Technology Advisory Group Meeting
May 24, 2013 2-3:30p

Name	Organization	
Atia Amin 	Network Health 	
Karen Bell	CCHIT 	
Claudia Boldman 	Information Technology Division 	
Larry Garber	Reliant Medical Group 	
Adrian Gropper 	 	
Pamela May	Partners Healthcare 	
Matthew Moss	South Shore Hospital 	
Mark Taricco	UMass Memorial Medical Center 	
Keith Worthley 	BIDMC 	
Bill Young	Berkshire Health Systems 	
John Kelly	EOHHS  	
Sean Kennedy	MeHI	
Support Staff	Massachusetts eHealth Collaborative	
Micky Tripathi	Massachusetts eHealth Collaborative	
Dave Delano	Massachusetts eHealth Collaborative	
Mark Belanger	Massachusetts eHealth Collaborative	
Erich Schatzlein	Massachusetts eHealth Collaborative	

Review of Materials and Discussion
Project Updates
•	Mass HIway Phase 2 Timeline Update (Slide 2)  
o	The group reviewed the Phase 2 timeline.  See slide for updates
o	Question – What does “go-live” indicate for the public health items?
•	Answer:  Go-live indicates that HIway participants can now submit public health data through the Mass HIway.  These interfaces to not provide the ability for participants to receive information from public health agencies.
•	Current Status Update (Slide 3)
o	Organizations have been connected previously in a technical manner, but very few transactions were crossing the Mass HIway.  Currently, transactions are growing substantially and should further increase with the start of the MeHI HIway Implementation Grant Program.
o	Hundreds of thousands for transactions have crossed the HIway in the past month, including large volumes of transactions from Tufts, Network Health, MAeHC, and BIDMC.
•	MeHI Grants Will Generate Demand for HIway Services, Sean Kennedy (Slide 4)
o	The goal of the implementation grant program was to build awareness of the HIway.  This goal has been accomplished, and will continue to succeed with the implementation grant process.  The HIway will be able to showcase the value of the services and produce cases studies for organizations to follow.
o	Correction to the slide: 32 planned awards total (slide indicates 31 awards)
o	27 of 32 planned awards are under contract now, and the remaining 5 will be worked on within the next week.  Grant included a requirement that the recipient organizations become connected to the HIway.
o	Comment:  There has been lot of confusion about how to use the existing tools of the Mass HIway within practices and organizations.  The suggestion was made to work on use cases for marketing the HIway services.
•	Response:   There have been greatly different understandings at different organizations on how to use the HIway services.  The HIway is now looking to move from a conceptual model to a “real-life” model.  This will be aided by the tangible use case examples from the grant recipients.
•	Question: Are you speaking of EHR to LAND models?
o	Answer: No, not technical, but more in the terms use case models to answer the question of “How does a practice yield value from the state’s HIE tool?”
o	Comment:  Previous use cases were for large organizations simply switching transactions to the HIway.  Now, the HIway will experience some of the smaller institutions using the HIway for a larger variety of reasons.  Once these use cases are in place, it will be easier for other organizations to draw insight from the new use cases.

HISP to HISP exchange
•	HISP Definition (Slide 6)
o	The group reviewed the definition of a HISP for “table setting” purposes
•	The term HISP has no meaning outside of the Direct project, and no meaning beyond Directed exchange.  It was a construct created as part of the Direct project, and is not an industry standard.
•	No separate formalized certification of HISPs from HITech.  Certifications cover EHRs, not HISPs.
o	The group reviewed what a HISP does and the three components a HISP provides.  See slides for details.
•	Breakdown in the HISP model (Slide 7)
o	Group reviewed slide content including the goals of HISPs and the reality of what currently exists.
o	Question:  What happened with the adoption of Direct standards that leads the HIway to believe that HISPs are necessary to complete point to point exchange of information?
•	Answer:  The payload must be encrypted; therefore an encryption certificate is required. 
•	Comment:  A fax is a way to exchange point to point information. The HIE is an open exchange network with the requirement to ensure the identity and the integrity of the information.  Previously, the idea was that EHRs would have exchange clients built in to the application.  Instead, it seems the EHRs have become aggregators of information exchanges.  A LAND box removes the need for the HISP, because the EHR can link directly to the LAND box and the LAND box acts as the gateway to the HIE.  The formation of HISPs is a bit of a perversion of the intention of the Direct standard.  They were not envisioned or intended at the time Direct was conceived, however due to the way the standard has evolved they are now a reality of Direct exchange.  The ideal would be EMR to EMR exchange (as was intended with Direct) without the need for a HISP to ‘authorize’ the transaction but we are not there yet.
•	Comment:  The way Direct was designed is the same way a person logs into a bank account now; the encrypted message travels from the user to the destination.  OCR (HIPAA) has made it clear that Directed exchange does not include the security practices of the recipient node.  The sender has a safe harbor if the recipient makes a mistake.
•	Comment:  There is no need for the HIway to be a HISP.
•	The original HIway HISP concept (Slide 8)
o	See slide for graphic and explanation.
•	Need for HISP to HISP policies (slide 9)
o	The group reviewed the original HISP concepts, and discussed how the proliferation of HISP contracts and models have lead to the need for additional policy, contact, and technical complexity considerations for HIway integration.
•	Need to define policy and technical approaches to variety of HISP models that exist in the market (Slide 10)
o	The group reviewed the potential options for participants, vendors, and HISPs to integrate with the HIway.
o	A question to be considered during HIway planning:  If the Mass HIway connects to a HISP that contains practices outside of Massachusetts, does the HIway want those organizations to have the same ability to contact the MA practices?  Does the HIway want to have participation agreements with these practices?
•	Question:  What legal requirement does the HIway have to require an agreement with one of these outside vendors or practice in other states?  Commenter suggests that HISPs are not real and are invented by those who want to make money.  The HIway does not have to buy into this, and should instead seek to identify mandates that require trust.
•	Answer:  From a Direct trust perspective, there are legal requirements for participants in the HIway to agree to.  
•	Response:  The actual question may be why does the HIway have participation agreements at all?  We need when we act as an RA and CA.  The willingness to post a direct address in the HIway’s directory is also subject to a participation agreement.  However, neither of these relate to a remote entity in another state.  Additional participation barriers reduce the value of the HIway.
o	Response:  What type of trust do we need between HISPs?  How much do we need to care about for basic email?  It is a fair question.
o	Comment: The HIway needs to be able to point to a law that says the HIway has to play the “gate keeper role.”
•	Many types of organizations that the HIway needs to consider (slide 11)
o	Breaks down the type of participants and how each fits into the HIway.  See slide for details.
•	Key areas to address in policy, contract, and technical requirements (Slide 12)
o	The group discussed if there a separate type of agreement for each of the types of participants.
o	Question:  The legal basis is chapter 224.  Is there an expectation that requirements on the Mass HIway will be passed on to the participants.  For example, the opt-in requirement?
•	Answer:  This would be a question for the HIway policy makers to decide.  The answer may be a “yes.”
o	Comment:  If the HIway does not end up supporting universal exchange, the value will be greatly reduced.  RA, CA (private security keys for data encryption), and the provider directory are services the HIway can sell, and users want.  Any barrier the HIway places here will make the HIway unsustainable, because users will find other places to exchange information.
•	Comment: The HIway was primarily designed to help take care of patients and increasing quality of care.  The HIway was not as worried about sustainability because of specific use cases that benefit state programs.  The HIway is opening up services to the public as a secondary option.
•	Comment:  The original idea was also to have the HIway as a “network of networks,” which is in the process of discussion now.
o	Comment:  Be careful, Direct trust is not a useful concept.  It is a coercive concept to the universal addressing capability that allows the patients and physicians to control the sharing of information.  
•	Response:  However, Direct is one of the few formal concepts out there now that we can look at and gather information.  The HIway recognizes Direct is not the solution to our information.
•	Is Direct Trust the answer? (Slide 13)
o	Please see slide for details.  Directtrust.org will provide full information on the concept.
•	What Direct Trust does not answer (Slide 14)
o	Please see slide for details.  
•	Other Considerations (Slide 15)
o	Please see slide for details.  
o	SMIME/XDR security issues will need to be discussed in-depth in another discussion
Phase 1 Consent
o	Consent for Phase 1 Services (Slide 17)
o	The group discussed the confusion that exists in the market about the current language on consent.  Discussion included the different approaches organizations are currently using for including consent for phase 1 services.
o	A proposed operational approach is presented on the slide.
o	Some organizations would like EOHHS to give the “nod” on the updated consent to treat and Notice of Privacy Practices (NPP) approach to count for the Opt-In.
•	Comment:  It is coercive to bundle HIway consent with a document that a patient has to sign to consent for treatment.  The intent of the law is to allow patients to revoke the consent at any given time in the future.  How can organizations bundle the two, and not be explicit with the ability to revoke consent?
•	Comment:  It is not constructive to use the word coercive.
•	Comment:  A suggestion was made for the HIway to look forward to phase 2 (with the enhanced services) when developing a consent policy.
•	Response:  Currently, there is not enough time, and is too complicated to consider phase 2 services when developing consent practices.  The HIway needs the consent policy for phase 1 now, as required by law.   Also, some organizations may only stay with phase 1 (and not participate in phase 2), so the policies for each phase must be unique.
o	Question:  If an organization collects a modified NPP with an addition that includes information on the HIway, how can the organizations flag in a system to indicate the consent has been collected?
•	Answer:  Phase 1 doesn’t require the consent to be recorded in the system.  Organizations should continue to record in the same way being used for recording NPP now.  Phase 2 will have the requirement, but we will work on that later.
Next steps 
•	Key points and comments synthesized and provided back to Advisory Group for final comments 
•	Presentation materials and notes to be posted to EOHHS website 
•	Next Technology Advisory Group Meeting – June 21, 2013, 2-3:30pm. Conference line only: (866) 792-5314, Code: 7814347906# 
•	Next HIT Council – June 3, 2013, 3:30-5:00 One Ashburton Place, 21st Floor 

An announcement was made by Sean Kennedy:  The HIway Interface Grant program information was released on May 23rd.  The grant program is a way to engage vendors and systems and ways to integrate them with the HIway.