2013-11-15T15:25:38-06:00 2012-12-31 352123203 KSM BUSINESS SERVICES INC PO BOX 40857 INDIANAPOLIS IN 462400857 990 2012-01-01 364550324 INDIANA HEALTH INFORMATION EXCHANGE INC INDI 3176441720 846 N SENATE AVENUE NO 300 INDIANAPOLIS IN 46202 BRIAN MODIANO 3176441720 2013-11-15 1 SCOTT A SCHUSTER P00019243 3175802000 2013-11-15 2012 2016-02-25 16:41:14Z HAROLD APPLE 846 N SENATE AVE INDIANAPOLIS IN 46202 13075200 0 X WWW.IHIE.ORG X 2004 IN OUR MISSION IS TO USE INFORMATION TECHNOLOGY AND SHARED CLINICAL INFORMATION TO: - IMPROVE THE QUALITY, SAFETY, AND EFFICIENCY OF HEALTH CARE - CREATE UNPARALLELED RESEARCH CAPABILITIES FOR HEALTH RESEARCHERS- EXHIBIT A SUCCESSFUL MODEL OF HEALTH INFORMATION EXCHANGE FOR THE REST OF THE COUNTRY 16 8 85 0 0 0 0 0 12828211 13024414 4963 2073 -71953 48713 12761221 13075200 0 0 0 0 6674128 7013243 0 0 0 6115317 6736180 12789445 13749423 -28224 -674223 5301958 2917178 3239259 1609308 2062699 1307870 X OUR MISSION IS TO USE INFORMATION TECHNOLOGY AND SHARED CLINICAL INFORMATION TO: - IMPROVE THE QUALITY, SAFETY, AND EFFICIENCY OF HEALTH CARE - CREATE UNPARALLELED RESEARCH CAPABILITIES FOR HEALTH RESEARCHERS- EXHIBIT A SUCCESSFUL MODEL OF HEALTH INFORMATION EXCHANGE FOR THE REST OF THE COUNTRY 0 0 8728291 CLINICAL MESSAGING - PROVIDE PATIENTS ELECTRONIC MEDICAL INFORMATION AND TEST RESULTS TO INDIANA HOSPITALS. 1540287 CLINICAL QUALITY - TO PROVIDE MEASUREMENT OF CLINICS TREATMENT OF PATIENTS - GOAL IS TO IMPROVE HEALTH CARE. 10268578 1 0 0 1 0 0 0 0 0 0 1 0 0 0 0 1 0 1 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 1 1 0 0 0 1 13 0 1 85 1 0 0 0 0 0 0 0 0 0 0 X 16 8 0 0 0 0 0 0 0 1 1 0 0 1 1 1 1 1 1 1 1 0 IN X HAROLD APPLE CEO 3176441720 846 N SENATE AVENUE SUITE 110 INDIANAPOLIS IN 46202 VINCENT C CAPONI 2.00 X X 0 2799320 53508 WILLIAM R CAST 2.00 X 0 0 0 DAVID COOK 2.00 X 0 0 0 DANIEL F EVANS JR 2.00 X 0 1413834 865442 MATTHEW R GUTWEIN 2.00 X 0 324453 26875 DAVID L JOHNSON 2.00 X X 0 404673 23574 NED LAMKIN 2.00 X 0 0 0 TERESA L LOVINS 2.00 X 0 0 0 BRYAN A MILLS 2.00 X 0 0 0 WILLIAM R TIERNEY 2.00 X X 0 323158 95974 D CRAIG BRATER 2.00 X 0 594186 20000 ROBERT BRODY 2.00 X 0 888412 719857 VIRGINIA CAINE 2.00 X 0 0 0 WAYNE DEVEYDT 2.00 X 0 0 0 JOHN ELLIS 2.00 X 0 0 0 DOUGLAS J LEONARD 2.00 X 0 691022 177433 HAROLD APPLE 40.00 X 253846 0 7056 THOMAS P PENNO 40.00 X 110758 0 4 BRIAN MODIANO 40.00 X 171995 0 12060 JANE NIEDERBERGER 40.00 X 155817 0 10119 JAMES S HILL 40.00 X 184174 0 8966 KENT HILLER 40.00 X 160378 0 8966 KESHIA COOPER 40.00 X 151797 0 10022 KEITH W KELLEY 40.00 X 166708 0 12040 ERIC T THIEME 40.00 X 148700 0 14066 JOHN P KANSKY 40.00 X 185029 0 16258 JOSH NELSON 40.00 X 175560 0 6556 1864762 7439058 2088776 25 0 1 0 REGENSTRIEF INSTITUTE 410 WEST 10TH STREET STE 2000 INDIANAPOLIS IN 46202 HEALTHCARE RESEARCH 3644377 AT&T PO BOX 5019 CAROL STREAM IL 60197 COMMUNICATION SERVICES 621462 ST VINCENT HEALTH 10330 NORTH MERIDIAN STREET INDIANAPOLIS IN 46290 IMPLEMENTATION AND PROJECT MANAGEMENT 321094 ANCHOR POINT TECHNOLOGY RESOURCES 8440 WOODFIELD CROSSING BLVD STE INDIANAPOLIS IN 46240 TECHNOLOGY STAFFING 236378 HEALTHCARE OPTIONS INC 3901 WEST 86TH STREET SUITE 270 INDIANAPOLIS IN 46268 BEACON PROJECT MANAGEMENT & DEVELOPMENT 170484 6 CLINICAL MESSAGING 519100 6316466 6316466 PROGRAM REVENUE 519100 5067559 5067559 ANALYTICAL SERVICES 519100 1138825 1138825 CONSULTING 541900 501564 501564 13024414 2073 2073 OTHER INCOME 900099 48713 48713 48713 13075200 13073127 0 2073 1084139 41484 1042655 4763397 3946560 816837 127599 87023 40576 574653 391916 182737 463455 316078 147377 90909 27072 63837 122188 122188 48105 48105 61903 45193 16710 89969 4466 85503 35801 35801 881804 835261 46543 276039 276039 147843 48421 99422 538936 256370 282566 37295 37295 CONSULTANTS 4240358 4209539 30819 EQUIPMENT LEASING 61422 44055 17367 TRAINING 27212 12495 14717 TELEPHONE 19135 19135 57261 2645 54616 13749423 10268578 3480845 0 1208009 197418 691422 1207 716631 1562162 573406 499096 546048 2480751 1301175 1381138 1179576 -899002 -978858 839623 662240 19510 19510 5301958 2917178 2280645 1289770 958614 319538 3239259 1609308 X 2062699 1307870 2062699 1307870 5301958 2917178 X -674223 -80606 X X 0 1 X 1 1 1 X X X 0 0 0 INDIANA UNIVERSITY HEALTH 351955872 LINE 3 1 1 1 0 COMMUNITY HOSPITALS OF INDIANA 350983617 LINE 3 1 1 1 0 HEALTH & HOSPITAL CORPORATION 356065697 LINE 6 1 1 1 0 INDIANA STATE MEDICAL ASSOCIATION 350411650 LINE 9 1 1 1 0 INDIANA UNIVERSITY 356001673 LINE 6 1 1 1 0 THE INDIANAPOLIS MEDICAL SOCIETY 127566088 LINE 9 1 1 1 0 MARION COUNTY HEALTH DEPARTMENT 356065697 LINE 6 1 1 1 0 SISTERS OF ST FRANCIS HEALTH SERVICES 350913537 LINE 3 1 1 1 0 ST VINCENT HOSPITAL & HEALTH CARE 352052591 LINE 3 1 1 1 0 CENTRAL INDIANA CORPORATE PARTNERSHIP 352065459 LINE 9 1 1 1 0 INDIANA HOSPITAL ASSOCIATION INC 350988753 LINE 9 1 1 1 0 INDIANA STATE DEPARTMENT OF HEALTH 356000158 LINE 6 1 1 1 0 12 0 0 0 0 0 0 0 1 48105 0 0 48105 0 EXPLANATION OF LOBBYING ACTIVITIES: PART II-B, LINE 1: THE ORGANIZATION ENGAGES A REGISTERED LOBBYIST IN THE STATE OF INDIANA TO REPRESENT ITS INTERESTS AT THE STATE LEGISLATIVE AND EXECUTIVE BRANCHES. WHILE THE ORGANIZATION ENGAGES A LOBBYIST ON A MONTHLY BASIS, NOT ALL ACTIVITIES CONDUCTED ARE "LOBBYING" UNDER THE DEFINITION IN INTERNAL REVENUE CODE (IRC) SECTION 4911 BECAUSE NOT ALL SUCH ACTIVITIES CONSTITUTE "INFLUENCING LEGISLATION," AS DEFINED IN IRC SECTION 4911(D)(1); HOWEVER, THE ORGANIZATION IS REPORTING HEREIN THE ENTIRE EXPENDITURE, WHICH NEVERTHELESS REPRESENTS AN INSUBSTANTIAL PART OF THE ORGANIZATION'S OVERALL EXPENDITURES. 65199 40505 24694 2415552 1260670 1154882 1179576 X 12994594 -80606 -80606 13075200 0 13075200 13749423 0 13749423 0 13749423 DESCRIPTION OF UNCERTAIN TAX POSITIONS UNDER FIN 48: PART X, LINE 2: IHIE IS EXEMPT FROM FEDERAL INCOME TAXES UNDER SECTION 501(C)(3) OF THE INTERNAL REVENUE CODE. THEREFORE, NO PROVISION OR LIABILITY FOR INCOME TAXES HAS BEEN INCLUDED IN THE CONSOLIDATED FINANCIAL STATEMENTS. IN ADDITION, IHIE HAS BEEN DETERMINED BY THE INTERNAL REVENUE SERVICE NOT TO BE A PRIVATE FOUNDATION WITHIN THE MEANING OF SECTION 509(A) OF THE INTERNAL REVENUE CODE. THERE WAS NO UNRELATED BUSINESS INCOME FOR THE YEARS ENDED DECEMBER 31, 2012 AND 2011. THE ORGANIZATION FILES TAX RETURNS IN THE U.S. FEDERAL JURISDICTION AND IN THE STATE OF INDIANA. THE ORGANIZATION IS NO LONGER SUBJECT TO U.S. FEDERAL AND STATE INCOME TAX EXAMINATIONS BY TAX AUTHORITIES FOR YEARS BEFORE 2009. PART XI, LINE 2D - OTHER ADJUSTMENTS: LOSS ON MERGETICS SHOWN IN FINANCIAL STATEMENTS -80,606. X X X X X 1 0 0 0 0 0 0 0 0 VINCENT C CAPONI 0 911900 0 1885605 0 1815 0 39978 0 13530 0 2852828 0 0 DANIEL F EVANS JR 0 1043576 0 313408 0 56850 0 838555 0 26887 0 2279276 0 0 MATTHEW R GUTWEIN 0 324453 0 0 0 0 0 16250 0 10625 0 351328 0 0 DAVID L JOHNSON 0 369553 0 35000 0 120 0 0 0 23574 0 428247 0 0 WILLIAM R TIERNEY 0 250000 0 8158 0 65000 0 47654 0 48320 0 419132 0 0 D CRAIG BRATER 0 509284 0 0 0 84902 0 344476 0 16273 0 954935 0 0 ROBERT BRODY 0 837337 0 0 0 51075 0 688603 0 31254 0 1608269 0 0 DOUGLAS J LEONARD 0 677648 0 0 0 13374 0 155436 0 21997 0 868455 0 0 HAROLD APPLE 253846 0 0 0 0 0 0 0 7056 0 260902 0 0 0 BRIAN MODIANO 171995 0 0 0 0 0 0 0 12060 0 184055 0 0 0 JANE NIEDERBERGER 155817 0 0 0 0 0 0 0 10119 0 165936 0 0 0 JAMES S HILL 184174 0 0 0 0 0 0 0 8966 0 193140 0 0 0 KENT HILLER 160378 0 0 0 0 0 0 0 8966 0 169344 0 0 0 KESHIA COOPER 151797 0 0 0 0 0 0 0 10022 0 161819 0 0 0 KEITH W KELLEY 166708 0 0 0 0 0 0 0 12040 0 178748 0 0 0 ERIC T THIEME 148700 0 0 0 0 0 0 0 14066 0 162766 0 0 0 JOHN P KANSKY 185029 0 0 0 0 0 0 0 16258 0 201287 0 0 0 JOSH NELSON 175560 0 0 0 0 0 0 0 6556 0 182116 0 0 0 SUPPLEMENTAL INFORMATION PART III PART I, LINE 4(A) A SEVERANCE PAYMENT WAS PAID TO THOMAS PENNO, FORMER CHIEF OPERATING OFFICER. THE AMOUNT OF SEVERANCE WAS $94,441. FORM 990, PART VI, SECTION B, LINE 11 THE 990 IS SUBMITTED TO THE FINANCE & AUDIT COMMITTEE FOR REVIEW AND APPROVAL. THE RETURN IS THEN SUBMITTED TO THE BOARD BEFORE FILING. FORM 990, PART VI, SECTION B, LINE 12C THE BOARD OF DIRECTORS OF INDIANA HEALTH INFORMATION EXCHANGE, INC. (THE CORPORATION), HAS ADOPTED A CONFLICT OF INTEREST POLICY (THE "POLICY") THAT REQUIRES EACH DIRECTOR, OFFICER AND MEMBER OF A BOARD COMMITTEE (DEFINED IN THE POLICY) TO PROVIDE THE CORPORATION AN ANNUAL DISCLOSURE OF ACTUAL OR POTENTIAL CONFLICTS OF INTEREST THAT ARISE AS A RESULT OF AN INDIVIDUAL SERVING AS A DIRECTOR, OFFICER OR MEMBER OF A BOARD COMMITTEE. THE POLICY ALSO REQUIRES CERTAIN ACTIONS TO APPROVE OR RATIFY A CONTRACT OR OTHER TRANSACTION BETWEEN THE CORPORATION AND AN INTERESTED PERSON (DEFINED IN THE POLICY). TO HELP ENSURE REGULAR AND CONSISTENT COMPLIANCE WITH THE POLICY, THE CORPORATION'S MANAGEMENT HAS ADOPTED THIS CONFLICT OF INTEREST MONITORING AND COMPLIANCE PROCEDURE. RESPONSIBLE INDIVIDUAL: THE CORPORATION'S CHIEF OPERATING OFFICER (THE "COO"). PROCEDURE: 1. THE COO WILL ANNUALLY COLLECT A WRITTEN DISCLOSURE OF ACTUAL OR POTENTIAL CONFLICTS OF INTEREST FROM EACH DIRECTOR, OFFICER AND MEMBER OF A BOARD COMMITTEE. 2. THE COO WILL PREPARE AND DISTRIBUTE TO EACH DIRECTOR, OFFICER AND MEMBER OF A BOARD COMMITTEE A LIST OF ALL ACTUAL AND POTENTIAL CONFLICTS DISCLOSED TO THE CORPORATION. 3. AT EACH MEETING OF THE BOARD OF DIRECTORS AND EACH BOARD COMMITTEE MEETING, THE COO WILL BE RESPONSIBLE FOR MONITORING COMPLIANCE WITH AND ENFORCING THE POLICY. FORM 990, PART VI, SECTION B, LINE 15 THE CORPORATION'S BYLAWS PROVIDE THAT THE CORPORATION'S EXECUTIVE COMMITTEE SHALL SERVE AS THE CORPORATION'S COMPENSATION COMMITTEE AND SHALL REVIEW AND, IF IN THE BEST INTEREST OF THE CORPORATION, APPROVE ALL COMPENSATION ARRANGEMENTS WITH KEY EMPLOYEES OF THE CORPORATION, PROVIDED, HOWEVER, THAT (1) EMPLOYMENT OF A PRESIDENT/CEO REQUIRES THE AFFIRMATIVE VOTE OF 2/3 OF THE CORPORATION'S DIRECTORS, (2) ANY COMPENSATION ARRANGEMENT IN EXCESS OF $100,000 AND LESS THAN $500,000 MUST BE APPROVED BY THE CORPORATION'S FINANCE AND AUDIT COMMITTEE AND (3) ANY COMPENSATION ARRANGEMENT IN EXCESS OF $500,000 MUST BE APPROVED BY 2/3 OF THE CORPORATION'S DIRECTORS. THE CORPORATION'S EXECUTIVE COMMITTEE CONSISTS OF THE OFFICERS OF THE CORPORATION AND TWO ADDITIONAL MEMBERS OF THE CORPORATION'S BOARD OF DIRECTORS ELECTED BY SUCH OFFICERS. THE PRESIDENT/CEO OF THE CORPORATION IS A NON VOTING, EX OFFICIO MEMBER OF THE EXECUTIVE COMMITTEE. THE PRESIDENT/CEO HAS NO INVOLVEMENT IN THE PROCESS OF SETTING HIS OR HER OWN COMPENSATION. FORM 990, PART VI, SECTION C, LINE 18 THE CORPORATION'S FORM 990 AND FORM 1023 ARE AVAILABLE TO THE PUBLIC UPON REQUEST IN ACCORDANCE WITH APPLICABLE LAW. THE PUBLIC CAN ALSO ACCESS THE CORPORATION'S FORM 990 AT WWW.GUIDESTAR.ORG. FORM 990, PART VI, SECTION C, LINE 19 THE CORPORATION'S ARTICLES OF INCORPORATION ARE AVAILABLE TO THE PUBLIC THROUGH THE INDIANA SECRETARY OF STATE'S WEBSITE AT HTTPS://SECURE.IN.GOV/SOS/BUS_SERVICE/ONLINE_CORPS/NAME_SEARCH.ASPX. THE CORPORATION'S BYLAWS, CONFLICT OF INTEREST POLICY AND FINANCIAL STATEMENTS MAY BE MADE AVAILABLE TO THE PUBLIC UPON REQUEST ON A CASE-BY-CASE BASIS. CHANGES IN NET ASSETS OR FUND BALANCES: FORM 990, PART XI, LINE 9: LOSS ON MERGETICS -80,606. OVERSIGHT OF FINANCIAL STATEMENTS: FORM 990, PART XII, LINE 2C THE FINANCE COMMITTEE ASSUMES RESPONSIBILITY FOR OVERSIGHT OF THE AUDIT OF ITS FINANCIAL STATEMENTS AND SELECTION OF AN INDEPENDENT AUDITOR. CENTRAL INDIANA CORPORATE PARTNERSHIP INC 111 MONUMENT CIRCLE STE 1800 INDIANAPOLIS IN 46204 352065459 PROMOTE GROWTH AND OPPORTUNITY IN CENTRAL INDIANA IN 501(C)(6) N/A 0 INDIANA UNIVERSITY HEALTH 950 NORTH MERIDAN ST GATEWAY INDIANAPOLIS IN 46204 351955872 PROVISION OF HEALTHCARE SERVICES IN 501(C)(3) 509(A)(1) N/A 0 COMMUNITY HOSPITAL OF INDIANA INC 1500 N RITTER AVE INDIANAPOLIS IN 46219 350983617 PROVISION OF HEALTHCARE SERVICES IN 501(C)(3) 509(A)(1) N/A 0 INDIANA STATE MEDICAL ASSOCIATION 322 CANAL WALK INDIANAPOLIS IN 46202 350411650 EXTEND MEDICAL KNOWLEDGE, ADVANCE MEDICAL SCIENCE, PROMOTE HEALTH CARE IN 501(C)(3) 509(A)(2) N/A 0 SISTERS OF ST FRANCIS HEALTH SERVICES INC 1515 DRAGOON TRL MISHAWAKA IN 46544 350913537 PROVISION OF CHARITABLE HEALTHCARE IN 501(C)(3) 509(A)(1) N/A 0 ST VINCENT HOSPITAL & HEALTH CARE 2001 W 86TH ST INDIANAPOLIS IN 46260 352052591 PROVISION OF HEALTHCARE SERVICES IN 501(C)(3) 509(A)(1) N/A 0 INDIANA HOSPITAL ASSOCIATION INC ONE AMERICA SQUARE NO 1900 INDIANAPOLIS IN 46282 350988753 EXTEND MEDICAL KNOWLEDGE, ADVANCE MEDICAL SCIENCE, PROMOTE HEALTH CARE IN 501(C)(6) N/A 0 HEALTH AND HOSPITAL CORPORATION OF MARION COUNTY DBA WISHARD HEALTH SERVIC 1001 W TENTH STREET INDIANAPOLIS IN 46202 356065597 EXTEND MEDICAL KNOWLEDGE, ADVANCE MEDICAL SCIENCE, PROMOTE HEALTH CARE IN 501(C)(3) 509(A)(1) N/A 0 INDIANA UNIVERSITY 107 S INDIANA AVE BLOOMINGTON IN 47405 356001673 EDUCATION IN 501(C)(3) 509(A)(1) N/A 0 THE INDIANAPOLIS MEDICAL SOCIETY INC 631 E NEW YORK ST INDIANAPOLIS IN 46202 127566088 EXTEND MEDICAL KNOWLEDGE, ADVANCE MEDICAL SCIENCE, PROMOTE HEALTH CARE IN 501(C)(3) 509(A)(2) N/A 0 MARION COUNTY HEALTH DEPARTMENT 3838 NORTH RURAL ST INDIANAPOLIS IN 46205 356065697 EXTEND MEDICAL KNOWLEDGE, ADVANCE MEDICAL SCIENCE, PROMOTE HEALTH CARE IN 501(C)(3) 509(A)(1) N/A 0 INDIANA STATE DEPARTMENT OF HEALTH 402 W WASHINGTON ST INDIANAPOLIS IN 46202 356000158 EXTEND MEDICAL KNOWLEDGE, ADVANCE MEDICAL SCIENCE, PROMOTE HEALTH CARE IN 501(C)(3) 509(A)(1) N/A 0 MERGETICS INC 846 NORTH SENATE AVENUE STE 300 INDIANAPOLIS IN 46202 261566118 HEALTH INFORMATION IN INDIANA HEALTH INFORMATION EXCHANGE C 8030 0.93000 0 0 0 0 0 0 0 0 0 0 0 0 1 0 1 0 1 0 0 0 MERGETICS INC P 106 FMV INDIANA UNIVERSITY HEALTH L 1839327 FMV ST FRANCIS HOSPITAL & HEALTH CENTERS L 1155449 FMV ST VINCENT HOSPITAL & HEALTH CARE CENTER INC L 1046388 FMV HEALTH AND HOSPITAL CORPORATION OF MARION COUNTY DBA WISHARD HEALTH SERV L 200000 FMV COMMUNITY HOSPITAL OF INDIANA INC L 689782 FMV CENTRAL INDIANA CORPORATE PARTNERSHIP INC L FMV INDIANA STATE MEDICAL ASSOCIATION L FMV THE INDIANAPOLIS MEDICAL SOCIETY INC L FMV MARION COUNTY HEALTH DEPARTMENT L FMV INDIANA STATE DEPARTMENT OF HEALTH L FMV INDIANA UNIVERSITY L 16000 FMV INDIANA UNIVERSITY D 16000 FMV ST FRANCIS HOSPITAL & HEALTH CENTERS D 96287 FMV HEALTH AND HOSPITAL CORPORATION OF MARION COUNTY DBA WISHARD HEALTH SERV D 50000 FMV INDIANA UNIVERSITY HEALTH D 29485 FMV COMMUNITY HOSPITAL OF INDIANA INC D 59020 FMV