Health Information Exchange Organization HIEO
INSTRUCTIONS TO CANDIDATES
ANSWER ALL QUESTIONS
Week Four: Health Information Exchange Organization (HIEO)
The Health Information Exchange Organization (HIEO) was launched several years
ago with the goal of helping lowering the state's staggering healthcare expenses and
improve the state's consistent poor rankings in leading health indicators, including
obesity, smoking, diabetes and heart disease. Improving healthcare through enhanced
use of information technology and data exchange is the heart of what we do. We
manage one of the country’s largest and most successful health information exchange
(HIE) networks, provide advisory services that help healthcare professionals effectively
use technology and improve care delivery, and supply health plans and accountable
care organizations (ACOs) with valuable data that enhance analytics and population
health programs. We’ve been in existence for several years and now have the majority
of the state’s hospital providers and have many physician, reference lab, diagnostic
radiology centers, mental health providers and other providers participating in our
exchange. All participating organizations send electronic health information to the
exchange including hospital transcribed documents (H&Ps, Discharge Summaries,
Operative Reports, etc.), lab results, diagnostic radiology results and other clinical
As an independent, nonprofit organization, we are dedicated to serving all of the state's
healthcare stakeholders including physicians, hospitals, behavioral health, emergency
medical services, public health, long-term care, laboratories, imaging centers, health
plans, communities and patients. We are self-sustaining and our funding comes from a
fee-based subscription model. We were previously the recipient of three grants focused
on building capacity for statewide health information exchange, including two grants
from the American Recovery & Reinvestment Act (ARRA) HITECH program.
Our Mission is: Through information exchange we improve health and healthcare.
Our Vision is: Patients will be measurably healthier as organizations and individuals
that contribute to health and healthcare effectively utilize information provided by the
HIEO to continuously improve patient care and population health.
1. Type of organization: State Health Information Exchange
2. Number of patients served, number of admissions etc.: Over 4.5M patients are
represented in our exchange database, representing over 75% of the state’s
3. Staff: The executive team is comprised of our CEO, CIO and CFO. We also
have marketing and sales staff, administrative and finance staff and technology
staff who support our exchange database and create and manage HL7 interfaces
between our database and each participating organization’s system. In the past
year, with the launch of our Information Governance (IG) program, we have
added a Chief Data Officer (CDO) and five Data Integrity Specialists to our team.
IG Program Description:
In partnership with the communities and people we serve, we have expanded our data
use policies with the goal of improving the integrity and quality of the data we store on
each patient. We created an HIM Steering Committee, chaired by the CDO, to provide
oversight to our IG activities and it is comprised of HIM and IT professionals from our
member organizations. This Steering Committee creates a report on a quarterly basis
that is presented at the HIEO board’s meeting and a more detailed report presented
monthly to the HIEO’s executive team. We have developed policies and procedures to
guide our Data Management processes. These policies cover data management
oversight, data management responsibilities, types of data management staffing
required, staff training requirements, quality assurance processes and reporting, and
accountability and authority of the HIEO, the Steering Committee and the CDO.
We are also a participant in the eHealth Exchange initiative, a group collaborating on
and working toward interoperable health information exchange, and DirectTrust, a nonprofit, competitively neutral entity created by and for participants in the Direct
community, including HISPs, CAs and RAs, doctors, patients, and vendors.
1. Staff: Currently 6 FTEs; Chief Data Officer is required to be a Registered Health
2. How long in place: Chief Data Officer for 2 years; Data Integrity Specialists for 2-
3. Culture: The first few years of the HIEO’s existence showed an entrepreneurial
culture where each employee was empowered to make decisions to support
growing the HIEO. While initially supportive of the growth, after time as it grew,
the organization became disorganized as their efforts were too much in silos. We
began receiving complaints from our members about not being able to find all of
one patient’s information in the database. The executive team pulled together
and developed a strategic plan to not only focus on growth but also on
developing a culture of teamwork, mutual trust and quality services.
4. Data System: The HIEO utilizes a centralized model for its data exchange. It
stores the clinical data for each patient and organizes that data in a single record
for the patient. This is accomplished through the databases “backbone”, its
Enterprise Master Patient Index (EMPI). Its exchange capability provides the
sharing of continuity of care documents (CCD), results, transcribed documents,
medication and problem lists and links to diagnostic images.
Prior State Analysis:
1. How was information organized prior to the IG program?
Participating organizations send interface transactions into the HIEO’s database and
contain information such as lab results, diagnostic imaging results, etc. These interface
transactions had to meet basic record match criteria such as matching on the Assigning
Authority from the sending organization and medical record number (or other unique
patient identifier for that organization.) If the transaction did not meet that first level of
record match a demographic data match was attempted. The last name, first name,
date of birth and address was used to determine if a record for that patient already
existed in the database. If these four elements matched exactly, the transaction was
posted to the existing record. If it did not meet these four criteria, a new person/patient
level record was created in the HIEO database and the transaction information posted
to the new record.
Additionally, transactions were evaluated to determine that minimum record and patient
identity data fields were populated including assigning authority, medical record number
(or corporate medical record number), patient’s last name, first name, date of birth and
gender. If these basic minimum requirements did not exist, the transaction failed to post
to the HIEO database.
No communication was sent to the participating organization regarding failed messages.
Additionally, no data integrity assessment was done on transactions received to
determine whether data values were populated with default data values and therefore
no reporting was provided back to the sending organization on the quality of the data
Describe data management program:
Following the completion of the HIEO’s new strategic plan, the CDO was hired to
implement a new data management program. Initially she had queries run on the HIEO
database to identify the volume of records with inadequate population of key record
matching data fields including the patient’s last name, first name, middle name, date of
birth, gender, last four of the SSN, address and telephone number. She analyzed the
results of these queries to stratify them by member, date ranges of transactions
received and each individual data field.
New policies and procedures were then developed to describe minimum data
requirements for patient identity, record matching guidelines, duplicate record validity
decision-making, interface requirements related to minimum data and data mapping,
interface test plans with scenario use cases and testing scripts, data integrity evaluation
and maintenance processes, record correction/merging procedures, reporting of data
integrity issues and duplicates to provider members and data integrity reporting. These
policies and procedures were presented by the CDO to the executive team. Following
the initial approval by the executive team, the CDO presented the program and the
policies to the full board and they were approved. The data management program was
Eighteen months ago the CDO began presenting to the executive team monthly reports
on member data integrity and quality. A high-level data integrity report was provided a
year ago to the HIEO board which showed by member (anonymously) the percent of
transactions the HIEO received with blank or default values on key demographic data
values. Additionally, research into new record matching algorithm and data integrity
products was completed and a product was selected that can be integrated into the
existing HIEO platform. After receiving the data integrity report and the financial
proposal for the record matching/data integrity product (“identity management” product),
the board approved the acquisition of this new technology. This new product utilizes an
advanced record matching algorithm that is error-tolerant of typical data discrepancies
across multiple records for the same patient. It also has a workflow tool that allows for
efficient review of possible duplicate records, error queues for data integrity issues and
the evaluation and reporting of such and to support management reporting needs. It
was implemented six months ago.
Additionally, in the past year, the CDO began hiring data integrity staff to monitor the
daily error logs and aggregate results from these error logs weekly and provide this data
to the CDO. Initially these specialists were only able to monitor and aggregate results
from the error logs. Subsequent to the implementation of the new identity management
product the specialists are now reviewing the potential duplicate queue in addition to
working the transaction error queues. One specialist was appointed as Data Manager
and she is responsible for compiling the reports to each member organization regarding
the summary of data integrity issues on a monthly basis. Additionally, she provides a list
of the data integrity issues for the applicable member’s records. Another responsibility
she has is to summarize the intra-facility duplicates sent to the HIEO by each
organization and provide that report monthly to the CDO. She also provides each
member with a list of their intra-facility duplicates in order for the member organization
to resolve these possible duplicates in their source system.
The CDO designed dashboard reports for presentation to the executive team and the
board generated from the identity management product. These reports will address the
HIEO’s strategic initiatives and goals set forth by the executive team, HIM steering
committee and board.
After the implementation of the identity management product a data analysis of the
entire HIEO EMPI database was completed. This analysis identified a 30% crossorganization duplicate rate, intra-organization duplicate rate of 8% and several data
integrity issues including 35% of the records having a blank value in the last 4 digits of
the SSN, 70% of the records missing a middle name value and 10% having a default
value in the date of birth field. All of these data integrity issues severely compromise
the HIEO in successfully matching records for the same patient from different member
organizations. The HIEO set a goal of reducing cross-organization duplicate rates to
less than 5% which was approved by its board and communicated to its members.
The CDO created a plan to resolve the duplicates, work with member organizations to
improve patient identity data capture processes in each organization and begin a
monthly reporting process to the members, the executive team and the board. The plan
included creating a data dictionary with definitions of key patient identity demographic
data elements to be shared with all members, documenting the HIEO’s EMPI data
model, working with the HIEO technical team to ensure appropriate data mapping of
values in transaction messages sent into the HIEO, contracting with an identity
management cleanup company to resolve cross-member duplicates, providing
members with their intra-organization duplicates and summary reports. Summary
reports included data integrity statistics and data patterns, member duplicate rates and
overall cross-organizations duplicates with the HIEO database created due to
incomplete or discrepant data.
Following the initiation of the reporting and post the cleanup, the HIEO was able to
reduce the cross-organization duplicate creation rate to less than 10%, and an
improvement in data capture of SSN, middle name and date of birth. Intra-organization
duplicate rates only dropped to 6%. These results allowed the data integrity team to
successfully manage these issues and provided the needed information for the CDO to
continue to work with member organizations on data integrity improvements in each
organization. The number of complaints filed by member organizations and providers
dropped 50% and it is expected they will continue to decrease as subsequent efforts by
the HIEO and member organizations continues.
The HIEO began to get complaints from participating physicians and other organization
members regarding four major issues:
a. Results and other information from the incoming transactions were posting to the
wrong patient (overlaid records)
b. Duplicate records existed in the HIEO’s database for the same patient sent from
each sending organization.
c. Lack of accountability to “cleanse” source system to assure information is valid.
d. No reporting back to sending organizations regarding the quality of the data
they’re submitting or the sending organization’s duplicate records.
As specific examples were researched, a fifth challenge was identified. This was
related to the HIEO’s system having immature tools to identify, resolve duplicate
records and pull apart data from an overlaid record.
IG Program Structure:
The Executive Vice President (EVP) for HIE Network Integration serves as the
accountable executive for the exchange program. S/he shall have the authority to
delegate strategic alignment to other accountable executives in the HIEO and has
delegate. The Chief Data Officer (CDO) is the strategic executive charged with
strategic development of the IG program as noted previously.
As a clinical data repository (CDR), our HIE is structured as a “centralized” exchange
model. Participating organizations shall sign a Business Associates Agreement (BAA)
which outlines the accountabilities of the HIEO and the participant. Our organization
has established an infrastructure and IT governance process that manages and keeps
secure all data contained within the CDR. The HIEO is accountable for assuring
version control of software, DURSA requirements for exchange, any necessary dispute
resolution. The CDR meets all of the Direct Trust requirements for interoperability.
The exchange of information is done via continuity of care documents (CCD’s) and a
subset of information from each participating organizations electronic medical record
(EMR). All organizations must have attested to meaningful use and have a fully
functional EMR which can interface with the HIE; a “common” EMR is not a
requirement. The participant organization is responsible for managing all IT interface
connection testing while incorporating the HIEO testing standards and “build”.
Participating organizations are responsible for managing their consent and authorization
process consistent with state/federal requirements, maintaining appropriate auditing
processes for users, maintaining secure log-on requirements and complex password
maintenance. The HIEO and the provider organization will work in a collaborative
manner to resolve any security threats or breach events that might result. The HIEO
shall stipulate to “good maintenance” requirements as a part of their oversight and
administrative duties. Servers with maintain the CDR data is maintained off premise in
the organizations data center with redundant servers located in a separate location.
The HIEO has an established information governance (IG) program to support the EMR
and the CDR. The framework for IG follows the tenants described by the American
Health Information Management Association (AHIMA) and the American Record
Management Association (ARMA).
The IG program has established an HIM steering committee as its governing body. At
the time of development, a project management (PM) approach was taken in order to
assure stakeholder involvement and strategic alignment. This organization has a
centralized approach to IG within the organization. There is a centralized authority led
by the EVP and CDO with a secondary group of leaders from across the organization
that provides control and decision-making authority for information obtained at the
enterprise level. There are subgroups with responsibilities for data within their
respective business areas, and additional staff can be brought into the program to
design workflows. (from AHIMA IG toolkit).
Project components in establishing our IG program included: (from AHIMA toolkit)
Identification of accountable executive
Charter development: A charter provides the framework for a project and is
intended to include and identify:
o Executive summary
o Project definition
o Project approach
o Measures of success
o Approval process
Project Plan Development to include
o Initiation: The initiation phase sets up the framework for the program.
Components to our initiation phase included creation of the charter, a
communications plan, defining the core team and the accountable
oversight committee, and identification of the project manager.
o Planning: The planning phase informed the development of our project
plan. We initially created a preliminary scope statement to allow us to
evaluate and prioritize ad hoc requests for work. An IG project plan was
developed and continues to be updated as new initiatives are undertaken.
The team defined time periods for planning and then adjusted as the
project moved forward
o Execution: Execution for IG plans can take many forms. Our
organization defined the project deliverables, focus, and quick wins we
could achieve to keep the momentum going for all of our activities.
Throughout the execution phase, the team focused on deliverables that
built value and created a compelling story for success. We created
processes, developed policies and procedures and trained our team.
o Monitoring/Control: Assessment of schedules, scope, budge and
change management process was ongoing throughout the implementation
of our IG program
o Project closure: project was completed, the project manager took steps
to appropriately close each milestone and deliverable. As each deliverable
was closed we updated the status report as well as identified any
operational owners who will manage these steps in the future.
The IG program has created new synergy in managing information that supports care
delivery for HIEO participants. The project plan, once implemented, created a standard
for information maintenance and accountability. During the implementation period,
there was significant focus on “quick wins” for the program and notably, there were
several challenges that were positively impacted.
After initiation of the project and a period of normalization, identified gaps in some of the
types of analytic reports, deeper understanding of consent management, operational
accountability for contributing partners for consent values and managing problem lists
and medication reconciliation were identified. The initial project plan had identified
“accountability” but did not describe specific requirements and analysis needs. This
has unfortunately resulted in unresolved redundant data in the EDW which has created
dissatisfaction and concerns of data accuracy and integrity. Audit tools exist within the
HIE process but the reports are difficult to interpret and need to be re-tooled to be more
user friendly. Patient matching has worked well, however the process for individual
organizations to manage respective EMR transactions has been problematic.
Consideration is underway by the CDO to implement a new project plan to identify gaps
and mediation strategies, specifically related to contributing partner consent
IG Challenges Resolved:
a. Reporting as a result of the governance tactics employed and working
with the respective provider groups, standard reports have been
developed for each of the practices. These provide information related to
numbers of individual patients contributed by the organization, query
results, required fields which need completion, user ID access.
Importantly, reporting has now expanded to include patients who appear
to have duplicate records and need to be merged. These are provided to
the organization in a “work queue” daily in order to be addressed by the
b. Data Management: Patient consent management is a significant
component of any exchange of information between providers. Best
practice standards have been established by the HIEO, which are shared
with the participating organizations for consideration in their doors to
manage duplicate patients, problem lists, medication lists (expired vs
c. Patient Identity management solutions: Policies and procedures, rules
related to patient identity, merge criteria, data correction/moves have been
established by the HIEO. Individual participant organizations must
develop P&P for management of their individual patient data. Measureable
improvements in patient identity data quality were realized. The level of
complaints from member organizations and providers dropped.
Following the implementation of the IG program and its related activities, the HIEO
gained knowledge regarding key data quality initiatives needed to effectively manage its
record matching. The staffing required to manage error queues and duplicates was able
to be maintained with increases, even as the HIEO membership grew and volume of
EMPI records increased. This was a direct cost savings to the organization. The HIEO’s
reputation within the state improved and additional member organizations joined.
The IG program has created new synergy and partnership in managing information that
supports care delivery for HIEO participants. Providers have a broader clinical profile
that supports population health and works to decrease costs. Patient matching tools
and initiatives have been implemented which has significantly improved the provider
experience, patient experience, decreased the need for redundant testing and improved
the care continuum for the patient.
Deliverables: Submit one (1) single presentation at the conclusion of Week Four no
later than Sunday, by 11:59 PM EST. This is an individual assignment.
Identify and develop a methodology to collect data that will guide or
influence strategic and/or organizational management. Identify key data
points, rates, indicators that can be used to measure EMPI data quality.
This effective exchange of medical information amongst HIEO members
relies on their trusting that each patient has one and only one unique
identifier within the HIEO system. Management of the HIEO’s Enterprise
Master Person/Patient Index (E/MPI) is a key strategic activity because
the E/MPI is the backbone of the HIEO’s clinical repository The Enterprise
Data Integrity Team is accountable to the HIEO Information Governance
Committee. Describe those individuals/ departments that should be
involved and define what each of their roles are. Define the purpose and
the value to the organization of an Enterprise Data Integrity team. Explain
the Enterprise Data Integrity team’s accountability within the enterprise.
Create an organizational guideline to measure data quality checks that
promote the accuracy of cross-organizational patient identity matching.
Define the organizational burden and accountability for each HIEO
member to assure integrity, completeness and accuracy of patient identity
Prepare an HIEO policy which provides clear guidance to all contributors
in the HIEO on the use of patient consent. Use the statutory guidance for
consent in your state in developing the policy. Is your state assumed to
have patient consent “opt in” unless they specifically decline or is your
state an “opt out” which assumes no consent for disclosure unless a
consent has been signed. In the policy, discuss how the consent value is
managed by the contributing parties, e.g., collected, stored, updated and
sent to the HIE. Identify any other specific types of consent values which
need to be considered for consent management (e.g., 42 CFR part 2 and
others specific to your state such as HIV, STD, genetic testing).
Create a business flow chart which identifies and describes the
accountable owner, information source system and transaction flow to the
HIEO; see attachment A as an example of an HIE transactional database.
Identify and describe the inbound and outbound interface transactions
from the central model of the HIE. Note additional components may be
used to describe the transactions.
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