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T he MARYLAND
HEALTH CARE COMMISSION
Discussion Topics
• Overview
• Learning Objectives
• Electronic Health Records
• Health Information Exchange
• Telehealth2
Overview - Maryland Health Care Commission
• Advancing value-based care delivery programs;• Identifying and addressing challenges regarding health IT implementation
and interoperability;• Promoting standards-based health IT through educational and outreach
activities;• Implementing a statewide HIE and harmonizing local area HIE efforts;• Diffusing telehealth in long term care (LTC), ambulatory care, and in
hospitals; • Designating management service organizations (MSOs) that meet select
health IT requirements; and• Promoting electronic data interchange (EDI) between payors and
providers, and certifying electronic health networks3
Health IT
Electronic Health Records
Health Information Exchange
Telehealth
Health IT Components
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Electronic Health Records – Foundation for Health Care Reform
Increase health care value
Improve quality Reduce Costs
Electronic health records
The goal
Tactics
Prerequisite
Valu
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Red
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Red
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itio
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Bu
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pay
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Inn
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ve c
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Accelerate Meaningful Use • EHRs are considered a critical tool for advancing high
quality patient centered care and are essential to practice transformation
• Achieving efficiencies in clinical practice and in quality requires using EHRs in a meaningful way
• MU is aligned with the national health care triple aim effort to improve patient care quality and satisfaction, increase population health, and reduce health care costs
• Maryland Medicaid administers the Medicaid EHR Incentive program in Maryland
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State Incentives• Maryland is the first State to build on the Medicare and Medicaid EHR
adoption incentive programs requiring State-regulated payors to provide incentives for the adoption of EHRs
• State incentives are separate and independent of federal incentives; there are different eligibility and participation requirements for each program
• Current Legislation• 2009 House Bill 706 Electronic Health Records – Regulation and
Reimbursement (HB 706) requires MHCC to establish regulation to require State-regulated payors (payors) to offer incentives to providers to promote the adoption of EHRs
• 2011 House Bill 736 Electronic Health Records – Incentives for Health Care Providers –Regulations (HB 736) further clarifies the incentive program established under HB 706
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State Incentive Program - Key Provisions
• Eligibility – primary care practices, including family, general, internal medicine, pediatrics, geriatrics, and gynecology
• Must adopt a certified EHR in order to qualify• The six largest private payors required to provide incentives
include: Aetna, CareFirst, Cigna, Coventry, Kaiser Permanente, and United Healthcare
• One time payment per payor per practice
• Incentive of up to $15,000 – based on the practice’s panel members, calculated at $25 per member
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• Over $8.3M to 370 primary care practices since October 2011
• Participation has increased by about 14 percent since April 2013
• The average number of applications that resulted in payments increased from 33 per month under the previous program to 43 per month under the revised program
State Incentive Program Progress
Source: Data reported by payors for period October 2011 – March 2015 10
EHR Adoption Among Office-based Physicians
EHR adoption among Maryland office-based physician has increased from 33.4 percent in 2011 (around the time the State incentive program went into effect) to 64.3 percent in 2014
18.6%23.8%
33.4%
49.2%
58.3%64.3%
21.8%27.9%
33.9%39.6%
48.1%54.0%
0%
10%
20%
30%
40%
50%
60%
70%
2009 2010 2011 2012 2013 2014
Maryland National
Sources:
• Maryland Data – Maryland Board of Physicians • National Data – 2009-2013 National Center for Health Statistics• National Data – Centers for Medicare and Medicaid Services EHR Incentive Program data, December 2014
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EHR Adoption – Acute Care Hospitals
77%81%
89% 89% 89%96%
72%
85%94%
97%
9% 12%16%
28%
44%
59%
76%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
2008 2009 2010 2011 2012 2013 2014
Hospitals in Maryland Hospitals Nationally - Certfied EHR Hospitals Nationally - Basic EHR
Sources:
• Maryland Data – Maryland Health Care Commission, Health Information Technology, An Assessment of Maryland Hospitals,
October 2014.• National Data – Office of the National Coordinator for Health Information Technology (ONC), ONC Data Brief, Adoption of Electronic
Health Record Systems among U.S. Non-Federal Acute Care Hospitals: 2008-2014, No. 23, April 2015.
100%
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• Health care reform is driving evolving electronic HIE strategies
• Sharing of clinical data among organizations not previously exchanging data
• More robust clinical data and analytic needs• More organizations entering the HIE market• Exchange activities expanding geographically, including
interstate exchange• HIE privacy and security regulations need to keep pace with
the changing landscape
HIE –Evolving Technology
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Health Information Exchange• The goal of HIE is to make health related information more accessible
across disparate health systems• Benefits
• Streamlined practice processes: Tasks currently conducted manually – requesting results and patient summaries, sending referrals and receiving reports, and sending prescriptions – can be completed electronically
• Better communication: View a more complete patient record electronically, including hospital visits, lab work, medications
• Improved health outcomes: Up-to-date information on patients, which can result in reduced medical errors and improved quality of care, especially during transitions of care
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HIE Considerations• HIE can help get the right data to the right place at the
right time
• To be effective, HIE needs to support and be integrated into workflows – not compete with them
• HIE needs to be adopted by all health care providers to achieve maximum benefits
• HIE query portal is accessible through the Internet; providers do not need to have an EHR to access the system
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The Development of the Statewide HIE
• Planning and legislative authority
• Two multi-stakeholder groups worked independently to identify best implementation strategy (May 2008 - Feb. 2009)
• Legislative authority to designate a statewide HIE in May 2009 - House Bill 706, Electronic Health Records – Regulation and Reimbursement
• The Chesapeake Regional Information Systems for our Patients (CRISP) was competitively selected in August 2009
• CRISP is a not-for-profit collaborative effort among the Johns Hopkins Health System, MedStar Health, University of Maryland Medical System, Erickson Retirement Communities, and Erickson Foundation, and more than two dozen major stakeholders across the state
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CRISP ServicesQuery Portal: Gives providers access to prior hospital and medication recordsDirect Secure Messaging: Enables referrals and other care coordinationEncounter Notification Service: Notifies providers in real time about patient visits to the hospitalPrescription Drug Monitoring Program: Monitor the prescribing and dispensing of drugs that contain controlled dangerous substances
Maryland’sState-Designated HIE
• The Chesapeake Regional Information System for our Patients (CRISP)• All 47 acute care hospitals and two specialty hospitals are connected and provide admission, discharge, and transfer information• Around 40 hospitals submit clinical data (e.g., labs, radiology, clinical documents) to the HIE infrastructure• Two national laboratory and three radiology centers are connected and provide laboratory and radiology reports
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• Legislative Authority • 2011 law requires the MHCC to adopt regulations for the
privacy and security of PHI exchanged through an HIE• Regulations
• The HIE Policy Board, a staff advisory group, consisting of various stakeholders proposed policies for privacy and security • Policies became the framework for the draft HIE
regulations • Final regulations, COMAR 10.25.18, adopted by MHCC
went into effect in March 2014
HIE Privacy and Security
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Regulation Section Summaries –Key Areas • Health care consumer rights concerning information
accessed, used, or disclosed through an HIE• Access, use, or disclosure of sensitive health information• Requirements for accessing, using, or disclosing PHI through
an HIE• Auditing requirements• Remedial actions to be taken by an HIE• Notice of breach or violation• Registration and enforcement
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• The regulations require HIEs that operate in Maryland to register with MHCC and renew their registration annually
• Information collected as part of registration:• Technical capabilities from HIEs • Service areas and types of participating organizations• Authentication and audit policies and procedures • Consumer educational materials• Audited financial statements• National accreditation if achieved; however, not required
Requirements under the Existing Regulations
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Registered HIEs
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“Now inhale deeply, Mrs. Saunders”
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Telehealth –A Statewide Perspective
• Fragmented adoption
• Acute care hospitals roughly 46 percent • Physicians about 10 percent
• Minimal use
• About 50 providers submitted roughly 78 telemedicine claims to State-regulated payors from October 2012 – June 2013
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Key Challenges to Telehealth Expansion• Little incentive for practices to move away from the traditional fee-for-
service (volume-based) business model• Limited government reimbursement• Medicare: About 60 evaluation and management services within
certain rural areas of the State• Medicaid: Restricted to two pilot programs• Lack of widespread awareness about how to incorporate the effective
use of telehealth into existing practice workflows• Technology adoption, integration and capability
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• Nationally: American Telemedicine Association estimates roughly 200 telehealth networks in the U.S.; connectivity to over 3,500 sites
• Roughly 28 percent of Maryland physicians that are using telehealth are primary care physicians, 10 percent are behavioral health, and approximately 62 percent other specialties
• Maryland health care organizations: Two emerging value-based reimbursement models in Maryland
• Retail health clinics: Included in pharmacies and supermarkets beginning to develop telemedicine programs
Telehealth Adoption
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• About 19 states have laws that require payors to compensate for telemedicine care
• Roughly 44 states have some method of telemedicine reimbursement for Medicaid
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Reimbursement
2014 Telemedicine Task Force Activities
• Develop recommendations to address telemedicine adoption challenges• Identify strategies to deploy a statewide phased approach to diffuse telemedicine technology in innovative care delivery models
• Identify appropriate use cases that could be regionally deployed in the State
• Finalize the technical architecture of a telemedicine registry
• Propose solutions to key policy challenges for reducing barriers to adoption and meaningful use of telemedicine28
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Telehealth Grants –Round One
• Awards made in October 2014• Goal: Improve transitions of care between a
comprehensive care facility (CCF) and a general acute care hospital using telehealth technology
• Required:• Use of telehealth, an EHR, and services of the State-
Designated HIE, CRISP• Assess the impact of using telehealth on hospital emergency
room visits, admissions, and readmissions• A dollar-for-dollar match contribution to the grant funds
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Atlantic General Hospital
• Partnership with Berlin Nursing and Rehabilitation Center (Berlin)
• Goal: Reduce both general acute care hospital costs and transportation costs associated with hospital admissions and readmissions from Berlin
• Hospital physicians will provide remote care to Berlin residents using telehealth technology
• Requested $30,000 in grant funding and intends to provide a matching contribution of $87,922
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Dimensions Healthcare System
• Partnership with Sanctuary of Holy Cross
• Goal: Improve transitions of care for residents at Sanctuary of Holy Cross through virtual consultations and remote monitoring for residents with pneumonia and heart failure
• Application includes services of Zane Networks, LLC, a State-Designated management service organization
• Requested $30,000 in grant funding and intends to provide a matching contribution of $32,000
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University of Maryland Upper Chesapeake Health
• Partnership with the Bel Air facility of Lorien Health Systems (Lorien Health Systems)
• Goal: Reduce avoidable hospital utilization originating from Lorien Health Systems using telehealth technology, extending emergency medical management expertise to Lorien Health Systems 24/7
• Real-time data on residents’ vital signs will be transmitted between Upper Chesapeake Health and Lorien Health Systems
• Requested $27,888 in grant funding and intends to provide a matching contribution of $27,888
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Telehealth Grants –Round Two
• Awards were made in April 2015• Goal: Use telehealth technology to improve overall health of
population being served, improve patient experience, and provide best possible care while lowering costs
• Required • Up to $30,000 in grant funds available per grantee• Use an electronic health record and services of the State-Designated,
CRISP• Provide a 2:1 financial match contribution to grant funds
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Crisfield Clinic
• Family practice clinic in Somerset County will deploy telehealth in two county schools to address asthma, diabetes, childhood obesity, and behavioral health issues
• 24/7 care will be provided via remote patient monitoring; virtual consultations will be provided via school-based telemedicine carts issued under another grant
• Goal: improve clinical data indicators, reduce lost school days, reduce emergency department visits, and improve patient’s perception of health
• Requested $30,000 in grant funding and intends to provide a matching contribution of $92,983
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Lorien Health Systems
• Skilled nursing facility and residential service agency in Howard County will deploy telehealth to address hospital PQI diagnoses, including uncontrolled diabetes, chronic heart failure, and hypertension
• Remote patient monitoring and videoconferencing will be provided at home post discharge from the skilled nursing facility
• Goal: improve clinical data indicators and reduce readmissions and admissions to an acute care hospital
• Requested $30,000 in grant funding and intends to provide a matching contribution of $63,220
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Union Hospital of Cecil County
• Acute care hospital in Cecil County will deploy telehealth to address hospital PQI conditions, including diabetes, chronic obstructive pulmonary disease, hypertension, heart failure, angina, and asthma
• Remote patient monitoring and health education will be provided to patients at home after discharge from the hospital to improve community and population health
• Goal: improve clinical data indicators and reduce readmission rates
• Requested $30,000 in grant funding and intends to provide a matching contribution of $60,000
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Next Steps
• Accelerate the implementation of health IT statewide where electronic patient information is available at the point of care delivery for all Marylanders and the data is used to influence knowledge-based decision making by providers and consumers
• Develop an achievable number of innovative health information exchange use cases in collaboration with stakeholders that improve population health, improve care delivery, and decrease health care costs
• Integrate leading ambulatory practice EHR systems; expand analytics and reporting; and, connect additional provider types based on value-specific HIE use cases
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Next Steps (Continued)
• Work with ambulatory practices to adopt and meaningfully use EHRs by leveraging the State-regulated payor incentive program, and building awareness of the federal incentives and penalties
• Foster statewide growth of telehealth through use case pilots where lessons learned provide the foundation for broader diffusion of the use case
• Continue to create sound policy to ensure the privacy and security of electronic health information that aligns with federal initiatives, policy, and regulations and allows for use case innovation, yet minimizes intrusion risks
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Want more information?
Visit the Maryland Health Care Commission’s website for more information mhcc.maryland.gov
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Melanie CavaliereMaryland Health Care Commission
Jenny McDanielUnitedHealthcare
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Appendix
Learning Objectives
• Be familiar with the telehealth landscape in Maryland
• Identify the work of the Maryland Telemedicine Task Force (task force) in expanding opportunities for telehealth adoption
• Understand how telehealth is being used to improve access to care
• Recognize the benefits of electronic health information exchange
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