ARIZONA STATE MEDICAID HEALTH INFORMATION TECHNOLOGY PLAN Version 5.1

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1 ARIZONA STATE MEDICAID HEALTH INFORMATION TECHNOLOGY PLAN Version 5.1 December 10, 2014 Thomas J. Betlach, Director AHCCCS 801 East Jefferson Street Phoenix, Arizona (602)

2 REVISION HISTORY AHCCCS initially submitted its SMHP in Since then, AHCCCS has submitted three major revisions, with Version 5 submitted August Version 5 includes numerous updates, which are reflected throughout the document. Version Number Submission Date Section Comments 1.0 March 22, 2011 All Submission to CMS for Approval 2.0 July 18, 2011 CMS Approval Letter for SMHP Version 1.0, Appendix A changes made Submission to CMS for Final SMHP Approval in response to 6/16/2011 Conditional Approval Letter 9/14/2011 via 3.0 May 9, program changes, e.g., patient volume 4.0 July 22, 2013 All 5.0 August 29,2014 All Not approved Submission to CMS for approval to implement 2014 Meaningful Use Stage 1 changes and update Arizona s current environment and HIT landscape. Approved November 19, Changes have been made throughout the document. Refer to Appendix B for a description of these changes including the addition of significant new information on the HIE vision, information on programmatic changes described in IAPD requests, new landscape assessment information, changes to program metrics and targets, and updates throughout. 5.1 December 10, 2014 Section C Administer and Oversee the EHR Payment Program Responding to questions 10, 15, 17, 18, 19, 22, 23, 26, 27, 28 Section B question 10 Page 2 of 129

3 Table of Contents TABLE OF CONTENTS... 3 INTRODUCTION STATE AND AHCCCS BACKGROUND ARIZONA HEALTH SYSTEM OVERVIEW... 8 AHCCCS OVERVIEW... 8 AGENCY S PRIORITIES FOR HIT CURRENT HIT LANDSCAPE, AS IS ENVIRONMENT GENERAL SECTION OVERVIEW EHR ADOPTION BY PROFESSIONALS AND HOSPITALS (SMHP TEMPLATE QUESTION #1) Physician Survey Landscape Assessment of Hospitals HIT IN FQHCS, IHS, AND VA FACILITIES (SMHP TEMPLATE QUESTIONS #3, Federally Qualified Health Centers (FQHCs) Indian Health Services (IHS) Veterans Administration (VA) Facilities BROADBAND AND TELEHEALTH/TELEMEDICINE ACTIVITIES (SMHP TEMPLATE QUESTIONS #2, 12) Communications Infrastructure Advisory Committee (CIAC) Telehealth/Telemedicine HEALTH INFORMATION EXCHANGE ACTIVITIES (SMHP TEMPLATE QUESTIONS #6, 7, 10, 11, 13) Introduction: A Brief Arizona HIT/HIE History HIE Background Governance HIE Functionality HIT and HIE Activities that Cross State Borders AHCCCS PLANS TO FACILITATE EHR AND HIE ADOPTION (SMHP TEMPLATE QUESTIONS #9, 11, 12) AHCCCS HIT/HIE Plan Regional Extension Center Activities Facilitating EHR Adoption Facilitating HIE Adoption HIE Onboarding Public Health Initiatives INTEROPERABILITY OF IMMUNIZATION REGISTRY & PUBLIC HEALTH SURVEILLANCE (SMHP TEMPLATE QUESTION #14) STAKEHOLDER ENGAGEMENT IN HIT ACTIVITIES (SMHP TEMPLATE QUESTION #5) MMIS IN THE CURRENT ENVIRONMENT (SMHP TEMPLATE QUESTION #8) SUMMARY MEDICAID TRANSFORMATION GRANT ACTIVITIES (SMHP TEMPLATE QUESTION #15) ARIZONA HEALTH IT ROADMAP FUTURE HIT LANDSCAPE, TO BE ENVIRONMENT GENERAL SECTION OVERVIEW FUTURE OF HIT AND HIE, EHR ADOPTION (SMHP TEMPLATE QUESTIONS #4, 5, 7) Challenges to Overcome and Lessons Learned Meaningful Use Stages Health Information Exchange Governance Steps to Encourage EHR Adoption Next 12 Months Future of Public Health: Reporting and Interoperability (SMHP Template Questions #1, 2) FIVE-YEAR HIT AND HIE GOALS (SMHP TEMPLATE QUESTION #1) HIT/HIE Agency Goals HIT/HIE Statewide Goals EHR Adoption Goals HIE To Be Page 3 of 129

4 3.4 VULNERABLE POPULATIONS AND POPULATIONS WITH UNIQUE NEEDS (E.G., CHILDREN, FQHCS, IHS, VA)(SMHP TEMPLATE QUESTION #6, 8) Leveraging FQHC Resources and Experiences FUTURE OF AHCCCS IT ARCHITECTURE (SMHP TEMPLATE QUESTION #2) FUTURE OF MEDICAID PROVIDER INTERFACE WITH IT SYSTEM AND IT SYSTEM ARCHITECTURE (SMHP TEMPLATE QUESTION #3) LEVERAGING HIT-RELATED GRANT AWARDS (SMHP TEMPLATE QUESTION #9) Medicaid Transformation Grant ONC Cooperative Agreement Funds State Innovation Model Grant Proposed NEED FOR NEW LEGISLATION OR STATE LAWS (SMHP TEMPLATE QUESTION #10) PROGRAM IMPLEMENTATION AND ADMINISTRATION ASSUMPTIONS (SMHP TEMPLATE QUESTION #29) IMPLEMENTING THE EHR INCENTIVE PROGRAM Identifying Eligible Professionals and Hospitals and Making Payments (SMHP Template Questions #1, 2, 3, 27) Calculating Patient Volume (SMHP Template Questions #5, 6, 7, and 12) Payments Methodologies (SMHP Template Questions #24, 25, 26, 27) Verifying the Adoption, Implementation, and Upgrade of Certified EHRs (SMHP Template Questions #11) Reporting of Meaningful Use (SMHP Template Question #10, 11, and 12) Integration of Meaningful Use Activities with Other Quality Initiatives (SMHP Template Question #13) ADMINISTRATION OF THE EHR INCENTIVE PROGRAM Communicating Key Information to Providers (SMHP Template Question #4) Establishing Adequate Technical Systems and Administrative Processes (SMHP Template Questions #14, 15, 16, 17, 18, 18, 20, 21, 24, 25, and 28) Appeals and Grievances (SMHP Template Questions #22) Role of Contractors (SMHP Template Question #28) AUDIT AND OVERSIGHT GENERAL AUDITING REQUIREMENTS AND PROCESSES (SMHP TEMPLATE QUESTION #1, 6) CONDUCTING PRE-PAYMENT AUDITS (SMHP TEMPLATE QUESTION #1, 5) CONDUCTING POST PAYMENT REVIEWS (SMHP TEMPLATE QUESTION #5) TRACKING MEANINGFUL USE (SMHP TEMPLATE QUESTION #4) MONITORING FRAUD AND ABUSE (SMHP TEMPLATE QUESTIONS #1, 2, 3, 7, AND 8) PROGRAM EVALUATION, METRICS, AND TARGETS AHCCCS HIGH-LEVEL STRATEGY FOR HIT (SMHP TEMPLATE QUESTIONS #1, 2, AND 3) Increase the Adoption of EHRs by EPs and EHs Accelerate Statewide HIE Participation for all Medicaid Providers and Plans Ensure Program Integrity (SMHP Template Question #4) APPENDICES APPENDIX A: ACRONYMS APPENDIX B: DESCRIPTION OF CHANGES VERSION 5.0 AUGUST APPENDIX C: CROSSWALK BETWEEN AHCCCS SMHP AND CMS REQUIREMENTS APPENDIX D: DESCRIPTION OF AHCCCS EXECUTIVE OFFICES APPENDIX E: HOSPITAL MEDICAID EHR INCENTIVE PAYMENT DETAIL APPENDIX F: SAMPLE OF ELIGIBLE HOSPITAL EHR INCENTIVE PROGRAM PAYMENT CALCULATION APPENDIX G: ARIZONA MEDICAID EHR INCENTIVE PROGRAM IMPLEMENTATION CALENDAR APPENDIX H-J Page 4 of 129

5 Introduction Title IV, Division B of the American Reinvestment and Recovery Act (ARRA) established the Medicare and Medicaid Electronic Health Record (EHR) Incentive Programs as one component of the Health Information Technology for Economic and Clinical Health (HITECH) Act. Section 4201 of ARRA provides funding for the Arizona Health Care Cost Containment System (AHCCCS) to: 1) Administer the incentive payments to eligible professionals and hospitals; 2) Conduct adequate oversight of the program, including tracking meaningful use by providers and 3) Pursue initiatives to encourage the adoption of certified EHR technology to promote health care quality and the exchange of health care information. Administrative Structure Arizona s Medicaid EHR Incentive Program is administered by AHCCCS, which is organized as described in Figure 1 below. Figure 1: Arizona Health Care Cost Containment System Organizational Chart Appendix D describes AHCCCS Executive Offices for the offices included in the organizational chart above. For executive oversight within AHCCCS, there is an HIT Steering Committee that reviews and approves major program changes to the AHCCCS Medicaid EHR Incentive Program. The members of the HIT Steering Committee are described below. Page 5 of 129

6 Table 1: AHCCCS HIT Steering Committee - Director, AHCCCS - Deputy Director, AHCCCS - Assistant Director, Division of Business and Finance - Assistant Director, Division of Fee for Services - Assistant Director, Division of Health Care Management - Assistant Director, Division of Member Services - Assistant Director, Information Services Division - Assistant Director, Office of Administrative Legal Services - Assistant Director, Office of Intergovernmental Relations - Administrator, Division of Health Care Management/Clinical Quality Management - Administrator, Division of Health Care Management/Reimbursement - Chief Medical Officer - Medicaid HIT Coordinator Arizona s State Medicaid Health Information Technology Plan (SMHP) provides an overview of the current and future HIT landscape in the State and describes the Agency s plan for administering and overseeing the Medicaid EHR Incentive Program and Arizona s HIT goals and roadmap for achieving these goals. The SMHP describes Arizona s historical, current and future efforts to improve health outcomes by leveraging EHR deployment, adoption and use by providers. Finally, the SMHP describes the Agency s priorities for health information exchange (HIE) and HIT and identifies opportunities for collaboration with Office of the National Coordinator for Health Information Technology (ONC)-funded grant programs and other key Medicaid stakeholders. AHCCCS developed its SMHP using the guidance and template provided by CMS. The AHCCCS SMHP is divided into the following sections, which also follow the SMHP template. Each section includes references to the SMHP to demonstrate compliance with the required elements. Additional information in the appendices also helps to illustrate how the AHCCCS SMHP is in compliance with CMS requirements. Section 1: State and AHCCCS Background. Provides background information about the Agency and discusses how the State economy, budget and health care reform are affecting the Agency environment. Section 2: Current HIT Landscape, As Is Environment. Describes the environmental scan and assessment conducted with CMS HIT Planning Advanced Planning Document funding and HIT activities impacting the Agency, members, and providers across the State. Section 3: Future HIT Landscape, To Be Environment. Describes the vision of the HIT future over the next five years and identifies achievable goals, objectives and points of engagement needed to get the Agency from where it is now to where it wants to be in terms of adoption and use of certified EHRs as well as overall implementation requirements, strategic plans and tactical steps to successfully implement the program and its related HIT and HIE goals and objectives. Section 4: Program Implementation and Administration. Describes Arizona s implementation plan and the processes to be employed to ensure that AHCCCS providers meet the federal and State statutory and regulatory requirements for the EHR Incentive Program payments. Section 5: Audit and Oversight. Describes Arizona s audit controls and oversight strategy for the EHR Incentive Program. Section 6: Program Evaluation, Metrics, and Targets. Describes AHCCCS defined annual measurable targets that are tied to the Agency goals in the EHR Incentive Program Section 7: Appendices. Reference documents including an acronyms list, guide to where required elements are located in the SMHP and a description of major changes made to the document, hospital payment calculations, program timeline and major milestones and approved application screens. Page 6 of 129

7 1 State and AHCCCS Background Arizona, nicknamed the Grand Canyon State, is home to vast deserts, canyons, pine forests, mountain ranges, lakes and valleys and has one of the fastest-growing and most dynamic economies in the nation. In 2013, Phoenix was the 13th largest metropolitan area in the nation with over 4.3 million of the State s 6.6 million residents residing there. In August 2014, the Phoenix and Tucson metropolitan areas represented nearly 75 percent of Arizona s entire population. Figure 1.1: State of Arizona and Counties The following table describes the population and geographic sizes of the counties of Arizona. Maricopa (Phoenix) and Pima (Tucson) have the highest number of residents. Table 1.1: Number of Counties in Arizona - 15 County Population Square Miles Apache 71,518 11,127 Cochise 131,346 6,256 Coconino 116, ,421 Gila 53,597 4,748 Graham 37,220 4,618 Greenlee 8,437 1,838 La Paz 20,489 4,518 Maricopa 3,817,117 9,226 Mohave 200,186 13,227 Navajo 107,449 9,910 Page 7 of 129

8 Table 1.1: Number of Counties in Arizona - 15 County Population Square Miles Pima 980,263 9,240 Pinal 375,770 5,386 Santa Cruz 47,420 1,246 Yavapai 211,033 8,091 Yuma 195,751 5,561 Note: Data Source Arizona Association of Counties 1.1 Arizona Health System Overview As of June 2014, Arizona s health system included: 133 hospitals (which includes acute, IHS, VA, Rehab, Critical Access, Psychiatric, Specialty) 20 Federally Qualified Health Centers 9 Rural Health Clinics 158 licensed long-term care facilities 42 licensed behavioral health facilities Almost 25,000 licensed professionals from the categories described in Table 1.2 below : Table 1.2: Number of Licensed Professionals as of June 2014 Provider Type Number MDs and DOs 14,545 Nurse Practitioners 4,705 Dentist 3,680 Certified RN/Midwife 222 Physician Assistants 1,772 Note: Data from ADHS, Licensing Services. Additionally, numerous Medicare ACOs have emerged in Arizona in varying degrees of maturity including the following: Arizona Care Network GIPPA ACO Yavapai Accountable Care Yuma Connected Community John C. Lincoln Accountable Care Organization Banner Health Network Arizona Connected Care 1.2 AZPCP-ACO, A Medical Corporation, PC AHCCCS Overview AHCCCS, the State s Medicaid Agency, uses federal, State and county funds to provide health care coverage to the State s Medicaid populations. Since 1982, when it became the first statewide Medicaid managed care system in the nation, AHCCCS has operated under a federal Section 1115 Research and Demonstration authority that allows for the operation of a total managed care model. The 1115 Page 8 of 129

9 demonstration provides authority to use managed care and does not impact the number or type of Medicaid providers that are eligible or participate in the Medicaid EHR Incentive Program. Unlike programs in other states that rely primarily on fee-for-service (FFS) reimbursement, AHCCCS makes prospective capitation payments to contracted health plans responsible for the delivery of care. The result is a managed care system that mainstreams recipients, allows them to select their providers and encourages quality care and preventive services. AHCCCS contracts with the following managed care plans for acute care: Health Net Access Health Choice Arizona United Healthcare University Family Care Phoenix Health Plan Care 1st Arizona Maricopa Health Plan CRS Fully Integrated CRS Partial Acute DES/CMDP Mercy Care Plan In addition to the acute care managed care plans, there are also four long-term managed care plans, Regional Behavioral Health Authority sites and Tribal Regional Health Authority sites. For the American Indian/Alaska Native (AI/AN) population, AI/AN members can switch their enrollment between AHCCCS American Indian Health Plan (fee-for-service) and an AHCCCS managed health care plan and back again at any time. To appreciate the context in which the State strategic and HIT plans were developed, it is helpful to review the current economic environment in which the Arizona health care delivery system is operating and the challenges that exist in the current system. While the FY 2014 AHCCCS budget resulted in a more stable fiscal environment, the debate over Medicaid and more specifically what to do with regards to restoration of the Proposition 204 childless adult population established by voters in 2000 dominated discussions. During her 2013 State of the State address, Governor Brewer announced that she wanted to restore and expand Medicaid coverage to fulfill the will of Arizona voters, stabilize the health care delivery system and provide affordable coverage for low-income Arizonans. In 2013, the Legislature enacted Governor Brewer s Medicaid Restoration Plan, which restored coverage to 300,000 childless adults following a two-year enrollment freeze. As a result of the enrollment freeze, the childless adult population had dropped from 250,000 to approximately 97,000 as of December However, since the Governor s Restoration Plan took effect on January 1, 2014, this population has increased to approximately 216,000 as of June As a mechanism to draw down enhanced federal funding to cover this population, the Governor s Restoration Plan also included a modest expansion in AHCCCS eligibility, from percent FPL, or about 57,000 individuals. Since January 1, 2014 when coverage for this expansion group became effective, approximately 20,000 individuals between percent have enrolled in coverage. The most recent Medicaid enrollment figures from August 2014 highlight more Medicaid enrollment trends. Page 9 of 129

10 Table 1.3: AHCCCS population by Category March August /1/14 4/1/14 5/1/14 6/1/14 7/1/14 8/1/14 AHCCCS Acute 1,182,307 1,248,693 1,292,843 1,333,231 1,373,952 1,410,690 KidsCare 2,143 2,098 2,083 2,008 2,012 1,990 ALTCS 1 54,763 54,973 55,110 55,299 55,509 55,624 Partial Services (FES, 103, , , , , ,289 SLMB, QI-1,Transplant Option 1) Total Population 2 1,342,831 1,416,940 1,465,431 1,508,689 1,552,186 1,591,593 Note: Data source is AHCCCS Population Highlights 1.3 Agency s Priorities for HIT AHCCCS has a multi-pronged strategy with numerous initiatives to address health care challenges across the State that all connect to HIT and HIE. The three overarching strategies are: 1) facilitate integration and decreasing system fragmentation; 2) improve care coordination; and 3) drive payment reform. These efforts will accelerate the delivery system s evolution towards a value-based integrated model that focuses on whole person health throughout the continuum and in all settings, and each of the components of the Arizona strategy will improve population health, transform the health care delivery system and/or decrease per capita health care spending. AHCCCS recognizes that there are significant benefits to clinicians, payers and Medicaid members once clinical data can be shared appropriately with care providers including: Improved flow and timeliness of clinical information for health care providers, Improved data submission and reporting between Medicaid health plans, providers and Agency operations, Improved care coordination and health outcomes by reducing medication and other medical errors, Stimulation of greater consumer engagement and management of their own health care needs, services and spending, and Increased Agency, health plan and provider efficiency by eliminating unnecessary paperwork and reducing redundant or unnecessary testing. The agency is acutely aware of the need to improve the quality of care for Medicaid members while simultaneously decreasing the costs of care and has developed its own strategic plan and is continuing to make progress in information technology and exchange by adopting multiple strategies that create more data flow in the health care delivery system through the following goals: Bending the cost curve while improving member health outcomes, Pursuing continuous quality improvement, and Reducing fragmentation in health care delivery. AHCCCS is also targeting efforts to specific areas where HIT and HIE can bring about significant change and progress: behavioral health; partnerships for integrated care; super-utilizers; American Indian care coordination; coordination between AHCCCS plans and Qualified Health Plans; and justice system transitions. Further, AHCCCS recognizes that it must develop the mechanisms needed to incorporate electronic health information into clinical quality performance measures such as HEDIS measures, CHIPRA measures, Adult Core Measures and Meaningful Use measure validation. Page 10 of 129

11 Currently, the Agency receives administrative data in the form of encounters or claims from AHCCCS MCOs. However, the data that is in EHRs is richer and more actionable than what is currently available to AHCCCS. Certified EHR technology will offer a much more robust and timely data source than administrative data, providing information such as laboratory values, indicating improvement in a member s health status or condition, and whether comprehensive preventive and follow-up services were provided during a visit, such as those required under the federal Early Periodic Screening, Diagnostic and Treatment Services (EPSDT) Program. Use of the data contained in EHRs may also provide an opportunity to focus intervention activities to improve clinical outcomes as well as enhance State and federal reporting capabilities. Additional information regarding these goals will be provided in Sections 2, 3 and 6. Page 11 of 129

12 2 Current HIT Landscape, As Is Environment 2.1 General Section Overview Section 2 ties to the As Is section of the CMS SMHP template and describes the current extent of Arizona s EHR adoption by practitioners and hospitals. It includes adoption information that is not just specific to Medicaid providers but to all practicing professionals in the State. The section describes the status of broadband internet and shares information about HIT adoption in Federally Qualified Health Centers (FQHC), the Veterans Administration (VA) and the Indian Health Service (IHS) clinical facilities. This section also summarizes the Medicaid Agency s relationship with the State Health Information Technology Coordinator and the status of statewide planning for enabling HIE. This section also describes the activities that AHCCCS is undertaking to facilitate HIE and EHR adoption and how AHCCCS is coordinating its HIT plan with its MITA transition plans. Additionally, this section of the SMHP includes a summary of Arizona s Medicaid Transformation Grant and describes the current status of public health reporting. Each sub-section includes references to the CMS template to demonstrate compliance with the template requirements. 2.2 EHR Adoption by Professionals and Hospitals (SMHP Template Question #1) AHCCCS has studied EHR adoption multiple times over the years through its own landscape assessments and through a partnership with Arizona State University (ASU). EHR adoption in Arizona consistently exceeds projections of adoption rates from national studies. Large numbers of physicians in group practices and medical school students, residents and fellows drives the comparatively high adoption of EHR Physician Survey Through a comprehensive survey of registered physicians, the Center for Health Information and Research (CHIR) at ASU reviewed EHR adoption by physicians in 2009 and Results published in February 2010 show a 45 percent physician adoption of some form of EHR. This research was supported by the Arizona Medical Board of Osteopathic Examination and the Arizona Medical Board; the two licensing boards included the survey as part of their license renewal process, which has increased the response rates by over 90 percent. Results from more recent studies show that the rate of physicians using EHRs increased from 45 percent between 2007 and 2009 to approximately 80 percent between 2012 and Current trends suggest that all Arizona physicians will be using certified EHRs by The surveys have found that EHR adoptions are largely related to physician age (inverse relationship) and size of practice. In addition, while most practices have internal EHR capacity, there is limited ability to share data across external providers/settings Professional Survey (March 2012 December 2013) The most recent survey results showed that Arizona physicians are rapidly increasing their use of EHRs and, for the first time, use of EHRs in the practice is more prominent than use of paper records, with approximately 78 percent of physicians using some form of EHR compared to 52 percent in the last measurement period. In addition: EHRs are the dominant method of storing medical records, whether as the sole medium of storage or in combination with scanned files and/or paper records. EHR use is most prevalent in government practice settings and least prevalent in private solo practices. Page 12 of 129

13 The comparatively high percentage of physicians using EHRs is thought to be due to the relatively large number of physicians in group practices and governmental organizations. High utilization rates also occur among academic physicians and medical school students, residents and fellows. FQHCs showed the strongest increase among practice types, with EHR utilization growing to 89 percent in 2012, up from 40 percent in the 2010 measurement. The survey also collected practitioner data from allopathic and osteopathic physicians eligible for license renewal. Survey questions were included with renewal applications. Following this two-year licensure renewal cycle, and after the data were aggregated and analyzed, a report was released in March The most recent survey was conducted between March and December of 2012, with a draft report released in March The earlier survey report released in March 2012 reported that 50 percent of the surveyed practitioners use some form of EHR in their practice and that EHR use is most prevalent among practitioners in groups and governmental organizations, including academic settings. Other findings include: EHR use is least prevalent among solo practitioners. The probability of EHR use, controlling for all other influences, is significantly related to practitioner age. All else equal, the probability of use declines as practitioner age increases. There is little difference in the prevalence of EHR use between the two most urban counties and more rural counties. Practitioners who use EHRs place a higher value on them than do practitioners who have yet to adopt EHRs. Two barriers were identified by the survey. One was that the use of EHRs does not necessarily equate with participation in Health Information Exchange (HIE). Just over one half (54 percent) of the practitioners who use EHRs transmit medical data electronically outside their own practice environment to other parts of the health care system (e.g. labs, pharmacies). In addition, practitioners cited cost, followed by time and training, as the most significant barriers to adopting EHRs. AHCCCS believes the Medicaid EHR Incentive Program can go a long way in encouraging adoption based on these concerns. More detailed results are presented in Figure 2.1 below. Table 2.1: ASU CHIR EHR Adoption Results EHR Adoption Rates by Type of Practice (N = 7,961) Type of Practice Utilization Rates (%) Physician-Owned Solo Practice 55.5 Physician-Owned Group Practice 80.6 Hospital or Medical School Physician Group Practice 92.7 Community or Rural Health Clinic 92.3 Government Health Organization (VA, Indian Health Service, etc.) 96 Private Hospital System 88.9 Non-Hospital Private Outpatient Facility 80.6 Medical School/University/Research Center 91 Health Insurer/Pharmacy/Health Related w/o Provision of Care 42.8 State or County Hospital System 74.1 Other 73.2 Source: AMB, ABOE Survey Data, Note: Rates = % of physicians within each practice type. 1,489 respondents were missing type of practice. Page 13 of 129

14 Additionally, the ASU CHIR study reviewed EHR systems in use by providers both in practices with greater than 130 users and less than 130 users. The figures below illustrate which systems are most in use in Arizona. Figure 2.1: EHR Use by Vendor 130 Users Figure 2.2: EMR Use by Vendor > 25< 130 Users Landscape Assessment of Hospitals Using an internal survey tool, AHCCCS conducted a high-level survey of Arizona hospitals to assess their level of interest in adopting EHR systems. Specifically, the survey was designed to evaluate hospitals readiness to participate in the Medicare and Medicaid EHR Incentive Programs and to identify ways in which Arizona policymakers can support efforts to qualify for these programs. Page 14 of 129

15 The hospital data was collected from Arizona hospitals in June In most cases, survey questions were answered by Chief Information Officers or a similarly titled hospital staff member. Following aggregation and analyses of the data, a final report was published in August All Arizona hospitals were surveyed. All responses represent hospitals participating in Medicaid. Thus, there was no need for an AHCCCS vs. non-ahcccs comparison. Respondent hospitals represent a reasonable representation of urban and rural as well as small, moderate and large facilities. Survey responses were received from approximately one-third of the targeted Arizona hospitals. Whereas all respondent hospitals use some type of electronic health care system application, nearly three quarters of respondents report current use of a Certified Commission on Healthcare IT (CCHIT) interoperable EHR. Approximately one half of respondent hospitals using a CCHIT EHR are located in rural areas. Approximately one half of respondent hospitals using a CCHIT EHR are considered small facilities (i.e. 100 beds). The majority of hospital respondents plan to upgrade current EHRs or install new ones by Respondent hospitals use EHRs most frequently in the laboratory, followed by radiology, pharmacy, outpatient clinics, inpatient services and emergency rooms. In respondent hospital emergency rooms and outpatient departments, system applications are used most extensively for clinical documentation, followed by order entry and quality reporting. Less than one half of respondent hospitals reported using system applications for e-prescribing or for exchanging health information between hospitals or community providers. o The majority of hospital respondents express a need for both financial and technical assistance in order to interface their EHR systems with HIEs. As of August 2014, AHCCCS has made incentive payments to nearly 70 hospitals under the Medicaid EHR Incentive Program. Almost 150 payments have been made over multiple years to some hospitals: 68 firstyear payments, 56 second-year payments and 23 third-year payments. There are approximately 12 hospitals registered with the CMS Registration and Attestation system that have not received Medicaid EHR Incentive Program payments, and most do not appear to be eligible for the Medicaid EHR Incentive Program due to various reasons including insufficient Medicaid patient volume. The table in Appendix E provides EH incentive payment details. 2.3 HIT in FQHCs, IHS, and VA Facilities (SMHP Template Questions #3, 4 Professionals who practice in FQHCs, IHS facilities and VA facilities make up an important component of the Medicaid delivery system. This section describes the HIT landscape for FQHCs and IHS, including VA facilities. Page 15 of 129

16 2.3.1 Federally Qualified Health Centers (FQHCs) FQHCs are active in building their capacity to adopt and implement certified EHR technology, six (6) different FQHCs have received HIT funding from the Health Resources and Services Administration (HRSA). Arizona has 20 FQHCs and 9 Rural Health Clinics (RHCs) that are qualified for the EHR Incentive Program. Seventeen of the 20 FQHCs (85 percent) have eligible professionals (EPs) that have received EHR incentive payments as of July Three of the nine RHCs (33 percent) have EPs that have received incentive payments in that same time period. FQHCs reported the strongest increase among practice types with EHR utilization growing to 89 percent in 2012; a 40 percent increase from As of August 2014, AHCCCS has paid over 800 EPs in FQHCs. Two of the three FQHCs who have not received a payment have an EP who has applied for the EHR Incentive Program. The following is a status on the facilities that have not yet received payment Chiricahua Community Health Centers: 12 EPs under review Native American Community Health Center: 2 EPs previously rejected and expected to re-attest Native Health: No submissions See table below for a description of EHR Incentive Payments made to EPs practicing in FQHCs. Page 16 of 129

17 Table 2.2: EPs in FQHCs Receiving Medicaid EHR Incentive Program Payments Facility No. FQHC/RHC Facility Legal Business Name and dba Payment Number Type of EPs Adelante Healthcare, Inc. FQHC Ajo Community Health Center dba Desert Senita Community Health Center FQHC Canyonlands Community Healthcare FQHC Chiricahua Community Health Centers, Inc. dba Business 4 Office County of Yavapai dba Yavapai County Community Health 5 Services FQHC FQHC El Rio Santa Cruz Neighborhood Health Center FQHC Marana Health Center Inc. FQHC Maricopa County Health Care For The Homeless FQHC Maricopa County Special Health Care District dba Maricopa Integrated Health System FQHC Mariposa Community Health Center FQHC Mountain Health and Wellness FQHC Mountain Park Health Center FQHC Native American Community Health Center, Inc. dba Native Health FQHC Native Health FQHC Neighborhood Outreach Access to Health, formerly Scottsdale Healthcare Hospitals dba Family Practice Center FQHC North Country Healthcare Inc. FQHC Sun Life Family Health Center, Inc. dba Sun Life Family Health Center FQHC Sunset Community Health Center FQHC United Community Health Center Maria Auxilladora Inc. dba Continental Family Med. Payment Years FQHC Wesley Community Center Inc. FQHC FQHC TOTAL Bisbee Hospital Association dba Copper Queen Hospital RHC Cobre Valley Regional Medical Center dba Cobre Valley Community Hospital RHC Community Healthcare of Douglas Inc. dba Southeast Arizona Medical Center RHC Community Hospital Association Inc. dba Wickenburgh Community Hospital RHC La Paz Regional Hospital, Inc. dba La Paz Regional Hospital RHC Mount Graham Regional Medical Center dba Copper Mountain Clinic RHC Northern Cochise Community Hospital Inc. RHC San Luis Walk In Clinic, Inc. RHC Summit Healthcare Association dba Summit Healthcare Specialty Physicians RHC RHC TOTAL Page 17 of 129

18 2010 Survey FQHC EHR Adoption According to a survey conducted of FQHCs and RHCs in the spring of 2010, there were six different health centers that indicated they received HIT funding from HRSA: Adelante Health Care Desert Senita Community Health Center El Rio Center Health Center HealthCare for the Homeless North Country Health Care Wesley Community Health Center The survey also asked the community health centers to describe the current status of EHR adoption and use. Many of the FQHCs that responded represented multiple locations/facilities. Of those centers that responded, 11 had an EHR system that was operational. Two of the FQHCs, El Rio CHC and Marana have also signed an agreement to participate in the HIE onboarding program. The Arizona Association of Community Health Centers (AACHC) represents health centers statewide and provides advocacy, professional education programs and financial services. The AACHC has many programs to assist member community health centers and the disadvantaged populations they serve. These programs vary from centralizing financial information and educational opportunities for members to the recent creation of an association sponsored and HRSA financed health care provider network for the uninsured in Maricopa County, (greater Phoenix) Arizona. The AACHC is also the Primary Care Association (PCA) for the State of Arizona. All states have one designated PCA in order to advance both the expansion of FQHC and advocate for the health care interests of the medically underserved and uninsured Indian Health Services (IHS) Arizona is home to over 250,000 American Indians, approximately half of whom are enrolled in AHCCCS. AHCCCS covers over 50 percent of all American Indian births, and more than two-thirds of all nursing facility days utilized by American Indians in Arizona. The IHS, tribal health programs operated under P.L , and urban Indian Health Programs (collectively referred to as I/T/U) are the primary providers of health care to the majority of the estimated 126,000 American Indians enrolled in the AHCCCS program as of April Three IHS Area Offices oversee a number of hospitals and health care centers in the state of Arizona. There are approximately 12 medical hospitals and health centers that are tribal health programs operated under P.L Additionally, there is a number of behavioral health programs operated under P.L among the 22 tribes in Arizona. Three urban Indian health programs oversee four health centers that are located in the urban centers of the state Phoenix, Tucson, and Flagstaff. Page 18 of 129

19 Figure 2.3: Indian Health Services versus Medicaid All of the IHS clinical facilities use the Resource and Patient Management System (RPMS) as their EHR system and have attested for Stage 1 of MU. RPMS is an integrated solution for the management of clinical, business practice and administrative information in healthcare facilities of various sizes. The RPMS has an ambulatory EHR, which most, if not all, facilities use. The RPMS also has an inpatient and emergency room component, which may be used by some IHS Facilities. The balance of the tribal sites use commercial EHR systems. Certain tribal health programs operated under P.L including urban Indian health programs may also use the RPMS. RPMS is 2011 certified and still awaiting 2014 certification. The process to obtain 2014 certification is underway with a target date of late 2014 for approval and implementation. Incorporated within the upgrade are provisions for the Continuity of Care Document Architecture that will enable the ability to communicate to the national ehealth Exchange, Healtheway, the Personal Health Record and Direct Messaging. The Phoenix and Navajo Area deploy the EHR to servers with-in the facilities while the Tucson Area is using an integrated EHR server for their Clinics Veterans Administration (VA) Facilities The VA operates three campuses with multiple clinical facilities in Arizona. It is assumed that each of them uses the VISTA system but still needs to be confirmed with the VA. The state HIT Coordinator is tasked with communicating with the VA and coordinates and tracks progress. The VA is currently participating in the Federal Health Architecture Work plan and is using Healtheway (formally NWHIN CONNECT) as its required transport for health data. All state HIEs must meet Health-e- Way requirements before VA data will be made available to any other HIE. One of the most important limitations to the statewide HIE now is that its current HIE vendor has significant exchange limitations. The HIE communicated with its members and identified all the new functionality and services members wanted from its next generation of HIE vendor. AHCCCS is working with HINAz to ensure that they are aware of this requirement and have a strategy as to how to meet Health-e-Way certification standards. Page 19 of 129

20 Phoenix VA Health Care System The Phoenix VA Health Care System serves veterans in central Arizona at its main medical center and outpatient VA Health Care Clinics. The Carl T. Hayden Veterans Medical Center is categorized as a Clinical Referral Level 1 facility. The facility serves more than 74,000 Veterans in central Arizona including the rapidly expanding metropolitan Phoenix area. The Medical Center provides acute medical, surgical and psychiatric inpatient care, as well as rehabilitation medicine, and neurological care. The Medical Center currently operates 73 Medicine beds, 14 Medicine ICU/General ICU beds, 22 Surgery beds, 10 Short Stay ICU/Surgical ICU beds, 36 Mental Health beds, 20 Substance and Alcohol Abuse Recovery Treatment Program beds via community contract and 104 beds for the Community Living Center. Northern Arizona VA Health Care System Prescott Arizona The Northern Arizona VA Health Care System provides inpatient and outpatient care at the Bob Stump VAMC in Prescott, Arizona and also provides outpatient care at community based outpatient clinics (CBOCs) in Anthem, Bellemont, Cottonwood, Kingman and Lake Havasu City, Arizona. The Northern Arizona VA Healthcare System is part of the Veterans Integrated Service Network (VISN) 18 and serves a population of about 75,000 Veterans in a primary service area that includes six counties in North Central Arizona. Southern Arizona VA Health Care System The VA Medical Center located at Tucson Arizona is the Flagship for the Southern Arizona VA Health Care System (SAVAHCS), which serves over 150,000 veterans located in eight counties in Southern Arizona and one county in Western New Mexico. This 283-bed hospital provides training, primary care and sub-specialty health care in numerous medical areas for eligible Veterans. SAVAHCS provides care at seven Community Based Outpatient Clinics located at Safford, Casa Grande, Sierra Vista, Yuma, Green Valley, Northwest and Southeast Tucson. 2.4 Broadband and Telehealth/Telemedicine Activities (SMHP Template Questions #2, 12) Arizona is largely rural with broadband access concentrated in a couple metropolitan areas and a few smaller cities and towns. The two metropolitan areas of Phoenix and Tucson account for over 80 percent of the population. In order for providers to exchange health information with one another and achieve meaningful use, the broadband infrastructure in the state must be expanded into all cities and towns throughout the state. Broadband access is an ongoing challenge to increasing provider participation in the HIE, especially for hospitals that have larger data sets and support multiple facilities. In 2011, Arizona participated in the national broadband mapping and planning project, and received the first of two grants available from the U.S. Department of Commerce's National Telecommunications and Information Administration (NTIA). The grant provided approximately $1.8 million over a two-year period for broadband data collection and mapping activities. The second grant was for approximately $500,000 over a three-year period for the purpose of broadband planning and determining future broadband needs. The results of these grants provided plans and direction for future broadband deployment in Arizona. Since 2005, small projects have been funded to provide Wi-Fi along a 30-mile corridor of Interstate 19 from Rio Rico to Green Valley for first responders, and to bring additional broadband access to the deficit areas in Pinal County, to the town of Wickenburg, and to the town of Superior. Two tribal entities, Navajo and Tohono O'odham, also received funding to provide middle mile and last mile broadband infrastructure access to their nations. Page 20 of 129

21 The Tohono O'odham Utility Authority (TOUA) was selected to receive a $3.6 million loan and a $3.6 million grant to design, engineer and construct a digital network to replace dial-up service. This project provided services throughout the Tohono O'odham Reservation using Fiber-to-the-Premises (FTTP) and fixed wireless broadband. The Navajo Tribal Utility Authority (NTUA) was also awarded an approximately $32.2 million federal grant through the American Recovery and Reinvestment Act (ARRA) of 2009 by the U.S. Department of Commerce s National Telecommunications & Information Administration (NTIA) Broadband Technology Opportunities Program (BTOP). This grant, along with partial matching funds, provided middle mile and last mile broadband infrastructure access to the Navajo Nation Communications Infrastructure Advisory Committee (CIAC) The Governor s Office of Information and Technology (now ASET) provides staffing support and strategic direction to the Arizona Communications Infrastructure Advisory Committee. This Public/Private committee is part of the Governor s Council on Innovation and Technology (GCIT). The CIAC focuses on the issues related to the ubiquitous deployment of Broadband capability to all of Arizona. Key issues include Middle Mile, Last Mile, Right-of-Way and definition funding solutions. Current efforts are concentrated on Rural Arizona along with other deficit areas in both urban and rural settings. The map below shows 2014 broadband coverage in Arizona by county and was conducted as part of the Broadband Assessment Project (BAP). The purpose of the Arizona Broadband Assessment Project (AZ BAP) is to identify the availability and speed of broadband services, the location of broadband infrastructure throughout Arizona including middle mile infrastructure, and the presence and characteristics of Community Anchor Institutions (CAIs). This project is provided through the American Recovery and Reinvestment Act of 2009 (ARRA) and the Broadband Data Improvement Act, and in conjunction with the National Telecommunications and Information Administration and the Federal Communications Commission (FCC). AZ BAP is managed by ASET under the Arizona Department of Administration in partnership with the Arizona State Land Department, contractor Data Site Consortium, Inc. (DSCI) and their GIS subcontractor, TerraSystems Southwest (TSSW). The map measures maximum advertised download speed by all technologies with the exception of satellite. Page 21 of 129

22 Figure 2.4: Arizona BAP Broadband Coverage Spring Telehealth/Telemedicine Telehealth, and more specifically telemedicine, is used widely across Arizona to provide care to rural and underserved communities. The Arizona Telemedicine Program (ATP) network is primarily devoted to improving access to specialized medical care throughout the state of Arizona through the use of telemedicine technologies such as digital imaging and real-time video conferencing. Dozens of clinical specialty services are available over the Arizona Telemedicine Program network from a variety of member providers. Teleradiology, teledermatology and tele-behavioral health are the most common specialties provided through the network. A large majority of the hospitals and rural clinics across the state maintain some form of involvement with ATP. In addition, through a grant with the Federal Communication Commission (FCC) and coordination with the New Mexico and Southwest IHS, the Arizona Telemedicine Program has become part of the Southwest Telehealth Access Grid, which enables health care providers in rural and low-income locations throughout the Southwest to access high-quality urban health centers through a broadband communications network. Page 22 of 129

23 The expectation for widespread EHR adoption, health information exchange, and telehealth, is that the three components will work together to make information available to all providers involved in a patient s care whether that care is provided in-person or via telehealth. Having EHRs and HIE means that a remote provider can more easily have access to a patient s medical record that can improve care coordination and the quality of care provided. Figure 2.5: Arizona Telemedicine Network As part of the SFY 13 legislative session, a bill was presented to revise current state statutes and expand the definition of health care to encompass telemedicine. This bill required a group and individual health insurance policies to provide coverage for health care services provided through the use of telemedicine if the health care service would have been covered were it provided in person. The bill will be effective as of January 1, 2015 and requires telemedicine reimbursement for the following conditions: trauma, burn, cardiology, infectious disease, mental health disorders, neurologic diseases including strokes, and dermatology. AHCCCS already covers telemedicine services for the above conditions as well as many others. Service provision requirements are outlined in the AHCCCS Medical Policy Manual and also include oversight requirements for this type of service delivery Health Information Exchange Activities (SMHP Template Questions #6, 7, 10, 11, 13) Introduction: A Brief Arizona HIT/HIE History In 2006, Arizona published its first HIT/HIE roadmap the Arizona Health-e Connection Roadmap (referred to as Roadmap 1.0). This broad-based engagement produced not only a roadmap but also an organizational structure called, Arizona Health-e Connection (AzHeC). AzHeC is a public private partnership, a statewide nonprofit that drives the adoption and optimization of HIT/HIE. Since its inception AHCCCS, the Arizona Department of Health Services (ADHS, public health), the Arizona Strategic Page 23 of 129

24 Enterprise Technology Office (ASET, the state IT office) and the Governor s Health Policy Advisor have permanent seats on the AzHeC board to facilitate state support and planning for information technology and exchange. AHCCCS received a CMS Medicaid Transformation Grant in where it successfully stood up a proof of concept Health Information Exchange called the Arizona Medical Information Exchange (AMIE). The Exchange included hospital discharge summaries from several Maricopa County based hospitals, laboratory test results from one large system and medication history and as of December 2009 was able to have over 3.1 million patients in the AMIE Master Patient index. While this grant was implemented under the state Medicaid Agency, the AMIE leadership felt a health information exchange could serve the community more broadly by being performed outside of state government and wanted to move it towards a public private governance model. In December 2009, the AMIE Board felt it would be best strategically to suspend its technical operations and pursue a vision of developing a single state level health information exchange and roadmap with SAHIE. It was felt this could be a complimentary strategy to what the Governor s Office of Health Information Exchange (GOHIE/GOER, now ASET) would be looking to develop through the ONC HIE Cooperative Exchange grant. The AMIE leadership merged with the Southern Arizona Health Information Exchange (SAHIE) nonprofit to form a state level health information organization committed to a single, statewide health information exchange in The joint AMIE-SAHIE Boards signed a Memorandum of Understanding to form a new organization to oversee the development of the exchange. The new organization, called the Health Information Network of Arizona (HINAz) once fully operating will represent over 70 percent of the hospital beds in the state and will cover almost 70 percent of the insured lives in the State of Arizona. The newly merged organization was HINAz. The new organization produced a consolidated board, bylaws and governance structure, and a Participation Agreement which includes a Business Associate Agreement, Services and Service Level Agreement with a vendor to provide the Services to HINAz and HINAz Participants and a Subscription Fees Schedule for Phase I of their operations and planning. For a current description of HIE governance see section below. In 2012, HINAz won a competitively bid RFP under the Office of the National Coordinator for Health Information Technology (ONC) State HIE Cooperative Agreement Program (SHIECAP) to build a master patient index, provider directory and record locator service. ASET, then GOER/GOHIE, received the funding for the State Health Information Exchange Cooperative Agreement Program. This grant program was created to support States or their State Designated Entities (SDEs) in establishing health information exchange (HIE) capability among healthcare providers and hospitals in their jurisdictions. Funding for HIE Cooperative Agreement expired at the beginning of 2014 but the Strategic and Operational plans can be found at The strategic plan focuses on three deliverables and builds on the ONC preferred strategy of point-to-point communication by providers. Specifically the plan addresses e-prescribing, laboratory results transmission and providing patient care summaries. The State HIT Coordinator (which operated as a shared role between the Medicaid agency and the Arizona Strategic Enterprise Technology Agency (ASET) wanted to invest a portion of its SHIECAP grant funds into an updated roadmap which could support health care transformation and evolving payment reform models. Starting in 2013 and published in February 2014, the state HIT Coordinator collaborated with Arizona Health-e Connection and Mosaica Partners, with extensive participation and contributions by Arizona s health care community, to produce Arizona s Health IT Roadmap 2.0. AHCCCS does not have any formal relationships with other HIT/HIE players at this time other than those health care and business organizations identified in the AzHeC board of directors or the HINAz Board of Directors. However, AHCCCS is interested in monitoring the landscape to identify other potential HIT/HIE players to coordinate efforts with. Of particular interest to AHCCCS is the emerging Behavioral Health Page 24 of 129

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