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 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 Health Information Exchange “The Network” The electronic movement of health-related information among organizations according to nationally recognized standards. HIT Health 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. HII (according to AzHeC website)… a less formal umbrella term describing 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. HIT (according to AzHeC website) - The application of information processing involving both computer hardware and software that deals with the storage, retrieval, sharing, and use of healthcare information, data, and knowledge for communication and decision making within a single health care provider organization. 2

Definitions- Network Terms HIE Health Information Exchange The electronic movement of health-related information among organizations according to nationally recognized standards. HIO Health Information Organization An organization that oversees and governs the exchange at health-related information among organizations according to nationally recognized standards. RHIO 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. National Alliance for Health Information Technology Report was conducted for ONC/HHS and they came up with standard national definitions. These are reflected here. While HIE in this slide is defined as a verb, i.e., the movement of health information, many still refer to HIE as a noun, meaning the same definition of HIO. HIO is a new term introduced by NAHIT that has not yet become a regular term throughout the industry. Source: National Alliance for Health Information Technology Report to HHS/ONC 3

Definitions- E-Records Terms EMR Electronic 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. EHR Electronic 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. Records terms relate to health information technology, the conversion of health information to an electronic format within the four walls of a healthcare organization (i.e., hospital, clinic, physician office, etc.) Discrepancies still exist between the definitions for EMR and EHR. PHRs are a newly increasingly popular method for consumers to aggregate their personal health information. Microsoft and Google’s efforts in this area may speed up consumer uptake of these products, but time will tell. Source: National Alliance for Health Information Technology Report to HHS/ONC 4

HIE Building the State Level HIT Infrastructure EHR1 EHR2 EHR3 EHRn Labs EHR1 EHR2 EHR3 Rxs EHR4 PHR5 Aggregate Database Other PHRn Highly desirable to couple with HIE

Implementation Grants HIT Enterprise Research State Opportunities for Funding HIT Hospitals Appropriation Program Area Agency Categories of Funds Medicare EHR Incentive Program $23.1 B CMS Medicare $745 M EHR Incentives via Carriers & TPA Doctors EHR Incentive Funds $46.8 Billion Medicaid EHR Incentive Program $21.6 B CMS Medicaid $300 M State Medicaid $1.05B Incentive via State Medicaid Health Centers HITECH FUNDING PROVISIONS ONC Planning Grants HIE Planning & Implementation $300 M Implementation Grants State Designated Entity Appropriated Grant Funds $2.0 B Loan Funds for States Other Providers EHR Adoption Loan Program TBD Health IT Research States Regional Tech Program Regional Tech Centers Universities Medical Informatics HHS NSF Workforce Training Tribes EHR For Med Education New Technology Research 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? This slide list the prerequisites for success. Importance of a statewide roadmap or strategic plan That there be accountable leadership in both the public and private sector Someone must be accountable for organizing and soliciting key stakeholder input There must be the Political Will to create the regulatory and policy framework and provide the public funding and support for the wide spread adoption. There must be an active effort to align the provider incentives and pay for performance initiative between, Medicare, Medicaid and commercial health plans. There must be available adequate capital for health information system investment and operating funds. Under capitalizing an effort of this magnitude is at best will sub optimizing the return on investment and at worse will cause a disaster.

State-wide HIT Strategic Alignment

Return on Investment From HIT

Improving Health Care Quality and 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 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: Lower Costs Better Outcomes This slide illustrates the areas that are impacted by wide spread adoption of Electronic Health Records and how EHR achieve return on investment. Improved patient Safety Reduced Complication Rates Reduced cost per episode of care Enhanced cost and quality performance accountability (being able to support medical homes) Example broken appointment rates higher, generic use, lower diagnostic ordering. Improved quality performance

Medicare Incentives for Non-Hospitals/Providers Criteria: For eligible professionals in a healthcare professional shortage area (HPSA), the incentive payment amounts will be increased by 10% 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 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 Is 2014 $ 8,000 $ 4,000 $ 2,000 $44,000 $41,000 $38,000

Opportunities: Medicaid Incentives for Non-Hospitals/Providers Criteria: Must demonstrated meaningful use for certified electronic health record Must have at least 30% Medicaid volume 3. Ability to produce quality reports and demonstrate quality improvement Payment Component 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 $63,750 Certified Nurse Mid-Wife Dentist Nurse Practitioner Physician Assistant

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 Incentive Payment Medicaid $2.0 M Variable $0 Variable Reimbursement Per Discharge For the first through 1,149th discharge $200 For the 1,150th through 23,000th discharge 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 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 Medicaid need a set of specific definitions regarding meaningful use of EHRs. The definition need to clarify the expect result of meaningful use. Medicaid needs to develop processes that validate meaningful use for the purpose of incentives payments and recognition and public accountability. States should use the 90/10 federal funding to set up incentive program business processes. Incentive program approaches can vary but the core principles and incentive programs processes should included: Voluntary incentive program with significant provider education resources made available before and during incentive program implementation. Identification of participating providers and on-going communication and tracking of progress. Consider phasing in the incentive program requirements over two to three years. Payout of dollars should be annual with some recognition to the provider being part of the incentive. Establish measurable goals for the program that include cost and quality performance goals. Incentive program must demonstrate that it drive EHR adoption, meaningful use, and improved quality and cost outcome performance to achieve maximum return on investment.

Meaningful USE Barrier PERFORMANCE Management Developing a Performance Outcomes for HIT Strategic HIT Focus Areas HIT Strategic Performance Metrics Performance Outcomes Reduced Unnecessary Cost/Utilization = Reduced PMPM & Lower % Admin Cost Meaningful Use of EHR to reduce Duplication, Errors and improve Admin Efficiency Cost Containment Quality Improvement Meaningful Use of EHR to better coordinate care and Quality Performance Improved Quality Against HEDIS and Other Benchmarks Strategic Planning Logic Map Higher Provider Satisfaction & Reduction in Admin. Cost Administrative Efficiency Meaningful use of EHR to Reduce Admin. Process Cycle Times Public Health & Research Meaningful Use of EHR to build Population Health Mgmt. & Research Public Health Responsiveness Reduction in Health Disparities 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 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 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 Widespread EHR system acquisition, upgrade, or integration Health information exchange infrastructure development and expansion Provide on-going technical support and assistance Provide practice reengineering support Clinical practice staff training and EHR competency development Clinical decision support integration Public Health Alert and Monitoring system integration Care management systems integration 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

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

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

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 Diagnostics Specialist Referral Primary Care Medical Home Provider Order Entry Lab Result Reporting EHR/HIE Research E-Prescribing Remote Patient Self Monitoring MCO Medical Medical Mgmt. 31

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