Academy Health
State Coverage Initiatives
Program
Strategic Opportunities for States in the
ARRA HITECH Provisions
Anthony Rodgers, Director
Arizona Health Care Cost Containment System
July 31, 2009
Definitions- HII, HIE and HIT
HII
Health 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.
HIE
HIT
Health Information Exchange
“The Network”
Health Information Technology
“The Record”
The electronic movement of health-related
information among organizations according
to nationally recognized standards.
Use of technology to support storage,
retrieval, sharing, and use of healthcare
information for communication and decision
making within healthcare organizations.
Definitions- Network Terms
HIE
HIO
RHIO
Health Information
Exchange
Health Information
Organization
The electronic
movement of healthrelated information
among organizations
according to nationally
recognized standards.
An organization that
oversees and governs
the exchange at healthrelated information
among organizations
according to nationally
recognized standards.
Regional 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
EMR
EHR
PHR
Electronic Medical
Record
Electronic Health
Record
Personal Health
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.
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.
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
EHR1
HI
E
EHR2
EHR3
EHRn
Labs
EHR1
EHR2
EHR3
EHR4
PHR5
PHRn
Rxs
Aggregate
Database
Othe
r
• Highly desirable to couple with HIE
State Opportunities for Funding HIT
EHR Incentive
Funds
$46.8 Billion
Program Area
Agency
Medicare
EHR Incentive
Program
$23.1 B
CMS
Medicare
$745 M
Medicaid
EHR Incentive
Program
$21.6 B
CMS
Medicaid
$300 M
Hospitals
Categories of Funds
EHR Incentives via
Carriers & TPA
Doctors
State
Medicaid
$1.05B
Incentive via
State Medicaid
Health Centers
Planning Grants
HIE Planning &
Implementation
$300 M
$2.0 B
Appropriated
Grant Funds
HITECH FUNDING PROVISIONS
Appropriation
EHR Adoption
Loan Program
TBD
Implementation Grants
ONC
New Technology
Research
Other
Providers
Health IT Research
Regional Tech
Program
Workforce
Training
Loan Funds for States
State
Designated
Entity
Regional Tech Centers
States
Universities
Medical Informatics
HHS
NSF
Tribes
EHR For Med Education
GME
Training
HIT Enterprise Research
Research
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
Provider EHR
Adoption Support
Program
Health Information
Exchange
Infrastructure
Quality and
Cost Effectiveness
HIT
Financing
Plan
Adoption Goals &
Meaningful
Use
Requirements
Health Information
Organizations (HIOs)
Data Sources
Business Associates
Quality Goals
And ROI
Expectations
EHR Incentives
Loan Programs
Grant 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
ROI of EHI at Point of Care:
•
•
•
•
•
Improved Patient Safety
Reduced Complications Rates
Reduced Cost per Patient
Episode of Care
Enhanced cost & quality
performance accountability
Improved Quality Performance
Better
Outcomes
Lower
Costs
Medicare Incentives for Non-Hospitals/Providers
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
Payment
Component
Base
Year
Year 2
Year 3
Year 4
Year 5
Total
$12,000
$ 8,000
$ 4,000
$ 2,000
$44,000
Maximum of 85% of EHR
Acquisition and
Implementation Costs
Physician
$18,000
If first payment year
Is 2011 or 2012
$15,000
If first payment year
Is 2013
$41,000
$12,000
If first payment year
Is 2014
$38,000
Opportunities: Medicaid Incentives for Non-Hospitals/Providers
Criteria:
1.
Must demonstrated meaningful use for certified electronic health record
2.
Must have at least 30% Medicaid volume
3.
Ability to produce quality reports and demonstrate quality improvement
Payment
Component
Base
Year
Year 2
Year 3
Year 4
Year 5
Year 6
Total
Maximum of 85% of EHR
Acquisition and
Implementation Costs
Physician
$21,250
$ 8,500
$ 8,500
$ 8,500
$ 8,500
$ 8,500
$63,750
Certified Nurse MidWife
$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
Opportunities: Medicare & Medicaid
Incentives for Hospitals
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
Payment
Component
Base
Year
Year 1
Year 2
Year 3
Year 4
Year 5
Incentive Payment Medicare
$2.0 M
Variable
Variable
Variable
Variable
$0
Incentive Payment Medicaid
$2.0 M
Variable
Variable
Variable
Variable
Variable
Variable Reimbursement
Per Discharge
$0
For the first through 1,149th discharge
$200
For the 1,150th through 23,000th discharge
$0
For any discharge greater than 23,000th
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.
2.
3.
4.
5.
6.
7.
Develop state specific policies and procedures for EHR incentive
program
Develop and implement provider education and EHR adoption
assistance
Identify providers that will be participating and track progress
Phase in of meaningful use requirements over three years
Payout Medicaid incentives on an annual basis
Provide other recognitions for physician EHR adoption for providers
that don’t qualify for Medicaid or Medicare EHR incentive
Verify return on investment in quality improvement and cost
containment
Developing a Performance Outcomes for HIT
Strategic Planning Logic Map
Strategic HIT
Focus Areas
HIT Strategic
Performance Metrics
Performance Outcomes
Reduced Unnecessary
Cost/Utilization =
Reduced PMPM &
Lower % Admin Cost
Cost
Containment
Meaningful Use of
EHR to reduce
Duplication, Errors
and improve
Admin Efficiency
Quality
Improvement
Meaningful Use of
EHR to better
coordinate care and
Quality Performance
Improved Quality
Against HEDIS and
Other Benchmarks
Meaningful use of
EHR to Reduce
Admin. Process
Cycle Times
Higher Provider
Satisfaction &
Reduction in Admin.
Cost
Meaningful Use of
EHR to build
Population
Health Mgmt. &
Research
Public Health
Responsiveness
Reduction in
Health Disparities
Administrative
Efficiency
Public
Health &
Research
Meaningful USE
Barrier
PERFORMANCE Management
Barrier
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







•
State designated authority





•
HIT planning and development
Policy setting
Standards
Priority setting
Oversight
Financing mechanisms




•
Data sources
Health Information Organizations
Data exchange systems
Health information business associates
Electronic health record system
Clinical Data Repositories
Health information users community
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 flows
2.
Widespread EHR system acquisition, upgrade, or integration
3.
Health information exchange infrastructure development and expansion
4.
Provide on-going technical support and assistance
5.
Provide practice reengineering support
6.
Clinical practice staff training and EHR competency development
7.
Clinical decision support integration
8.
Public Health Alert and Monitoring system integration
9.
Care management systems integration
10. 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 Phase
2010 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
E-Health Infrastructure Configuration
Security
Portal Services
Interfaces
Healthcare
Information
Exchange
(HIE)
Web Portal Services
Electronic
Health Record
(EHR)
EHR Repository
EHR Analytics
(Public health
Disease
Management
Bio-surveillance)
Contract
Enforcement
Single Sign on
Customization
External
System
Interfaces
System and Application
Management Repository
Load Balancers
Web Servers
Consent
Management
Customer and Technical Support
Security
Authentication
Authorization
High Availability
Management and Tools
Infrastructure
Data Conversion and Mapping Tools
Firewalls
System Administration
Management and Monitoring
Tools
Middleware
Application Administration Management and Monitoring Tools
Operating
Systems
EHR “Initial Use” Phase
2011 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 Phase
2012 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
Medicaid e-Health
Information Technology Environment
2011 and Beyond
Single Sign on
Information Site
Secure Site
Web Portal
Security
Authentication
Authorization
Exchange Web
Portal
Trading Web
Portal
Medical Web
Portal
Utility Administration
EHR UI
Analytics UI
Application Administration UI
HIE
EHR
Analytical
Applications
Direct Care
Record Locator
Service
Contract
Enforcement
Supportive
Roles, Application
Admin and
configuration
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
Public Health
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 are
CCHIT Certification
HL7 Functional
MITA Business Architecture
Governor’s Roadmap
Management
and Monitoring
System
External
Interfaces to
Business
Partners
Sonora Quest
Bio-surveillance
Roles,
Application Admin
and configuration
External Applications
OLAP/ROLAP
Information
Infrastructure
Consent
Management
Management
Support
UI
Application
Disease
Management
Roles,
Application Admin
and configuration
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
Roles,
Application Admin
and configuration
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.
Utility
Administration
·
·
·
·
·
User
Role
Business Partner
Data Partner
Patient
Audit
Integration
Migration
Data Conversion
Reporting
Roles, Application
Admin and
configuration
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.
EHR “Optimized Use” Phase
2013 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
Integrating Clinical and Patient Decision
Support For Value Added E-Health Care
Provider Based EMR
Server
Web Based
Clinical
Decision Support
Tool
Provider
Registration
Database
External
Firewall
Medicaid
Clinical Decision
Support
Extranet
Health Care
Provider
Web Based
Personal
Health
Record Value
Driven
Decision
Support Tools
Medicaid
Beneficiary
Internal
EHR Firewall
Web Portal
Medicaid
Health
Information
Exchange
Legend
Count
Description
2
Server
2
Terminal
1
Cell phone
1
Printer
1
PDA
2
Firewall
Master Patient
Index
Patient
E-Learning
Audio/Video Files
Legend Subtitle
Symbol
Clinical
Decision
Support
Application
Patient Clinical
Information
Database
The Above
Sections of the
Diagram in Yellow are
in scope for this
project
Medicaid Electronic Health Information
System Environment
Patient Episode
Of Care
Database
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
Hospital Care
Coordination
Order
Entry Lab
Result
Reporting
Diagnostics
Specialist Referral
EHR/HIE
Primary
Care
Medical
Home
Provider
Research
E-Prescribing
Remote Patient
Self Monitoring
MCO Medical
Medical Mgmt.
Questions?