Introduction & Context
The transformative New York State five-year Delivery System Reform Incentive Payment (DSRIP) Program, part of New York’s 1115 Medicaid Waiver, requires organizations across the State to create regional provider networks called Performing Provider Systems (PPSs) that will coordinate care to manage the health of the Medicaid population in their respective regions. At its core, DSRIP is designed to move these PPSs over time towards value based care, where providers are rewarded for the quality of care rather than quantity of care through incentive dollars. A cornerstone of this program is the requirement to share (1) “EHR [Electronic Health Record] systems with local health information exchange/RHIO/SHIN-NY,” and (2) “health information among clinical partners, including secure notifications/messaging by the end of Demonstration Year 3 [March 2018].”1
PPS lead organizations are required to develop and execute a strategy that fulfills three key aspects of data sharing: (1) enable bi-directional data sharing between PPS partners to conduct population health activities; (2) connect all partners to the Statewide network; and (3) ensure that all participating providers are able to receive Clinical Event Notifications or “alerts” and Direct Messages. Bi-directional data sharing allows different organizations to share data to and from each other’s EHR system in real-time. The Statewide Health Network of New York (SHIN-NY) is a network of Regional Health Information Exchanges (RHIOs), also called Qualifying Entities (QEs) – licensed RHIOs – that will allow providers to look up patients’ clinical data across the state, given that organizations are successfully connected to the SHIN-NY. Clinical Event Notification allows providers to receive alerts of their patients’ health activities across the continuum of care, while Direct Messages allow providers to communicate with each other regarding their patients in a HIPAA compliant manner.
The State’s Support (RHIOs and SHIN-NY)
New York State is taking swift steps to expand and align their statewide interoperability strategy with DSRIP by becoming collaborators in helping PPSs achieve their DSRIP requirements. At its core, the SHIN-NY is a network of nine QEs or RHIOs that are connected to individual providers’ or PPSs’ Electronic health record systems, with the intent to increase access to patient health information across the state.
They have defined a set of “dial tone” services, considered to be core HIE services to be delivered through the RHIOs. These include: (1) Patient Record Lookup (community and statewide), (2) Secure Messaging Direct, (3) Consent Management, (4) Clinical Event Notification, (5) Identity Management & Security, (6) Provider and Public Health Clinical Viewer, (7) Public Health Integration and (8) Result Delivery.
Strategy Development Considerations from the Mount Sinai PPS
The Mount Sinai PPS is one of the largest PPSs in New York, covering the Manhattan, Brooklyn, and Queens boroughs of New York City. Meeting DSRIP requirements will be a complex task from technological, clinical care coordination, and operational perspectives, given that DSRIP itself is continually evolving – “It’s like building a car while driving it and changing the tire,” says Donny Patel, Director of Interoperability at Mount Sinai Health System. The State has proposed five models for data sharing that scale from lowest to highest levels of interoperability and reusability that highlight the innovation needed. The lowest level is exemplified as entirely on paper. A medium level consists of providers with the same EHRs collaboratively connecting to a RHIO. The highest level entails PPSs developing interoperable hubs or private HIEs that will connect to providers in the PPS network and the RHIOs. Mount Sinai is considering the highest level of interoperability through analysis of four key areas, outlined below, to define a pioneering technology strategy that meets the PPSs unique needs and also positively impacts the achievement of performance dollars in DSRIP years three, four and five.
The Current Interoperability Landscape
To approach the challenge of connecting a large number of “unrelated” organizations, learning about existing infrastructure and how best to leverage it is a crucial first step. Mount Sinai PPS worked closely with DOH and the QEs to learn about their interoperability plans to support DSRIP through statewide collaborative meetings and planning efforts. While the state solutions must certainly be leveraged, understanding the level of robustness needed should also be considered. DSRIP requires more sophisticated data needs that go beyond core services, such as reference laboratory, radiology, referral management and more. Conducting an assessment of DSRIP requirements, PPSs’ capabilities, and the external environment, while aligning those results with long-term strategy and sustainability plans will reveal essential needs that should be factored into the general HIE strategy.
Who is being Connected?
Understanding the partner network may be a seemingly simple task, but is one of the more complex aspects of and a critical success factor within the NY DSRIP program. While partner information can be fluid, the approach of establishing an initial understanding of partners by provider types has proven to be successful and insightful. By categorizing the network into 10 – 12 provider types, the partner network can be scaled down to a level where the approach and technology solutions to connect them are manageable to define. This not only makes the approach to strategy development less unwieldly, but allows us to still remaining comprehensive enough to meet most partners’ needs.
Tactical Approach to Strategy Development
The development of data sharing pathways enable partners to be stratified and analyzed through the lens of their current technology maturity. Mount Sinai PPS developed four data sharing pathways: (1) provider with an MU certified EHR connected to a QE; (2) provider with an MU certified EHR not connected to a QE; (3) provider with an EHR that is not MU certified; and (4) a provider in a paper based world with no EHR. While these pathways helps organize partners into meaningful categories, it is essential to keep in mind that each provider is nuanced and may in fact be in transition or between pathways. The importance of pathways lies in using them as an approach to define the high-level technology solutions, which will eventually be scoped and scaled for individual partners.
Collaboration Can Pay Off
Ultimately, the bi-directional data sharing requirement is the same for everyone working to support this initiative. Additionally, many providers, particularly in downstate New York, are part of multiple PPSs. This will inevitably lead to providers implementing different strategies for the same requirements if PPSs aren’t encouraged to collaborate with each other. Several regional trade associations and agencies, including DOH, are bringing PPS leads together to share best practices, and approach strategy and requirement development together in a manner that allows organizations to mitigate risks of maintaining their competitive edge in the market outside the Medicaid space. Not all PPSs have moved in this direction, but in the current landscape, several PPSs are quickly seeing the benefits of such partnerships and are defining joint strategies to implement core IT solutions.
Long-term Sustainability Plan
As innovative and far-reaching as these requirements may seem, achieving them will enable large scale, perhaps unprecedented, data sharing, care coordination, and population health activities across the state of New York for all Medicaid patients. DSRIP is a game changer for HIE services as demand has increased and all types of healthcare companies, from providers to insurance companies are jumping on the “HIE band-wagon,” says Donny Patel. He feels this will not only bring about tremendous positive change for care coordination, but perhaps completely transform the way we practice care through increased digitalization. As he works to define a strategy to meet DSRIP needs, he is actively working on a sustainability plan that will keep these services going after DSRIP ends. Certainly the demand and awareness help, but the future of HIE will be secured through a natural alignment to the value-based care and payment model in the future state that prioritizes care coordination.
COPE Health Solutions has deep knowledge and expertise in DSRIP and population health, and the role of technology in supporting the changing healthcare landscape. Our team has worked side by side with the Mount Sinai Health System population health IT team providing expertise on strategy development from defining the solutions, stakeholder engagement and buy-in, vendor identification and implementation planning.
Donny Patel is the Director of Interoperability at Mount Sinai Health System with 15 years of experience in the Health IT space. He has a Master of Business Administration in Finance and Leadership from the University of Central Oklahoma.
Footnotes:
1Domain 1 Project Requirements Metrics and Milestones; Project 2.a.i – Requirement 4.