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Building an ESD System for Texas - Report Summaries

Note: To help the reader navigate this report, a chart of acronyms is provided at the beginning of Chapter 2 in Exhibit 1 .

2.8.1. Report Summaries

The report summaries presented below begin with those identified in state legislation as programs required to explore EBT alternatives. This includes the Medical Identification (Med ID) and Child Support programs. These are followed by EBT2 and WIC that currently have EBT/ESD initiatives either operating or in process. The remaining summaries are programs that have potential ESD opportunities but have not initiated ESD activities.


The current Med ID form (TDHS Form 3087) is used to notify both providers and recipients of eligibility for 11 types of programs, including Medicaid, and certain Medicare and other health programs. Med IDs are issued monthly, based on eligibility determined by TDHS through information entered into the System for Application, Verification, Eligibility, Referral, and Reporting (SAVERR). Additional eligibility information is derived from Social Security Administration's State Data Exchange (SDX) system, the EPSDT system, and the Med ID system itself.

While the Medicaid eligibility and record system is electronic, the distribution of that information is paper based. Currently, the Med ID 'card' is mailed and serves as a vehicle for distributing both medical and other state agency program information to clients.

Problems with this system include a high weekly/monthly postage cost, an early monthly cutoff which does not allow for effecting end of the month data changes, and client confusion resulting from the large number and type of cards received in a family household. Timely access to the medical eligibility data is also a problem. Claims are sometimes based on inaccurate eligibility or service authorization information because of late or delayed delivery of the ID card, and online access to eligibility files is inadequate.

Collaborating state agencies are considering ESD solutions, including magnetic stripe/smart card technology, voice response and other interface options, and expansion of the pharmacy POS system to other health service providers. A variety of configurations of services and delivery technologies will be explored.

Issues to consider related to an ESD System:

  • HCFA regulations regarding access to medical eligibility information (reference HIPAA regulations);
  • Multiple agency and program area (DIR, HHSC, TDH, TDHS, TXMHMR, PRS, OAG) use of the card;
  • Authorized representatives use of the card to purchase prescription medications for another individual; and
  • Alternatives for distribution of information currently provided on the Med ID card.

Child Support Enforcement - OAG

The Office of the Attorney General (OAG) receives child support payments, manually and electronically, from obligors, employers, and counties. An electronic disbursement file is created and sent on tape to the Comptroller of Public Accounts (CPA) office. Warrants are printed and mailed to custodial parents. This system is simple, fairly cost-effective, and works well, but it is paper intensive and slow due to processing and mail time.

House Bill 3272 requires the OAG to explore the use of an EBT system. As a result, the OAG is investigating other ESD possibilities. Electronic funds transfer (direct deposit) will be available for child support recipients by early 2001. Custodial parents who are TANF recipients or who do not have bank accounts are prime candidates for an ESD process for distribution. ESD possibilities include low cost or no cost bank accounts with debit EBT cards.

There is a pass-through payment to TANF parents of up to $50, referred to as a supplemental grant, that is currently processed by OAG. Since this is a simple cash benefit like TANF, consideration should be given to adding this payment to the Lone Star Card.

NOTE: TDHS has indicated in their review of the draft report that TDHS has made the decision to add the supplemental grant to the Lone Star Card. 43

The OAG conducted a customer survey in 1996, to identify preferences regarding distribution of child support funds. The results indicated that custodial parents prefer receiving warrants rather than other proposed options including direct deposit and EBT. A second customer survey, conducted in August 2000, had similar results regarding use of EBT. The majority of respondents indicated that they do not want to use the Lone Star Card to access their child support payments, in spite of the fact that 53 percent of the respondents have at one time or are currently using the card. Some respondents did indicate a willingness to use a Child Support EBT card; however, 75 percent are now interested in direct deposit as the preferred method of access.

Issues to consider related to an ESD System:

  • Stated preferences for current distribution methods;
  • Cost for establishing bank accounts and debit card fees;
  • Perceived negative attitude toward users of the Lone Star Card; and
  • Options for implementing an ESD system. The OAG suggested that consideration be given to a three phased approach to include:
    Phase 1 - TANF $50 supplemental grant handled by TDHS as part of the Lone Star Card;
    Phase 2 - Non-TANF - banked population with direct deposit; and
    Phase 3 - Unbanked population - debit card or state opened/paid banking account.


EBT2 will replace the current EBT system, through which TANF and Food Stamp benefits are delivered. The new system is an enhanced approach to EBT that will continue to use the magnetic stripe Lone Star card, but will offer significantly greater features and flexibility. The transition from a single vendor to a multi-vendor structure will be completed in January 2001.

TDHS has led the nation in developing a more competitive procurement process for EBT services. TDHS' three component strategy allowed more vendors to compete for each component. TDHS staff has done a commendable job of handling this very complex technology project and operating as the system integrator for the new EBT2 system.

Three vendors will work with the state. Affiliated Computer Services (ACS) will replace and maintain POS devices, and transactions will be processed through ACS/Card Systems as a third-party processor. A second vendor, GTECH, will provide a bilingual call center, and Northrop Grumman Technical Services, Inc. (NGTSI) will operate the data center for the system.

In this new arrangement, the state, in the role of prime, will have a perpetual license from the original EBT contractor for the software and can make modifications to add new applications. TDHS will have the source code required to make these modifications. Other agency programs and services can be added with the payment of an additional license fee. TDHS programs can be added with no additional fee.

EBT2 offers a more open infrastructure - allowing more retailers, ATMs, and programs with cash benefits to be added. It will have three mirrored systems running at the same time to provide backup in case of system failure. TDHS has tried to bring farmers' markets into the EBT service network with mixed success since phone line connections are difficult in these locations. In addition, emergency disaster recovery is also problematic if phone lines are not working. Improvements in EBT wireless card reader technology brings the opportunity to reassess solutions to both of these areas.

Issues to consider related to an ESD System:

  • Importance of all stakeholders - retailers, clients, and others;
  • Options for payment of fees for ATM transactions;
  • Retailers' concern regarding large cash transactions and the amount of money required on-hand for these transactions; and
  • Options for administration of a one card, one platform, multiple services system.

Supplemental Nutrition Program for Women, Infants, and Children (WIC) - TDH

The WIC Program prescribes specific foods that meet nutritional needs of pregnant and postpartum women, infants, and children that are obtained through a manual system, using paper vouchers. Redeemed vouchers are batched by retailers and submitted to the Texas Department of Health (TDH) for payment. TDH is planning to replace the paper food voucher and retailer claims system with a hybrid Lone Star Card that contains a magnetic stripe to access Food Stamp and TANF benefits and a chip to provide the WIC food prescription.

In 1999, Texas and New Mexico jointly released an RFO to contract with a prime vendor for development of a system and for a pilot project, but no responsive bids were received. The RFO was revised and another joint RFO was issued in June 2000 for a card integrator for the WIC program in both states. The RFO specified a hybrid card and included a bar code in the specifications. The plan calls for a pilot in 2001 in El Paso, Texas and Truth or Consequences, New Mexico. The states will act as prime vendors, continuing the Texas Trend. 45

TDH worked with retailers in the development of their WIC approach, especially in the development of nationally accepted WIC messaging standards. TDH responded to retailer concerns over the state's having two cards by developing a hybrid card for TDH and TDHS programs. TDH identifies the advantages of an off-line system using the hybrid card as avoidance of grocers' online transaction fees for WIC.

In the planned system, the food prescription will be loaded on the hybrid card at the health clinic where the client is seen. Retailers will read the food prescription off-line, with a smart card reader at the checkout stands. Authorized purchases will be debited from the balance on the card. The cost of the transaction is to be stored on the store's front-end system, or in a separate file within the store, and at the end of the day a single financial settlement will be made with the state's host system.

Considering expansion of this system at some point in the future, TDH may include demographic and immunization information on the card so this information can be shared with other providers.

Issues being considered related to an ESD System:

  • Many retail grocers prefer an integrated system for WIC and Food Stamps/TANF, and do not favor an off-line, smart card system;
  • The replacement rate and cost of replacement for cards (to be studied during pilot);
  • Cost of new equipment and other infrastructures, and who bears the costs; and
  • Options for operating and managing an ESD system across agency lines.

Vendor Drug Program - TDH

The Vendor Drug Program uses an online system to pay pharmacies for authorized prescriptions. A file is sent to the Comptroller's office for electronic payment. A paper Med ID card confirms client eligibility to the pharmacy and essentially guarantees payment. This system seems to be functioning adequately, however the following complaints have been expressed:

  • The Med ID card used to verify prescription eligibility is subject to client fraud;
  • If the current system is down on weekends, some clients are denied purchases until the system is back up for authorization; and
  • The length of time required from eligibility determination to the issuance of an ID card to a client is excessive and may delay services to clients.

Pharmacies are currently responsible for identifying potential drug interactions among prescriptions for an individual. TDH is planning an automated system to check for those. The system will be able to detect a potential interaction within two seconds and terminate a transaction within 15 seconds. No other ESD changes are being planned.

Issues to consider related to an ESD System:

  • Alternatives for communicating information currently provided on the Med ID card.

Medicaid Managed Care - TDH

The Medicaid managed care program is a state initiative that delivers health care services through HMO's to about a third of the state's Medicaid population, and is available in eight areas of the state. Expansion of the system is currently under a moratorium by the state legislature until a current evaluation is completed.

Eligibility is determined by TDHS and Medicaid data resides on the SAVERR system. The Med ID card and an HMO card are used together to obtain services.

A number of problems with the current system are leading TDH to explore the possibility of using an ESD system as the identifier/authentication mechanism for Medicaid, but the financial and programmatic impact of ESD on the agency programs has not been determined. The agency is interested in an ID card, with a back-up system, that also holds basic health information, and that would allow eligibility access online, in real time.

Major problems that could potentially be alleviated by an ESD approach are:

  • Out-of-date Med ID cards (provider online access is an alternative for resolving this problem);
  • Dependency on TDHS cut-off date for processing Med ID cards; and
  • Duplication and unauthorized use of current Med ID cards.

Issues to consider related to an ESD system:

  • Equipment or alternate interfaces for 'low-tech' providers;
  • Interoperability;
  • Highly mobile population moving from an HMO area to a non-HMO area;
  • Linking the Med ID card and the HMO card - one card or two; and
  • Card loss.

Children's Health Insurance Program (CHIP) - HHSC

CHIP is a state-sponsored insurance program designed for families who earn too much money to qualify for Medicaid health care, yet cannot afford to buy private insurance. Families pay premiums that vary depending on family income, regardless of the number of children in the family. These costs could be as little as a $15 annual premium, or as much as $18 paid each month ($216 a year). Most families also have co-payments that vary on a sliding scale, depending on family income. Children enrolled in CHIP are guaranteed 12 months of coverage. Children must be re-enrolled annually.

The program began accepting applications in April 2000, and health care coverage started May 1, 2000. Enrollment is expected to reach 100,000 in fiscal 2001. The original projection was for 400,000 after two years, but Texas is currently ahead of the pace of other states' startup experiences.

A third-party administrator, Birch and Davis, determines eligibility and is responsible for premium payment collection. Applications are currently taken over the phone and by mail.

The state contracts with private HMOs to provide the medical coverage. The HMOs issue a member card to enrollees-just like any HMO card. The provider uses the telephone to check eligibility, cost-sharing and co-payment information; or can call the health plan to check services. The system is comparable to commercial market coverage. Members can change plans once a year or more frequently with good cause. Although the program is supported with state funds, members see it as private insurance, and it has a non-governmental profile.

ESD applications could potentially improve this program by streamlining some of the current telephone processes relating to confirmation of cost sharing and co-payments liability. A card system could also carry basic health information, immunization records and other health-related information.

Another enhancement would be to allow CHIP premiums to be paid at various cash payment sites, like grocery stores, similar to the way utility bills are currently handled. Issues around such an initiative would need to be explored.

Texas Healthy Kids Corp. is a private, non-profit program similar to CHIP, but it was started before CHIP. It is expected that CHIP-eligible kids enrolled in that program will eventually migrate into CHIP.

Issues to consider related to an ESD System:

  • There may be concerns about a central repository of health data; however, that could be minimized if the data were input by the health provider on client-controlled cards, instead of accessed from a large database;
  • Because of the program's profile, any card used would have to avoid the image of a 'welfare' card. Also, since the program is open to legal immigrants, any image of connection to a government sponsored program (especially one perceived to relate to INS) is an emotionally charged area; and
  • The HMOs currently view their client member cards as a marketing tool which must be considered if the card is to serve as the HMO identifier.

Facility Residential Services - TXMHMR

TXMHMR operates state hospitals and state schools, which provide residential mental health and mental retardation services, respectively. Upon admission, a client is registered on the centralized, automated case management (CARE) system. CARE is not a complete case file, but does document clients served and the services they receive. Upon discharge, clients are followed in the community by their local Mental Health and Mental Retardation authority (usually the local Community MHMR Center). In TXMHMRs traditional system, the medical record is a hard copy file, which is maintained in the unit's nursing station. Entries in the record are made by hand or typed following dictation by the attending staff. Hand-written charts are time consuming, and duplication of records cost time and paper, making this manual system cumbersome.

TXMHMR is implementing an electronic medical record system for state facilities. A master electronic record is maintained within the facility that clinicians access through workstations for reading and for direct data entry to the charts. A voice response system is being explored for direct dictation into the system. TXMHMR is also investigating options for intra-agency sharing of the medical records, across facilities and community centers.

The new system is implemented in eight facilities: four state schools and four state hospitals. Facility-wide rollout was planned for the end of fiscal 2002, however implementations in state schools are scaled back due to funding issues. State hospital implementation should be complete on or before that date.

Another area for exploration is patient trust fund accounts. Debit cards or similar technology might be considered.

Issues to consider related to an ESD System:

  • ADA issues and the need to accommodate access needs of a variety of client and professional capabilities.

Training and Support Services - TXMHMR

" Training and Support Services" is a label employed to describe a group of mental health and mental retardation services designed to support natural living arrangements in community settings. These outpatient services are delivered through the local Community MHMR Centers (CMHMRC). Local case managers determine need and authorize services. Most CMHMRCs have a paper-based system, but this varies across the state, as each is a separate local non-profit corporation. Services may be delivered by CMHMRC staff or by contracted providers. In some cases, clients are given a voucher for services that is redeemed by service providers. Eligible clients are entered on the statewide client database with basic identifying and service delivery information.

The system is reasonably reliable, but there is not a good way to monitor or assure that services contracted by outside providers are delivered as contracted, especially in areas such as in-home attendant care. About fifteen years ago, an American Express card-based system was tried for approximately eight months as a mechanism for tracking service authorization and payment, but it lacked acceptance from business managers, as they were not satisfied with the system's audit trail.46

Some type of smart card technology may be possible for services involving specific dollar authorizations granted to the client, if adequate controls are incorporated into the system. Card-based technology could also be used to document service delivery, such as providers that come to a client's home to deliver attendant care.

Issues to consider related to an ESD system:

  • The home environment of some clients, and its impact on possible hardware that might be installed there (problems have been documented with electronic emergency monitoring devices for the elderly - such as the problem of roaches that have invaded the devices and eaten away their components, rendering them useless); and
  • ADA issues and the need to accommodate access needs of a variety of client and professional capabilities.


NorthSTAR is an integrated behavioral health (mental health and chemical dependency) project mandated by state law, operating in the seven-county Dallas service area. It serves Medicaid recipients and some medically indigent and other non-Medicaid people based on their need for behavioral health services.

All behavioral health services are delivered through two behavioral health organizations (BHOs). Client eligibility is documented on the SAVERR system, just as in the regular STAR program that serves the rest of the state's Medicaid-eligible clients. The BHO is paid per enrolled member, per month. Claims are processed and paid by the BHO.

The project uses existing TDHS, TDH, TXMHMR and TCADA automated systems for eligibility determination, claims, and payments. The BHOs must maintain records in a fashion that can link electronically to these systems. Of issue to this project is their inability to update client information on the automated eligibility system, as TDHS staff are the only ones who can access the GWS and SAVERR. It sometimes takes as much as seven months to get eligibility changes into the system. As a result, caseworkers sometimes are dealing with inaccurate or incomplete information.

Staff suggest that the NorthSTAR system could be improved by use of card technology that contains specific mental health care information on the client, including prescriptions, immunizations, number of visits, and other relevant data. The project could link cards to the project's database.

Issues to consider related to an ESD System:

  • Need for direct linkage to the eligibility information system; and
  • Use of kiosks by the clients to access the database for updates such as address changes.

Workforce Development: Choices and Welfare to Work - TWC

The Texas Workforce Commission's (TWC) Choices and Welfare to Work (WtW) programs are employment and training programs serving TANF applicants and recipients. Because services are administered and delivered by 28 local Workforce Development Boards (WDB) and a variety of contract providers, the service delivery systems vary considerably, although they are virtually all paper-based systems.

TWC would be interested in a card that could track a variety of data regarding employment-related services such as attendance and participation rates. The question is whether a card could hold sufficient information or allow access to the information in an efficient, cost-effective manner. TWC identified the need also for demographic data on a card that will allow easier entry of this information into various databases.

Oklahoma is using a card system for childcare that is combined with the TANF/Food Stamp card. A card is also issued for clients who are not TANF or Food Stamp recipients. TWC has identified the possible need for a similar approach for Texas.

Issues to consider related to an ESD system:

  • Access to and expense of equipment for small childcare providers such as grandparents or other family members who are contracted providers; and
  • Need for a manual or alternate system for those with no equipment.

Unemployment Insurance - TWC

TWC's Unemployment Insurance (UI) program provides temporary income to unemployed former wage earners. All UI claims are handled through call centers (in-person contact is not required) and warrants are issued and mailed every two weeks by TWC. The warrant is cut the same day the request for payment is approved and can be sent to a claimant anywhere in the U.S. A statement of account is mailed with each warrant, showing funds availability and account balances, as well as deductions including child support, income taxes withheld, and other relevant information. TWC is satisfied with the current system.

TWC conducted a feasibility study regarding EBT and direct deposit in 1997. The results of the study indicated cost for EBT for UI would be at least 97 cents per transaction, compared to the current cost of 41 cents per warrant. In addition, the study did not support direct deposits to banked claimants despite the fact that 65 percent to 70 percent of the claimants had bank accounts. At the time of the study, only 27 percent of claimants surveyed indicated an interest in direct deposit. There are some barriers to setting up direct deposits because of TWC's new telephone filing system and the Comptroller of Public Account's procedures for direct deposit. Other states have set up direct deposit systems for UI with varying degrees of success.

TWC is not opposed to reexamining ESD options, especially in light of new technologies. ESD could be a viable option if new technologies and the potential for volume discounts could reduce costs.

Issues to consider related to an ESD system:

  • The requirement to provide current account information to the claimant;
  • The size of checks may be too great for a grocer to become the banker;
  • UI claimants may need access to funds through an ATM structure; and
  • Barriers for setting up direct deposit need to be addressed.

Vocational Rehabilitation and Disability Determinations - TRC

The Texas Rehabilitation Commission provides Vocational Rehabilitation (VR) and Disability Determination Services (DDS). VR has implemented a client database for tracking actions with clients. Disability claims processing is usually done by phone and mail, using existing paper medical records.

In Vocational Rehabilitation, the counselor determines eligibility then enters that information into an electronic case file. This file system is purely informational, giving some options to guide the counselors in providing services to the client. It does have the capacity to inform staff if the applicant is already active in the system. The vendor payment system uses a printed purchase order and invoice. Payments are processed through the state's regular payment system. Problems with this delivery system are mainly noted as those related to individual service providers, in that there is no consistency in report format across vendors, and it is difficult to verify that services have been provided as agreed, by both the client and the providers. In the late 1980s and early 1990s, laser card technology was considered and piloted in a small area, but did not work for the applications for the TRCs client population.

TRC has designed their internal client service and purchasing systems to take advantage of Internet processing technologies. Also, federal Social Security Administration staff believes that the Internet holds the greatest potential as a vehicle for medical reporting in the future.

Issues to consider related to an ESD System:

  • Clients with physical and mental disabilities may have limited use of certain technology;
  • Small providers may not be able to accommodate some electronic vendor systems; and
  • Since this is not a large population, it may be more cost-efficient to piggyback on other systems.

Texas Department of Protective and Regulatory Services

This agency has three primary service groups: Protective Services to Children; Adult Protective Services; and Childcare Licensing. Because of the nature of the services, PRS has links with most of the health and human service agencies and the school systems.

PRS staff use an automated Child and Adult Protective System (CAPS), to register cases and assist with reporting requirements. Connections through this system allow information sharing with TXMHMR. However, the case record is still a paper system that is maintained locally. Currently payments to foster parents and adoption subsidy payments, and payments to local contracted providers are handled with paper warrants.

PRS has not explored the use of an ESD system, but staff have identified opportunities that have the potential to benefit service delivery. These could include cards or direct deposit for foster care and adoption subsidies; access to school records of foster care and other PRS case-related children; and access to law enforcement records for children within the PRS system.

Issues to consider related to an ESD system:

  • Local Child Welfare Boards deliver child protective services so an ESD system could potentially accommodate local provider payments; and
  • Privacy and access issues related to school records.

Employees Retirement System - Tex Flex Card

The Employees Retirement System operates a program called Tex Flex-tax-favored reimbursement accounts regulated by Section 125 of the Internal Revenue Code. Money is automatically deducted from state employees' paychecks before federal income and Social Security taxes are calculated. These accounts can be used by employees to reimburse themselves for eligible health care expenses (such as eyeglasses or medical/dental expenses) and for eligible dependent care (such as child day care). The accounts result in tax savings to the employee, as those funds are sheltered from taxes.

Currently claims are filed using hard copy forms and receipts from providers for eligible expenses. The IRS requires that any funds remaining unclaimed in a Tex Flex account at the end of the year be forfeited. Use of these forfeited funds for plan administration has allowed ERS to eliminate the monthly fee that was formerly charged to employees for processing the Tex Flex accounts.

On September 1, 2000, ERS implemented a new magnetic stripe FLEXcard, which operates similarly to a debit card, for accessing funds from employees' reimbursement accounts. The employee will give the card to any provider with a credit card reader. The provider will then be paid directly out of the employee's reimbursement account, for eligible services.

Use of the card is not mandatory. Manual claims will still be processed if that is the employee's preference; and the manual claims process will have to be used for providers that do not have card readers, such as small day care providers.

The change was suggested by the third party administrator, and is the first state government implementation of such a system, although some private systems do exist. The administration of the program is funded out of Tex Flex forfeitures at the end of the year. The total program cost is $2.25 per month per employee, plus transaction costs. The employee pays a $1 per month charge plus a 50-cent per transaction fee for processing. ERS is absorbing the other $1.25 per month.

Issues to consider related to an ESD system:

  • Cost of the smart card infrastructure. ERS is interested in partnering with other agencies and functions for sharing system costs;
  • Health Insurance Portability and Accountability Act (HIPAA) Requirements. Even if compliance with the new HIPAA requirements is not difficult for state agencies, the issue will be with contractors. The concern would be if Blue Cross or the local physicians have privacy controls in place. Putting medical records on cards will depend on these providers being HIPAA compliant. That requirement will need to be included in contracts in the future; and
  • ERS is interested in migrating to smart card technology, with the possibility of incorporating other functions such as: state employee ID; insurance carrier information; and insurance co-pay information.

The University of Texas

The 15 university facilities under the UT System have varying degrees of ESD activity. Pilots have been initiated at UT Austin, UT El Paso, UT San Antonio, and the UT Medical Branch at Galveston (see below). At UT Austin, the School of Business is piloting a smart card system for students and faculty identification, covering functions such as building and computer access. The School of Business was selected for this pilot because all the equipment and technology within the school was compatible. Possible additional uses of a campus or UT System-wide ID card could include purchase of cultural and sporting event tickets, admission to student union activities, and payment for other services. The university has investigated the use of Verasign documents for authentication purposes, but that technology continues to be expensive, and UT identified concerns about liability.

Issues to consider related to an ESD system:

  • One authentication credential is needed across the UT system covering about 250,000 students, faculty, and staff;
  • Any system would need to be flexible enough to allow a variety of functions, to operate autonomously, such as housing, meals, and laundry; and
  • The technology must be accessible to all users including those with disabilities.

University of Texas Medical Branch at Galveston (UTMB)

UTMB currently operates two ESD systems: a card for campus security, and one for employee identification. They are in the planning stages for development of system enhancements.

The facility is planning a card identification system that will allow a single sign-on to all systems at the level authorized for each employee. All business actions will be attributable to a specific individual, including entries on patient records, department purchases, and other transactions. A procurement system is being purchased which uses e-commerce technology. UTMB plans to have computer-based training (CBT) with this system before authorizing users.

UTMB would like to move storage of information to the Internet or a virtual private network, which would be accessible anywhere. Doctors could then access the medical records and link to related files and systems.

Issues to consider related to an ESD system:

  • Much of what UTMB develops will be affected by the Healthcare Information Portability and Accountability Act (HIPAA).