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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 - PowerPoint PPT Presentation
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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?