.  
 Consent to Query 

In Florida, providers need authorization to query a patient’s health care information. This approach allows the patient to specify the provider accessing their health information. The HIE covers 23 percent of hospitals beds in the state.  Opt-Out 

Five surveyed states (MD, MI, NE, UT, WV) are opt-out. The general consensus was that there was no significant challenge or issues with their consent policy. Fewer than 3 percent of patients have opted out in each state – some states have had no reported opt-outs. Future considerations to improve consent management for privacy and patient engagement was mentioned. All states rely on HIPAA as the standard for their HIE.  
Levels of Consent Seen Across States 

Health Policy  Commission | 27 

•Most state HIEs – regardless of consent model – have challenges with their consent management for patient information subject to enhanced protections. Specifically, most state HIEs have not found a practical strategy to manage 42 CFR Part 2 information or HIV / other transmittable disease data subject to increased protections.   
•Many states see the opt-in model as an impediment to an HIE’s development. As a result, the opt-out approach now dominates the state-based HIE market.   In Rhode Island, an opt-in HIE, providers are able to get basic ENS alerts under HIPAA (functioning as opt-out relative to the HIE); authorizing treatment equates to authorizing view of record to properly treat. Opting-in to the HIE means that the nurse or care manager can access information beyond a basic ADT alert.  Utah was initially an opt-in state but later moved to an opt-out model. For Utah, the opt-in model impeded efforts to develop a centralized data repository. In 2013, the state passed legislation to include Medicaid, Medicare, CHIP, and Public Employees Health Program beneficiaries automatically in the HIE (subject to an opt-out provision). The HIE now follows HIPAA as its privacy standard and is fully opt-out.   
•For an opt-in HIE to be successful, many report that a comprehensive education plan is essential to support and  educate healthcare providers and patients about the value of HIEs.   
•A single, blanket consent policy may not be the optimal solution for Massachusetts. For example, Direct (because of the trust-fabric of known users at both ends) may be optimally subject to HIPAA without additional consent, while services such as ENS may be more appropriate under an opt-out consent.   

Consent lessons learned from other states 1 
2 3 4 

 
Consent Initiative and Event Notification Service Initiative 
–Introduction:  Ipek Demirsoy 
–Where we are today with Mass HIway Phase 2 consent:   Mark Belanger 
–Lessons learned from other states:  David Seltz 
–Expansion of Query & Retrieve Services with Event Notifications:  Ipek Demirsoy 
–Discussion of consent model options:  Ipek Demirsoy    
Agenda 
28 

Reasons that the HIway is planning an Event Notification Service (ENS) 
•ENS can improve care coordination: 
oEvent Notification Service (ENS) would provide real-time notifications to providers when a patient is admitted, discharged or transferred to, from, or within a hospital. This in turn would allow clinicians to respond with information and/or clinical support. 
•ENS has been identified as a need in MA: 
oThe need and the demand for ENS from providers is increasing as a result of payment and care delivery reform 
oOther state-wide HIEs have already successfully implemented an ENS, and several providers have inquired about the possibility of HIway offering an ENS 
oSome providers are piloting ENS through private vendors; however, overall penetration is limited.  
oSeveral providers stated that providing a robust public option with an ENS through the HIway ensures that all providers (and patients) could benefit. 
29 

Key Considerations for ENS 
Key considerations: 
1.ENS could be built upon the current demographic data that is collected through Admit Discharge Transfer (ADT) messages, which get sent to the HIway for the Relationship Listing Service (RLS). 
2.To implement an ENS, the HIway would begin utilizing information that is contained in ADTs but previously has not been used (e.g., the “message type” information that conveys if the ADT is related to an admission vs. transfer vs. discharge). 
3.Current HIway consent policies and procedures may need to be updated for the HIway to implement the ENS.  

Issues that EOHHS is seeking feedback on: 
1.Some stakeholders have mentioned that notifications could become more useful if they include clinical information (e.g., “chief complaint”), although not all stakeholders agree that this added information should be included. 
2.Since the usefulness of an ENS increases as the volume of ADTs increases, some stakeholders have suggested that EOHHS should encourage or require all acute-care hospitals in the state to send ADTs to the HIway to ensure a robust, state-wide "ADT repository".    
30 

 
Consent Initiative and Event Notification Service Initiative 
–Introduction:  Ipek Demirsoy 
–Where we are today with Mass HIway Phase 2 consent:   Mark Belanger 
–Lessons learned from other states:  David Seltz 
–Expansion of Query & Retrieve Services with Event Notifications:  Ipek Demirsoy 
–Discussion of consent model options:  Ipek Demirsoy    
Agenda 31 

To briefly review, discussions of Phase 2 services and feedback from stakeholders have brought the consent model back into the forefront: 
•The Consent workgroup has met and reviewed a range of opt-in and opt-out models. 
•Each model has a range of considerations. We have heard from a range of providers/stakeholders who favor a centralized opt-out model, though other providers/stakeholders have expressed differing views. 
•The majority of HIEs in other states have adopted opt-out consent models, and several states have shared their belief that an opt-in model would have slowed their progress. 
•Today, we aim to review and receive input from the HIT Council on options for consent, how a centralized opt-out model could work, and other considerations that should be evaluated.   
•We will evaluate next steps after today’s meeting. 
Recap: Drivers for reconsidering HIway consent model for Phase 2 32 

Consent options under consideration  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. Consent is required to disclose any data, and is collected separately at each Participant that a person interacts with. Consent is assumed, but any opt-out choices are collected separately at each Participant that a person interacts with. 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 33 

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  
As a reminder, the current opt-in model for Phase 2 services requires significant investment and engagement at each provider. Current model: Opt-in for Phase 2 services 34 1.  HIway Opt-in Consent 

3.  View Patient Relationships (constrained to patients with established relationships and “break seal” access for emergency providers) 

Option 3: Overview of Participant and Patient workflow Patient contacts HIway if they want to  opt-out  Patient visits Participant Participant educates patient on  opt-out consent and how to  contact HIway to “opt out”  In addition there are  state-wide education efforts  
If the patient opts-out:  
 
Then the HIway blocks the sharing of  information about that patient Participant sends  ADTs to HIway   (no need to capture consent) 

Participant Workflow Patient Workflow    A key component of a move to centralized opt-out would be a state-wide patient awareness and education campaign so that any patient decision is informed   35 

Option 3: Centralized opt-out – Considerations 
1.May require a legislative change to move HIway consent to centralized opt-out for Phase 2 services 
•The centralized global opt-out consent policy could apply to both the RLS and ENS since the RLS is a foundational element of an ENS.   
•Patients could contact HIway directly at any time to change consent preference. 
•Potential enhancement after initial launch:  could allow a Participant to communicate a patient’s opt-out preference to the HIway (to save a patient the step of contacting HIway). 
2.Information protected by 42 CFR Part 2 could be excluded from the RLS and ENS.   
•Provider organizations could be responsible for filtering this information out of ADTs sent to the HIway. 
•The HIway would not accept ADTs from stand-alone substance use disorder treatment facilities. 
3.Initially, centralized opt-opt would be “Global”  (instead of “Participant-Specific”) If a patient chooses to opt-out, this could be recorded by the HIway and apply to all Participants. 
•Potential enhancement after initial launch:  could allow patients to opt-out for specific Participants.  
4.Phase 2 services, accelerated by a centralized opt-out model, could allow the HIway to more effectively facilitate the sharing of clinical information between providers to improve care coordination.  Clinical information could be shared in two ways: 
a)Following an ENS with information shared via Direct Messaging, or Query & Retrieve 
b)Including some clinical information (e.g., primary complaint) in an ADT 

36 

Option 3: Several 2nd-order design details to consider Design details for future consideration Thus far, stakeholders have highlighted the following implementation and operational areas for more detailed consideration: 1. Identity proofing:  How will the HIway verify the identify of consumers contacting the HIway to opt out? 2. Patient matching: How will the HIway match consent preferences to the ADTs for that patient? 
3.Discovery service / synchronization: How will the patient’s consent preference be shared between the HIway and a Participant? What information do Participants need to receive from the HIway about consent preferences?  
4.Promotion of a robust ADT repository:  Should EOHHS encourage or require all acute-care hospitals to send ADTs to the HIway?  
37 

1.Decreased administrative burden on Participants 
a)Consent is managed by HIway instead of by the Participants 
b)Participants may not need to implement a workflow to capture  consent in patient portals, EHR systems, billing systems 
2.Less costly for Participants to implement than decentralized opt-in 
3.Easier and less confusing for most patients 
a)Patients only need to contact HIway once to opt-out for all sharing, instead of contacting multiple organizations.  
b)HIway consent process would be very similar to the MIIS consent process for vaccines which has been working well.  
4.Improvements in care coordination for all clinicians & patients through robust public option for phase 2 services  

    Potential Benefits of Centralized Opt-out consent 38 

1.Some Participants have concerns about sending information to the HIway without first getting a patient’s expressed consent. 
2.Some patients who want to opt-in for one Participant but opt-out for a different Participant, would need to wait for HIway enhancements since this would not be an initial feature of centralized opt-out. 
3.Some patients may be concerned that under an opt-out model, less time will be spent with patients to help them make an educated decision regarding consent. 

To address this potential challenge, would need to consider: 
a)A comprehensive state-wide education and outreach campaign  
b)Staff training at Participant sites  
4.Some Participants have successfully implemented opt-in consent management and prefer to share best practices rather than change the model 
•However, most Participants in the state do not use the HIway for care transitions, and consider consent management a significant barrier to adoption, even with assistance on best practices.  

Potential Challenges of Centralized Opt-out 39 

Discussion Questions & Next Steps 
Discussion Questions for the HIT Council: 
1.Are there additional potential pros & cons for centralized opt-out?   

Next Steps: 
1.We will evaluate next steps after today’s meeting. 

  40 

 
Discussion Item 4:  Fast Initiative  
David Bowditch, Mark Belanger 41 

Introduction to the FAST Initiative 
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) 
42 

Current Outreach and Onboarding Process 
•Discover: Customer determines needs for services, price, and seeks answers to their questions 
•Sign-On: Customer makes decision to join HIway and executes agreements 
•Connect: Customer connects their health information system(s) to Mass HIway 
•Actively Use: Customer completes process changes and begins using Mass HIway for initial use case 
•Expand Use: Customer begins using Mass HIway for additional use cases. Customer may sign up for additional Mass HIway services 

Customer Lifecycle – Customer Point of View Discover  Sign-on  Connect  Actively Use Expand Use of HIway 

43 

Delay drivers to be addressed as part of FAST Initiative 
•Discover phase issues and sources of delay: 
–Participant time for IT leadership to “sell” HIway to clinical and business leadership 
–Complexity and overhead of programs linked to HIway implementation (e.g., MU, grants) 
–Confusion about who runs HIway, where to look for information, and who to contact 
•Sign-on phase issues and sources of delay: 
–Sign on decision requires multi-lateral discussions to determine connection type 
–Multiple leaders are required to make sign-on decision  
–Participation Agreements are complex - Up to 10 forms to navigate and sign 
–There is confusion about the MA law with absence of Chapter 118i regulations 
•Connect phase issues and sources of delay: 
–Connecting to EHR vendors that are immature and still figuring out direct messaging 
–Standards optionality and variability 
–Addressing and Provider Directory 
•Actively Use phase issues and sources of delay : 
–Along with technology changes, new processes need to be defined and implemented with clinical and administrative staff and in collaboration with vendor 
–Processes are cross-organizational and require ongoing collaborative planning among organizations to solve for multiple cruxes 
•Expand Use of HIway phase issues and sources of delay: 
–Public Health reporting is often the first use case and not extensible to Transition of Care 
–RLS has 2 known issues to resolve before customers proceed 
44 

FAST Initiative –  Discrete projects to address issues 
Customer Lifecycle – Customer Point of View Discover  Sign-on  Connect  Actively Use Expand Use of HIway 

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

45 

FAST Initiative Projects 

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 	

•Core content refresh 
•Website update and consolidation 
•Sales packet refresh 
•Outreach campaign 
	
•Connection type decision tree 
•Outreach meeting improvement 
•Contractual Agreement streamline 
•Regulations promulgation 
	
•Vendor relationship management 
•EHNAC certification 
•Provider Directory 2.0 
•Connection type simplification 
	
•Trading Partner matchmaking 
•Post and maintain trading partners and their readiness 
•Technical support for clinical workflow improvement? 
	
•RLS Search fix 
•eMPI – Matching configuration change - Tuning in production 
•RLS Early Adopter Recruitment 

46 

Discussion Item 5: Operations Update 
David Bowditch 47 

48                HIway Participation New Participation Agreements (Sep - Oct) 
•Behavioral Health Network Inc. 
•Chelmsford Dermatology, P.C. 
•Edgewood Retirement Community, Inc. 
•Michael C Zaslow, MD PC 
•Northborough Pediatrics 
•Pediatric & Adolescent Medicine 
•Pediatric Associates of Northwood 
•Sanphy Podiatry Group (Partner's Affiliate) 
•South Shore Dermatology Physicians PC 
•University Skin Oncologist (Partner's Affiliate) 
•William A. Mitchell Jr, MD PC  

49 
               HIway Participation 
New Connection Activity (Sep - Oct) 
•Adams Street Dermatology Associates P.C. 
•Care at Hand, Inc. 
•CareWell Urgent Care 
•Dr. Committo 
•Gogstetter, Darin S MD 
•Haines, James MD 
•Kenneth M Reed MD, PC (Derm ASAP) 
•Marino Center at Mount Auburn 
•Mercy Medical Center      

•Needham Wellesley Family Medicine 
•Northborough Pediatrics 
•Pediatric Associates of Northwood 
•Pleasant Hill Pediatrics 
•Sanphy Podiatry Group (Partner's Affiliate) 
•South Coast Physician Group 
•University Skin Oncologist (Partner's Affiliate) 
•Whittier Street Health Center 
•William A. Mitchell Jr, MD PC  

50 Customer Status Dashboard 

51 
 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.   3,217,192  Transactions* exchanged in October (9/21 to 10/20/2015**) 27,358,907  Total Transactions* exchanged inception to date  

 -
 500
 1,000
 1,500
 2,000
 2,500
 3,000
 3,500
Oct
Nov
Dec
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
2014
2014
2014
2015
2015
2015
2015
2015
2015
2015
2015
2015
2015
Transactions (000's)
573
655
623
1,129
1,412
1,626
1,815
1,964
2,148
2,293
2,888
2,713
3,217
% Change
14%
-5%
81%
25%
15%
12%
8%
9%
7%
26%
-6%
19%Transactions (thousands) 

52 

2015 HIway Production Transaction Trends by Use Case Type 
HIway Transaction Analysis * Note: Reporting cycle is through the 20th of each month. 88%  of HIway activity year-to-date* was for production transactions  89%  of HIway activity in October* was for production transactions   

 -
 500,000
 1,000,000
 1,500,000
 2,000,000
 2,500,000
 3,000,000
Jan.2015
Feb.2015
Mar.2015
Apr.2015
May.2015
Jun.2015
Jul.2015
Aug.2015
Sep.2015
Oct.2015
Public Health Reporting
Quality Data Reporting
Payer Case Management
Transition of CareOctober:  84% of production volume 38 senders, 37 receivers    October:  9% of production volume 5 senders, 1 receiver    October:  1% of production volume 4 senders, 3 receivers    October:  6% of production volume 174 senders, 157 receivers  

HIway RLS - Unique Patients 53  13 Month RLS Growth – Cumulative Unique Patients Count 
Note: Starting 12/20/2014, reporting cycle is through the 20th of each month. 

 -
 5,000
 10,000
 15,000
 20,000
 25,000
 30,000
Oct
Nov
Dec
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
2014
2014
2014
2015
2015
2015
2015
2015
2015
2015
2015
2015
2015
Unique Patients
1,318
1,989
2,080
2,111
2,138
2,176
2,209
2,211
8,408
14,739
20,050
24,126
28,557
% Change
51%
5%
1%
1%
2%
2%
0%
280%
75%
36%
20%
18%

# 	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 	eClinicalWorks Plus 	  	  	  	  	2015-Nov 	
21 	UpDox 	  	  			2015-Nov 	
22 	MaxMD 					2015-Nov 	

HISP to HISP Connectivity 54 

Registry 	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 	
Specialized registry - Disease surveillance and case management system (MAVEN) 	Connected 	HL7 XML from ESP (or other) via Web service 	
Opioid Treatment Program (OTP) 	Connected 	XML Enrollment, HL7 	
Childhood Lead Poisoning Prevention Program (CLPPP) 	Connected 	.CSV, .TXT (All txt files are fixed length files)  	
E-Referral 	Connected 	HL7, XML 	
Adult Lead 	Connected 	HL7 	
PMP 	Testing 	HL7 	

DPH Connection Status 55 

EHR Vendor 	MIIS 	Opioid Treatment Prg. 	E-Referral 	Syndromic  Surveillance 	Cancer Registry 	
SMART 		Live 				
Netsmart 		Live 				
eClinicalWorks 	Live 		Live 			
GE Qvera 	Live 					
Cerner 	Live 			Live 		
Allscripts 	Live 					
athenahealth 	Live 				Testing 	
Aprima 					Initiated 	
Surescripts 	Live 					

DPH Connection Status By Vendor 56 

HIway Availability Trends 

57 Metric Targets:  
•“Total Monthly Availability” – no lower than 99.9% (downtime no more than ~44 minutes/month)  
•In the month of October, we had 2 days when Severity 1 incidents occurred and 2 days when Severity 3 incidents occurred.  
•Please see the appendix slides for additional details.