MITA to RHIO: Medicaid Enterprise as a Communication Hub. A CNSI White Paper

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1 MITA to RHIO: Medicaid Enterprise as a Communication Hub A CNSI White Paper

2 Table of Contents 1. Introduction 1 2. Medicaid Enterprise and MMIS A Historical Perspective 2 3. Medicaid IT Architecture 3 4. MMIS Maturity Model 4 5. Regional Health Information Organizations 6 6. Medicaid Enterprise as a Communication Hub 7 7. Extending MMIS Systems Services References CNSI i

3 1. Introduction In Medicaid IT Architecture (MITA) vision, a Medicaid Enterprise will transform into a communication hub, with interoperability and data exchange with Regional Health Information Organizations (RHIOs), state and federal agencies, beneficiaries, provider networks and other payer networks. This white paper will cover business architecture, information architecture and technical architecture of Medicaid Enterprises as envisioned in MITA Maturity Model. It also will specifically address the structure of and communication protocols for the National Health information Network (NHIN) and State Health Information Networks (SHINs), architecture of the Medicaid Communication Hub of the future, and MMIS interfaces with external hubs and RHIOs CNSI 1

4 2. Medicaid Enterprise and MMIS A Historical Perspective Medicaid system evolution over the last 30 years has led to disparate systems that are not integrated. The Medicaid Management Information Systems (MMIS) started out in the 1970s as financial and accounting systems and as additional functions managed care, performance outcomes measurements, fraud detection and public health data analysis were added, they grew into uneven, disparate and diffuse systems, with each state implementing the add-on functions differently. These additional functions were implemented on different systems, with each platform requiring its own architecture and hard-coded in some cases. Communication between the systems is difficult, and aggregation, correlation and analysis of data have become cumbersome CNSI 2

5 3. Medicaid IT Architecture The MITA framework consists of three architectures: Business Information Technical The Medicaid IT Architecture (MITA) initiative is a plan to transform the MMIS from a claims processing engine to an integrated communication hub using national standards and networks. MITA promotes interoperability and reusability by providing a common, scalable, robust system architecture with clearly defined business processes, consistent data models and a scalable Services Oriented Architecture (SOA). The MITA framework consists of three parts: Business Architecture, Information Architecture and Technical Architecture. Business architecture gives a roadmap from the as-is state to an enhanced system for efficiently managing members, providers, contractors, beneficiary care, and business operations. Information architecture gives the scope and guidelines for developing conceptual and logical data models and specifications for data standards. Currently there are no national data models for Medicaid enterprises. Technical architecture is, at a high level, a mapping of business processes to technical functions and services in a Services Oriented Architecture. MITA architecture allows the business and technical functions to be implemented as a set of plug and play services. This approach promotes modular, scalable development and interoperability. Figure 1 depicts a high-level topology of the MITA Services Oriented Architecture. Figure 1: Services Oriented Architecture Source: MITA Framework CNSI 3

6 4. MMIS Maturity Model The MMIS MITA maturity model consists of five levels of maturity. Medicaid enterprises will evolve over a 10- year period to achieve level 5. To aid the States in improving their Medicaid enterprises and enhancing their MMIS systems through a methodical, self-paced path, the Center for Medicare and Medicaid Systems (CMS) has introduced the concept of MITA Maturity Model (MMM), which provides guidelines and performance measures for transforming a Medicaid Enterprise from its current (as-is) state to progressively higher levels of maturity and performance. The MMM classification uses five levels of maturity within a timeframe of ten or more years. As an illustration, Table 1 describes the levels of maturity for a few specific MMIS capabilities. Table 1: Medicaid Maturity Levels Capability Level 1 Level 2 Level 3 Level 4 Level 5 General capabilities for the enterprise Enrollment of eligible members and accurate payment of claims Cost management to improve quality and access to care Secure data access to clinical data, focus on improved outcomes Timeliness of business process Improved health outcomes Data maturity Meets mandated requirements of timeliness Focus on payment of provider claims to encourage provider participation Source of data is primarily the claim Data is nonstandard Exceeds legal requirement through web portal, EDI and other forms of automation Improved health outcomes through cost management Claim and encounter data are accessible to Agency users HIPAAmandated data standards are not widely used Adopt national standards, collaborate with other agencies, develop reusable business processes Interagency collaboration, use of data sharing and standards and data exchange at State/regional level National data standards, collaboration with other agencies Data standards adopted nationally with shared depositories of data Clinical data available in real time. Immediate response, action and outcomes with real-time clinical data Access to clinical data, which improves analysis of health outcomes Access to standardized clinical data through regional data exchanges Optimize program management, planning and evaluation Processes further improved through interoperable connectivity at federal and state level Most business processes are executed at the point of service Access to data at national level to compare outcomes across a broad spectrum Data exchange at national level optimizes decisionmaking capabilities Decisions are immediate and consistent with access to clinical data Source: MITA Framework CNSI 4

7 MITA framework describes in detail the maturity levels for each of the business processes. In general, enterprises at Level 1 perform only claims processing with some automation and a great deal of manual labor for operations. Level 2 is an increased level of automation, but mostly focused on claims management. At Level 3, enterprises implement SOA, with data sharing and exchange at state and regional levels, with common data standards. At Level 4, Medicaid enterprises share data with other state and federal agencies and Regional Health information Organizations (RHIOs), and the data includes claims and clinical data in the form of electronic health records (EHR). Level 5 optimizes business processes and enables national level data analysis, comparative studies and performance analysis. At maturity Levels 3 and 4, a Medicaid enterprise transforms into a communication hub CNSI 5

8 5. Regional Health Information Organizations RHIOs create a provider centric framework for information sharing A RHIO is a regional network that connects providers, payers and beneficiaries in a geographical region and shares clinical and payment data. While current MMIS systems are payer-centric, RHIOs are provider-centric with EHRs being the major part of the data that is shared among the providers. RHIOs are currently implemented in three models. In a co-op model, generally in a rural setting, small hospitals, providers and payers join to form a RHIO and share their resources and collaborate in providing services. Such a RHIO may use a centralized database and all providers will have access to it. In a federated model, typically run by health care organizations, RHIOs work with decentralized data. Data is stored at the points of creation and is shared with other providers, when necessary, through authorized access mechanisms. Large networks with multiple RHIOs use a hybrid model of centralized and decentralized databases. The National Health Information Network (NHIN), when it is fully developed and implemented, will connect hundreds of RHIOs and will facilitate sharing of clinical and other data in a standardized format, such as an EHR, among providers with appropriate and authorized access protocols. A national network of RHIOs will not only bring efficiency, automation and improved service through reduced errors and savings, but also facilitate, at a national level, data aggregation and analysis, epidemiological studies, research, public health management and national security monitoring such as bio-surveillance CNSI 6

9 6. Medicaid Enterprise as a Communication Hub A Medicaid enterprise will evolve into a communication hub when it achieves Level 3 or 4 of the MITA maturity model At maturity Levels 3 and 4, Medicaid enterprises will be networked with RHIOs, transforming themselves into communication hubs. Some states may develop their own State Health Information Networks (SHINs) ahead of NHIN implementation, if there are some fully functional RHIOs in those states. Hub architecture facilitates data exchange and sharing, while ensuring security and privacy. Through a set of access services and protocols, encapsulated data can be exposed to authorized users. A hub provides common services needed by all subscribers by sending and receiving messages and by data exchange and sharing. Hubs use centralized capabilities that allow multiple systems to communicate with one another using automated coordination. MMIS, as a communication hub, interacts with multiple RHIOs and other hubs. The scope, reach and functionality of an MMIS hub can be expanded by widening the network and developing new interfaces, without having to change the core architecture of the system. A generic hub architecture is shown in Figure 2. Source: MITA Framework 2.0 Figure 2: A Communication Hub 2006 CNSI 7

10 Source: MITA Framework 2.0 Figure 3: Medicaid Enterprise as a Communication Hub Figure 3 shows the Medicaid Enterprise as a communication hub and its flow of communication. In a typical scenario, a member accesses a RHIO portal and applies for benefits. After receiving approval of eligibility, the member selects a physician based on his or her needs and makes an appointment online, viewing the available dates and times. The physician confirms the appointment and requests the member to send all prior medical history from all previous providers, regardless of their locations. After the member gives permission to the physician to collect the member s medical history, the system automatically collects the data and builds an EHR for that member. The physician receives the member's Medicaid benefits eligibility information and the member s electronic health record, which the member will be able to inspect and verify during the visit. The physician sends out prescriptions online and receives the member's lab results electronically, which will also become part of the EHR. During treatment, the member can update his or her Personal Health Record (PHR), which the physician can review from the clinic and suggest changes or modifications, as necessary. As the hospital, physicians, laboratories, and 2006 CNSI 8

11 pharmacies continue to treat the member, they add diagnostic, service, and referral information to their health records, which will later become part of the member's EHR. Each service entry from any of the providers triggers a message requesting payment, and administrative information in the health records directs the message to the primary payer, the Medicaid enterprise. The patient registry at the RHIO coordinates benefits and makes payment requests to appropriate secondary and other payers. Providers receive instant notification that the service is payable and the member is advised accordingly. These payments are processed automatically, with little or no human intervention. Based on triggers and thresholds, key information stored in health records creates reports to state and federal agencies, such as public health and the Department of Homeland Security (DHS) for bio-surveillance and other reportable conditions. To interact with various organizations with different interfaces, the Medicaid enterprise will be capable of generating and receiving messages in several formats (e.g., ASC X12 for payment information, HL7 codes for clinical data and DICOM messages for imaging) CNSI 9

12 7. Extending MMIS Systems MMIS systems can be extended using MITA and SOA to implement and advanced business functions while the NHIN is being designed. With the NHIN still in the design phase and EHR standardization still in the review process, it may take a few years before the aforementioned enhancements to Medicaid enterprise systems are realized. In the interim, states can implement some advanced business functions by extending the current MMIS systems using MITA framework and SOA architecture. The following are some considerations for transitional improvements to the existing MMIS systems: 1. Using MMIS as a platform, states can establish a Health Information Exchange (HIE) framework within their State Health Services enterprises. 2. This HIE framework can link services such as Medicaid, mental health, aging, child health and long-term care. 3. States can establish core aggregated patient data from the beneficiary's health and claims information and create structured electronic data, which can eventually be implemented as an EHR. 4. States can develop analysis tools for decision making and outcome measurements on aggregated data. 5. A central client repository can be established with centralized indexing and cross referencing between different systems, with probabilistic and rules-based matching. 6. Using an Enterprise Service Bus and SOA architecture, some business services can be implemented incrementally. Some of these services and data can be made available to external entities such as RHIOs, as needed CNSI 10

13 8. Services Medicaid enterprises must start evolving their systems into the MITA maturity model in a phased approach For a Medicaid enterprise to progress through the MITA MMM levels, a state will need to perform several tasks in a phased manner. 1. Conduct a self-assessment study. Using MITA criteria for each of the business processes, information models and technical architecture, a state will need to perform an "as-is" analysis and arrive at its current maturity level. 2. Prepare mid-term (2- to 3-year) and long-term (10 year) plans to achieve MMM Level Incorporate Medicaid IT architecture into the state s enterprise IT architecture. 4. Identify services and functions, and determine their priorities. 5. Identify and develop interfaces for EDI, HL7 and other formats. 6. Develop network interfaces for the State's RHIOs. 7. Develop conceptual and logical data models for claims and clinical data. 8. Implement EHR and PHR construction modules. 9. Implement client repositories with centralized indexing and rules-based matching. 10. Implement MITA-based business functions incrementally. Within the next ten years, national healthcare and its IT infrastructure will undergo a major transformation and Medicaid enterprises have a leading role to play in that change. The MITA framework provides an architectural vision and roadmap that will enable the Medicaid enterprises to provide services to their beneficiaries with great efficiency and cost savings CNSI 11

14 9. References Robin Blair, RHIO Nation, Health Management Technology, February Nancy Ferris, The Chicken and the Egg, Which Comes First: Medicaid Reform or Medicaid IT, Government Health IT, August Medicaid IT Architecture (MITA) Framework 2.0, Center for Medicare and Medicaid Services, March Brian Robinson, RHIOs for Beginners, Government Health IT, August CNSI 12

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