1. HEALTH HOMES HEALTH HOMES TECHNOLOGY SIMULATION WORKSHOP Ron HendlerNish Thakker

2. PERSON-CENTERED MEDICAID SYSTEMS Several Centers for Medicare and Medicaid Services (CMS) initiatives including: Money Follows Person (MFP) Balancing Incentive Program (BIP) Health Homes -are prompting states to address requirements of “person-centered Medicaid systems” This has direct implications for HCBS programs.

3. HEALTH HOMES INFORMATION REQUIREMENTS Describe the State’s methodology for tracking avoidable hospital readmissions to include data sources and measure specifications. Describe the State’s methodology for calculating cost savings that result from improved chronic care coordination and management achieved through this program, to include data sources and measures specifications. Describe the State’s proposal for using health information technology in providing health home services under this program and improving services delivery and coordination across the care continuum (including the use of wireless patient technology to improve coordination and management of care and patient adherence to recommendations made by their provider ).

4. SIGNIFICANT TECHNICAL CHALLENGES These Affordable Care Act Programs encourage improvement in the delivery of Home and Community-based Long-term supports and services. These Programs also present significant technical challenges associated with coordinating care across disconnected specialty providers and software platforms which can overwhelm staff responsible for designing and implementing the changes.

5. HEATH HOMES TECHNOLOGY SIMULATION WORKSHOP This workshop will focus on demonstrating how standards and software, developed by CMS and ONC (Office of the National Coordinator), simplifies the interoperability required for sharing records across the Medicaid Enterprise These technologies enable states to: Exchange clinical records between provider EHR systems Capture performance metrics and quality measures. Achieve meaningful use incentive money eligibility Manage consent and referrals using rigorous security standards Finally, a novel prototype system will be demonstrated that allows care coordinators to “actively” manage CMS Funded Health Home activities

6. TECHNOLOGY STANDARDS AND SYSTEMS ENABLE HEALTH HOMES Scenario describes a typical Health Home where a patient has 2 chronic conditions 1.Behavioral Health condition: Anxiety 2.Primary Care condition: Diabetes

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8. EXISTING SYSTEMS USED BY SPECIALTY PROVIDERS BH Providers Primary Care Long-Term Care/ HCBS FQHCs Developmental Disabilities Quality Measures Custom Queries Providers and EHRs

9. EXISTING SYSTEMS USED BY SPECIALTY PROVIDERS BH Providers Quality Measures Custom Queries WITS System Used by 28 States and Counties Meaningful Use Certified Over 2.3 Million Client Records

10. EXISTING SYSTEMS USED BY SPECIALTY PROVIDERS Quality Measures Custom Queries Long-Term Care/ HCBS eLTSS System in production in MD Recently chosen by Mississippi Covers BIP requirements, waiver management, MFP, Electronic Visit Verification

11. EXISTING DATA STANDARDS: CCD The Continuity of Care Document (CCD) XML document containing most common medical records elements Vitals, demographics, lab tests, medications, encounters, etc. Made Ubiquitous thanks to Meaningful Use CCD BH Providers Primary Care Long-Term Care/ HCBS FQHCs Developmental Disabilities Providers and EHRs

12. HEALTH INFORMATION EXCHANGES (HIE) Secure Record Sharing HIE Most States have HIEs and include: 1.A Directory of Participating Care Provider Addresses 2.Secure email (DIRECT) Compatible with EHRs

13. HEALTH INFORMATION EXCHANGES (HIE) Secure Record Sharing HIE Sending a DIRECT Message with a CCD attachment

14. HIE STANDARDS Secure Record Sharing HIE CCD DIRECT An HIE transfers data using standards for: 1.Messaging (DIRECT) http://wiki.directproject.org/http://wiki.directproject.org/ 2.Secure Transmission of Interoperable Records (Encryption) 3.Assured Record Authenticity (Digital Signing) 4.Content (CCD) DIRECT

15. SHARING CONFIDENTIAL INFORMATION ACROSS AN HIE Consent2Share (C2S) Bolt-on to an HIE for managing consent and privacy at the data element level patient portal that enables patients to electronically provide and update their privacy preferences Alleviates administrative burden placed on providers Secure Record Sharing HIE Consent2Share 42 CFR pt2

16. SHARING CONFIDENTIAL INFORMATION ACROSS AN HIE Consent2Share (C2S) Collaboration between VA and SAMHSA Designed for very restrictive Substance Abuse Data Referral restrictions Secure Record Sharing Consent2Share 42 CFR pt2

17. SHARING CONFIDENTIAL INFORMATION ACROSS AN HIE Consent2Share (C2S) Electronic Signature Uses Adobe EchoSign Secure Record Sharing Consent2Share 42 CFR pt2

18. HIE & C2S STANDARDS Uses: CCD DIRECT And XACML eXtensible Access Control Markup Language HIEs can ask C2S patient’s privacy preferences permit sharing of a CCD Providers only receive Patient Health Information when patient preferences “ Permit ” DIRECT CCD XACM L Secure Record Sharing HIE Consent2Share 42 CFR pt2 XACML

19. PopHealth Open Source Project from MITRE and ONC Takes CCD document to calculate required NQF Quality Measures Used in CMS pilot “Value-based Purchasing” Program Docs that report claims and QMs receive higher reimbursement Perfect foundation for Pay for Performance HEALTH HOME QUALITY MEASURES popHealth Quality Measures

20. PopHealth Includes unique Quality Measures required for Health Homes HEALTH HOME QUALITY MEASURES popHealth Quality Measures

21. QRDA Quality Reporting Document Architecture HL7 standard for transporting Quality Measures http://wiki.hl7.org/index.php?title=Quality_Reporting_ Document_Architecture http://wiki.hl7.org/index.php?title=Quality_Reporting_ Document_Architecture QUALITY MEASURES STANDARDS: QRDA popHealth Quality Measures DIRECT CCD XACML QRDA

22. The Home Health Dashboard NOW POSSIBLE…. Referrals Plans of Care Care Coordination Billing Integrated services require integrated software Simulation only Acts as the “Quarterback” instead of a separate EHR Should use Open Systems Federally-Funded Data Standards Allows for Care Coordinators to “Actively” Manage a Patient’s care

23. Referrals Plans of Care Care Coordination Billing... WITH OPEN SOURCE ARCHITECTURE

24. Secure Record Sharing BH Providers Primary Care Long-Term Care/ HCBS FQHCs Developmental Disabilities HIE Consent2Share 42 CFR pt2 popHealth Quality Measures Providers and EHRs CCD DIRECT XACML QRDA The Home Health Dashboard Referrals Plans of Care Care Coordination Billing