The Wave That Never
Breaks: Health IT
Implementation and
Adoption Initiatives
Medicaid/CHIP and Innovation
Patricia MacTaggart, GWU
AcademyHealth
Monday 6/29/09
Acronyms Abound
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HIT
EHR
EMR
CPOE
e-prescribing
e-xxxx
How Far Has the IT Come?
Enterprise
Information
Portals
Executive
Information
Systems
(EIS)
Financial
Reporting
Systems
World Wide
Web
Analytic
Applications
Web
Analytics
Data
Warehouses
Transaction
Systems
Decision Support
Systems (DSS)
Data Mining
Online Analytical
Processing
(OLAP)
Ad Hoc
Query Tools
Extract
Files
1970
CMS
Reporting
Systems
(MARS +SURS)
1985
Relational
Databases
1990
Multidimensional
Databases
1995
2006
HC Reform Link to HIT for Consumers
• Access to Insurance Coverage: Eligibility Systems
• Benefits Appropriate to Health Care Need provided
once covered for Insurance: Clinical Decision Support
• Capable Providers who will provide the Benefits:
Claims Processing
• Deference to the Culture and Language: Web-based
“Literacy”
• Elimination of Medical Errors
• Factual “Circumstances”: High Percent of Homeless
Have Cell Phones
• Guaranteed “view” of Data: Personal/Individual
Health Records
HC Reform Link to HIT for
Providers
• Adequate Reimbursement: Funding for HIT
Infrastructure
• Benefits to Serving Populations out way
Negatives: Tools
• Cultural Competency: Awareness and Tools
• Deference to Clinical Judgment: “Alert”
Fatigue
• Expedited Payment and Decision Making:
e-bank transfers, e-billing
HC Reform Link to HIT for States
• Alignment of Incentives for Consumers,
Providers, Taxpayers, Regulators to improve
quality of health and health care delivery
• Balancing of “3 Legs of the Stool”: quality,
access and affordability
• Continuity of Care + Continuity of Providers +
Continuity of System of Care
• Development from Payer to Purchaser using ehealth
• Evidence Based Medicine
Opportunities through HIT
• Actual Literacy = Health Literacy +
Computer Literacy
• Better Communication =
Interoperability + Integration
• Data Dominated Information:
– Evidence Based= Retention of data – dirty
date + data distribution
– Efficiency, Effectiveness and Ease of Use
Top State Identified eHealth Priorities for Next 2
Years in 2007
eHIE Adoption
25
eHIE Policy Development
12
EHRs and EMRs
9
E-Prescribing
7
Privacy and Security Issues
5
Quality & Transparency
3
Telehealth
3
Public Health Registries
2
PHRs
2
Medicaid HIT or MMIS Upgrades
Other
Number of States
(N = 42)
1
6
Source: The Commonwealth Fund & NGA eHealth Survey, conducted by HMA, 2007.
Barriers to Accomplishing eHealth Priorities
Funding
26
Stakeholder Impacts, Buy-in
20
Establishing Business Case, Sustainability
13
Lack of Standards
12
Privacy/Security Concerns
11
Governance Issues
4
Technical Resources
4
Number of States
Legal Issues
Other
4
N = 42
7
Source: The Commonwealth Fund & NGA eHealth Survey, conducted by HMA, 2007.
State Voices of Experience: Lessons
Learned
• “Proceed slowly – gaining trust & fully exploring policy
issues related to privacy & security, access,
authorization, authentication”
• “Involve stakeholders early”
• “Use a HIE model that doesn’t lock out prospective
participants…”
• “You don’t need all the answers today to move forward;
plan broadly, implement incrementally”
• Provide “strong project management & dedicated
resources”
• Provide for “...sustained collaboration & an entity
whose business it is to leverage different interests &
resources for a common good”
Source: The Commonwealth Fund & NGA eHealth Survey, conducted by HMA, 2007.
HIT Initiatives – Systems & Components
Identified as Most Significant by States
E-Prescribing
Electronic Health Records
Electronic Medical Records
Telehealth
Decision Support Tools
AR,IL,MA,NH,PA,RI,KY
AR,DC,KS,MN,MO
FL,HI,NM,OR,RI
HI,NE,NM,OR,WV
ME,MO,IN,VT
Web-Based Tools AL,MA,UT
Patient Health Records OR
MMIS Replacement ND
Source: The Commonwealth Fund & NGA eHealth Survey, conducted by HMA, 2007.
First Step: Medicaid Transformation Grants
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HIEs
EHRs
E-prescribing
Fraud and Abuse
Decision Support/Data Warehouse
Disease Management
Public Reporting/Transparency
Clinical Decision Support
Web-based Eligibility Screening
Surveillance and Performance Monitoring
Opportunities through Children’s Health
Insurance Program Reauthorization Act of
2009 (CHIPRA), H.R. 2
• Expanding Eligibility: Streamline
enrollment/retention: Express Lane Eligibility
and Outreach
• Improving Quality:
– Develop and implement evidence-based quality
measures – HHS develop core set of measures
– Encourage development and dissemination of
model children’s e-health record
Opportunities through ARRA for
Medicaid Providers: Incentives
• Non-hospital based professionals: have at least 30
percent patient volume attributable to Medicaid patients,
including physicians, dentists, certified nurse mid-wives,
nurse practitioners and certain physician assistants
• Non-hospital based pediatricians: have at least 20
percent of their patient volume attributable to Medicaid
patients
• Children’s Hospitals
• Acute-care hospital: has at least 10 percent patient
volume attributable to Medicaid patients
• Federally Qualified Health center or Rural Health Clinic :
has at least 30 percent of the center or clinic’s patient
volume attributable to needy individuals
Incentive Payments for “Meaningful
Use” of Certified EHR Technology
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“Meaningful Use”:
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Established by State
Acceptable to the
Secretary
Aligned with Medicare
Exchanges information
across different health
care providers
Reporting quality
measures
Including Support
Services:
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Maintenance and Training
Adoption and Operation
• Certified EHR Technology
Includes:
– Patient demographic and
clinical health information
– Clinical Decision Support
capacity:
• Support physician order
entry
• Capture and query
information relevant to
healthcare quality
• Exchange electronic health
information with, and
integrate such information
from other sources.
Maximum Medicaid Incentive
Payments to Providers
• No more than 85% Percent of Net Average
Allowable Costs for:
– Certified EHR technology
– Support services including maintenance and training that is
for, or is necessary for the adoption and operation
• For Hospitals Payments:
– Medicare Payment Algorithm
– Two Differences from Medicare:
• Fully weighted for the first four payment years rather descending
weights in use for Medicare incentive payments
• Medicaid patient load instead of the Medicare patient
Questions/Comments
Biosurveillance
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Use Case Summary – Transmit essential visit, utilization, and lab result data in a
standardized electronic format to Public Health Agencies in <24hrs.
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Current Obstacles to Medicaid State Systems Participation:
– Medicaid is not generally considered a “Public Health Agency” – reporting to
Medicaid and public health would be redundant
– Incomplete data in current MMIS environment
– As a historical data systems, the availability of data with value to clinical analysis
would lag date of service by weeks or months
– No direct/real-time connection to providers
– Few State systems are configured for interactive Web sessions
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Potential Benefits for State Medicaid Programs if Implemented:
– No identified direct benefit to Medicaid Program
– Possible benefit to Public Health – MMIS CDM could serve as back-up to Public
Health Data Repository.
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Possible Solutions or Related Activities:
– 5-10 years
• Implementation of Clinical Data Module for MMIS
Need…
• HIT Financial Support $$$ for Medicaid
Initiatives
• Adoption of standards for PHR/EHR
• Data requirements for registration summary and
medication history
• Universally recognized definition of HIT within
Medicaid Enterprise
• Increased awareness among providers and State
Agencies regarding benefits of HIT
• Willing and able State partners with which to
conduct pilots
Use Case Summary
• Medicaid State systems could have a role in 2 of the 3
HITSP Use Cases, Consumer Empowerment and
Laboratory Results
• The MMIS will need better connectivity to other
healthcare entities in the near term to have a meaningful
role in HIT initiatives
• Although the role of the MMIS has been steadily
expanding, it is basically a financial system. The role of
the MMIS would change significantly in the future with
– Addition of a Clinical Data Module
– Capability to process EHRs
– Addition of HIE capabilities (RHIO or similar
network)
– Enhancement of Web-enabled services
And In Closing…
“Those are my
principles, and if you
don't like them... well, I
have others.”
-Groucho Marx
(1890-1977)