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MITA Case Studies: Which came first – the enterprise or the architecture? Presented to: MMIS Conference 2005: Big Sky, MT August 14 - 18, 2005 Mary Tavegia.

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Presentation on theme: "MITA Case Studies: Which came first – the enterprise or the architecture? Presented to: MMIS Conference 2005: Big Sky, MT August 14 - 18, 2005 Mary Tavegia."— Presentation transcript:

1 MITA Case Studies: Which came first – the enterprise or the architecture? Presented to: MMIS Conference 2005: Big Sky, MT August , 2005 Mary Tavegia – IME Project Director, State of Iowa DHS Erin Harris – IME MITA Coordinator, Software Engineering Services

2 MITA Case Study - Iowa Medicaid Enterprise2 The Iowa Medicaid Enterprise Iowa Facts and Figures IME Vision Similar to MITA Goals Implementing the Vision RFPs, Contracts, and Performance Measures DDI – Building the IME The Enterprise is Live! Initial Results Whats Next MITA-sizing the IME

3 MITA Case Study - Iowa Medicaid Enterprise3 Medicaid in Iowa Iowa Population – 2.9 million Currently 10% of population Medicaid eligible Medicaid impacts one out of every three Iowans Dramatic Medicaid Cost Increases Average Monthly Eligibility (> 39% in 5 years) Average Monthly Total Payments (> 69% in 5 years) Results-based Accountability in Iowa Performance measurement Cost-effective healthcare

4 MITA Case Study - Iowa Medicaid Enterprise4 MMIS in Iowa Last procurement in 1995 Fiscal agent customized MMIS Pharmacy Point of Sale (POS) Decision Support System (DSS) Medically Needy Managed Care Operated on Contractor hardware in Pennsylvania and Georgia Professional Services and operational support by Fiscal Agent Interfaces with state-operated Medicaid eligibility systems (Title XIX, ISIS) Ability to adapt to change constrained

5 MITA Case Study - Iowa Medicaid Enterprise5 Iowa Medicaid Enterprise (IME) The Vision Improve service to Iowa Medicaid members, providers, and partners Shift control from Contractor to the State Increase accountability throughout Medicaid operations Enhance decision making ability Implement Best practices in key Medicaid business functions State management with Best of Breed Contractors Improve health outcomes for members Enhanced primary care case management Initiate disease management program Collect and analyze cost and outcome information Collaboration rather than competition Increase flexibility and adaptability Leverage state IT infrastructure

6 MITA Case Study - Iowa Medicaid Enterprise6 IME Similar to MITA Goals RFP for IME released in 2003 MITA Framework 1.0 published in January 2004 MITA Goals 1.Integration and interoperability 2.Flexibility to respond rapidly to change 3.Enterprise view to align technology and business needs 4.Data that supports analysis and decision making 5.Performance measurement for accountability and planning 6.Coordination with partners to improve overall health IME Strategy Co-location state, contractors Integrate contractor systems Modular business units Begin technology migration Collaborative business model Workflow integration Collect clinical data Improve DSS capabilities Performance-based contracts Enhanced monitoring and reporting of trends, costs Enhanced case and disease management PDL, pharmacy/clinical coordination

7 MITA Case Study - Iowa Medicaid Enterprise7 Implementing the IME Vision Single RFP, multiple components Systems Professional Services Contract with Best of Breed service providers 8 Systems and Professional Services Contractors Operational support from the State Departments Division of Data Management (DDM) Network Support Data Warehouse Other Medicaid State Systems Department of Administrative Services Iowa Technology Enterprise (ITE) Printing and Mailing Services Separate Responses MMIS administration, Workflow, Imaging Pharmacy POS Medical Services Pharmacy Medical Services Member Services Provider Services SURS Provider Cost Audits and Rate Setting Revenue Collection

8 MITA Case Study - Iowa Medicaid Enterprise8 DDI – Building the IME One-year timeframe IV&V and PMO contract services Early transfer MMIS to state hardware Build and transfer Medicaid Data Warehouse Shared Data and Tools Co-location Common data sources for all IME staff MMIS Medicaid Data Warehouse Workflow Process Management System Integrate on- and off-site contractor systems with MMIS Performance based contracts and Report Cards

9 MITA Case Study - Iowa Medicaid Enterprise9 The Enterprise is Live! Initial Results Preferred Drug List Pharmacy Point Of Sale MMIS, Workflow & Contractor systems Began Paying claims with Payment Cycle Phasing in Medicaid Reform: IowaCare Phase 1 Next Steps Medicaid Reform: Next phases IowaCare Better integration, expand SOA capabilities Monitor performance and fine tune collaboration Continue MITA-sizing and enterprise architecture development

10 MITA Case Study - Iowa Medicaid Enterprise10 Enterprise Architecture: MITA-sizing the IME MITA activities for the IME Opportunities for Enterprise Architecture (EA) MITA Tools for the IME EA Business Process Model Capabilities and the Traceability Matrix EA and IME Strategic Planning MITA self-assessment Business–focused IT planning

11 MITA Case Study - Iowa Medicaid Enterprise11 MITA for the IME MITA Activities in Parallel to DDI at the IME Track and assess MITA framework Contribute to MITA definition Apply MITA principles to the IME Current DDI recommendations Problematic in timeframe MITA continuing to evolve Plans and contracts for the IME already underway Assess MITA impact for future planning Validate/pilot MITA and enterprise architecture Business process modeling Collect architectural elements, artifacts

12 MITA Case Study - Iowa Medicaid Enterprise12 IMEs Opportunities for Enterprise Architecture Redesign of business operations Document business processes Workflow Operational procedures Cross-functional integration Planning for quality by measuring performance Extract and document business rules from transferred MMIS Technical environment adapted to business needs Configured for operational efficiency Flexible, adaptable modularity

13 MITA Case Study - Iowa Medicaid Enterprise13 MITA Lifecycle

14 MITA Case Study - Iowa Medicaid Enterprise14 IT View: Enterprise Information Architecture Where is the Business? Richard Watson, Lawrence Livermore National Laboratory csdl2.computer.org/comp/proceedings/hicss/2000/0493/07/ pdf

15 MITA Case Study - Iowa Medicaid Enterprise15 Business-centric Focus Multiple dimensions of MITA EA Business Process Capability Data Application Technical Time MITA Maturity Business Drivers

16 MITA Case Study - Iowa Medicaid Enterprise16 EA Modeling Questions What? – the process Verb + Object (Process Claims) How? – the capability/competency Qualities: Timeliness Accuracy Efficiency Quality Cost-effectiveness Value Who? – stakeholders, actors, customers What information? – the data With what? – the application(s) With who, when, where? – the technical infrastructure

17 MITA Case Study - Iowa Medicaid Enterprise17 IME Business Process Model Functional framework in IME RFP Business units Requirements capabilities IME operational procedures manuals Decompose and recombine chronological events Develop outline of business processes (table) Create graphical representation (model) Review/Assess/Modify – visual aid to refine model Functional hierarchy, redundancy, trigger events

18 MITA Case Study - Iowa Medicaid Enterprise18 IME BPM Models

19 MITA Case Study - Iowa Medicaid Enterprise19 MITA - IME BPM Crosswalk Revealed Gaps in IME BPM Differences in granularity of BPMs Multiple IME BPs map to a MITA BP BPs that cross IME business areas Highlights areas for BP and/or system integration Provides roadmap for self-assessment Keeps IME BPM relevant to IME business model No forcing the framework onto the enterprise

20 MITA Case Study - Iowa Medicaid Enterprise20 Crosswalk Sample MITA Business Model v21b IME Business Model Business AreaIntermed 1Intermed 2Business Process Intermed 2Intermed 1Business Area Member Management Eligibility Determination Determine Eligibility Determine Medicaid Eligibility DHS Eligibility Administration Enrollment Enroll Member Enrollment Broker for Managed Health Care Member Services Enroll Member for Waiver, Mental Health DHS Eligibility Administration Enroll Selected Members and Providers for EPCCM Enhanced Primary Care Case Management (EPCCM)Medical Services Enroll Selected Members and Providers for Disease Management Program Disease ManagementMedical Services Lock-in Enrollment Lock-inMedical Services

21 MITA Case Study - Iowa Medicaid Enterprise21 Initial Traceability Matrix Example IME Business Area/Key Process "As is" Current Capability "To be" IME Capability "As is" -> "To be Gap Description StakeholdersBusiness ValueGoal Alignment Medical Services Medical Support Claim ReviewReview claims for administrative and Judicial appeals. Request additional information from providers as needed. Provide well-qualified Medical Director (MD/OD) and professional staff or consultants for medical review functions. Dispersed clinical review services with Limited staffing. Increasing Program focus on health outcomes. Medical Director Med Srv Unit Mgr Med Srv Ops Mgr Claim Rev Suprvsr Policy Rep Elig Rep Atty Gen, Rep Partner w/local medical community to ensure fair review using established standards of care. #1 Improve service – H (3) #3 Best Practices - H (3) Total Goal Alignment = 6 Pre-procedure/Pre- admission Review Process paper or fax PAs and requests for exception to policy. Accept electronic PAs. Provide medical consulting services to DHS regarding policy changes, and to providers regarding policy for PAs and billing. Track all communications with providers regarding policy electronically. Limited legacy system EDI capabilities. Dispersed clinical review services with limited staffing. No automated CRM or Document management systems. Medical Director Med Srv Unit Mgr Med Srv Ops Mgr PA Supervisors Policy Rep Provider Srv Rep Member Srv Rep Improved response time and accuracy of prior authoriza- tions improves provider and patient relations, and increases accuracy of billing. #1 Improve service – H (3) #2 State control - L (1) #3 Best Practices - H (3) #4 Flexibility/Adapt - M (2) #5 Leverage state IT–L (1) Total Goal Alignment = 10 Retrospective Inpatient and Outpatient Review Perform medical review of 10% of all claims. Initiate revenue adjustments as needed. Dispersed clinical review services with limited staffing. Increasing program focus on claims quality. Medical Director Med Srv Unit Mgr Med Srv Ops Mgr Policy Rep Retro Review Sprvsr Improved payment accuracy and monitoring of utilization. #1 Improve service – L (1) #2 State control - M (2) #3 Best Practices - H (3) Total Goal Alignment = 6 Capabilities/Goals/Business Value

22 MITA Case Study - Iowa Medicaid Enterprise22 Traceability Matrix – EA Example IME Business Area/Key Processl de "To be" IME Capability Related IME Requirements Documents Related IME Design Documents Technical Solutions Notes Data Architecture Notes Medical Services Medical Support Claim ReviewProvide well-qualified Medical Director (MD/OD) and professional staff or consultants for medical review functions. > Requirements Confirmation Workbook – FINAL > SRS Medical Support > MQUIDS DSD MQUIDS > VB.NET using Visual Studio 2003 > 2-tier environment > Crystal reports > ADO.NET object model > SQL Server 2000 > MMIS Claims History Pre-procedure/Pre- admission Review Accept electronic PAs. Provide medical consulting services to DHS regarding policy changes, and to providers regarding policy for PAs and billing. Track all communications with providers regarding policy electronically. > Requirements Confirmation Workbook – FINAL > SRS Medical Support > MQUIDS DSD > WDS915.2_Prior Authorization > WDS913_Workview > WDS907.2_Medical Services MQUIDS > VB.NET using Visual Studio 2003 > 2-tier environment > Crystal reports > ADO.NET object model OnBase Tech Env. ELVIS Tech Env MMIS Tech Env > SQL Server 2000 > MMIS Prior Auth Master Retrospective Inpatient and Outpatient Review Perform medical review of 10% of all claims. Initiate revenue adjustments as needed. > Requirements Confirmation Workbook – FINAL > SRS Medical Support > MQUIDS DSD MQUIDS > VB.NET using Visual Studio 2003 > 2-tier environment > SQL Server 2000 > Crystal reports > ADO.NET object model > SQL Server 2000 > MMIS Claims History EA Dimensions

23 MITA Case Study - Iowa Medicaid Enterprise23 More EA/MITA Details in Extended Traceability Matrix IME Business Area/Key Process "To be" IME Capability TimelinessAccuracyEfficiencyQualityCost- Effective- ness ValuePerformance Measures Medical Services Medical Support Claim ReviewProvide well-qualified Medical Director (MD/OD) and professional staff or consultants for medical review functions. Extend details captured in matrix for each EA dimension: Capability/competency definition (MMM qualities, performance measures, etc.) Application architecture (COTS, legacy systems, subsystems, etc.) Data architecture (files, locations, formats,..., metadata repository) Technical architecture (hardware, telecomm, operating systems, integration, services, etc.) EA details collected in matrices provide information to perform MITA self-assessment MITA Maturity Model (MMM) Qualities/Performance Measures

24 MITA Case Study - Iowa Medicaid Enterprise24 EA and IME Strategic Planning MITA self-assessment BPM extended traceability matrix + crosswalk self- assessment Business–focused IT planning Traceability matrix collects EA artifacts Provides process change roadmap Gaps, goals, stakeholders, data, applications, technical infrastructure Scope and impact of change Incremental Iterative process Granularity Focus: business process, functional area, business area, enterprise

25 MITA Case Study - Iowa Medicaid Enterprise25 Questions Mary Tavegia, (515) Erin Harris, (615)


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