Implications of Medicaid Goals on a Health Information Exchange
July 28, 2010
Russ Waitman
Director of Medical Informatics
The University of Kansas Medical Center
Purpose and plan from Federal Legislation (taking a Medicaid focus):
-
Improve quality
Reduce medical errors
Reduce disparities (mentioned twice)
Patient centered
Guide medical decisions
Reduce costs
Improve the coordination of care
Facilitate research and quality
Detect, prevent, and manage chronic disease
More effective marketplace: consumer choice, systems analysis, improved outcomes
Exchange ... use … and enterprise integration
Each person has an EHR by 2014
Select observations from state HIE strategic plans regarding Medicaid (NM, UT, TN, PA, MD, SC):
-
Provide a low/no cost EMR for Medicaid providers (NM)
Seed the HIE with claims data, leverage MMIS (NM, UT, PA, SC)
Use clinical and administrative data for both clinical and payment decisions (UT)
State actively uses HIE to continually monitor quality (TN)
Align state reporting measures with HITECH Meaningful Use (TN)
ePrescribing integrated with MMIS (PA)
Focus on long term care integration and coordination (PA)
Current and planned metrics for use and quality aligned with HIE (PA)
Focus on modernizing MMIS (MD)
Integrated with state data warehouse; 300 of 803,000 enrollees have opted out (SC)
Informal observations from an industry analyst: http://chilmarkresearch.com/2010/02/25/the-greatland-grab-of-2010-or-the-play-for-state-hies/
“Vendors are also facing several challenges responding to these RFPs, primary among them, little
commonality from one state to the next. The most obvious one is that each state has their own unique
approach to their technical architecture. They range from Idaho with its desire for a single statewide
network (Idaho Health Data Exchange) to Indiana with multiple, independent, local HIEs, and no
statewide architecture. Additionally, most states are issuing RFPs that include a number of use cases that
go beyond just basic data exchange functions. While the statewide HIEs obviously need to plan for the
future, it is creating uncertainty among vendors in how they respond and price their solutions given that
some of the use cases outlined in an RFP may never be implemented.”
KHPA SMHP Meeting: HIE Implications, Russ Waitman rwaitman@kumc.edu
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Elements of the Draft Kansas State Medicaid HIT Plan (SMHP) with Direct Implications:
The SMHP‘s primary goal will be promoting and achieving widespread adoption and meaningful use of
HIT, with an emphasis on the use of this technology to exchange health information, improve health care
delivery, and implement a medical home for all Medicaid recipients, using Kansas Medicaid providers as
an effective way to encourage HIT adoption and use for these purposes
Additional Kansas Medicaid goals in the development and use of the Kansas HIE include:
 Utilize the HIE to measure meaningful use;
 Utilize the HIE to gather data needed to document and measure qualification for Medicaid
incentive payments; and,
 Utilize the HIE to gather data in order to compute quality measures, and to help manage care to
ensure meaningful use for beneficiaries – regardless of their connection to a primary care medical
home.
Activities and Collaborations:
Coordination
Description
Support documentation and
measurement of
qualifications for Medicaid
incentives and HIT adoption.
The State Medicaid HIT Plan anticipates initially using attestation to verify HIE
use, but will define during their planning activity methods to over time use HIE
data as a method to observe and verify progress. SMHP also anticipates annual
re-surveying using the provider survey to supplement information about
providers’ specific progress.
Meaningful use of HIT through the state’s approved HIEs will be a critical step
forward in achieving Kansas’ statutory medical home goals. These goals are
outlined above and will be addressed in more detail in the SMHP.
This will be further addressed in the implementation of the SMHP.
Develop HIE support of
Medicaid’s legislated
Medical Home effort.
Deploy a proactive HIE that
supports Medicaid’s needs to
interact directly with
Medicaid eligible individuals,
especially those not engaged
with a provider.
Integrate system
development and acquisition
around common framework
components.
Expand capabilities of
provider directory
management.
Identify state agencies’ investments that might be leveraged including Medicaid
eligibility system, MMIS, and others in addition to Medicaid.
Explore opportunities to maximize care coordination through financial and nonfinancial incentives, HIE fee reductions, or other payment strategies in
partnership with Medicaid, state employee health plan and others, including
identifying the number of members or patients that would benefit.
 State hosted directories could include but not be limited to:
o
Health care providers
o
Health plans (from the Kansas Insurance Department)
o
Licensed clinical laboratories (from KDHE)
o
Organizations (including RHIOs, IDN, identified from the
environmental scan)
o
Lists of consent directories
o
Web services directories
o
Licensing boards
 KHIE will create a mechanism for providers to update their information
in the provider registry. This may be a requirement in the Data Participation
Agreement.
KHPA SMHP Meeting: HIE Implications, Russ Waitman rwaitman@kumc.edu
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Analysis and Discussion
It’s important to define the plan and subsequent requirements with enough specificity to make sure the
efforts by KHIE Inc and its vendors will meet your goals. I see three categories of work in the plan:
infrastructure, analysis, and active patient engagement.
Infrastructure: Integrate/leverage other state investments (MMIS) and provide state hosted provider
directories
Integrating MMIS data within the HIE seems to be a common thread across states.
- How will that data be integrated into the exchange or views of data so it helps with care and
doesn’t add “noise”?
The state has already invested significantly in provider directories.
- is KHPA the “source of truth” for such information for the HIE or is there another source?
Analysis: Measuring meaningful use, qualifying for incentive payments, and computing quality
measures.
This would suggest KHPA will need to quantify meaningful use based on actual transactions in
comparison to claims data.
- Will this be manual, sampled automatically on a periodic basis, or computed from all transactions
against claims data in MMIS?
How does KHPA currently compute quality measures? Which data sources and where are they?
Will clinical data be added in a similar manner to complement current claims based metrics or will a new
method need to be devised?
Active patient engagement: “implement a medical home for all Medicaid recipients”, “supports
Medicaid’s needs to interact directly with Medicaid eligible individuals, especially those not engaged
with a provider”, and “help manage care”.
Mentioning a medical home for all recipients is novel and commendable in comparison with the other
plans I reviewed. The spirit of a medical home infuses the original federal goals, vision statements, and
state plans. Aligning the two efforts may provide explicit guidance for the HIE if medical home
objectives are well defined.
What is the current medical home plan and how we do match that against potential HIE capabilities?
How do we reconcile that most of the medical home definitions revolve around a patient’s primary care
provider while we state many Medicaid patients are not engaged with a provider? Do we know the
distributions with versus without primary care provider?
Are we asking for a low/no cost EMR for Medicaid patients with clinical decision support? How much?
Materials on the KHPA website indicate foresight but need to matched against current planning:
http://www.khpa.ks.gov/stakeholders/03112009_medical_home_stakeholders.html
http://www.khpa.ks.gov/stakeholders/download/030209SN_PHW_HIT_HIE_Barnett_Committee.pdf
KHPA SMHP Meeting: HIE Implications, Russ Waitman rwaitman@kumc.edu
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Background from the HITECH legislation: http://waysandmeans.house.gov/media/pdf/111/hitech.pdf
ENTERPRISE INTEGRATION.—The term ‘enterprise integration’ means the electronic linkage of
health care providers, health plans, the government, and other interested parties, to enable the electronic
exchange and use of health information among all the components in the health care infrastructure in
accordance with applicable law, and such term includes related application protocols and other related
standards.
PURPOSE.—The National Coordinator shall perform the duties under subsection (c) in a manner
consistent with the development of a nationwide health information technology infrastructure that allows
for the electronic use and exchange of information and that—
‘‘(1) ensures that each patient’s health information is secure and protected, in accordance with applicable
law;
‘‘(2) improves health care quality, reduces medical errors, reduces health disparities, and advances the
delivery of patient centered medical care;
‘‘(3) reduces health care costs resulting from inefficiency, medical errors, inappropriate care, duplicative
care, and incomplete information;
‘‘(4) provides appropriate information to help guide medical decisions at the time and place of care;
‘‘(5) ensures the inclusion of meaningful public input in such development of such infrastructure;
‘‘(6) improves the coordination of care and information among hospitals, laboratories, physician offices,
and other entities through an effective infrastructure for the secure and authorized exchange of health care
information;
‘‘(7) improves public health activities and facilitates the early identification and rapid response to public
health threats and emergencies, including bioterror events and infectious disease outbreaks;
‘‘(8) facilitates health and clinical research and health care quality;
‘‘(9) promotes early detection, prevention, and management of chronic diseases;
‘‘(10) promotes a more effective marketplace, greater competition, greater systems analysis, increased
consumer choice, and improved outcomes in health care services; and
‘‘(11) improves efforts to reduce health disparities.
KHPA SMHP Meeting: HIE Implications, Russ Waitman rwaitman@kumc.edu
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‘‘(3) STRATEGIC PLAN.—
‘‘(A) IN GENERAL.—The National Coordinator shall, in consultation with other appropriate Federal
agencies (including the National Institute of Standards and Technology), update the Federal Health IT
Strategic Plan (developed as of June 3, 2008) to include specific objectives, milestones, and metrics with
respect to the following:
‘‘(i) The electronic exchange and use of health information and the enterprise integration of such
information.
‘‘(ii) The utilization of an electronic health record for each person in the United States by 2014.
‘‘(iii) The incorporation of privacy and security protections for the electronic exchange of an individual’s
individually identifiable health information.
‘‘(iv) Ensuring security methods to ensure appropriate authorization and electronic authentication of
health information and specifying technologies or methodologies for rendering health information
unusable, unreadable, or indecipherable.
‘‘(v) Specifying a framework for coordination and flow of recommendations and policies under this
subtitle among the Secretary, the National Coordinator, the HIT Policy Committee, the HIT Standards
Committee, and other health information exchanges and other relevant entities.
‘‘(vi) Methods to foster the public understanding of health information technology.
‘‘(vii) Strategies to enhance the use of health information technology in improving the quality of health
care, reducing medical errors, reducing health disparities, improving public health, increasing prevention
and coordination with community resources, and improving the continuity of care among health care
settings.
‘‘(viii) Specific plans for ensuring that populations with unique needs, such as children, are appropriately
addressed in the technology design, as appropriate, which may include technology that automates
enrollment and retention for eligible individuals.
KHPA SMHP Meeting: HIE Implications, Russ Waitman rwaitman@kumc.edu
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Background notes from other states’ strategic plans regarding Medicaid
Note: I used the map on the eHAC website (http://www.kanhit.org/other-states-plans.htm), to review
several states plans for Medicaid specific details.
New Mexico:
http://www.nmhic.org/supporting_files/NM%20State%20HIE%20Strategic%20and%20Operational%20P
lan%20V2.pdf.pdf
Medicaid will
-
Member of steering committee.
Provides some funding to support the HIE
Supply Medicaid claims and encounters to the HIE and info from non-Medicaid providers
available to Medicaid
Offer a low cost or no cost EMR product for Medicaid providers
Administer Medicaid HIT adoption and meaningful use incentive program.
Medicaid agency is a node in the network
Utah:
http://health.utah.gov/phi/UT_HIE_StrategicPlans_Final_2009.pdf
Utah Medicaid Participation in the Statewide HIE
The Utah Medicaid program was a charter member of the Board of Directors of UHIN when, in 1993,
administrative data began to flow through the UHIN switch between health care providers and payers.
Medicaid assumed a leadership role in the development and implementation of standards for the eight
Health Insurance Portability and Accountability Act (HIPAA) transactions that are currently exchanged in
Utah. Like other payers, Medicaid pays transaction processing fees to UHIN, and in this way contributes
significantly to the financial sustainability of the Utah HIE.
Medicaid has continued its active participation in health information exchange planning in Utah since our
focus has shifted to planning for clinical information exchange. The primary planning body/community
consensus group for clinical exchange is the UHIN Community Program Management Committee, which
is co-chaired by a representative of Utah Medicaid. The committee is comprised of a mix of subject
matter experts interested in either administrative or clinical information exchange, because they continue
to see advantages to bringing both of these perspectives to bear on the problems of exchanging clinical
information. As noted elsewhere, much clinical data, such as laboratory results, are used for both clinical
and claims payment decisions.
Medicaid Promotion of EHR
Utah Medicaid matched funds from the 2007 and 2008 legislature for HealthInsight to provide
consultation to medical practices (serving Medicaid clients) investigating adoption of EHR systems, as
well as technical assistance to eighty of these practices that adopted systems during this period. These
KHPA SMHP Meeting: HIE Implications, Russ Waitman rwaitman@kumc.edu
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efforts included an EHR readiness inventory of 350 practices that serve Medicaid patients. Clearly, Utah
Medicaid is committed to promoting EHR adoption among Medicaid providers.
Assistance for Integrating the Long Term Care Population into State Grants to Promote Health IT
Utah Medicaid’s interest in EHR adoption extends to providers of long term care. The program provided
incentives in 2009 for nursing homes to adopt HIT, and these incentives have been extended for 2010.
The president of the Utah Health Care Association, whose members are long term care providers,
participates in the overall State Grant governance body, the Utah HIT Governance Consortium, and will
receive some funding to ensure coordination with projects supported under this State Grant.
State Medicaid/CHIP Programs
Medicaid staff and staff of the Utah HIT Coordinator will jointly develop the Advance Planning
Document to prepare the Medicaid program to provide incentives for meaningful use of EHR. We are
currently investigating the possibility of using the administrative data already exchanged through UHIN
to determine which providers have sufficiently large Medicaid practices to be eligible for Medicaid EHR
subsidies.
Tennessee:
http://www.tennesseeanytime.org/ehealth/documents/TennesseeHIEStrategicPlan_v20_Final.pdf
KHPA SMHP Meeting: HIE Implications, Russ Waitman rwaitman@kumc.edu
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1.4 HIE Strategy as Framework for Tennessee’s Medicaid Health IT Plan
CMS, an agency of the U.S. Department of Health and Human Services, is providing guidance to and
funding for states to foster the meaningful use of EHRs.
Tennessee’s strategy for statewide HIE is guided by the principle that the State has a responsibility to
ensure that those citizens who are dependent upon TennCare (Tennessee’s Medicaid program), and their
providers cannot be left behind. In fact, it is the State’s intention to design and implement HIE so that
people served through TennCare receive the greatest level of health improvements and quality of care
possible, whether their providers are eligible for incentive payments or not.
Active coordination between statewide eHealth efforts and TennCare efforts is essential to achieving
Tennessee’s eHealth vision. Furthermore, this collaboration leverages opportunities to advance HIE in a
way that also ensures the investments are made wisely.
1.5 HIE Strategy Consistent with Tennessee’s State Health Plan
Tennessee’s strategy for statewide interoperable HIE is consistent with and supportive of the State’s
overall State Health Plan developed by the Division of Health Planning of the State Department of
Finance and Administration.
The following five principles comprise the basis of the State Health Plan, based on the Health Planning
Division’s enacting legislation:
1. The purpose of the State Health Plan is to improve the health of Tennesseans;
2. Every citizen should have reasonable access to health care;
3. The State’s healthcare resources should be developed to address the needs of Tennesseans while
encouraging competitive markets, economic efficiencies, and the continued development of the State’s
healthcare industry;
4. Every citizen should have confidence that the quality of health care is continually monitored, and
healthcare providers adhere to standards; and
5. The State should support the development, recruitment and retention of a sufficient and quality
healthcare workforce.
8.1 Coordination with TennCare
Tennessee’s Office of eHealth Initiatives and TennCare, along with the Department of Health, are
working together currently on development of the Medicaid health IT strategic vision, goals and
objectives, and the design of the Medicaid incentive program, recognizing that the State Medicaid Health
IT Plan activities and statewide HIE efforts are interdependent and thus coordination and integration
between the areas are critical to maximize their impact and prevent duplication in efforts. Tennessee’s
HIE strategy will leverage provider participation in the Medicaid incentive program while the Medicaid
health IT strategy will integrate statewide HIE capabilities that enable providers to meaningfully use
EHRs and fully realize benefits of healthcare coordination and quality improvement. Key objectives of
the Medicaid Health IT strategic planning process include:
Meaningful Use – Current TennCare public health and clinical quality reporting requirements, such as
HEDIS and CAHPS measures, are consistent with meaningful use objectives and anticipated quality
reporting requirements under the HITECH Act. To the degree final rules permit, Tennessee will align
these measures, and incorporate Tennessee’s HIE goals in defining requirements for meaningful use at the
state level. Increasing requirements for meaningful use will be timed with the HIE requirements under the
federal Medicare meaningful use definition. TennCare and eHealth objectives and initiatives will be
KHPA SMHP Meeting: HIE Implications, Russ Waitman rwaitman@kumc.edu
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coordinated to encourage health IT and HIE adoption and meaningful use in the Medicaid provider
population. TennCare will pursue design strategies to make health IT broadly available and affordable.
Medicaid Incentive Program Deployment – The mechanism for disbursement of Medicaid incentives
will be designed to encourage and support adoption of EHRs among TennCare providers and to
coordinate with other state-level initiatives and funding opportunities. The use of qualified intermediaries
will be explored as an option for deployment of Medicaid incentives. Qualified intermediaries will
coordinate with tnREC activities and can further increase successful adoption of EHRs by providing
community-wide technical assistance and facilitating group purchasing.
Pennsylvania:
http://www.emarketplace.state.pa.us/FileDownload.aspx?file=6100009286/Solicitation_15.pdf
Strengthen current and future health initiatives to improve clinical outcomes, improve patient safety,
ensure security and reduce costs by supporting the health information exchange needs of all providers,
including those involved in the Medical Assistance Program, Commonwealth Chronic Care Initiative,
Public Health, Long-Term Living and other health care initiatives
Pennsylvania Department of Public Welfare – Medical Assistance
DPW’s Office of Medical Assistance Programs (OMAP) is responsible for creating programs and
initiatives to support and validate “meaningful use” among their providers and hospitals. PHIX is being
viewed as the mechanism to enable achievement of the Medicaid State Health IT Plan (SMHP). The
development of PHIX will be coordinated with the SMHP and other medical assistance initiatives that
will contribute to and benefit from PHIX.
Leveraging resources managed by DPW, including Pennsylvania’s Medicaid Management Information
System (MMIS), known as PROMISe, is crucial. This system provides Internet capabilities for providers,
including claims submission and inquiry, updates to provider enrollment information and the electronic
submission of outpatient pharmacy claims. PROMISe currently utilizes Web services and Application
Programming Interfaces (APIs) for internal and external access. The upcoming Medicaid Information
Technology Architecture (MITA) ”To-Be” assessment will be used to investigate methods to enhance the
use of Web services and Service Oriented Architecture (SOA) principles for increased flexibility and
interoperability.
Development of an interactive statewide Medicaid e-Prescribing network is one area in which DPW is
moving forward to enhance HIT in the Medicaid community. The e-Prescribing solution will integrate
with PROMISe to ensure that prescriptions are medically appropriate and accurate in relation to a
Medicaid beneficiary’s eligibility and coverage rules. This system and its comprehensive data sources are
also important assets that can be leveraged by PHIX.
Pennsylvania’s Medical Assistance Program has been awarded a $9.8 million, five-year grant under the
Children’s Health Insurance Program Reauthorization Act of 2009 to develop a new pediatric electronic
record format to support quality improvements. This effort is expected to greatly enhance the use of HIT.
Pennsylvania Office of Long-Term Living (OLTL)
Currently, interoperability and exchange of health information across different health care settings serving
older Pennsylvanians and individuals with disabilities remains a serious challenge. The sharing of
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electronic medical records, especially between hospitals and primary care providers, home and
community based providers and nursing facilities will enhance the efforts of the OLTL to balance the
long-term care system. Information technology provides a means to seamlessly transfer health
information for seniors and people with disabilities throughout their acute treatments and then back to
their homes. Electronic transfer would reduce the need to copy and transmit the large volume of medical
records that are needed for everything from eligibility determinations to ongoing support service in the
community.
As part of the environmental scan efforts, OLTL solicited input from their stakeholder community. There
are HIT opportunities and challenges facing the long-term care population.
The older, disabled and chronically ill individuals who long-term care providers serve often have a
multitude of health issues, multiple care providers and transition frequently from one setting to another.
Hence, this population stands to benefit the most from interoperable health information exchange and
other health information technologies to reduce duplicative procedures, medical errors, and preventable
costs and improve the quality of care.
Long-term care (LTC) providers need the ability to exchange information to:
- improve and expedite the clinical eligibility process and coordination of services between primary
care and LTC providers; and
- support discharge planners for individuals returning home or in need of rehabilitation in a nursing
facility
The lack of funds to purchase technology and cover the costs of technical assistance for the
implementation of HIT makes it difficult for the wide range of LTC providers, including agencies that
provide support coordination/care management, home and community based services, nursing facilities
and home health agencies to take advantage of EMRs/EHRs and telehealth (telecare) systems.
Medicaid Methods and Evaluation Tools to Reach Improved Care
To correspond with Medicaid’s EQUIPs initiatives, an evaluation approach is being proposed in their
vision document. As OMAP begins to receive provider comments about EQUIPs and determine those
clinical data that will be collected and exchanged between providers and the Commonwealth, OPMAP
will begin to develop the Methods and Evaluation Tools to Reach Improved Care (METRICs) that will be
tied to adoption of certified EHRs and to the implementation of EQUIPs. As EHR data requirements
become final at the federal level for specific provider groups, MA will incorporate these requirements into
detailed METRICs. The early identification and implementation of METRICs will allow MA to enhance
quality improvement projects over time based on outcomes, comments about the METRICs and the
continued spread of HIT by health care providers across Pennsylvania.
Although additional work needs to be done to define the measures and mechanisms that will be used to
assess the effects and impact of the PHIX development efforts, the evaluation process at a minimum will
include:
-
Performance metrics identified during the development of the operational plan and specified in
the ONC State HIE Cooperative Agreement Program, including ARRA-required performance
measures; and
evaluation and revision of Pennsylvania’s strategic and operation plans on an annual basis or as
needed.
METRICs will enable Pennsylvania to provide rich information about how Medicaid providers have
attained “meaningful use”.
KHPA SMHP Meeting: HIE Implications, Russ Waitman rwaitman@kumc.edu
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Maryland:
http://mhcc.maryland.gov/electronichealth/hiestateplan/hit_state_plan_060910.pdf
Medicaid Coordination
The Maryland Department of Health & Mental Hygiene, Office of Systems, Operations, and Pharmacy
(DHMH OSOP) assessed the current State of the Maryland Medicaid Management Information System
(MMIS) along with the current Medicaid processes used by the State of Maryland and developed a
transition plan to align with the federally mandated Medicaid Information Technology Architecture
(MITA) requirements and state HIT and HIE initiatives. The new system will modernize existing system
functions and significantly enhance the goals of the MMIS ensuring that eligible individuals receive the
health care benefits to which they are entitled, and that providers are reimbursed promptly and efficiently.
Coordination between DHMH and the MHCC is in place to ensure that opportunities for data sharing and
the HIE are maximized. DHMH intends to replace its legacy MMIS claims processing system with a new
MMIS system based on MITA 2.0 principles that will include imaging and workflow management, and a
robust business rules engine to aide in creating and managing flexible benefit plans. The new MMIS will
process all Medicaid claims and eliminate the duplicative adjudication of the Mental Hygiene
Administration (MHA), Developmental Disabilities Administration (DDA), and dental claims. The new
MMIS system will also support coordination of benefits, surveillance and utilization review, federal and
management reporting, case management, and the statewide HIE. In conjunction with the MMIS
replacement, DHMH intends to add a Decision Support System (DSS); implement a Service Oriented
Architecture (SOA) Integration Framework to provide a platform for the system that will enable better
interoperability with existing legacy applications; and develop a Member and Care Management portal.
These enhancements will help eliminate manual processes and will improve general population health by
targeting individuals by cultural, diagnostic, or other demographic indicators to ensure that appropriate
and cost-effective medical or medically-related social and behavioral health services are identified,
planned, obtained, and monitored for individuals identified as eligible for care management services
under programs such as:
Medicaid Waiver Program Case Management;
Home and Community-Based Services;
Employed Individuals with Disabilities (EID);
Primary Adult Care (PAC);
Breast and Cervical Cancer;
Rare and Expensive Case Management (REM);
Traumatic Brain Injury (TBI);
Disease Management;
Catastrophic Cases; and
Healthy Start Program.
The SOA Integration Framework will enable a bi-directional real-time interface with the State’s Client
Automated Resources Eligibility System (CARES) and the statewide HIE to facilitate better access to the
complete eligibility record, resolve data integrity issues across systems, improve claims payment accuracy
by capturing the most current eligibility information, and support inter-agency coordination to provide
appropriate and cost effective medically necessary care management services. The SOA Integration
framework will eventually support an evolutionary approach to information sharing and integration for
the Medicaid enterprise and the statewide HIE to allow the creation of a single source of a recipient’s
demographic, financial, socio-economic, and health status information. The desired system will have the
ability to support EHR initiatives and provide enough flexibility to respond to the changing needs of these
initiatives. The system will also allow for required system modifications made by the HIE and to access
and utilize data from other state HIEs, EHRs, and PHRs, as permissible. The desired system will also
have an indicator mechanism on the electronic claim to measure provider participation in the statewide
HIE.
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Medicaid HIT P-APD Project
The Maryland Medical Assistance Program in consultation with the MHCC will collaborate in the
development of the Health Information Technology Planning-Advanced Planning Document (HIT APD),
which initially will be used to request Federal Financial Participation (FFP) from CMS for administrative
costs to support planning activities authorized by the ARRA to promote the use of HIT and EHRs among
Medicaid providers. Under the ARRA HIT incentive program, providers can qualify for 100 percent of
Federal incentive funding for adoption and meaningful use of certified EHR technology and support
services, such as maintenance and training. The program also authorizes a 90 percent FFP for reasonable
administrative expenditures to support state efforts to administer this program. The purpose of the HIT PAPD is to create the State Medicaid HIT Plan (SMHP) that will outline the strategic HIT vision for the
Maryland Medical Assistance Program. The SMHP will lay the groundwork for achieving this vision by
describing the current “As-Is” HIT landscape, the desired “To-Be” HIT landscape, and a comprehensive
five year plan for expanding HIT using MITA principles and approaches as a foundation. The HIT PAPD activities will also include planning to support the incentive payments for EHR systems authorized
in Section 4201 of the ARRA. Section 4201 of the ARRA provides funding support for certified EHRs
through Medicaid adoption and implementation payments. CMS and the Maryland Medical Assistance
Program will provide oversight, as directed in the ARRA. The MHCC and the Maryland Medical
Assistance Program have held monthly meetings since August 2009 to work through the challenges in
coordinating the development of the HIT P-APD. As of April 2010 a preliminary HIT P-APD exists.
Included in this HIT P-APD will be a description of a series of planning tasks pertaining to: provider
education and awareness activities; development of the SMHP comprised of an “As-Is” HIT landscape
assessment of the current status of HIT, particularly among Medicaid providers; a “To-Be” vision and
Roadmap Plan; development of the HIT Implementation Planning Advance Planning Document (HIT
APD) to implement activities identified in the Roadmap Plan necessary to support the “To-Be” vision and
the SMHP; and the development of an Request for Proposal (RFP) for a vendor to provide operational
support and program audit services.
South Carolina
https://training.scdhhs.gov/hit/plans/StrategicPlanFinal042010.pdf
South Carolina has made significant progress in EHRs and data exchange. In 1992, South Carolina
established a state data warehouse in ORS. A legislative proviso requires that all state agencies submit
data to the warehouse for use in program evaluation and outcomes analysis. Each agency maintains
control over its own data. In 1996, state law mandated the submission of all inpatient, emergency
department, and outpatient claims meeting certain criteria to ORS with patient and provider identifiers.
The South Carolina Data Oversight Council, a multi-stakeholder public body, oversees the principles and
protocols for the release of this data. This model provides a strong precedent for SCHIEx and its
governance.
The 2007 Electronic Personal Health Record (EPHR) Pilot Project included five practices in five
counties. ORS developed a clinical interface to display data. Notification letters and notices of privacy
practices were mailed to Medicaid beneficiaries in the affected counties. Participating providers were
responsible for obtaining opt-in consent from beneficiaries, which was a barrier to obtaining a high level
of participation. This pilot project served as the foundation to develop the web-based SCHIEx.
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SCHIEx with an EHR viewer of 10 years of Medicaid claims history was launched in July 2008 and used
an opt-out beneficiary consent model resulting in increased participation. Looking to the future, South
Carolina will continue to collaborate to ensure the best practices in privacy and security in SCHIEx and
other HIT efforts. The SCHIEx architecture centers on the standards-based federated exchange of clinical
information among providers that use EMRs. This federated service oriented architecture is coordinated
by a state-level Record Locator Service/Master Patient Index (RLS/MPI) and uses the repository of
claims for both Medicaid and hospital billing data (UB92/UB04).
In July 2008, SCHIEx was launched by SCDHHS and ORS Based on the existing RLS/MPI, the SCHIEx
network has the capability to allow healthcare providers to view 10 years of Medicaid claims data stored
in the ORS data warehouse. From claims data, health information is available on diagnoses, prescriptions,
procedures, etc., enabling a provider to access the health record of a patient. Claims-based information on
any of the state’s 800,000 beneficiaries is available to properly authorized Medicaid providers.
The vision and cooperation of state leaders, the availability of data through the data warehouse, and the
statewide RLS have enabled the ORS to also build a web-based, HIPAA compliant, secure Client
Management System (CMS) which tracks South Carolina public sector clients and their services across
multiple agencies for treatment and operations. In addition, CareEvolution HIEBus™ technology powers
the Medicaid Electronic Health Record (MEHR) that has been developed for SCDHHS (Medicaid
agency) which is used by private providers. This system gives providers a view of all of the health
services that were paid by Medicaid. Both the CMS and MEHR allow for more efficient and effective
coordination of care.
SCHIEx was conceived as a “Public Utility” in 2006, with production pilots in 2007 and production use
in 2008. The architecture is “standards based” and designed around privacy, security, and ease of
meaningful use. Leveraging the extensive data repository within ORS provides the potential for health
analytics and reporting increasing the overall benefit of the HIE. This is the foundation of the current
initiative and will be expanded to be the HIE for the state of South Carolina.
Several ongoing projects were also maintained including Medicaid EHR, CCC, and AccessHealth SC,
which were initiated in the spring of 2009. These projects will support connections to SCHIEx. The
adapters for these projects are compatible with SCHIEx. Those projects currently connected will
transition to a fee schedule.
3.0 Focus on Data Assets to Build Clinical Appeal
By leveraging the data already available in their data warehouse, ORS was able to seed the data available
from SCHIEx with longitudinal records for over 4 million residents of the state. Specifically, the data
includes all Medicaid claims data (including pharmacy and physician office visits), as well as UB-92
inpatient, ambulatory surgery, and emergency department claims. The result is that SCHIEx provides a
nearly comprehensive record of all providers who have served a given patient or clinic since 1996.
Additionally, the Medicaid claims data is supplemented with “clinical data adapters” that can connect
national lab vendors, prescription history sources, the state immunization registry, and local and regional
EMR-enabled systems. The end result is an extensive dataset of patient information from the very
beginning of SCHIEx. Other potential HIE implementations should strive to include such data from the
very beginning of HIE operation, since this makes the value of the system much easier to demonstrate.
4.0 Public Utility Approach
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As a neutral, non-regulatory agency, the ORS can only solicit and encourage participation by both private
and public partners, not mandate participation. From the beginning, ORS focused on identifying the data
that agencies wanted to participate. The ORS has a reputation for being good stewards of such data; that
reputation along with long-standing professional relationships with the data owners enabled the ORS to
obtain permission to share that data. The HIE team acknowledges that the success of their approach to
addressing key pain-points was at least partially driven by these long-standing relationships. Thus, a
critical component of SCHIEx’s success was the ORS’ position as a neutral, trusted agency benefitting
from long-standing relationships with key stakeholder groups. The fact that the ORS is staffed with
trusted public servants made it much easier to gain the trust of various participants. Private sector startups
that attempt to build HIEs lack this advantage.
6.0 Medicaid Coordination
MITA and ARRA are highly interdependent. MITA emphasizes the role of technology in improving
health outcomes, and ARRA lays out a few key routes for that transformation. SCDHHS completed a
MITA State Self-Assessment (SS-A) report in 2009 and gained CMS approval in 2010 to build a new
Medicaid Management Information System (MMIS), which is expected to be implemented in 2015
Coordination with the MMIS project team is underway to evaluate and plan for the integration of
HITECH requirements such as accepting clinical quality measures electronically by 2012.The necessary
work and specifications to implement these requirements will be submitted with the State Medicaid HIT
Plan (SMHP) in summer of 2010.
Medicaid’s current project with SCHIEx allows Medicaid providers to view 10 years worth of Medicaid
claims through a SCHIEx EHR viewer. Medicaid providers agree to comply with privacy and security
procedures when accessing the internet portal. Medicaid adopted an opt-out consent process whereby
beneficiaries are notified of this option with the receipt of their Medicaid card and call the Medicaid
Resource Center to request to “opt out”. Member level data is blocked in SCHIEx if the beneficiary has
opted out. Currently, approximately 300 of 803,000 enrollees have opted out.
There are plans underway to add clinical decision support functionality to the Medicaid EHR viewer. The
Medicaid agency is also working with Decision Support System/Surveillance and Utilization Review
Subsystem (DSS/SURS) contractor to be ready to receive quality measures data and potentially link this
with claims data. Analysis on how to accomplish this is underway.
Since SCDHHS is the agency tasked with promoting, measuring and rewarding meaningful use of HIT
for the state of South Carolina, the future Medicaid Enterprise must facilitate the measuring, tracking and
reporting of meaningful use and the distribution of incentive payments to meaningful users. Recognizing
this, SCDHHS is collaborating with CMS on the National Level Repository (NLR) and has been assigned
as members to the CMS System Technical Advisory Group (S-TAG) to interact about the NLR.
New York:
http://www.health.state.ny.us/funding/rfa/0903160302/health_it_strategic_plan.pdf
Strategic Goals
New York seeks to meet the following strategic goals for health information exchange:
1. Meaningful exchange of health information by the majority of practicing health providers across
settings and disciplines, and consumers
2. Creation of a highly valuable system for information exchange – one where benefits of provider
participation outweigh costs of participation
3. Exchange of all information sets required to meet meaningful use requirements
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4. Technical infrastructure in place to enable interoperable electronic health records for Clinicians,
interoperable personal health records for Consumers, and interoperable information portals for the
Community
5. Clinical Informatics Services (CIS) and tools in place for the aggregation, analysis, decision support
and reporting of data for purposes of quality improvement and public health
6. SHIN-NY in place to provide architecture, common health information exchange protocols and
standards to enable health information sharing between providers, patients, public health personnel,
and other relevant health care stakeholders
7. Technical infrastructure aligned with emerging NHIN design, standards, and certifications to enable
future health information exchange beyond NY State
From their vision:
However, health IT alone will not result in the expected quality and population health improvement and
efficiency goals. Key alignment of health IT with public health and clinical practice models, new quality
and outcomes-based reimbursement models, prevention and wellness initiatives as well as services to
support clinicians in learning how to consistently use information to realize the value are essential to
improve quality, affordability and outcomes for all New Yorkers. Coordination with Medicaid, other state
health programs and private payers is essential to achieve this broader objective.
The successful development and implementation of New York’s health information infrastructure will be
defined by how beneficial health information is in improving quality, reducing health care costs and
improving health outcomes. Electronic health records (EHRs), for example, are essential but not enough
to ensure effective use of information and improved health for New Yorkers. An environment must be
created and substantial efforts made to utilize the information and enable clinicians to learn how to
consistently realize the benefits from vastly improved availability of health information.
The high level objectives for New York’s HIE initiatives are as follows:
Improvements in Efficiency and Effectiveness of Care: Provide the right information to the right
clinician at the right time regardless of the venue where the patient receives care.
Improvements in Quality of Care: Enable access to clinical information to support improvements
in care coordination and disease management, help re-orient the delivery of care around the patient and
support quality-based reimbursement reform initiatives.
Reduction in Costs of Care: Reduce health care costs over time by reducing the costs associated
with medical errors, duplicative tests and therapies, uncoordinated and fragmented care, and preparing
and transmitting data for public health and hospital reporting.
Improvements in Outcomes of Care: Evaluate the effectiveness of various interventions and
monitor quality outcomes.
Engaging New Yorkers in Their Care: Lay the groundwork for New Yorkers to have greater
access to their personal health information and communicate electronically with their providers to
improve quality, affordability and outcomes.
Improvements in Public Health: Integrate health care delivery information with public health
surveillance systems to support public health goals
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Office of the National Coordinator: http://healthcarereform.nejm.org/?p=3732&query=home
KHPA SMHP Meeting: HIE Implications, Russ Waitman rwaitman@kumc.edu
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