Implications of Medicaid Goals on a Health Information Exchange

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 anindustry analyst:

“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 fromIdaho 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.”

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 qualificationfor Medicaid incentive payments; and,
• Utilize the HIE to gather data in order tocompute 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.
Develop HIE support of Medicaid’s legislated Medical Home effort. / 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.
Deploy a proactive HIE that supports Medicaid’s needs to interact directly with Medicaid eligible individuals, especially those not engaged with a provider. / This will be further addressed in the implementation of the SMHP.
Integrate system development and acquisition around common framework components. / 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 non-financial 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.
Expand capabilities of provider directory management. /

• State hosted directories could include but not be limited to:
• Health care providers
• Health plans (from the Kansas Insurance Department)
• Licensed clinical laboratories (from KDHE)
• Organizations (including RHIOs, IDN, identified from the environmental scan)
• Lists of consent directories
• Web services directories
• 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.

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:

Background from the HITECH legislation:

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 patientcentered 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.

‘‘(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.

Background notes from other states’ strategic plans regarding Medicaid

Note: I used the map on the eHAC website ( to review several states plans for Medicaid specific details.

New Mexico:

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:

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 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:

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, isproviding guidance to and funding for states to foster the meaningful use ofEHRs.

Tennessee’s strategy for statewide HIE is guided by the principle that the Statehas a responsibility to ensure that those citizens who are dependent uponTennCare (Tennessee’s Medicaid program), and their providers cannot be leftbehind. 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 improvementsand quality of care possible, whether their providers are eligible for incentivepayments or not.

Active coordination between statewide eHealth efforts and TennCare efforts isessential to achieving Tennessee’s eHealth vision. Furthermore, this collaborationleverages opportunities to advance HIE in a way that also ensures the investmentsare made wisely.

1.5 HIE Strategy Consistent with Tennessee’s State Health Plan

Tennessee’s strategy for statewide interoperable HIE is consistent with andsupportive of the State’s overall State Health Plan developed by the Division ofHealth Planning of the State Department of Finance and Administration.

The following five principles comprise the basis of the State Health Plan, basedon 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 ofTennesseans 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 iscontinually monitored, and healthcare providers adhere to standards; and

5. The State should support the development, recruitment and retention of asufficient and quality healthcare workforce.

8.1 Coordination with TennCare

Tennessee’s Office of eHealth Initiatives and TennCare, along with theDepartment of Health, are working together currently on development of theMedicaid health IT strategic vision, goals and objectives, and the design of theMedicaid incentive program, recognizing that the State Medicaid Health IT Planactivities and statewide HIE efforts are interdependent and thus coordination andintegration between the areas are critical to maximize their impact and preventduplication in efforts.Tennessee’s HIE strategy will leverage provider participation in the Medicaidincentive program while the Medicaid health IT strategy will integrate statewideHIE capabilities that enable providers to meaningfully use EHRs and fully realizebenefits 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 qualityreporting requirements, such as HEDIS and CAHPS measures, are consistentwith meaningful use objectives and anticipated quality reporting requirementsunder the HITECH Act. To the degree final rules permit, Tennessee will align

these measures, and incorporate Tennessee’s HIE goals in definingrequirements for meaningful use at the state level. Increasing requirements formeaningful use will be timed with the HIE requirements under the federalMedicare meaningful use definition. TennCare and eHealth objectives andinitiatives will be coordinated to encourage health IT and HIE adoption andmeaningful use in the Medicaid provider population. TennCare will pursuedesign strategies to make health IT broadly available and affordable.