Academy Health State Coverage Initiatives

ProgramStrategic Opportunities for States in the

ARRA HITECH Provisions

Anthony Rodgers, DirectorArizona Health Care Cost Containment System

July 31, 2009

Definitions- HII, HIE and HIT

HIEHealth Information Exchange

“The Network”

The electronic movement of health-related information among organizations according

to nationally recognized standards.

HIIHealth Information Infrastructure

The wider arena of policies, procedures, technologies and industry standards that facilitate secure and accurate online sharing of electronic medical information between providers,

payors and ultimately, patients and their guardians via HIE/HIT.

HITHealth Information Technology

“The Record”

Use of technology to support storage, retrieval, sharing, and use of healthcare

information for communication and decision making within healthcare organizations.

Definitions- Network Terms

HIEHealth Information

Exchange

The electronic movement of health-related information

among organizations according to nationally recognized standards.

HIOHealth Information

Organization

An organization that oversees and governs the

exchange at health-related information

among organizations according to nationally recognized standards.

RHIORegional Health

Information Organization

A health information organization that brings

together healthcare stakeholders within a defined geographic area and governs health information exchange among them for the purpose of improving health and care

in that community.

Source: National Alliance for Health Information Technology Report to HHS/ONC

Definitions- E-Records Terms

EMRElectronic Medical

Record

An electronic record of health-related

information on an individual that can be

created, gathered, managed and consulted by authorized clinicians

and staff within one healthcare organization.

EHRElectronic Health

Record

An electronic record of health-related information on an individual that conforms to

nationally recognized interoperability standards and

that can be created, managed and consulted by

authorized clinicians and staff across more than one

healthcare organization.

PHR Personal Health

Record

An electronic record of health-related information

on an individual that conforms to nationally

recognized interoperability standards and that can be

drawn from multiple sources while being managed,

shared and controlled by the individual.

Source: National Alliance for Health Information Technology Report to HHS/ONC

Building the State Level HIT Infrastructure

Labs

Rxs

Other

EHR1 EHR2

EHR3EHR4

PHR5

PHRn

EHR1EHR2

EHR3EHRn

HIE

Aggregate Database

• Highly desirable to couple with HIE

Ap

pro

pri

ated

G

ran

t F

un

ds

$2.0

B

EH

R In

cen

tive

F

un

ds

$46.

8 B

illio

nMedicare

EHR Incentive Program$23.1 B

Medicaid EHR Incentive

Program$21.6 B

HIE Planning &Implementation

$300 M

EHR AdoptionLoan Program

TBD

Regional TechProgram

Appropriation

Workforce Training

New TechnologyResearch

CMSMedicare$745 M

EHR Incentives via Carriers & TPA

CMSMedicaid$300 M

ONC

HHSNSF

Incentive viaState Medicaid

StateMedicaid$1.05B

Planning Grants

Implementation Grants

Loan Funds for States

Health IT Research

Regional Tech Centers

Medical Informatics

EHR For Med Education

HIT Enterprise Research

Hospitals

Doctors

Health Centers

State Designated

Entity

Program Area

States

OtherProviders

Tribes

Agency

Universities

Research

GMETraining

HIT

EC

H F

UN

DIN

G P

RO

VIS

ION

SState Opportunities for Funding HIT

Categories of Funds

State Readiness Check List

Has an state level environmental scan and gap analysis been completed? Is there a comprehensive state level roadmap or strategic plan with specific

measurable goals and project accountabilities? Is the public and private health care leadership engagement and organized? Do you have key stakeholder involvement? Has your Governor and legislature demonstrated the political will to support

adoption of HIT? Has the Governor identified the state’s accountable authority for HIT

coordination? Has the role of the Medicaid agency in driving HIT adoption been clarified

and accepted? Is the planning process addressing the long term view in the state’s HIT

planning and development? Will you have adequate public and private capital for health information

system infrastructure development and operating funds? Have the technical and support resources for provider EHR adoption been

identified and organized?

State-wide HIT Strategic Alignment

HIT Strategic Plan

Provider EHRAdoption Support

Program

Provider EHRAdoption Support

Program

Quality and Cost Effectiveness

Quality and Cost Effectiveness

Health InformationExchange

Infrastructure

Health InformationExchange

Infrastructure

Adoption Goals &Meaningful

Use Requirements

Adoption Goals &Meaningful

Use Requirements

Health InformationOrganizations (HIOs)

Data SourcesBusiness Associates

Health InformationOrganizations (HIOs)

Data SourcesBusiness Associates

Quality Goals And ROI

Expectations

Quality Goals And ROI

Expectations

HITFinancing

Plan

HITFinancing

Plan

EHR IncentivesLoan ProgramsGrant Priorities

EHR IncentivesLoan ProgramsGrant Priorities

Return on Investment From HIT

Return on Investment: Wide Spread Adoption of Electronic Health Information

(EHI) Technologies Can Better Outcomes and Lower Cost

Improving Health Care Quality and Cost Performance

BetterOutcomes• Improved Patient Safety

• Reduced Complications Rates

• Reduced Cost per Patient Episode of Care

• Enhanced cost & quality performance accountability

• Improved Quality Performance

ROI of EHI at Point of Care:

LowerCosts

Medicare Incentives for Non-Hospitals/Providers

PaymentComponent

Base Year

Maximum of 85% of EHR Acquisition and

Implementation Costs

Year 2 Year 3 Year 4 Year 5 Total

Physician $18,000 If first payment year

Is 2011 or 2012

$15,000 If first payment year

Is 2013

$12,000 If first payment year

Is 2014

$12,000 $ 8,000 $ 4,000 $ 2,000 $44,000

$41,000

$38,000

Criteria:1.For eligible professionals in a healthcare professional shortage area (HPSA), the incentive payment amounts will be increased by 10%2.Payments are not available to hospital-based professionals, such as pathologist, emergency room physician, or anesthesiologists)3. In 2015 Medicare starts reducing provider Medicare payments for not having EHRs

Opportunities: Medicaid Incentives for Non-Hospitals/Providers

PaymentComponent

Base Year

Maximum of 85% of EHR Acquisition and

Implementation Costs

Year 2 Year 3 Year 4 Year 5 Year 6 Total

Physician $21,250 $ 8,500 $ 8,500 $ 8,500 $ 8,500 $ 8,500 $63,750

Certified Nurse Mid-Wife

$21,250 $ 8,500 $ 8,500 $ 8,500 $ 8,500 $ 8,500 $63,750

Dentist $21,250 $ 8,500 $ 8,500 $ 8,500 $ 8,500 $ 8,500 $63,750

Nurse Practitioner $21,250 $ 8,500 $ 8,500 $ 8,500 $ 8,500 $ 8,500 $63,750

Physician Assistant $21,250 $ 8,500 $ 8,500 $ 8,500 $ 8,500 $ 8,500 $63,750

Criteria:1.Must demonstrated meaningful use for certified electronic health record2.Must have at least 30% Medicaid volume3. Ability to produce quality reports and demonstrate quality improvement

Opportunities: Medicare & Medicaid Incentives for Hospitals

PaymentComponent

Base Year

Year 1 Year 2 Year 3 Year 4 Year 5

Incentive Payment Medicare

Incentive Payment Medicaid

$2.0 M

$2.0 M

Variable

Variable

Variable

Variable

Variable

Variable

Variable

Variable

$0

Variable

Variable Reimbursement Per Discharge

$0For the first through 1,149th discharge

$200For the 1,150th through 23,000th discharge

$0 For any discharge greater than 23,000th

Criteria: Demonstrates use of a certified EHR in a meaningful manner Demonstrates the EHR technology is connected in a manner that provides electronic exchange of information to improve the quality of health care, such as promoting care coordination Submits information for each period on clinical quality measures

What States Need to Do to Create a Medicaid EHR Incentive Program?

• Definition of Meaningful Use in Medicaid– A clear set of definitions for each category of eligible provider – Create an auditable EHR meaningful use validation process

• Steps to administering a Medicaid EHR incentive program 1. Develop state specific policies and procedures for EHR incentive

program 2. Develop and implement provider education and EHR adoption

assistance3. Identify providers that will be participating and track progress 4. Phase in of meaningful use requirements over three years5. Payout Medicaid incentives on an annual basis6. Provide other recognitions for physician EHR adoption for providers

that don’t qualify for Medicaid or Medicare EHR incentive7. Verify return on investment in quality improvement and cost

containment

CostContainment

QualityImprovement

AdministrativeEfficiency

Public Health &Research

Meaningful Use of EHR to better coordinate care andQuality Performance

Meaningful use ofEHR to Reduce Admin. Process Cycle Times

Meaningful Use ofEHR to build PopulationHealth Mgmt. & Research

Meaningful Use of EHR to reduce Duplication, Errors and improveAdmin Efficiency

Strategic HIT Focus Areas

Reduced UnnecessaryCost/Utilization = Reduced PMPM & Lower % Admin Cost

HIT Strategic Performance Metrics

Performance Outcomes

Higher Provider Satisfaction & Reduction in Admin.Cost

Public Health ResponsivenessReduction in Health Disparities

Improved QualityAgainst HEDIS andOther Benchmarks

Meaningful USE Barrier

PERFORMANCE ManagementBarrier

Str

ateg

ic P

lan

nin

g L

og

ic M

apDeveloping a Performance Outcomes for HIT

State Specific Strategies

State specific strategies for achieving wide spread adoption and meaningful use of electronic health records must include:

Strategies for building state HIT infrastructure

Strategies for supporting successful provider EHR adoption

Strategies for financing and sustaining HIT at the state level

Building State Wide HIT Infrastructure• Scope of HIT infrastructure

Data sources Health Information Organizations Data exchange systems Health information business associates Electronic health record system Clinical Data Repositories Health information users community

• State designated authority HIT planning and development Policy setting Standards Priority setting Oversight

• Financing mechanisms Public and private contributions Payers contributions Providers use fees Consumers subscriptions

• Provider user support and technical Assistance Technical Assistance Extension Centers Medicaid Others

Strategies to Support Provider EHR Adoption and

Meaningful Use• Technical assistance extension centers• Medicaid program support of provider adoption• State designated authority • Graduate medical education training programs• Federal outreach and education• Other state agencies • Hospitals and major group practices

HIT Financing Strategies• Federal EHR incentive funds for Medicare and Medicaid• Provider EHR loan program• Pool EHR provider financing support

– Payers– Hospitals– Others

• Transaction or user fees to support HIE sustainability• Health plan tax for HIE support• 90/10 federal Medicaid funding• Grants • Research fund assessment

Managing Risk of Failure

Building a sustainable HIT Infrastructure and achieving wide spread EHR adoption is a high risk enterprise that requires a multi-year commitment and a well organized process at the state level

Identify the potential risks Identify the risk mitigation strategies Build-in adequate planning and development time

– Environmental Assessment– Stakeholder involvement– Develop common planning and system development tools

Identify organizational accountability

Scope of State Level HIT Activities from 2010 thru 2015

1. Health System strategic HIT plan– Statewide environmental scan to determine readiness and gaps – Description of approaches, methods, and timelines for organized

EHR adoption assistance and financial support– HIE network infrastructure and EHR interface design development– Clinical Data Repositories data architecture design and development

and data flows2. Widespread EHR system acquisition, upgrade, or integration3. Health information exchange infrastructure development and expansion4. Provide on-going technical support and assistance 5. Provide practice reengineering support 6. Clinical practice staff training and EHR competency development7. Clinical decision support integration8. Public Health Alert and Monitoring system integration9. Care management systems integration10. Integration of patient decision support tools

Logical Phases of State Level HIT Development

• HIT infrastructure development phase• EHR initial implementation and use phase

– Practice workflow redesign– Training and user support

• EHR managed performance phase– Improve practice workflow and EHR use– Better process outcomes

• EHR optimization phase– EHR configuration for optimization– Improved quality and cost effectiveness outcome– Maximized return on investment

Structural Development Phase2010 thru 2012

• Acquisitions and Installation of a certified EHR– E-prescribing– Computerize order entry results reporting– Quality reporting capabilities– Clinical Decision Support capability

• Ability to exchange health information and continuity of care documents (CCD) at each patient care delivery point

• Development of clinical data repository and disease registries

• User support for provider practice and clinical process reengineering and EHR integration

Infrastructure

Web Portal Services

Healthcare Information Exchange

(HIE)

Electronic Health Record

(EHR)

EHR Repository

EHR Analytics(Public health

Disease Management

Bio-surveillance)

External System

Interfaces

SecurityFirewalls

Web ServersLoad Balancers

SecurityAuthenticationAuthorization

Consent Management

Portal Services Interfaces

System and Application Management Repository

Single Sign on Contract Enforcement

System Administration Management and Monitoring

Tools

Customization

High Availability Management and Tools

Da

ta C

on

vers

ion

an

d M

ap

pin

g T

oo

ls

Ap

plic

atio

n A

dm

inis

tra

tion

Ma

na

ge

me

nt

an

d M

on

itorin

g T

oo

ls

Cu

sto

me

r a

nd

Te

chn

ica

l Su

pp

ort

Operating Systems Middleware

E-Health Infrastructure Configuration

EHR “Initial Use” Phase2011 thru 2013

• Building EHR Meaningful Use Competency (EHR System Burn In)

• Technical assistance and support for provider practice

• Focus on process and practice productivity improvement

• Data conversion assistance and support• Implement EHR system failure “risk reduction”

strategies• Interface external data sources and HIE connectivity

EHR Managed Performance Phase2012 thru 2014

• Participation in quality networks for comparable performance analysis and improvement

• Medicaid specific configuration and effective use of clinical decision support

• Web connectivity with patients for compliance management (electronic reminders, messaging, and telehealth)

• Use of health e-learning tools for patient health literacy and compliance

• Electronic performance reporting• Disease registries

Web Portal

HIE EHR

Application Administration UI

EHR UI

Record Locator Service

Direct Care

Supportive

Information Infrastructure

Analytical ApplicationsOLAP/ROLAP

Analytics UI

Management and Monitoring

SecurityAuthenticationAuthorization

External Interfaces to Business Partners

Medical Web Portal

Exchange Web Portal

Trading Web Portal

ManagementSupport

UI

External Applications

Utility Administration

· User· Role· Business Partner· Data Partner· Patient

AuditIntegrationMigrationData ConversionReporting

Utility Administration

Single Sign on

Information Site

Secure Site

Consent Management

The Healthcare Information Exchange (HIE) Application enables the sharing of data between Physicians, Labs, Imaging, Plans/Payors, Medicaid.

Also provides Administrative process support and Administrative Data management

The Electronic Health Record (EHR) Application provides Clinical Data Management with Decision Support for processes where possible.

Also provides Administrative process support and Administrative Data management

Models to align areCCHIT CertificationHL7 FunctionalMITA Business Architecture Governor’s Roadmap

The Analytical Applications of the Utility provide support for Public Health, Bio-surveillance and Disease Management

Also provides Administrative process support and Administrative Data management

The System and Application Management and Monitoring Applications provide operational support for the Utility in order to provide High Availability and zero maintenance window service levels.

External Interfaces to Business Partners’ Applications create seamless links to their applications through prior arranged protocols for application sharing and privacy.

Administration Applications provide the tools for the Utility Operations team to run the utility, integrated with application roles, admin and configuration from integrated applications.

Contract Enforcement

Roles, Application Admin and

configuration

Roles, Application Admin and configuration

Roles, Application Admin and configuration

Roles, Application Admin and configuration

Roles, Application Admin and

configuration

Public Health

Bio-surveillance

Disease Management

System

ApplicationSonora Quest

Medicaid e-Health Information Technology Environment

2011 and Beyond

EHR “Optimized Use” Phase2013 and Beyond

• System configuration for optimization of patient management– Optimization analysis and system configuration– Patient center care – Best practice

• Personal Electronic Health Record extensions from the EHR

• Advanced messaging and alerts• Integration of Web 2.0 functionality for patient support

and care management • Integration of remote monitoring tools, telemedicine,

telehealth and health e-learning functionality and tools• Integrated with health plan care management systems• Translational research participation and quality network

infrastructure

2 Server

2 Terminal

1 Cell phone

1 Printer

1 PDA

2 Firewall

Legend

Symbol Count Description

Legend Subtitle

Provider Registration Database

Clinical Decision Support

Application

Health CareProvider

Patient Clinical Information Database

Master Patient Index

Patient E-Learning

Audio/Video Files

MedicaidBeneficiary

Medicaid Clinical Decision

Support Extranet

Web Portal

Medicaid Health

Information Exchange

InternalEHR Firewall

Provider Based EMRServer

External Firewall

Web BasedClinical

Decision SupportTool

Medicaid Electronic Health Information System Environment

The AboveSections of the

Diagram in Yellow are in scope for this

project

Patient EpisodeOf Care

Database

Web BasedPersonal

HealthRecord Value

Driven Decision

Support Tools

Integrating Clinical and Patient Decision Support For Value Added E-Health Care

Organizing YourTools Box of HIT Planning, Development and Adoption

• Identify designate HIO entities• Create or identify an accountable organization that is

dedicated to support EHR adoption and achievement of meaningful use (State QIO etc.)

• Organize HIT development phases• Create a preferred list of EHR vendors to help with

providers adoption• Develop a provider loan program• Create opportunities for joint EHR purchasing

arrangements• Support hospital organized EHR assistance programs • Develop hub and spoke EHR support strategies

The Connected Healthcare System

Remote PatientSelf Monitoring

Hospital Care Coordination

Order Entry LabResult Reporting

EHR/HIE

Specialist Referral

E-Prescribing

MCO Medical Medical Mgmt.

PrimaryCareMedical HomeProvider

Research

Diagnostics

Questions?