Health Information Technology Council
Report to the Massachusetts Legislature
Reporting Period: January 2019 to December 2019
Submitted in February 2020
by the Health Information Technology Council
Contents
Executive Summary 1
1: Introduction 1
2: Mass HIway Operations 2
A: Connection Requirement 2
B: Clinical Gateway Nodes to the Department of Public Health 3
(1) Background 3
(2) Business and Architectural Review of the CG Nodes 3
(3) Consolidated Clinical Gateway Program 4
C: HIway 2.0 4
(1) HIway 2.0 Background 4
(2) HIway 2.0 Migration 5
a: Clinical Gateway Node Migration 5
b: Participant Migration 5
D: 2019 HAUS Program Update 5
(1) Background 5
(2) HAUS Progress 6
3: Future HIE Initiatives 7
A: Regulatory changes: HIway-facilitated Services 7
B: Event Notification Service – Update 8
(1) ENS Background 8
(2) ENS Certification Process 9
C. Query HIE & FHIR research project 9
4: Monitoring federal developments 10
5: Monitoring other state Health IT developments 10
A: Digital Health Council 10
Executive Summary
The Massachusetts Health Information Exchange Highway (Mass HIway) is a health information
exchange (HIE) program within the Commonwealth of Massachusetts' Executive Office of Health and
Human Services (EOHHS) and advised by a Health Information Technology Council (HIT Council)
composed of consumer, provider, legal and policy, and technology stakeholders. In 2019, the Mass
HIway saw several positive advancements in the exchange and interoperability, including the
development of the Event Notification Service (ENS) framework, as well as the upgrade of the HIway’s
Direct Messaging system. There were also significant policy developments at the federal level, where
the Office of the National Coordinator for Health Information Technology (ONC) and the Centers for
Medicare and Medicaid Services (CMS) proposed a pair of rules to improve the interoperability of health
information and address barriers to HIE adoption.
Mass HIway 2019 operations marked a successful year through key improvements to provider usage,
technical infrastructure, and adoption of new services. The Mass HIway continues to leverage the
statutory-based connection requirement under M.G.L. Chapter 118I, Section 7, to increase hospital,
health center, and physician connections to the HIway. In conjunction with the Department of Public
Health (DPH), providers use HIway Direct Messaging as the uniform transporting mechanism for public
health reporting. HIway Direct Messaging underwent a technological upgrade during the summer of
2019 to expand its connected network to include more providers locally and nationally. HIway account
managers and service managers helped 252 providers migrate their connections to the upgraded
system.
The Mass HIway engaged in the design and development of new HIE initiatives in 2019. First, it amended
its policies to create a new category of HIE services – HIway-facilitated Services – that seek to leverage
existing services and technologies in the market through a regulatory framework. ENS represents the
first offering within this new category of HIway-facilitated Services and will leverage existing market
solutions through state-certification to expand access to ENS for providers across the Commonwealth.
Vendor certification is expected to be completed in early 2020.
1: Introduction
Under M.G.L. c. 118I, the Massachusetts Legislature authorized EOHHS to coordinate and promote the
development of a statewide HIE.1 EOHHS created the Mass HIway program to embody those HIE
coordination and promotion efforts. The same enabling statute also created the HIT Council to serve as
an advisory body to EOHHS and the HIway program.1
This HIT Council Report to the Massachusetts Legislature fulfills the statutory requirement under M.G.L.
Chapter 118I, Section 15, for the HIT Council to file an annual report that: (a) describes the activities of
the HIT Council; and (b) describes the progress made in developing the statewide health information
exchange and recommending legislative action, if deemed appropriate.
This report provides an update on notable accomplishments and activities related to the state’s HIE that
occurred between January 1, 2019 and December 31, 2019. This report follows the previous report,
which covered activities through December 31, 2018.
1
M.G.L. c. 118I, Health Information Technology.
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The Mass HIway promotes the adoption of HIE through a variety of policy and technical levers.
Currently, it operates a Direct Messaging network (HIway Direct Messaging) that offers healthcare
entities the ability to securely and seamlessly transmit vital health data electronically, regardless of
affiliation, location, or differences in technology. The Mass HIway also has a health information
technology consulting service, HIway Adoption Utilization and Support (HAUS), to help Medicaid
providers make their systems interoperable by assessing a client’s technology and workflow, developing
a plan to meaningfully exchange health data, and supporting the implementation of that plan. The Mass
HIway is currently implementing a framework to leverage existing market-based solutions to provide
ENS to providers in the Commonwealth. The HIway’s activities aim to increase the Commonwealth’s
adoption of health information exchange and technology to improve care coordination, quality, patient
satisfaction, and public health reporting, while containing costs.
2: Mass HIway Operations
Mass HIway 2019 operations included important improvements to provider usage, technical
infrastructure, and adoption of services. The Mass HIway saw an increase in submitted attestations with
all acute care hospitals and almost every community health center. Commonwealth providers continue
to use HIway Direct Messaging as the uniform transporting mechanism for public health reporting.
HIway Direct Messaging underwent a technological upgrade over the summer of 2019 to increase its
connected network to include more providers locally and nationally. HIway account managers and
service managers helped 252 providers migrate their connections to the upgraded system.
A: Connection Requirement
As set forth in M.G.L. Chapter 118I, Section 7, and as detailed in the Mass HIway Regulations (101 CMR
20.00), healthcare providers in the Commonwealth are required to connect to, and to utilize HIway
Direct Messaging. This requirement is phased in over a four-year period, intended to incrementally
encourage the use of HIway Direct Messaging for provider-to-provider communications and bi-
directional exchange of health information.
Each organization shows how it met its annual requirement to connect to the Mass HIway by submitting
an attestation form. If an organization had not fulfilled the connection requirement, it was required to
submit a Health Information Exchange Exception Form explaining why the connection requirement had
not been met and the organization’s plans to comply with the requirement. During the 2019 attestation
period, Acute Care Hospitals were required to submit a Year 3 Attestation Form; Medium/Large Medical
Ambulatory Practices and Large Community Health Centers were required to submit a Year 2 Attestation
Form; and Small Community Health Centers were required to submit a Year 1 Attestation Form.2
In the winter and spring of 2019, the Mass HIway considered how to improve the 2019 attestation
process through which healthcare providers declare to the Commonwealth whether they have fulfilled
the connection requirement. To improve the process, the Mass HIway clarified language on the
attestation forms, added a “save and continue” function to the forms so they could be completed over
multiple sittings, and intensified outreach to Medium/Large Medical Ambulatory Practices (via targeted
2
Providers must meet harder attestation benchmarks each year to qualify as connecting to the HIway. In
Attestation Year 1, a provider must either send certain information to DPH or send or receive information with
another provider. Attestation Year 2 requires a provider to send or receive information with another provider.
Attestation Year 3 requires a provider to send and receive information with another provider.
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emails and a postal mail advisory). Overall, these improvements in process resulted in a higher
percentage of completed attestation and exception forms in 2019.
At the close of the 2019 attestation period, a total of 192 organizations had submitted either an
attestation or exception form. Among these organizations were 88 Medium/Large Medical Ambulatory
Practices (60 attestations, 28 exceptions), 37 Community Health Centers (34 attestations, 3 exceptions),
and all 67 Acute Care Hospitals (43 attestations, 24 exceptions). The HIway analyzes these submissions
to identify trends and potential opportunities for outreach to provider organizations to improve HIE.
B: Clinical Gateway Nodes to the Department of Public Health
(1) Background
The Clinical Gateway (CG) nodes are Mass HIway software applications that connect providers securely
to DPH and other state health care agencies for public health reporting. Providers send public health
reports via Direct Message to the Mass HIway, which transforms the message into a useable format for
agency systems. The CG node transformation processes include decryption of the original message,
validation that the data is correctly submitted, and transformation of the message into a format
acceptable to the receiving system. Reporting providers and state agencies benefit by allowing each
group to keep their existing technology infrastructure while the CG node does the transformative work
to allow seamless transfers.
Each of the following CG nodes is a separate application which supports a corresponding public health
reporting back-end application:
 Children’s Behavioral Health Initiative (CBHI)
 Childhood Lead Poison Prevention Program (CLPPP)
 Electronic Lab Reporting (ELR)
 Opioid Treatment and TB Reporting Programs (I-EATS)
 Massachusetts Cancer Registry (MCR)
 Massachusetts Immunization Information System (MIIS)
 Syndromic Surveillance Program (Syndromic)
The architecture for the existing CG nodes was developed in 2012 with the launch of HIway Direct
Messaging. The CG nodes were scaled up by copying the first CG node and recoding it as a separate
application to be able to connect to a respective DPH system. The multiple CG nodes are currently
running in the EOHHS Private Cloud Data Center, LogicWorks Virtual Gateway (VG).
(2) Business and Architectural Review of the CG Nodes
The Mass HIway conducted a business and architectural review of the CG nodes in 2019 with the goal of
identifying current and future needs and challenges of the CG nodes. The comprehensive review
identified the following challenges:
 Infrastructure not positioned to meet emerging FHIR-based API standards.
 Infrastructure not easily scalable or extensible.
 Infrastructure requires long turnaround time to update nodes including routine software
updates.
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(3) Consolidated Clinical Gateway Program
Starting in October 2019, and intended to be complete in Q1 of 2021, the Mass HIway team began to
transform the current set of CG nodes into a single Consolidated Clinical Gateway (CCG) application. The
CCG will allow the HIway to resolve the issues identified in the business and architectural review
discussed above. The CCG will meet the developing national trends by creating a new web service link to
DPH using APIs and FHIR. The CCG will undergo a technical shift from the current independent multiple
applications to a single application for all public health reporting needs. This shift will improve scalability
for future DPH reporting requirements as the Mass HIway will only need to create a single module, A
single CCG will streamline the upgrade process by having a single upgrade to the CCG rather than
individual updates for each of the seven CGs. In addition, the CCG will move to another data center,
Amazon Web Services, which will result in higher efficiency as operating resources required will be
reduced and usage fees lowered compared to the VG environment.
The following exhibit presents a high-level technical view of the proposed technical architecture of the
CCG (see Exhibit 1).
Exhibit 1
C: HIway 2.0
HIway 2.0 was an initiative led by the Mass HIway to upgrade its Direct Messaging system. The HIway
achieved this upgrade by moving Mass HIway operations to Communicate, Orion Health’s commercial
off-the-shelf solution. HIway 2.0 improves the ability of HIway Direct Messaging to connect to providers
around the country.
(1) HIway 2.0 Background
The Mass HIway was initially developed in 2012 by Orion Health as a custom solution (HIway 1.0) for
Massachusetts. In January 2018, EOHHS and Orion Health executed a new contract for EOHHS to
transition from the custom solution to Communicate.
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Communicate is a Health Information Service Provider (HISP) used by more than 20 clients across the
US. The Communicate HISP is accredited by the Electronic Healthcare Network Accreditation
Commission (EHNAC) to participate in DirectTrust. DirectTrust is a national framework that allows any
user of a DirectTrust HISP to send or receive Direct messages with any other provider using another
DirectTrust-accredited HISP. Thus, by transitioning to Communicate as the platform for HIway Direct
Messaging, connected Massachusetts providers can communicate with more providers within
Massachusetts and nationally.
On the technical side, Communicate allows for faster enhancements, product updates, and functionality
improvements through economies of scale. The system is maintained using internationally recognized
standards for health information exchange. Using Communicate, which is a Software as a Service (SaaS)
product, enables the state to leverage Orion Health’s infrastructure, and no longer maintain state
infrastructure to operate the system.
(2) HIway 2.0 Migration
HIway 2.0 became available for use in June 2018 after the migration of all CG nodes, and all HIway
Participant migration projects were completed by June 2019. Upon completion of the migration,
provider access to HIway 1.0 was shut down, following an extensive communications and awareness
campaign. All HIway Participants successfully made the transition to the new system.
a: Clinical Gateway Node Migration
HIway 2.0 Migration began with the seven CG nodes. Each CG node was upgraded to adhere to the
latest standards and then migrated one by one. This effort was completed in June 2018.
b: Participant Migration
During the project, the HIway Operations Team migrated all 316 active connections, used by 252 HIway
Participants, from HIway 1.0 to HIway 2.0. To ensure a secure environment, a key component of the
migration was the identity proofing of all participants. Identity proofing is a way to ensure that messages
are delivered to the intended recipient, through a chain of verified identities. The HIway 2.0 identity
proofing process uses a third party and requires a notarized form from each HIway Participant
organization.
D: 2019 HAUS Program Update
(1) Background
The primary goal of the HAUS program is to improve patient transitions of care among Medicaid
provider organizations through electronic provider-to-provider communication. A secondary goal of this
program is to assist providers in achieving Meaningful Use measures through integration of electronic
exchange of information.
The HAUS program is aimed at offering high-touch, hands-on consulting services to eligible provider
organizations to ensure use cases are fully implemented by sending and receiving organizations. Typical
use cases and the reasoning behind them include:
 Sending a referral to a specialist with patient information such as current condition, reason for
consultation, and expected outcome of consultation. The use case goal is for specialist
treatment to be more effective; the expectations of the primary care provider (PCP) are clear at
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 the outset and the specialist has all patient information at hand (therefore does not have to
engage in duplicative testing to understand the presenting illness).
 Sending a discharge summary from a hospital to a skilled nursing facility (SNF). Discharge
summaries are often lost in transit when given as a paper copy, SNFs need Discharge Summaries
to ensure continuity of care.
 Exchange of care plans between behavioral health community partners (CP) and PCPs in an
Accountable Care environment.
The following are examples of typical activities performed during a HAUS engagement:
 Creating cross-functional teams between participants to enhance coordination. These teams
may include clinical, information technology, and business leadership to ensure that the needs
of all stakeholders (clinicians, clinical staff, etc.) are addressed and that the information
exchange approach genuinely improves patient care, not just complies with information
exchange regulations.
 Facilitating “face-to-face” communication between multiple provider organizations to define
clinical information exchange requirements and protocols.
 Documenting agreed-upon clinical protocols, including the content of clinical documen