1. 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

2. 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

3. 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

4. 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

5. 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

6. 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

7. 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.

8. State-wide HIT Strategic Alignment

9. Return on Investment From HIT

10. 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

11. 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

12. Opportunities: Medicaid Incentives for Non-Hospitals/Providers
Criteria:
Must demonstrated meaningful use for certified electronic health record
Must have at least 30% Medicaid volume
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

13. 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

14. 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.

15. 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

16. 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

17. 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

18. 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

19. 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

20. 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

21. 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

22. 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

23. 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

24. E-Health Infrastructure Configuration

25. 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

26. 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

27. Medicaid e-Health Information Technology Environment 2011 and Beyond

28. 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

29. Integrating Clinical and Patient Decision Support For Value Added E-Health Care

30. 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

31. 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

32. Questions?