ARIZONA STATE MEDICAID HEALTH INFORMATION TECHNOLOGY PLAN Version 5.1 December 10, 2014 Thomas J. Betlach, Director AHCCCS 801 East Jefferson Street Phoenix, Arizona 85034 (602) 417-4000 www.azahcccs.gov
REVISION HISTORY AHCCCS initially submitted its SMHP in 2011. Since then, AHCCCS has submitted three major revisions, with Version 5 submitted August 2014. 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 email 3.0 May 9, 2013 2013 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, 2013. 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
Table of Contents TABLE OF CONTENTS... 3 INTRODUCTION... 5 1 STATE AND AHCCCS BACKGROUND... 7 1.1 1.2 1.3 ARIZONA HEALTH SYSTEM OVERVIEW... 8 AHCCCS OVERVIEW... 8 AGENCY S PRIORITIES FOR HIT... 10 2 CURRENT HIT LANDSCAPE, AS IS ENVIRONMENT... 12 2.1 GENERAL SECTION OVERVIEW... 12 2.2 EHR ADOPTION BY PROFESSIONALS AND HOSPITALS (SMHP TEMPLATE QUESTION #1)... 12 2.2.1 Physician Survey... 12 2.2.2 Landscape Assessment of Hospitals... 14 2.3 HIT IN FQHCS, IHS, AND VA FACILITIES (SMHP TEMPLATE QUESTIONS #3, 4... 15 2.3.1 Federally Qualified Health Centers (FQHCs)... 16 2.3.2 Indian Health Services (IHS)... 18 2.3.3 Veterans Administration (VA) Facilities... 19 2.4 BROADBAND AND TELEHEALTH/TELEMEDICINE ACTIVITIES (SMHP TEMPLATE QUESTIONS #2, 12)... 20 2.4.1 Communications Infrastructure Advisory Committee (CIAC)... 21 2.4.2 Telehealth/Telemedicine... 22 2.5 HEALTH INFORMATION EXCHANGE ACTIVITIES (SMHP TEMPLATE QUESTIONS #6, 7, 10, 11, 13)... 23 2.5.1 Introduction: A Brief Arizona HIT/HIE History... 23 2.5.2 HIE Background... 25 2.5.2.1 Governance... 26 2.5.2.2 HIE Functionality... 29 2.5.3 HIT and HIE Activities that Cross State Borders... 30 2.6 AHCCCS PLANS TO FACILITATE EHR AND HIE ADOPTION (SMHP TEMPLATE QUESTIONS #9, 11, 12)... 31 2.6.1 AHCCCS HIT/HIE Plan... 31 2.6.2 Regional Extension Center Activities... 32 2.6.3 Facilitating EHR Adoption... 33 2.6.4 Facilitating HIE Adoption... 35 2.6.4.1 HIE Onboarding... 36 2.6.4.2 Public Health Initiatives... 39 2.7 INTEROPERABILITY OF IMMUNIZATION REGISTRY & PUBLIC HEALTH SURVEILLANCE (SMHP TEMPLATE QUESTION #14)... 48 2.8 STAKEHOLDER ENGAGEMENT IN HIT ACTIVITIES (SMHP TEMPLATE QUESTION #5)... 48 2.9 MMIS IN THE CURRENT ENVIRONMENT (SMHP TEMPLATE QUESTION #8)... 49 2.10 SUMMARY MEDICAID TRANSFORMATION GRANT ACTIVITIES (SMHP TEMPLATE QUESTION #15)... 53 2.11 ARIZONA HEALTH IT ROADMAP 2.0... 54 3 FUTURE HIT LANDSCAPE, TO BE ENVIRONMENT... 57 3.1 GENERAL SECTION OVERVIEW... 57 3.2 FUTURE OF HIT AND HIE, EHR ADOPTION (SMHP TEMPLATE QUESTIONS #4, 5, 7)... 57 3.2.1 Challenges to Overcome and Lessons Learned... 57 3.2.2 Meaningful Use Stages... 58 3.2.3 Health Information Exchange Governance... 59 3.2.4 Steps to Encourage EHR Adoption Next 12 Months... 59 3.2.5 Future of Public Health: Reporting and Interoperability (SMHP Template Questions #1, 2)... 60 3.3 FIVE-YEAR HIT AND HIE GOALS (SMHP TEMPLATE QUESTION #1)... 60 3.3.1 HIT/HIE Agency Goals... 60 3.3.2 HIT/HIE Statewide Goals... 64 3.3.3 EHR Adoption Goals... 66 3.3.4 HIE To Be... 66 Page 3 of 129
3.4 VULNERABLE POPULATIONS AND POPULATIONS WITH UNIQUE NEEDS (E.G., CHILDREN, FQHCS, IHS, VA)(SMHP TEMPLATE QUESTION #6, 8)... 67 3.4.1 Leveraging FQHC Resources and Experiences... 67 3.5 FUTURE OF AHCCCS IT ARCHITECTURE (SMHP TEMPLATE QUESTION #2)... 68 3.6 FUTURE OF MEDICAID PROVIDER INTERFACE WITH IT SYSTEM AND IT SYSTEM ARCHITECTURE (SMHP TEMPLATE QUESTION #3) 70 3.7 LEVERAGING HIT-RELATED GRANT AWARDS (SMHP TEMPLATE QUESTION #9)... 70 3.7.1 Medicaid Transformation Grant... 70 3.7.2 ONC Cooperative Agreement Funds... 71 3.7.3 State Innovation Model Grant Proposed... 72 3.8 NEED FOR NEW LEGISLATION OR STATE LAWS (SMHP TEMPLATE QUESTION #10)... 73 4 PROGRAM IMPLEMENTATION AND ADMINISTRATION... 74 4.1 ASSUMPTIONS (SMHP TEMPLATE QUESTION #29)... 74 4.2 IMPLEMENTING THE EHR INCENTIVE PROGRAM... 75 4.2.1 Identifying Eligible Professionals and Hospitals and Making Payments (SMHP Template Questions #1, 2, 3, 27) 75 4.2.2 Calculating Patient Volume (SMHP Template Questions #5, 6, 7, and 12)... 75 4.2.3 Payments Methodologies (SMHP Template Questions #24, 25, 26, 27)... 77 4.2.4 Verifying the Adoption, Implementation, and Upgrade of Certified EHRs (SMHP Template Questions #11) 77 4.2.5 Reporting of Meaningful Use (SMHP Template Question #10, 11, and 12)... 78 4.2.6 Integration of Meaningful Use Activities with Other Quality Initiatives (SMHP Template Question #13) 80 4.3 ADMINISTRATION OF THE EHR INCENTIVE PROGRAM... 81 4.3.1 Communicating Key Information to Providers (SMHP Template Question #4)... 81 4.3.2 Establishing Adequate Technical Systems and Administrative Processes (SMHP Template Questions #14, 15, 16, 17, 18, 18, 20, 21, 24, 25, and 28)... 82 4.3.3 Appeals and Grievances (SMHP Template Questions #22)... 84 4.3.4 Role of Contractors (SMHP Template Question #28)... 85 5 AUDIT AND OVERSIGHT... 86 5.1 GENERAL AUDITING REQUIREMENTS AND PROCESSES (SMHP TEMPLATE QUESTION #1, 6)... 86 5.2 CONDUCTING PRE-PAYMENT AUDITS (SMHP TEMPLATE QUESTION #1, 5)... 88 5.3 CONDUCTING POST PAYMENT REVIEWS (SMHP TEMPLATE QUESTION #5)... 90 5.4 TRACKING MEANINGFUL USE (SMHP TEMPLATE QUESTION #4)... 91 5.5 MONITORING FRAUD AND ABUSE (SMHP TEMPLATE QUESTIONS #1, 2, 3, 7, AND 8)... 91 6 PROGRAM EVALUATION, METRICS, AND TARGETS... 93 6.1 AHCCCS HIGH-LEVEL STRATEGY FOR HIT (SMHP TEMPLATE QUESTIONS #1, 2, AND 3)... 93 6.1.1 Increase the Adoption of EHRs by EPs and EHs... 94 6.1.2 Accelerate Statewide HIE Participation for all Medicaid Providers and Plans... 95 6.1.3 Ensure Program Integrity (SMHP Template Question #4)... 96 7 APPENDICES... 97 7.1 APPENDIX A: ACRONYMS... 98 7.2 APPENDIX B: DESCRIPTION OF CHANGES VERSION 5.0 AUGUST 2014... 100 7.3 APPENDIX C: CROSSWALK BETWEEN AHCCCS SMHP AND CMS REQUIREMENTS... 105 7.4 APPENDIX D: DESCRIPTION OF AHCCCS EXECUTIVE OFFICES... 110 7.5 APPENDIX E: HOSPITAL MEDICAID EHR INCENTIVE PAYMENT DETAIL... 111 7.6 APPENDIX F: SAMPLE OF ELIGIBLE HOSPITAL EHR INCENTIVE PROGRAM PAYMENT CALCULATION... 115 7.7 APPENDIX G: ARIZONA MEDICAID EHR INCENTIVE PROGRAM IMPLEMENTATION CALENDAR... 118 7.8 APPENDIX H-J... 129 Page 4 of 129
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
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
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 116,320 134,421 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
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
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 2013. However, since the Governor s Restoration Plan took effect on January 1, 2014, this population has increased to approximately 216,000 as of June 2014. 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 100-133 percent FPL, or about 57,000 individuals. Since January 1, 2014 when coverage for this expansion group became effective, approximately 20,000 individuals between 100-133 percent have enrolled in coverage. The most recent Medicaid enrollment figures from August 2014 highlight more Medicaid enrollment trends. Page 9 of 129
Table 1.3: AHCCCS population by Category March August 2014 3/1/14 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, 103,618 111,176 115,395 118,151 120,713 123,289 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
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
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. 2.2.1 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 2013. 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 2013. Current trends suggest that all Arizona physicians will be using certified EHRs by 2018. 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. 2013 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
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 2012. The most recent survey was conducted between March and December of 2012, with a draft report released in March 2013. 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 2012 2013 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, 2012-2013. Note: Rates = % of physicians within each practice type. 1,489 respondents were missing type of practice. Page 13 of 129
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 2.2.2 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
The hospital data was collected from Arizona hospitals in June 2009. 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 2009. 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 2011. 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
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 2014. 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 2010. 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
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 1 2 3 1 Adelante Healthcare, Inc. FQHC 20 20 0 0 2 Ajo Community Health Center dba Desert Senita Community Health Center FQHC 5 5 0 0 3 Canyonlands Community Healthcare FQHC 15 15 0 0 Chiricahua Community Health Centers, Inc. dba Business 4 Office County of Yavapai dba Yavapai County Community Health 5 Services FQHC 0 0 0 0 FQHC 13 13 0 0 6 El Rio Santa Cruz Neighborhood Health Center FQHC 229 141 88 0 7 Marana Health Center Inc. FQHC 50 46 4 0 8 Maricopa County Health Care For The Homeless FQHC 1 1 0 0 9 Maricopa County Special Health Care District dba Maricopa Integrated Health System FQHC 230 151 79 0 10 Mariposa Community Health Center FQHC 14 12 2 0 11 Mountain Health and Wellness FQHC 11 11 0 0 12 Mountain Park Health Center FQHC 109 73 36 0 13 Native American Community Health Center, Inc. dba Native Health FQHC 0 0 0 0 14 Native Health FQHC 0 0 0 0 15 Neighborhood Outreach Access to Health, formerly Scottsdale Healthcare Hospitals dba Family Practice Center FQHC 5 5 0 0 16 North Country Healthcare Inc. FQHC 75 62 13 0 17 Sun Life Family Health Center, Inc. dba Sun Life Family Health Center FQHC 13 13 0 0 18 Sunset Community Health Center FQHC 28 28 0 19 United Community Health Center Maria Auxilladora Inc. dba Continental Family Med. Payment Years FQHC 26 19 7 20 Wesley Community Center Inc. FQHC 3 3 0 FQHC TOTAL 847 618 229 0 1 Bisbee Hospital Association dba Copper Queen Hospital RHC 10 10 0 0 2 Cobre Valley Regional Medical Center dba Cobre Valley Community Hospital RHC 0 0 0 0 3 Community Healthcare of Douglas Inc. dba Southeast Arizona Medical Center RHC 0 0 0 0 4 Community Hospital Association Inc. dba Wickenburgh Community Hospital RHC 0 0 0 0 5 La Paz Regional Hospital, Inc. dba La Paz Regional Hospital RHC 2 2 0 0 6 Mount Graham Regional Medical Center dba Copper Mountain Clinic RHC 0 0 0 0 7 Northern Cochise Community Hospital Inc. RHC 0 0 0 0 8 San Luis Walk In Clinic, Inc. RHC 6 6 0 0 9 Summit Healthcare Association dba Summit Healthcare Specialty Physicians RHC 0 0 0 0 RHC TOTAL 18 18 0 0 Page 17 of 129
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. 2.3.2 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. 93-638, 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 2013. 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. 93-638. Additionally, there is a number of behavioral health programs operated under P.L. 93-638 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
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. 93-638 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. 2.3.3 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
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
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. 2.4.1 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
Figure 2.4: Arizona BAP Broadband Coverage Spring 2014 2.4.2 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
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. 2.5 2.5.1 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
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 2007 2009 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 2010. 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 2.5.2 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 www.aset.azdoa.gov. 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
Information Network of Arizona (BHIN), which is working on developing an HIE to serve the needs and of behavioral health professionals across the state. 2.5.2 HIE Background The Network (Health Information Network of Arizona or HINAz) is a program of Arizona Health-e Connection that provides secure access to patient health information as well as the secure exchange of patient health information between the Network and its participating organizations and providers. The Network is Arizona s largest and only statewide health information organization (HIO) and its participants include hospitals, physicians, health plans, references labs and other health care organizations and providers. Funding The HIE receives over $3 million in funds from numerous sources to reflect the benefits that will accrue to various stakeholders across Arizona. The following payers are contributing funds to the HIE: Table 2.3: HIE Annual Benchmarks, July 1, 2013 June 30, 2014 HIE Annual Benchmarks Total Contribution Source of Funding Total Payments Hospitals $709,424 Health Plans $459,330 Labs $30,000 Other Providers $89,025 HIE Cooperative Agreement Contract $1,621,277 AHCCCS $411,668 TOTAL $3,320,724 The figure below describes the percentage of total funds made up by each contribution. Figure 2.6: Payer Contributions to the HIE, 7/1/13 to 6/30/14 Hospitals AHCCCS 12% Hospitals 21% Health Plans Labs Other Providers ONC Cooperative Agreement 49% Health Plans 14% Labs 1% ONC Cooperative Agreement AHCCCS Other Providers 3% With these funding sources, the financial status of the HIE is sound and audited financial statements for 2013 are provided in Appendix J. Page 25 of 129
Connections As of June 30, 2014, the HIE has established connections with 7 hospital systems (representing 20 hospital facilities), 8 other provider entities (excluding Sonora Quest Labs) representing 10,400 professionals (for this purpose are defined as MDs, DOs, nurse practitioners and physician assistants). For the Medicaid EHR provider breakdown, 20 hospital facilities are included but the number of eligible Medicaid EHR Incentive Program professionals connected is unknown. The total number of patients with clinical information in the HIE is 3,461,369. In addition to the number of contributions and connections, CMS is requiring Arizona to report annually on a number of other HIE benchmarks as a condition of using EHR Incentive Program funds for HIE. These benchmarks are located throughout the SMHP. The table below describes these requirements and where they can be found: Table 2.4 HIE Benchmarks July 1, 2013 June 30, 2014 CMS Annual Required HIE Benchmark Contributions Successful Connections Covered Lives Goal Progress Financial Status Electronic Quality Measures Meaningful Use Benchmark Description SMHP Page Number Identify all other payers and how much they have contributed to the HIE. Specify whether it was direct funding and/or in-kind each year. Please provide details. High-level pie chart 25 Provide the cumulative number and % of total providers successfully connected to the HIE each year overall. Provide the same for total Medicaid providers, and of those, separate by Medicare, Medicaid Eligible Hospitals, or EPS 26 Provide cumulative number and % of total Medicaid covered lives. Provide context needed to understand the growth or lack of growth (may include Medicaid providers: accessing the HIE viewer to get information, receiving hospital alerts from provider notification services, sending data to the HIE from their EHR or having a direct account regardless of how it is used. 26 Provide a status update on meeting the Year 1 goals for onboarding hospitals and FQHCs/RHCs 38 Provide prior year's financial statement for the HIE plus any other details to help explain financial status Appendix J Provide information on progress for using the HIE to capture clinical quality measures electronically from EHRs for Medicaid providers participating in the Medicaid EHR incentive program 67 Provide information on progress in enabling MU (e.g., connections to public health facilities and successful transmissions of summary of care records) 67 2.5.2.1 Governance To support policymaking and oversight of health information exchange, the Agency has participated on the board of Arizona Health-e Connection since its inception in 2007. There are three other state government representatives including the Arizona Department of Health Services, the Arizona Strategic Enterprise Technology Office and the Governor s Health Policy advisor. The AHCCCS Director represents the Agency on this board. Page 26 of 129
At one time, the Agency also held a separate seat on the HINAz Board, but during the Roadmap 2.0 project, a significant change occurred in the relationship between Arizona Health-e Connection and HINAz. Through a series of conversations and stakeholder interviews, Arizona health care stakeholders sent a clear message to both organizations that a closer association between these two key organizations would produce valuable synergies. As a result, AzHeC and HINAz created a more formal affiliation between the two organizations. This new model provides a single point of access for all community wide HIT and HIE activities. Figure 2.7: Arizona HIT/HIE Organizations and Resources, Arizona Health IT Roadmap 2.0 The State HIT coordinator attends the HINAz Board meetings as a guest and represents the Medicaid Agency. All of the Medicaid Acute Health Plans are required to join HINAz to support engagement in health information exchange and care coordination. Page 27 of 129
Table 2.4: List of AzHeC Board Members and Associated Organizations Page 28 of 129
HIT Steering Committee To support HIE within the Agency and across the divisions, the Agency has established a HIT Steering Committee made up of the Senior Leadership of the Agency. Chaired by the Director of the Agency and staffed by the Medicaid HIT Coordinator and three-person project team, the committee is overseeing all dimensions of the Agency s participation in health information exchange and EHR adoption. The full list of HIT Steering Committee members is providing in the Introduction to the SMHP. Private ACOs There are a number of private HIEs (including those being developed by Accountable Care Organizations (ACOs) and other payer management organizations) that are forming across the state. AHCCCS has no governance relationship with any private HIE entities. 2.5.2.2 HIE Functionality The Network Services Basic Network services include: Secure access to authorized patient health information Secure exchange of patient health information with The Network and Network participants Comprehensive implementation guidance and assistance The Network also helps providers comply with Arizona law that requires those who participate in a health information organization (HIO), like The Network, to have in place a consent notification and opt out process. Data Access and Exchange Methods Data can be exchanged and accessed through the following methods: Viewer access Patient information can be accessed one patient at a time via a web-based viewer commonly referred to as a virtual health record (VHR) viewer. Bi-directional exchange The Network is connected to a certified EHR allowing a Network participating organization to automatically send patient information to the network, and it allows patient information from the certified EHR to be queried by authorized Network providers and be available directly through the Network. Health Plan exchange The Network transfers relevant patient data to a Health Plan facilitating use of this data by the plan s authorized users for care coordination and care management purposes. Data Formats Data can be exchanged with The Network in one of two formats: HL7 Version 2.x. Discrete data that is machine-readable only and not in a human-readable format. Continuity of Care Document (CCD) using HL7 Version 3.x. Data presented as a single integrated document that is both machine-readable and human-readable. Page 29 of 129
Types of Data Exchanged Utilizing the HL7 v2 standard transactions, The Network collects and is able to supply the following types of patient data to authorized Network users: Admission, Discharge, and Transfer (ADT) transactions Discharge summaries Lab results & reports Radiology reports Medication histories o This information is provided exclusively by Surescripts and is available only through an explicit patient level query via the VHR viewer. Utilizing the HL 7 v3 standards for CCDs, The Network attempts to collect the following information within the CCDs that it receives: Advance Directives Allergies and Other Adverse Reactions Diagnostic Results Encounters Health Care Providers Hospital Course Immunizations Information Source (Data Provider ID) List of Surgeries and Other Procedures Medications (includes Current Meds) Payers/Insurance Personal Information Problem List Vital Signs Upcoming changes and considerations for changes to functionality features of The Network will be discussed in Section 3. 2.5.3 HIT and HIE Activities that Cross State Borders Due to Arizona s geography, most of the health services are delivered within the borders of Arizona. However, there are instances where accessing care out of state is the standard as the Arizona residents are physically closer to a more robust services delivery system in a neighboring state. For example, most Page 30 of 129
people living in the far North West corner of Arizona get specialized hospital care in Las Vegas, Nevada. Also, AHCCCS has a requirement that the health plans have Primary Care, Dental and Pharmacy contracts with providers in Kanab, Utah because it is the closest place for people who live north of the Grand Canyon. Aside from these geographic imperatives, AHCCCS also contracts with some out-ofstate hospitals for the provision of covered transplant services that are not available in Arizona. From a care coordination perspective, AHCCCS recognizes that there could be great value in being able to send and receive health records from other states. AHCCCS members travel and get emergency care out of state as well as the regular care described above. Care Coordination is especially important among the Northern/Eastern part of Arizona, which borders New Mexico and Utah, in the Navajo Nation. The Navajo have a large population that depends on the health care delivery system including clinics and hospitals that are in several states. Under the ONC HIE Cooperative agreement Program, cross state exchange was also an area of interest. The State HIT Coordinator and Sr. Project Manager were participants in the Western States Consortium where Arizona was able to track the progress and implementation of a pilot program between the state of Oregon and the State of California to exchange information across their state boundaries using the Direct protocol. Arizona was not able to do send any information but monitored the progress of the cross state exchange activities and policy issues. In addition, AHCCCS supports Medicaid EHR Incentive Programs in neighboring states through Agency staff sharing information necessary for provider attestations, e.g., supporting information on out-of-state Medicaid patient volume. 2.6 2.6.1 AHCCCS Plans to Facilitate EHR and HIE Adoption (SMHP Template Questions #9, 11, 12) AHCCCS HIT/HIE Plan In response to Arizona s healthcare marketplace, provider experience and federal initiatives including HITECH and ACA (including the State Innovation Model grant program), AHCCCS created an Agency HIT/HIE plan that recognizes the national priorities, goals and challenges and at the same time maximizes all of the resources it has in the health care community to ensure providers continue to move through the MU Program milestones. With those goals in mind, AHCCCS created its own strategic plan and has been continuing to make progress in information technology and exchange by adopting multiple strategies that create more data flow in the health care delivery system. The CMS triple aim for improving healthcare underpins all of Arizona s healthcare goal setting: Bending the cost curve while improving member health outcomes, Pursuing continuous quality improvement, and Reducing fragmentation in health care delivery. AHCCCS has a multi-pronged strategy with numerous initiatives to address healthcare 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; 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. Page 31 of 129
2.6.2 Regional Extension Center Activities AzHeC was awarded the ONC Regional Extension Center Program in April 2010. The REC Program has been successful in assisting hospitals and providers to adopt EHRs and achieve success in being able to attest to Adopt, Implement, Upgrade and Meaningful Use Stage 1. The REC has been successful in assisting over 1,260 priority primary care providers (PPCPs) and 16 critical access hospitals (CAHs) and rural hospitals (RHs) in Arizona achieve Meaningful Use Stage 1 in the CMS EHR Incentive Program. AzHeC provides an unbiased approach in utilizing health IT to improve and transform health care delivery and practice. One of 62 federally funded and designated RECs nationwide, the REC today serves all Arizona providers regardless of size or specialty, including hospitals and clinics. REC Benefits Health IT development and assistance Assistance for Meaningful Use or developing the health IT foundation for participation in patientcentered medical homes or accountable care organizations Practice transitions and development A one-stop shop for gap analysis, project planning and project management from privacy and security issues to health information exchange A national network of information and resources Connection to information, answers and solutions from state and federal government, as well as, a network of 62 regional extension centers nationwide REC Services In addition to the benefits described above, REC participation includes: News and information services - A quarterly e-newsletter, the REC Bulletin, that provides health IT news to REC members and special e-mail notices (REC Alerts) for breaking news Health IT events and webinars - Online registration and discounts for webinars and other events Vendor Alliance Program - Access to qualified EHR and non-ehr health IT vendors, including some vendors that offer discounted rates to REC participants. Competitively priced a la carte services - The REC offers tailored health IT services to practices, hospitals and other health care organizations. Here is a sampling of the available services: Practice assessment Vendor evaluation Project planning, monitoring & management Workflow redesign Meaningful Use gap analysis & assistance Privacy & security Application training Page 32 of 129
System configuration & customization Data migration Assistance with PCMH certification Quality improvement Interoperability assistance 2.6.3 Facilitating EHR Adoption In a report published by the Office of the National Coordinator for Health Information Technology (ONC) for 2008-2013, it was found that hospital adoption rate of at least a basic EHR system was significantly higher in Arizona than the national average. ONC reported that in 2013, nearly six in ten hospitals have adopted at least a basic EHR system, which represents an increase of 34 percent from 2012 to 2013. In this survey, ONC reported that approximately 72 percent of non-federal acute care hospitals in Arizona adopted a basic EHR, which is also significantly higher than the national average. Since implementing the AHCCCS EHR Incentive Payment program, 3,154 incentive payments have been issued to eligible professionals, 2,573 for AIU and 581 providers have received payments for meaningful use. As of June 30, 2014, over $178 million dollars has been paid out to eligible providers. Arizona estimates that an additional 1,200-1,800 eligible professionals will apply for the incentive payment by 2016. As of June 2014, AHCCCS reported the following regarding the percentage of Medicaid EPs receiving EHR Incentive Payments: Page 33 of 129
Table 2.5: Summary of Medicaid EHR Incentive Payment Summary Activity as of June 30, 2014 Eligible Providers EP Disbursements EH Disbursements All Provider Disbursements EP Recoupments EH Recoupments All Provider Recoupments Net EP Payments Net EH Payments Net Provider Payments Number of Payments Disbursed Number of AIU Payments Disbursed Number of MU Payments Disbursed AIU Disbursement Amount MU Disbursement Amount Total Disbursement Amount Program Year 2011 Program Year 2012 Program Year 2013 3,043 2,506 537 $54,109,594 $4,146,586 $58,256,180 $27,915,425 $24,985,753 $5,355,002 113 67 46 $76,667,851 $42,921,623 $119,589,474 $51,154,925 $46,573,269 $21,861,279 3,156 2,573 583 $130,777,445 $47,068,209 $177,845,654 $79,070,350 $71,559,022 $27,216,281 (2) 0 (2) $0.00 ($17,000) ($17,000) $0.00 ($17,000) $0.00 0 0 0 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 (2) 0 (2) $0.00 ($17,000) ($17,000) $0.00 ($17,000) $0.00 3,041 2,506 535 $54,109,594 $4,129,586 $58,239,180 $27,915,425 $24,968,753 $5,355,002 113 67 46 $76,667,851 $42,921,623 $119,589,474 $51,154,925 $46,573,269 $21,861,279 3,154 2,573 581 $130,777,445 $47,051,209 $177,828,654 $79,070,350 $71,542,022 $27,216,281 Page 34 of 129
AHCCCS Initial Five Year Goals The Agency initially established five goals for HIT/HIE that it hoped to achieve over the first five years of the EHR Incentive program. These goals included targets for certified EHR adoption and Meaningful Use for eligible professionals and hospitals and are described in the table below. In February 2014, AHCCCS released the Arizona Health IT Roadmap 2.0 which involved stakeholders from across the State who were convened to help develop this strategy document. AHCCCS is refining the EHR goals to more closely align with the current environment and future direction of the Incentive Program and the intersection between the Roadmap and goals for the Medicaid EHR Incentive Program are described in Section 6. Table 2.6: AHCCCS Initial Five Year Goals for HIT/HIE AHCCCS Goals Description Health Information Exchange Participate in sustainable HIE which has a focus on promoting healthcare quality, ensuring privacy and security of data for members and providers, and financial viability/sustainability Health Information Technology Hospitals representing 90% of AHCCCS inpatient days will qualify and meet Meaningful Use Health Information Technology 90% of all EPs working in FQHCs would qualify and meet MU of all Adoption for Professionals EPs working in IHS Facilities would qualify and meet MU 90% of all EPs working in 638 Tribal Operated Facilities would qualify and meet Meaningful Use Program Integrity Provide adequate oversight of the EHR Incentive Program, resulting in no federal disallowances EHR Incentive Payment Program Launch the Medicaid EHR Incentive Program by July 2011 2.6.4 Facilitating HIE Adoption CMS-Approved HIE Initiatives The Agency is updating its HIE strategy to ensure it leverages Medicaid investment with investments by other stakeholders and payers to establish a sustainable business model. AHCCCS is supporting the development of HINAz to enhance the quality of clinical data that is available to health care providers at the point of care. In order to achieve greater care coordination across disparate systems, AHCCCS needs to support its largest trading partners access and use of basic health HIE services. Over the course of the next three years, Medicaid wants to act as a catalyst and ensure its data partners join and develop bidirectional exchange capabilities using the state level HIO. AHCCCS has approval from CMS to use HITECH funds for the following initiatives: Onboarding Program: Support the state level HIE by paying for one-time onboarding costs for Medicaid EHs and EPs. The current amount AHCCCS will make available for Onboarding Fees is not to exceed $2.1 million per federal fiscal year. Public Health: Assist ADHS in enhancing their systems for supporting public health objectives and onboarding providers so they have the capability to achieve Stage 2 Meaningful Use. At this time, there is not likely to be any other funding outside of the Medicaid EHR Incentive Program payment to support EHR adoption by Medicaid providers. The budget is also forcing the agency to make difficult decisions resulting in the elimination of many remaining State-only programs. With only Medicaidfunded individuals in these programs, it is an appropriate time to re-evaluate the current structure. It is recognized that each of these populations could benefit from greater care coordination between different health care stakeholders. More information on these programs is provided below. Page 35 of 129
2.6.4.1 HIE Onboarding AHCCCS is covering the HIE onboarding activities for setting up Medicaid providers on the HIE as a way to encourage these providers to participate in electronic exchange of health information for their patients. A new agreement was developed between AHCCCS and HINAz to cover these activities which HINAz refers to as the HIE Subsidy Program. Having Medicaid participate in paying for one-time onboarding costs will allow more hospitals and eligible professionals to join HINAz, as well as ensure there is adequate staffing at HINAz to guide and coordinate technical implementations with a range of stakeholders and capabilities. The Agency is proposing to act as a catalyst to help establish the HIE infrastructure and is relying on the broader participants in the HIE to support the ongoing business operations of the HIE. The one-time onboarding costs noted above are inclusive of the following costs: Onboarding Support: HINAz will support the following activities of Eligible Participants to establish the bidirectional connection with HINAz: o o HINAz Participation Agreement execution Development and execution of a technical statement of work of currently available capabilities o Development and approval of privacy and security policies and processes to support the patient consent process at Eligible Participant o Building, testing and implementation of appropriate technical interfaces Program Eligibility: Eligibility to participate in the subsidy program is based on several factors. Network participants must meet the following criteria in order to participate in the program: o o o o Be a hospital, FQHC, FQHC-look alike or rural health clinic, Participate in the Arizona Medicaid EHR Incentive Program, Utilize federally-certified EHR technology, and Abide by the Subsidy Program requirements, including signing a Network participation agreement, signing the HIE Subsidy Program amendment to the participation agreement, and completing bidirectional connectivity with HINAz and agreeing to continue HIE participation for at least three years after initial connectivity is complete. Payment Allocations: HINAz will be entitled to Onboarding Fees depending on the classification of Eligible Participant as a Large Hospital, Medium Hospital, Small Hospital, or FQHC/FQHC Look-Alike/RHC. The amounts (each an Eligible Participant Payment ) are defined by HINAz and are allocated as follows: o Large Hospital (a hospital or hospital system consisting of more than 180 hospital beds) - $150,000.00 o Medium Hospital (a hospital or hospital system consisting of between 51 and 180 hospital beds) - $100,000.00 o Small Hospital (a hospital or hospital system consisting of 50 or fewer hospital beds ) - $80,000.00 o FQHC/FQHC Look-Alike/RHC (a federally qualified health center, as defined by 42 C.F.R. Section 405.2401(b) and a rural health clinic, as defined in 42 C.F.R. Section 491.2 ) $75,000.00 Page 36 of 129
Payment Mechanics: AHCCCS requires HINAz be able to receive payments electronically. AHCCCS will pay HINAz as set forth below: o o o One-third of Eligible Participant Payment will be made to HINAz when an Eligible Participant signs the HINAz Participation Agreement and the AHCCCS Program Amendment, and HINAz submits an invoice to AHCCCS One-third of Eligible Participant Payment will be made to HINAz when one-way communication between Eligible Participant and HINAz is complete and HINAz submits an invoice to AHCCCS. One-way communication is either Data Inbound from Eligible Participant to HINAz. Data Inbound from Eligible Participant to HINAz means an interface between Eligible Participant and HINAz has been established and Eligible Participant is able to make patient data available to HINAz according to currently available mechanisms and in alignment with HINAz s core data set. An alternative data set may be used upon mutual written agreement of both HINAz and Eligible Participant. One-third of Eligible Participant Payment will be made to HINAz when two-way communication between Eligible Participant and HINAz is complete and HINAz submits an invoice to AHCCCS. Two-way communication includes both Data Inbound from Eligible Participant to HINAz and Data Outbound from HINAz to Eligible Participant. With respect to Data Inbound from Eligible Participant to HINAz and Data Outbound from HINAz to Eligible Participant, the currently available mechanisms and the core data set will be documented by HINAz and provided to AHCCCS for review. The figure below describes the cash flow for the HINAZ onboarding process. It is a visual representation of how payment workflow is anticipated to work between AHCCCS and HINAz/The Network. Page 37 of 129
Figure 2.8: 90/10 HINAz Onboarding Cash Flow Onboarding Initiative Goals and Milestones As part of the request for CMS funds for the onboarding initiative, HINAz and AHCCCS developed the following goals. Progress towards these goals will continue to be updated but the table below describes accomplishments through the end of June 2014 and anticipated total accomplishments through September 2014. Table 2.7: Onboarding Initiative Goals and Accomplishments Goals (through 9/30/14 Accomplishments (through Anticipated Total Accomplishments 6/30/14 (through 9/30/14 Hospitals = 14 Hospitals = 4 achieved Milestone 1, 4 achieved Milestone 2 Hospitals = 10 achieved Milestone 1, 6 achieved Milestone 2 FQHCs/RHCs = 7 FQHCs/RHCs = 2 achieved Milestone 1, 1 achieved Milestone 2 FQHCs/RHCs = 3 achieved Milestone 1, 2 achieved Milestone 2 Notes: Milestone 1 = sign-up for the program Milestone 2 = unidirectional exchange complete Milestone 3 = bidirectional exchange complete Page 38 of 129
The delays in meeting the original Year 1 goals are due to a combination of two things: (1) the delays in getting the contract/program initiated and (2) the process of upgrading to a new technology platform. AHCCCS anticipates an increase in the number of HIE connections, as the Agency supports a number of activities to influence the continued adoption of HIT and use of HIE over the next five to ten years. AHCCCS will need to increase its focus on monitoring and reporting on clinical outcomes rather than processes or episodes of care. AHCCCS anticipates needing to be able to capture and share data related to performance and quality outcomes with a variety of stakeholders, including members/patients, other health care professionals, policy makers and the public at large. This underscores the importance of providers using certified EHRs and participating in secure health information exchange. 2.6.4.2 Public Health Initiatives This section contains background, description of current state, proposed stage 2 MU requirements, workflow diagrams, goals, and funding formulas to address the public health objectives for immunizations, electronic lab reporting, and syndrome surveillance. All of the strategies below are interim strategies to support providers to reach Meaningful Use Stage 2 but currently ADHS is limited in its ability to send and receive electronic information. The long term strategy that AHCCCS envisions with ADHS is that EPs and EHs will use the state-level HIE and its public health portal to support provider electronic reporting to the public health registries. Consistent with the CMS Seven Conditions and Standards, these strategies are all being leveraged and coordinated with existing AHCCCS and ADHS activities to assure that no activities are duplicated and that all efforts are implemented efficiently. AHCCCS received approval for the fair share formulas described below and ADHS is using State General Funds for its portion of the fair share allocation. ADHS is providing the 10% state match for this project. For State FY 2014, ADHS received an Operating Budget Appropriation of $136,688,200. Of this amount $82,780,500 is appropriated from the State s General Fund. The Operating Budget provides funding for a wide variety of administrative functions and program activities, including the Arizona State Hospital, the Division of Licensing Services, Division of Planning and Operations and Divisions of Public Health. ADHS is proposing that up to $350,000 of General Fund from this appropriation be transferred to AHCCCS to be used to meet the 10% State Match for the HIE IAPD for Public Health for the current fiscal year, with similar amount as needed in the future to complete the project. The primary revenue sources for the General Fund are income, sales and use taxes. All revenue to the GF are general government revenues. The description of what makes up the state General Fund is available at: http://www.ospb.state.az.us/documents/2013/appendix%20book%20fy14- FY15.pdf. As approved by CMS, there is an established process that ADHS follows to provide state match. At the beginning of each quarter, ADHS transfers to AHCCCS via a Companion Transfer (Form GAO-614) the estimated amount of state match needed for the quarter. After the end of each month ADHS prepares an expense report and submits this report to AHCCCS. AHCCCS then reimburses ADHS. ADHS deposits all funds received in Fund 2500 - Interagency Service Agreement Fund. ADHS created a unique Grant Number, Grant Phase and Index, and electronically tracks all revenue and expenditures through the Arizona Financial Information System (AFIS). All transactions, signature authority and accounting meet the standards prescribed in the State of Arizona Accounting Manual. Immunization Registry The Arizona Department of Health Services operates the Arizona State Immunization Information System (ASIIS) or Immunization Registry for the State of Arizona. Under state statute (ARS 36-135 and 32-1974), health care providers are required to report all immunizations administered to individuals 18 years and younger and pharmacists are required to report all immunizations administered into ASIIS. Pediatric practices most commonly utilize ASIIS, but other practice types report into the system as well including family practice and general physician practices, obstetrician offices, pharmacies, public health Page 39 of 129
departments, community health clinics, IHS facilities, hospitals, military facilities, fire departments, and urgent care centers. In 2013, over 1,000 unique provider sites reported into ASIIS. Over 8 million doses of vaccine were reported into ASIIS in 2013. Current Environment for Immunizations Historically, immunizations records have been reported to ASIIS through paper reporting (mail or fax), or through manual data entry by the healthcare provider through an electronic interface. Recent efforts have been underway to enhance the interoperability of ASIIS with electronic medical records in order to achieve automated reporting. Interest in this capability has increased with the introduction of the Meaningful Use program. For Stage 1 MU the Department has created a MU Immunization information page located at: http://www.azdhs.gov/meaningful-use/asiis/index.htm. Under Stage 1 MU, ADHS worked with a small number of healthcare providers to achieve electronic submission of immunizations data using HL7 v2.5.1. Nearly 1,400 providers submitted messages through the attestation site under MU Stage 1 requirements. This number has been used as an estimator of the total number of providers likely to approach the ASIIS program to engage in ongoing message submission under MU Stage 2. At this time there are almost 340 providers currently engaged in ongoing submission of data to ADHS via HL7 messaging, and an additional 157 providers engaged in testing HL7 v2.5.1 messaging with the ASIIS programming preparation for moving into production. This is about 35 percent of the anticipated number of providers who will eventually attest for Stage 2. Since March of 2013, the number of messages entering the test system has increased from 768 test messages to 15,525 messages in August. Under the ONC HIE Cooperative Agreement program, the ADHS was able to create a Direct gateway that was hosted at the ADHS data center in the TEST environment. The goal of the project was to be able to move the project to the production environment, which would allow providers the ability to send immunizations data electronically via Direct. ADHS was not able to achieve a production environment due to challenges with new software releases from their Immunization registry vendor and ADHS staffing shortages, however future plans for immunization data exchange include Direct implementation. Stage 2 Meaningful Use and Electronic Immunization Submission AHCCCS received approval in 2013 2014 to use federal HITECH funds to augment existing ADHS immunization staff in order to support rapid testing and onboarding of multiple providers and hospitals simultaneously. Without these additional funds, program staffing was insufficient to support rapid onboarding of multiple providers from either the technical or programmatic perspective. Goals for Immunization Registry ADHS is continuing its work in connecting ASIIS paper-submitting providers to a standardized HL7 interface. These providers currently submit data to ASIIS via paper. Over the next two years, ADHS will continue connecting Medicaid providers via standardized HL7 interfaces to allow them to achieve Stage 2 MU reporting requirements. Over the long term, ADHS proposes to collaborate with the Network, the Health Information Network of Arizona, to allow EHs and/or EPs to report directly from the exchange, but the Network s current vendor does not support a public health portal. The Network has plans to adopt a new technology vendor that can offer this type of functionality within an 18 24 month timeline. The goals for onboarding providers are as follows: December 31, 2014: Onboard 300 unique providers December 31, 2015: Onboard 500 unique providers December 31, 2016: Onboard 500 unique providers Page 40 of 129
The following figure provides an overview of the implementation process for electronic immunization submissions. Figure 2.9: Arizona Immunization Registry Interface Implementation Process Page 41 of 129
Approved Fair Share Formula Immunization Registry AHCCCS has an existing Interagency Agreement in place with ADHS to pass through Federal Financial Participation (FFP) for services rendered in conjunction with ADHS updating and maintaining the Immunization Registry for Title XIX Medicaid enrolled children. As ADHS updates and maintains the data in this database, ADHS qualifies for match funding for the percentage of overall children entered into their database that are qualified Title XIX members. The formula calculates the percentage of Title XIX lives under age 19 compared to total State of Arizona Census lives age 19 and under. AHCCCS is following the same methodology that was developed for the maintenance of the registry to fund the onboarding of providers for electronic submission of immunization data. Due to the Medicaid expansion we expect more children to be covered under Medicaid during the next two years which may increase this percentage; IAPD is based on 37.5 percent but actual expenditures will use the current rate. Table 2.8 Calculation of AHCCCS age 19 and under population Compared to State of Arizona age 19 and under population Title XIX 7/1/2013 7/1/2012 AHCCCS Data Age 19 and under, all programs 709,254 687,369 Deduct KidsCare (45,050) (15,331) Deduct HIFA Parents 664,204 672,038 Arizona Census Data TBD 1,799,412 Percentage of AHCCCS Population 37.35% ADHS CDC Grants and State Funds Share For Immunizations, ADHS had multiple CDC grants that provided funding for enhancing the interoperability of the state's immunization registry. These grants along with additional ADHS administrative funds support the personnel, contracts with the ASIIS vendor, and other information technology positions who prepare the ASIIS environment for receipt of electronic messages and provide technical assistance with onboarding, ASET ONC HIE Cooperative Agreement Share In addition to these source of funds, ASET has provided some of the ONC HIE Cooperative agreement program funds to ADHS in order to build and establish Direct messaging capability for the immunizations registry in a production environment, and onboard the providers. Funding supports capital equipment and consultant staff to accomplish this objective. Immunizations HITECH Registry Eligible Percentage Total Project CDC Grants $1,159,636 49.30 $1,270,833 ASET Grant $185,000 7.86 $185,000 ADHS $125,599 5.34 $125,599 Medicaid IAPD $882,142 37.50 $882,142 Total $2,352,377 100.00% $2,463,574 Page 42 of 129
Electronic Lab Reporting State statute also requires healthcare providers to report diseases and public health conditions. Electronic Lab Reporting (ELR) is an automated process that transfers data from commercial, public health, hospital, and other labs to state and local public health departments; this is done through an EHR system or a Laboratory Information System (LIS). Current Public Health Environment for Electronic Lab Reporting All laboratories in Arizona (hospital, commercial reference labs and public health lab) report results to the Bureau of Epidemiology and Disease Control at ADHS. At this time 96 percent of hospitals are submitting reportable laboratory results through paper to ADHS, via fax or mail. The other four percent are sending lab reports to the Electronic Disease Surveillance Program through Electronic Laboratory Reporting Currently there is no robust statewide HIE that could promote and assist providers in submitting hospital labs electronically. Discussions have started between the state level HIE, HINAz, and ADHS to consider streamlining public health reporting through HINAz but the HIE is not very robust at this time and is not likely to be able to add any more functionality to its implementation plans for at least 12 24 months. In absence of this, ADHS needs to onboard each hospital lab independently to the ELR system. ADHS has previously implemented an ELR system that receives standardized HL7 messages containing reportable results from reference laboratories and hospitals. These reportable lab results are parsed to the appropriate state disease surveillance program database based on Logical Observation Identifiers Names and Codes (LOINC) and Systematized Nomenclature of Medicine (SNOMED) codes. Under Stage 1 MU, ADHS developed a process to support individual hospitals and hospital vendors to initiate electronic lab reporting. ADHS worked to onboard the first hospital labs to support the ELR measure for MU while also onboarding the largest commercial lab in Arizona. The amount of effort to onboard new labs is very time consuming. With ELR becoming a required objective for hospitals in Stage 2, ADHS needs to increase their capacity to onboard hospitals. Stage 2 Meaningful Use and Electronic Lab Reporting In preparation for Stage 2, ADHS held a day-long ELR technical workshop on May 17 th 2013 to initiate communication with hospital stakeholders and their vendors about the current Stage 1 process and the Stage 2 requirements. Feedback was positive, but due to the complexity of the interfaces and heavier needs for technical assistance that were requested from the hospitals and their vendors, ADHS is in the process of redesigning their process for engaging the stakeholders and has identified the need for a robust onboarding system that validates the lab data against the standard structure and vocabulary and verifies the connectivity between the hospital and the ELR system. ADHS anticipates onboarding at least twelve hospitals during the first year of Stage 2 MU. ADHS has developed a structured process as shown below, according to the CDC guidelines for onboarding providers to the ELR system. In conjunction with the new process, ADHS needs to expand its infrastructure for onboarding providers that will allow for timely validation and verification processes, and for parallel data submission comparisons between the manual and electronic processes. Each hospital will need to pass several tests before gaining access to the production ELR system and completing their transition to electronic reporting. Goals for Electronic Lab Reporting Starting in October, 2013, ADHS increased its ability to work with unique hospital laboratories and put them through the test environment and be able to successfully validate and move into production with the appropriate messaging and vocabulary standards. The ADHS goals for Electronic Lab Reporting are: September 30, 2014: Onboard 12 unique laboratories for ELR September 30, 2015: Onboard additional 12 unique laboratories for ELR Page 43 of 129
September 30, 2016: Onboard additional 12 unique laboratories for ELR Description of ELR Implementation Process The public health environment for ELR currently sees only 4 percent of hospitals in Arizona sending lab reports through ELR, while the other 96 percent reports lab results with paper (fax or mail) to ADHS. Given this discrepancy between electronic and paper reporting, it comes as no surprise that there is currently no comprehensive statewide HIE that could facilitate more electronic submissions of hospital labs. ADHS will need to individually onboard each hospital lab to the ELR system. The flow chart in the next section describes the process that ADHS will be using for each hospital lab to ensure they are successfully on boarded to ADHS. Figure 2.10: Arizona Electronic Laboratory Reporting Implementation Process Page 44 of 129
Approved Fair Share Formula for ELR AHCCCS has worked with ADHS to create a proposed fair share formula for the creation of the electronic submission of required electronic lab results for Stage 2 MU. The preferred formula is defined as: NUMERATOR: Number of Medicaid Hospitals Number of Hospitals that are registered in the CMS R&A as Medicaid 69 Dually Eligible Hospitals 2 Children s Hospitals 71 Total number of Medicaid eligible hospitals DENOMINATOR: Total Projected Users of ELR Number of entities that are required to submit results electronically 70 Short Term Hospitals in the state 14 Critical Access Hospitals in the state 2 Children s Hospitals in the State 5 Commercial Labs 91 Total number of projected ELR users Medicaid Fair Share: 71 Medicaid Hospitals divided by 91 Total Users = 78% Description of Funds ADHS has to Support ELR Multiple CDC grants provide funding to support electronic laboratory reporting (ELR) work at ADHS. These support personnel, information technology contractors with responsibility to prepare and enhance the ADHS environment to accept ELR from laboratories, equipment to enhance the existing infrastructure for receipt and storage of ELR messages, and the onboarding of labs to the ELR. Electronic Lab Reporting HITECH Eligible Percentage Total Project CDC Grants $802,285 22.00 $939,882 ASET Grant 0.00 ADHS 0.00 Medicaid IAPD $2,844,462 78.00 $2,844,462 Total $3,646,747 100.00 $3,784,344 Page 45 of 129
Syndromic Surveillance Syndromic surveillance systematically uses health and health-related data in near "real-time" to make information on the health of a community available to public health departments for use in detecting or responding to public health outbreaks or events in a rapid manner. Syndromic Surveillance systems are populated with clinical data provided to PHAs for all patient encounters (not a subset). Current Public Health Environment for Syndromic Surveillance ADHS has traditionally used BioSense, a syndromic surveillance system which was developed by CDC and is governed by the Association for State and Territorial Health Officials (ASTHO) in its newest 2.0 iteration. Although not currently accepting electronic submissions of syndromic surveillance messages for Meaningful Use, ADHS is in the first stages of implementation with eligible hospitals. A Data Use Agreement (DUA) with ADHS is required for all hospitals sending data to BioSense. Additionally, a DUA with ADHS is required for all Arizona local PHAs interested in using BioSense. The DUAs for both these groups are being distributed for signature. ADHS also convened an Arizona BioSense Workgroup to engage stakeholders in the planning and implementation of BioSense for Meaningful Use for the State of Arizona. This group includes representation from state and local PHAs, hospitals, vendors, and the Arizona Strategic Enterprise Technology office. There are no plans to accept syndromic surveillance submissions from eligible professionals; however ADHS has created a webpage to educate providers about the status of this measure: http://www.azdhs.gov/meaningful-use/syndromic-surveillance. Stage 2 Meaningful Use and Syndromic Surveillance ADHS will augment existing syndromic surveillance staff in order to support rapid onboarding of multiple hospitals simultaneously. Current staffing for the program includes one informatician, a program project specialist, an epidemiologist and a small percentage of program management and administrative support. Given the anticipated number of hospitals that will approach ADHS to initiate syndromic surveillance under MU Stage 2, additional staff and infrastructure are needed. This includes continuation of the informatician and program project specialist to support the programmatic aspects of hospital onboarding and assist local health departments with the onboarding process, and an addition of an HL7 analyst to perform initial validation of HL7 messages and assist in ongoing quality review of submissions at the outset of onboarding. One of the challenges for IHS EPs has been being able to submit EP-level information for the syndromic surveillance Meaningful Use attestation. ADHS through BioSense, does not support, nor plans to support, individual EP syndromic surveillance. This presents a challenge to IHS EPs since they would like to use syndromic surveillance for IHS EPs. To date, planning and preparatory work have been initiated to streamline future plans for onboarding. ADHS anticipates onboarding 60 hospitals through 2016. Goals for Syndromic Surveillance September 30, 2014: Onboard 18 unique hospitals to include 3 critical access or rural hospitals September 30, 2015: Onboard additional 24 unique hospitals to include 2 critical access or rural hospitals September 30, 2016: Onboard additional 24 unique hospitals to include 1 critical access or rural hospitals The onboarding process for syndromic surveillance is described below. Page 46 of 129
Figure 2.11: Arizona Syndromic Surveillance Onboarding Process Approved Fair Share Formula for Syndromic Surveillance The approved fair share formula for syndromic surveillance is focused on only hospitals being able to choose this as a menu measure for Stage 1 or as a required measure for Stage 2. This is similar to the formula that was agreed upon for the Electronic Lab Reporting. NUMERATOR: Number of Medicaid Hospitals Number of Hospitals that are registered in the CMS R&A as Medicaid 69 Dually Eligible Hospitals 2 Children s Hospitals 71 Total number of Medicaid eligible hospitals DENOMINATOR: Total Projected Users of Syndromic Surveillance Number of entities that are required to submit results electronically 70 Short Term Hospitals in the state 14 Critical Access Hospitals in the state Page 47 of 129
2 Children s Hospitals in the State 86 Total number of projected users Medicaid Fair Share: 71 Medicaid Hospitals divided by 86 Total Users = 82 percent Description of Funds ADHS has to support Syndromic Surveillance Multiple CDC grants provide funding to support onboarding of hospitals to BioSense 2.0 for syndromic surveillance purposes. These grants support personnel costs to assist with development of a syndromic surveillance onboarding and data analysis program, contractual funds to award to local health departments to facilitate hospital recruitment to BioSense 2.0, and onboarding of hospitals to the syndromic surveillance system. In addition, ASET provides funding to ADHS in order to enhance the department's ability to onboard hospitals, test for Meaningful Use requirements, and meaningfully use syndromic surveillance data reported into the BioSense system. Syndromic Surveillance HITECH Eligible Percentage Total Project CDC Grants $96,673 4.29 $110,109 ASET Grant $308,855 13.71 $330,000 ADHS 0.00 Medicaid IAPD $1,847,409 82.00 $1,847,409 Total $2,252,937 100.00% $2,287,518 2.7 Interoperability of Immunization Registry & Public Health Surveillance (SMHP Template Question #14) As described in the previous section, AHCCCS is working with ADHS and CMS to fund public health initiatives. These initiatives are necessary because Meaningful Use Stage 2 requires ongoing electronic data submissions and some public health measures are now Core objectives for EPs and EHs. Public Health Agencies like ADHS must be prepared to onboard numerous providers within a short time. EPs and EHs must be prepared for new clinical workflows to support ongoing submission of data. This will demand development of infrastructure and functionality for each of the public health Meaningful Use measures at ADHS. ADHS is a separate state Agency from the State Medicaid Agency. The Director of the Agency reports to the Governor and for the EHR Incentive Program, Medicaid is totally dependent on making ADHS successful in establishing the functionality needed for EPs and EHs to meet Stage 2 MU. The Arizona Department of Health Services link is: http://azdhs.gov/index.htm. ADHS has already established web pages to support providers in meeting Stage 1 of Meaningful Use, located at: http://www.azdhs.gov/meaningful-use. 2.8 Stakeholder Engagement in HIT Activities (SMHP Template Question #5) Arizona has supported stakeholder engagement in the HIT and HIE development process from the inception of these activities on through its work in producing a state Roadmap in 2006, in forming a nonprofit public private partnership organization to support HIE/HIT efforts, and as part of the Medicaid Page 48 of 129
Transformation Grant Program through CMS. Arizona recently updated its HIT/HIE Roadmap and AzHeC and AHCCCS released Arizona s Health IT Roadmap 2.0 in February 2014 as a follow-up to the first state Roadmap which included significant partnership from stakeholders. In addition, Arizona continues to strategically partner with other agencies and organizations focused on promoting and expanding the use of HIT/HIE in Arizona. Arizona s Health IT Roadmap 2.0 also includes two specific goals related to stakeholder engagement: Stakeholder Engagement and Collaboration: continues current, and develops and implements new, programs that promote statewide multi-stakeholder engagement and collaboration. Stakeholder Information and Education: continues current, and develops and implements new, HIT/HIE educational and outreach programs for various health care stakeholder segments. There are many organizations in the State who contribute to the current landscape and each has its own set of partners and stakeholders that provide input on HIT and HIE activities in Arizona. The three most significant partners are highlighted below. Table 2.9: Top Organizations Engaged in Statewide HIT/HIE Activities Organizational Mission Arizona Health-e Connection (AzHeC) Health Information Network of Arizona (HINAz, or the Network ) Arizona Strategic Enterprise Technology (ASET) Office Established in January 2007, AzHeC is a not-for-profit organization whose mission is to lead Arizona's establishment of health information exchange (HIE), and adoption of HIT. AzHeC was selected as the single state Regional Extension Center (REC) for the CMS EHR Incentive Program. Arizona Health-e Connection led the development of an updated HIT/HIE Roadmap for Arizona. The process will include health care providers, payers (including AHCCCS), consumers, and health plans. The project started in May 2013 and the Roadmap 2.0 was delivered in February 2014. The Health Information Network of Arizona (HINAz) is a nonprofit organization providing a secure electronic health information exchange (the Network ). The HINAz mission is to support the appropriate and secure exchange of electronic health information and the adoption of health information technology, to enable and improve quality of care, contain cost, and support the Meaningful Use of certified health records. Organized by Governor Janice Brewer oversaw all ARRArelated projects. ASET (formerly GOER) was the ultimate decision making organization responsible for planning, coordinating, and reporting for the ONC HIE Cooperative Exchange Agreement Program in Arizona. The state HIT Coordinator reported to the ASET Director and managed the state cooperative agreement grant. 2.9 MMIS in the Current Environment (SMHP Template Question #8) The AHCCCS Prepaid Medicaid Management Information System (PMMIS) is a state-operated MMIS. PMMIS is a fully integrated system developed in the late 1980s and implemented in 1991. Its modular framework uses CA IDEAL and DATACOM which runs on a mainframe. The core subsystems include Recipient, Provider, Claims/Encounters, Reference, Case Management, Utilization Review/Quality Assurance, Health Plan, Information Management, and Finance. Other modules have been added to PMMIS since its implementation including Premium Billing, ACE (eligibility), Data Warehouse, Electronic Page 49 of 129
Transaction Interface, web portals for providers and members, Health-e AZ Plus for applicants and members, Program Integrity service, and a new system for the Medicaid EHR Incentive Program named e-pip, making PMMIS an integrated multi-platform system. PMMIS adheres to HIPAA 5010 and ICD-9 standards for its electronic transactions and the ICD-10 standards are being added. Providers register with AHCCCS via a website designed especially for the Medicaid EHR Incentive Program. It is called the electronic Provider Incentive Payment (epip) system. Registration and Attestation for the EHR Incentive Program can be requested and is managed through this site; which is also the portal used for payment processing. Providers are able to login at any time to see the current status of their requests. See Section 4 for graphics and full explanation. Applicants may submit their applications on-line using the Health-e AZ Plus (HEAplus) or the Federal Facilitated Marketplace. Health-e AZ Plus handles the determination of simple cases and passes more complex cases onto either ACE or AzHeC. By 2016, both ACE and AzHeC will be incorporated into HEAplus. The Federal Facilitated Marketplace passes potential Medicaid cases onto HEAplus. In turn, HEAplus sends those not eligible for Medicaid onto the Federal Facilitated Marketplace. Demographic data for all those determined eligible for Medicaid, CHIP, or long-term care, is sent electronically to and maintained in the Recipient Subsystem of PMMIS. This data is updated on a daily basis with additions and changes from the source agencies, and also includes newborn data from the counties and death certificate information from the Department of Health Services. AHCCCS hosts a secure web portal for verifying eligibility of its members which is used by providers and contracted health plans. Members access and update their information on HEAplus. The PMMIS Provider Subsystem contains all of the Medicaid eligible providers whether they provide health care services for managed care members or Fee-for-Service members, or both. The system regularly updates the provider data with the current licensure data of the Arizona Medical Boards, noting any changes in the provider s status. PMMIS accepts and sends HIPAA transactions using secure File Transfer Protocol (FTP). An Electronic Data Interface validates transaction data and converts HIPAA and proprietary data into the appropriate format. AHCCCS is a managed care program. Providers submit claims to the member s health plan, and the health plans submit these transactions to AHCCCS as encounters using the standard HIPAA claims transaction format. For members in the Fee-for-Service program such as the American Indians and the Federal Emergency Services program, providers submit claims directly to AHCCCS. Most providers submit electronic HIPAA transactions, but AHCCCS also accepts direct claims entry through a web portal, as well as facsimile or paper claims. Both claims and encounters are processed in PMMIS Claims/Encounter Subsystem, and then loaded into the Data Warehouse for reporting. Payments are generally made directly to the provider s bank account, for others, checks are mailed to the provider. Remits are sent electronically. Providers can access a web portal to check claim or payment status. The epip system interfaces with PMMIS to validate provider status, verify patient volumes, make incentive payments, and save pertinent information about provider participation in the incentive program. A provider s Medicaid status will be verified using the PMMIS Provider Subsystem which maintains the current status of all Medicaid providers in Arizona. Patient volume reported by providers will be compared to the number of unduplicated claims and encounters for that provider in the PMMIS Data Warehouse. Once the epip determines the incentive payment amount, it will submit a payment transaction to the PMMIS Payment Subsystem for processing; once payment is issued (via EFT), the Payment Subsystem will send the provider s EFT transaction number to epip. The provider s registration, attestation, and payment information will be stored in the Data Warehouse for future reference. The diagrams below show how epip fits in to the overall Medicaid IT Environment along with the specific interfaces. Page 50 of 129
Figure 2.12: Integrated Medicaid IT Environment (Current 2014) Page 51 of 129
AHCCCS supports the development of a statewide HIE, and is participating with ASET, AzHeC, and other stakeholders in defining the governance structure and security and privacy policies. Preliminary discussions have included using PMMIS as the source of Medicaid eligibility and enrollment information for building an HIE Master Patient Index. The HIE currently has the following data available for its participants: Admission/Discharge/Transfer(ADT) notifications, including o o o Inpatient Admissions ED Registrations Inpatient Discharges Laboratory Results Radiology Reports Medication History Transcriber Reports, including o o o Discharge Summaries Post-Op Summaries H&P Summaries The Integrated Medicaid IT Environment shows the primary components of the PMMIS and the access available to applicants/members, and providers. Accordingly, the following provides additional information on applicants/members: 1. HEAplus: New applications, updates, supporting materials, demographic changes, renewals 2. Federal Facilitated Marketplace: New applications, updates, supporting materials 3. Social Security Administration: New applications, updates Additional information on providers are the following: A. CMS Registration and Attestation: Register for EHR Incentive Program with CMS B. Public Health Registry: Records immunization, laboratory, and syndromic surveillance data C. HIE: Reports outcome information D. epip: Collects attestation information for EHR Incentive Program E. AHCCCS On-Line: Designed for registered providers and offers convenience and efficiency of several online services, including Fee-for-Service (FFS) Claims Status, Fee-For-Service (FFS) Claims Submissions, Member Eligibility and Enrollment Verifications, Provider Authorization Inquiries, Provider Information, and Provider Verifications F. EDI: Submit and record HIPAA transactions Page 52 of 129
MITA Strategy MITA provides guidance for improving overall effectiveness of government health care business processes with an emphasis on Medicaid. Arizona s MITA State Self-Assessment was completed in 2008 with the overall goal of transitioning the focus of the Medicaid program from a claims payer to a prudent purchaser of quality healthcare. The resulting Transition Strategy developed a broad based enterprise foundation with automated business processes, health information exchange, electronic data exchange, enterprise management, and real time data access. Following the Plan, the Agency implemented many of the recommended solutions and continues to make progress on others. This MITA roadmap shared a common vision with the SMHP in that both encourage the use of EHRs and promote data exchange among providers and with payers to improve quality of care and care outcomes. AHCCCS sits on the AzHeC Board and the HIT Coordinator attends all HINAz meetings but is not a voting member. AHCCCS also requires its MCOs to participate in the HIE. The HIE is actively onboarding new participants, while at the same time is in the process of upgrading to a new platform. PMMIS, supports the Medicaid EHR Incentive Program through its interfaces with epip to the Provider directory, Payments/Finance, and the Data Warehouse subsystems. Eventually, as the HIE matures, the PMMIS will interface with the statewide HIE to further automate the administration and oversight of the Medicaid program. The Agency is making plans to conduct a MITA Self-assessment during Calendar Year 2015 which is envisioned to include a portion devoted to the HITECH pieces of the overall project. MMIS IAPDs Arizona obtained approval for the following IAPD as it built its MMIS system. Some of these are closed but this list provides historical background for the MMIS IAPDs that form the current system. HIPAA Second Generation PAPD - closed HIPAA 5010 IAPD closed ICD-10 IAPD NCCI APD - closed Data Warehouse PAPD - closed Data Warehouse IAPD (DW DSS) OIG Data Analytics PAPD (program integrity) MACBIS APD (T-MSIS) 2.10 Summary Medicaid Transformation Grant Activities (SMHP Template Question #15) AHCCCS was awarded a Medicaid Transformation Grant, on January 25, 2007 to develop AMIE. CMS grant funds were used to support the planning, design, development, testing, implementation, and evaluation of an exchange. The inaugural users had Medication history (PBM claims aggregator), discharge summaries (3 hospital systems) and Laboratory Testing results (SonoraQuest). Over time additional providers were trained and additional data was made available, through the federated exchange that had statewide reach. By the time the grant suspended its operations in January of 2009, there were 100+ users in diverse clinical settings with ten hospitals, 6 PBMs and 1 laboratory. AMIE had over 7.6 million records available with over 3.1 million patients in the AMIE Master Patient Index. The grant also enabled the creation of an early version of the REC concept, called the Purchasing and Assistance Collaborative for EHRs (PACeHR). It was created to foster EHR adoption and information sharing by leveraging web-based technologies, economies of scale, aligned metrics and strategic partnering. Page 53 of 129
The PACeHR program closed in January of 2009, but the organizations staff consolidated with the Regional Extension Center and supported the RECs efforts to provide EHR screening and assessment processes, provider on-boarding support, and shared contracting expertise for small to medium sized practice groups. Arizona also received significant funds under the ONC HIE Cooperative Agreement Program and many activities were supported with AzHeC to promote EHR Adoption and to facilitate HIE. 2.11 Arizona Health IT Roadmap 2.0 In addition to the AHCCCS priorities and goals for HIT and HIE, AHCCCS also worked with other HIT stakeholders to help develop the Arizona HIT Roadmap 2.0 which sets the statewide goals through 2019. Overall Roadmap 2.0 identifies three essential strategies that will guide the continued adoption and advancement of HIT/HIE in Arizona. To be successful, the statewide community wanted to: Continue to support physicians and other providers in their adoption and use of technology Accelerate and expand the secure sharing of health information among health care providers and Continue to coordinate and convene health care stakeholders to develop strategies that meet evolving HIT/HIE business needs Arizona s Health IT Roadmap 2.0 describes 19 key initiatives to advance HIT/ HIE recommending action in areas ranging from stakeholder engagement and policy development to technology infrastructure implementation, and exploration of innovative technology models that support care delivery transformation. Roadmap 2.0 is found on the AzHeC website and downloaded from: http://www.azhec.org/?page=healthit_roadmap There were 19 key initiatives that were described in the roadmap and are displayed here: Stakeholder Engagement & Participation 01 - Stakeholder Engagement and Collaboration Continues current, and develops and implements new, programs that promote statewide multistakeholder engagement and collaboration. 02 - Stakeholder Information and Education Continues current, and develops and implements new, HIT/HIE educational and outreach programs for the various health care stakeholder segments. Governance, Policy, & Planning 03 - Statewide Governance of Health Information Exchange Refines and clearly describes the roles, responsibilities, and accountabilities of the AzHeC and HINAz boards and the State of Arizona related to statewide HIT/HIE within the public/private partnership governance model. 04 - Interoperability and Content Standards Agreement and Adherence Ensures that Arizona uses HIT/HIE interoperability and content standards for the exchange of health care information. 05 - Statewide Unique Patient Identifier Page 54 of 129
Explores the feasibility for alternative approaches for identifying a patient. 06 - Incentives to Support Continued Expansion of HIT/HIE Builds upon current programs for incenting providers to adopt HIT and participate in HIE. Explores and identifies innovative ways to incent providers to continue to adopt and/or mature their use of HIT/HIE. 07 - Collaboration and Support for Broadband Access Coordinates information on broadband access assistance available to health care providers 08 - Influence HIT and HIE Vendors Develops an approach to help Arizona providers bring their needs to the attention of HIT and HIE vendors and promotes the development of appropriate solutions to address the needs. 09 - Statewide Vision and Framework for HIE Develops the process and provides the content for Arizona s ongoing vision for health information exchange. State Level HIT/HIE Business Infrastructure 10 - HIT/HIE Program Information and Collaboration Office Establishes an office and formalizes a program to gather and disseminate information on HIT/HIE related tools and activities. 11 - Statewide HIE Rollout, Onboarding, and Use Develops and implements a plan to expand the statewide HIE Rollout, Onboarding, and Use of its services 12 - HIT/HIE Assistance to Providers Privacy & Security Continues, and develops and implements new, programs to assist health care providers adopt and expand the use of HIT/HIE. 13 - Patient Consent Approach Technology Creates a common approach that can be used statewide for complying with patient consent requirements. Ensures alignment with state and federal regulations relating to consent for securely sharing physical and behavioral health information. 14 - Statewide HIE Services and Technical Architecture Description Creates and maintains a resource that describes the services provided by the statewide HIE (functional description), and the statewide HIE technical architecture (technical description) 15 - HIE Consent Management Engine Develops a technical infrastructure to support the common statewide patient consent approach and processes identified in the initiative Patient Consent Approach. Initiative 13 Page 55 of 129
16 - Statewide MPI/RLS Expansion Explores opportunities to leverage the statewide HIE master patient index (MPI) / record locator service (RLS) technical framework. 17 - Tools to Support Public Health Reporting Develops a strategic approach that uses HIT/HIE tools and resources, including the statewide HIE, to streamline the sending and receiving of data between ADHS and providers. 18 - Tools and Support for Health Care Transformation: Care Coordination, Analytics, and Emerging Technologies Develops a resource to gather and provide information on tools that support health care transformation, including the alignment with new payment models. As needed, develops community-wide strategies for tool implementation. 19 Integrated Physical and Behavioral Health Information Exchange Creates and implements a strategy for the integrated sharing of information between behavioral health and physical health care providers. Page 56 of 129
3 Future HIT Landscape, To Be Environment 3.1 General Section Overview Section 3 ties to the To Be section of the CMS SMHP template and describes the specific HIT/HIE goals and objectives AHCCCS expects to achieve over the next five years and the strategies it is using to ensure EHR adoption of certified technology. The plan describes the HIT related grant awards and shows how the state is leveraging the findings and governance structure created under the Medicaid Transformation Grant. Each sub-section includes references to the CMS template to demonstrate compliance with the template requirements. The Arizona landscape for HIT and HIE is changing rapidly and AHCCCS is making great efforts to keep the provider community and key health care stakeholders as informed as possible of the Agency s goals and strategies that assist providers in reaching Meaningful Use. 3.2 3.2.1 Future of HIT and HIE, EHR Adoption (SMHP Template Questions #4, 5, 7) Challenges to Overcome and Lessons Learned According to summaries gathered from providers that were awarded grant funds under the ONC State HIE Cooperative Agreement Program (SHIECAP) several barriers and common problems were encountered as they worked to adopt CEHRT and implemented transport and exchange options. Several of these lessons learned are listed below: Sometimes there may not be an immediate Return on Investment (ROI) for the participant for EHR adoption and HIE participation. Currently there is a lack of readily available, affordable technology support for some providers throughout the technology adoption and implementation cycle. The time involved in planning and implementing the HIT/HIE technology and strategy took longer and was more complex than many providers originally had expected. Implementation of both HIT and HIE took a very focused and ongoing commitment from providers and staff with many providers needing to supplement staff doing the work with subject matter experts. The EHR vendor community has been challenged to deliver the required software changes to make all of the MU Program changes in a timely fashion. With the transition from ONC grant funded projects like the State HIE Cooperative Agreement and the Regional Extension Center, providers and payors must continue to identify sustainable options for technological support. Because each provider workflow is unique, it can be challenging to make large scale replicable implementations work each implementation was unique making the rate of adoption slower than in other types of implementation projects. The Agency believes that in order to move towards care improvement and cost reduction, clinical information needs to flow freely across networks and between providers. For this reason, ensuring certified EHRs systems can be interoperable with the state level HIE, is an important priority. Page 57 of 129
As the Agency comes to better understand the type of data it will need to provide the Secretary for quality measures and we operationalize how to receive the Meaningful Use quality information, the Agency will need to spend more time identifying its functionality requirements and data reporting standards. Increased collaboration between AHCCCS and ADHS as well as ADHS internal buildup to support Stage 2 requirements will be necessary to ensure continued success of the EHR Incentive Program. Meaningful Use Stage 2 continues the requirement for use of CEHRT that meet 2014 certification standards. Because Meaningful Use Stage 2 requires ongoing submission and some measures are now Core for EPs and EHs, Public Health Agencies (PHA) s need to be prepared to onboard many more providers. EPs and EHs need to be prepared for new clinical workflows to support ongoing submission. This is going to demand development of infrastructure and functionality for each of the measures at ADHS. Currently there is no robust statewide HIE that could promote and assist providers in submitting patient data to public health through one portal, therefore this request is to enhance ADHS s ability to receive messages from providers and hospitals. By increasing the Agency s technical and administrative resources with the funds of the IAPD, ADHS will not need to turn away Arizona providers from Meaningful Use attestation and qualification for incentive funds due to lack of capacity. With the requested funding, ADHS will be able to provide more real time access to data which will provide for more complete services to Arizonans and provide more correlated data for public health improving health outcomes. 3.2.2 Meaningful Use Stages Arizona, like all other states, is currently in the middle of assisting providers to complete all three stages of the Meaningful Use incentive program mandated under the Health Information Technology and Economic Health (HITECH) Act of 2009. During the first five years of the HITECH Act, Arizona Medicaid focused on implementing and administering the EHR incentive program. This was a needed first step in ensuring that providers could capture health information electronically through the use of Certified Electronic Health Records Technology (CEHRT). Much progress has been made in accomplishing this goal. This illustration captures the three stages of Meaningful Use and the projected years that they will occur: Figure 3.1: ONC National Stages of Meaningful Use 2016 Stage 1: Data Capture and Sharing Stage 2: Advanced Clinical Processes 2014 Stage 3: Improved Outcomes 2012 Page 58 of 129
Since the start of the HITECH Act, there have been significant challenges for providers, vendors, and MU Program administrators in being able to achieve the national Meaningful Use Program objectives envisioned by both CMS and ONC in the timeline originally laid out. AHCCCS has not kept up with the goals as described by ONC on the national stages of Meaningful Use, e.g., there are still challenges with the 2012 goal related to data capture and sharing. The ONC timeline lays out general goals but the timeframes do not appear to be realistic. 3.2.3 Health Information Exchange Governance Currently AHCCCS has a seat on AzHeC. A complete roster of board members and description of governance is in Section 2. AHCCCS has signed a participation agreement with HINAz, which allows Medicaid to participate in the planning for state level HIE. Funding by a consortium of organizations on their boards is ensuring the development of a sustainable HIE business plan. This governance structure is a result of feedback from Arizona healthcare stakeholders and is subject to change as the environment for HIE, HIT funding, and Medicaid continues to change. 3.2.4 Steps to Encourage EHR Adoption Next 12 Months AHCCCS will continue to provide general assistance to providers, including outreach and education resources, workforce support, and tools and resources to assist in all aspects of adopting and implementing EHRs and HIT. In addition, AHCCCS will partner with the REC to provide key technical assistance services, which include project management, practice and workflow redesign, and system implementation. Assessing Need for Technical Assistance AHCCCS is relying on the REC to provide general Assistance to Medicaid EPs. AHCCCS is asking each of its health plans to send information about the free REC services to their providers in mailings and via other outreach initiatives. The Arizona REC is providing general assistance and has also contracted with subject matter experts to provide the technical assistance. The program will provide critical services to EHR adoption as outlined in the figure below. Table 3.1: REC Services Regional Extension Center Services General Assistance Technical Assistance Outreach and education Vendor selection and preferred pricing Workforce support Project management Tools and resources in all aspects of EHR and HIT Practice and workflow redesign System implementation Interoperability and HIE implementation AHCCCS shared all of its registration, enrollment, and AIU/MU policies with the REC early on, so that both organizations could collaborate and develop a toolkit for EPs. The toolkit is finalized and available on the AHCCCS website for EPs to utilize. AHCCCS shared the toolkit with health plan outreach personnel prior to the implementation of the EHR Incentive Program and provides notification to the REC and Contractors any time an update is made to the Toolkit. Page 59 of 129
This division of labor and tasks between the REC and AHCCCS will allow AHCCCS to focus on provider registration and payment oversight through the epip web portal. 3.2.5 Future of Public Health: Reporting and Interoperability (SMHP Template Questions #1, 2) Based on the HIT Roadmap 2.0, the Network recognized it needs to update its platform to offer new services including greater public health reporting functionality. The process of reviewing functionality, identifying needs, and identifying a vendor that can provide this support is under way. The following figure provides a proposed high-level view of the HIE data flow planned by AHCCCS for meaningful use public health reporting. This flow assumes a public health portal: Figure 3.2: Proposed High Level HIE Data Flow for Meaningful Use Public Health Reporting Assumes Public Health Portal As described in section 2, ADHS is using the Medicaid EHR Incentive Program funds to support providers with submitting immunization, electronic lab reporting, and syndromic surveillance information. Project activities, processes, and goals are described in Section 2. 3.3 3.3.1 Five-Year HIT and HIE Goals (SMHP Template Question #1) HIT/HIE Agency Goals In order to meet its own strategic goals, AHCCCS has developed three HIT/HIE program goals which leverage its resources to ensure Medicaid providers in Arizona continue to adopt EHRs and have a secure statewide HIE infrastructure: Page 60 of 129
Ensure eligible professionals and eligible hospitals continue to move through the Meaningful Use continuum Accelerate Statewide HIE Participation for all Medicaid Providers and Plans Increase Agency Use and Support for HIT/HIE 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, Qualified Health Plan coordinate, and justice system transitions. These goals work in concert with the ONC/CMS national strategy and the Agency s strategic priorities. The following illustration provides an overview of AHCCCS s goals and priorities: Figure 3.3: AHCCCS Goals and Priorities for HIT/HIE Leverage HIT Investments to Reduce Fragmentation and Improve Care Coordination Goal 1 Ensure EPs and EHs Migration Through the Meaningful Use Continuum Goal 2 Accelerate Statewide HIE Participation for All Medicaid Providers and Plans Goal 3 Increase Agency Use and Support for HIT/HIE 1A - Recruit Non-participating EPs and EHs by 2016 2A - Support Care Coordination Between Physical and Behavioral Health Providers 3A - Seek Alternative Funding for Non-participating EHs and EPs for EHR Incentives and Connectivity 1B - Support Movement of EHs and EPs from Stage 1 to Stage 2 1C - Support ADHS Public Health Onboarding for Meaningful Use Measures 2B - Launch HIE Onboarding Program for Medicaid Hospitals, FQHC s, RHC s and Look a Likes 2C - Support Acceleration of Electronic Prescribing by Arizona Providers 3B - Identify and Deploy Electronic Solutions to Reduce Healthcare Admin Burden 3c - Support Population Health Surveillance with ADHS/Public Health 1D - Support Ongoing Provider Education about the HIT/HIE 1E - Achieve Program Integrity Plan goals 2D - Join the State Level HIE for Governance, Policy Making and IT Service Offerings 2E - Support Increased Health Plan use of The Network (State HIE) to Improve Health Outcomes 1F - Administer the EHR Incentive Program Final August 2014 Page 61 of 129
AHCCCS will employ the following strategies to accomplish Goal 1, Ensure EPs and EHs Migration Through the Meaningful Use Continuum : Strategy 1A - Recruit Non-participating EPs and EHs by 2016 1. Continue to partner with the Regional Extension Center to identify and enroll eligible providers. 2. Update all AHCCCS EHR Incentive Education Program tools to encompass Registration, AIU, Stage 1 and Stage 2 of the MU Program 3. Update the Agency s EHR Incentive Web page to make it easier for providers to locate information 4. Enhance the functionality of epip to be more automated for the administration of the EHR program 5. Work collaboratively with the MCOs to support outreach and education of providers in their networks 6. Monitor progress of provider adoption through creation of executive dashboard. 7. Identify and coordinate county and state level corrections EPs that are eligible and can participate in the EHR incentive program. Strategy 1B - Support Movement of EHs and EPs from Stage 1 to Stage 2 1. Track AHCCCS progress against CMS heat map of other states and with national trends 2. Survey the stakeholders to determine what issues are most problematic for providers moving from AIU to Stage 1 and barriers they anticipate moving from Stage 1 to Stage 2 3. Review epip data to determine how many Medicaid providers are more than one year out from AIU without moving to Stage 1 and determine if this is a meaningful target population to engage 4. Work with CMS to understand best practices from other state Medicaid programs for supporting providers that are having a hard time meeting MU Stage 1 5. Provide education and outreach to EPs/EHs regarding the benefits of moving from Stage 1 to Stage 2 Strategy 1C - Support ADHS Public Health Onboarding for Meaningful Use Measures 1. Review and update ADHS and AHCCCS Interagency Service Agreement to ensure providers goals and funding formulas are current 2. Promote ADHS progress in onboarding providers through meetings with ADHS staff to review registrations, ongoing submissions and finances regarding expenditure of funds 3. Collaborate with ADHS on developing long term use of the HIE to enhance public health reporting Strategy 1D Support Ongoing Provider Education about HIT/HIE 1. Partner with the REC to continue outreach to priority provider 2. Engage Medicaid MCO to identify high volume providers that are engaged in HIT/HIE 3. Work with Medicaid MCOs and AzHeC to provide basic HIT/HIE education to Medicaid Members as a way to improve patient engagement Strategy 1E - Achieve Program Integrity Plan Goals 1. Ensure Agency has engaged Audit Subject Matter Experts (SMEs) to support the review and implementation of Agency EHR audit program 2. Collaborate with Agency Office of Inspector General (OIG) to ensure strong program oversight and program integrity 3. Participate in CMS sponsored Community of Practice for Program Integrity 4. Increase frequency of provider audits and provide training with REC about best practices/lessons learned Strategy 1F - Administer the EHR Incentive Program 1. Encourage Medicaid providers to adopt, implement, or upgrade to CEHRT 2. Implement and maintain electronic Provider Incentive Payment System (epip) 3. Implement and maintain communications, materials and tools for providers and members 4. Develop and maintain Policies and Procedures documentation 5. Process provider registrations, attestations and payments 6. Conduct payment audits 7. Report results of the EHR Incentive Program performance to stakeholders 8. Conduct provider surveys to determine the impact of the EHR program 9. Participate in the governance of the state level HIE 10. Participate in trainings including Communities of Practice (CoPs), All-States CMS Calls and HIT-related conferences and events 11. Develop and update State Medicaid HIT Plan (SMHP) and HIT funding documents 12. Participate in Agency wide MITA HIT State self-assessment Page 62 of 129
AHCCCS will employ the following strategies to accomplish Goal 2, Accelerate Statewide HIE Participation for All Medicaid Providers and Plans : Strategy 2A - Support Care Coordination Between Physical and Behavioral Health Providers 1. Recruit any eligible Behavioral Health providers to the EHR incentive program. 2. Support the alignment and coordination of data sharing policies between AzHeC/The Network and the Behavioral Health Information Network of Arizona (BHINAz) and the Mercy Maricopa Integrated Health contractor for Phoenix. 3. Track the progress of the Agency s State Innovation Model (SIM) grant application that addresses the acceleration of behavioral health and physical health integration. Strategy 2B - Launch HIE Onboarding Program for Medicaid Hospitals, FQHCs, RHCs and Look a Likes 1. Using Federally approved 90/10 HITECH funds, identify eligible providers for the HIE onboarding program to accelerate bidirectional data flows between participating organizations. 2. Working with CMS, seek approval to include other eligible providers that can be included in the AHCCCS HIE onboarding program. Strategy 2C- Support Acceleration of Electronic Prescribing by Arizona Providers 1. Review each health plan s e-rx reports to identify how each plan will address acceleration of e-rx by the providers in their network. 2. Monitor overall state progress in e-prescribing through the SureScript s Annual State Rankings report. 3. Work with AzHeC to identify common education materials and subject matter expertise to improve Medicaid provider s adoption of e-prescribing. Strategy 2D - Join the State Level HIE for Governance, Policy Making and IT Service Offerings 1. Ensure executive participation on the state level Arizona Health-e Connection which is providing oversight to the state HIE (The Network) 2. Share Arizona HIT and HIE benchmarks with Board Members as requested 3. Monitor growth of the state level HIE including the type of data elements being shared, the formats of the data, the volume of the messages being sent and records available through the HIE Strategy 2E - Support Increased Health Plan Use of The Network (State HIE) to Improve Health Outcomes 1. Establish a baseline of health plan participation with the HIE. 2. Provide HIE benchmarks to Quality Improvement staff to update the Agency s clinical strategy and health plan performance measures. Page 63 of 129
AHCCCS will employ the following strategies to accomplish Goal 3, Increase Agency Use and Support for HIT/HIE : Strategy 3A - Identify and Deploy Electronic Solutions to Reduce Healthcare Admin Burden 1. Monitor the HIE capacity and user needs to identify opportunities for administrative efficiency in the Fee for Service Program and others. Strategy 3B - Support Population Health Surveillance with ADHS/Public Health 1. Collaborating with ADHS on establishing MU measures and electronic capacity for public health reporting. 2. Working with the HIE to support electronic public health reporting for population health outcomes work. Strategy 3C - Support Key Trading Partners to Join the Network (HINAz) at AzHeC 1. Support the Networks Healtheway certification to ensure the availability of clinical data for use by Arizona providers and AHCCCS. 2. Identify and coordinate possible agency uses of electronic health information coming from federal agencies as a result of the Healtheway certification, including data from Indian Health Service, Veterans Administration and Social Security Administration. 3. Identify and coordinate county and state level corrections providers participation in the ERH incentive program and use of the HIE for improved clinical data exchange. Strategy 3D- Seek Alternative Funding for Non-participating EHs and EPs for EHR Incentives 1. Support writing and researching grant applications that can promote and accelerate HIT/HIE adoption and use for non-mu eligible providers and facilities. 2. Working through HRSA, ONC and CMS identify additional funding opportunities. 3. Support community based collaboration with foundations and others to make funding available for those providers that want to participate in HIT/HIE. Strategy 3E - Coordinate Other State Agency Participation in HIE Decision Making 1. Through the State HIT Coordinator, AHCCCS will support the ongoing education and sharing of progress of The Network and its services to all interested agencies. 3.3.2 HIT/HIE Statewide Goals As described in Section 2, Arizona s Health IT Roadmap 2.0 describes 19 key initiatives to advance HIT/ HIE in Arizona. The Roadmap 2.0 recommends action in the following domains: stakeholder engagement, governance and policy, privacy, technology and business infrastructure. These initiatives are consistent and complementary with the AHCCCS goals described above. The Arizona HIT Roadmap 2.0 also sets forth timeframes for the 19 key initiatives as described below: Page 64 of 129
Figure 3.4: Health IT Roadmap 2.0 and Timeline Page 65 of 129
3.3.3 EHR Adoption Goals As described in Section 2, a 2013 survey of Arizona Physicians, Arizona State University researchers found that 81 percent of physicians used some form of EHR. This compares with rates of 52 percent in 2009 2011 and only 45 percent in 2007 2009. These same researchers predict that almost 100 percent of Arizona physicians will be using an EHR by 2018. ASU researchers also tried to measure the prevalence of providers that were able to exchange clinical patient information and found there was a marked disparity between the high number of providers that used EHRs and the number of providers that identified themselves as sharing clinical information. Figure 3.5: EHR Adoption Rates The ASU report identifies the single most important obstacle to the sharing of electronic health information as the lack of a successful or widely deployed health information exchange solution. For the Arizona Medicaid program, HIT and HIE efforts will be directed to try and increase the number of providers that adopt EHRs and ways to accelerate the secure electronic sharing of information among providers. The Agency will be organizing its resources to leverage HIT investments to reduce care fragmentation and improve care coordination. AHCCCS is embracing technology as a way to accelerate the delivery system s evolution towards a value-based, integrated model that focuses on whole person health in all settings regardless of coverage source Source: ASU Center for Health Information and Research 3.3.4 HIE To Be Based on the HIT Roadmap 2.0, the Network recognized it needs to update its platform to offer new services such as greater support for care coordination and ACOs, use of Direct, and being able to use the platform to meet Meaningful Use requirements. More specifically: Use of Direct and Query based protocols for sending and receiving data among providers Ability to receive Healtheway certification to ensure ability to exchange data with SSA, VA and IHS all high priority organizations for stakeholders given the size of the IHS, VA, and disabled populations Enhanced public health reporting Ability to support Meaningful Use Stage 2 for EHs and EPs Tools for care coordination, analytics and planning Ability to implement a complex consent management protocol for Arizona An environment which could send and maintain records for health plan or payer access as well as access and exchange with care providers like hospitals and other provider types A capability to develop, implement, and manage a HIPAA compliant Part 2 CFR 42 Behavioral Health and substance abuse data and record management including messaging Ability to capture electronic clinical quality measures Page 66 of 129
Platform Updates to the Network and Vendor Discussions The Network is currently working to upgrade its technology platform to provide more robust services to its participants. HINAz completed an HIE vendor evaluation process in August 2014, where it had subject matter experts from the HINAz participating organizations, review RFPs from vendors. Once these were narrowed down, four vendors were invited to come and do demonstrations for any interested HINAz participant. An additional ad hoc workgroup was formed to develop/ discuss /review possible changes to the financial model for HINAz to accommodate for the new platform adoption and transition costs for this first year with a new vendor. The ability to capture clinical quality measures electronically from EHRs related to Meaningful Use was discussed with all vendors considered for the new platform. At this time, the vendors considered do not have this capability, but The Network will continue to discuss this possibility with the selected vendor of choice to consider as a future functionality and offering. To enable and facilitate Meaningful Use attestation, the selected vendor of choice must have the capability to meet multiple Stage 2 requirements, including connecting to ehealth Exchange, meeting public health reporting requirements, and delivering care summaries via Direct or ehealth Exchange during transitions of care. All of these services will be offered in 2015 by The Network once the transition to a new vendor platform is complete. 3.4 Vulnerable Populations and Populations with Unique Needs (e.g., Children, FQHCs, IHS, VA)(SMHP Template Question #6, 8) Internally, AHCCCS will be monitoring the number and type of providers (including FQHC, IHS and VA providers and pediatricians and dentists) that are successful in receiving a payment through the incentive program as well as hearing about any barriers or challenges EPs may be having at the Quarterly EHR Incentive Advisory Committee meetings. Provider organizations that are on the EHR Incentive Advisory Committee include: the American Academy of Pediatrics, the AZ Dental Association, ADHS, the three different IHS Area Offices and Tribal organizations, and a core group of FQHCs. Through the Agency s HIT Steering Committee, each of the AHCCCS-covered populations is represented. The Assistant Directors from the Division of Health Care Management and Fee for Service Management are taking the leads in care coordination for behavioral health, dual eligibles and Children s Rehabilitative Services (CRS). In future years, the Meaningful Use criteria may address children s issues and include more of a focus on improving the quality of preventive healthcare for children. AHCCCS will work with ADHS and AHRQ to ensure that data and reporting efforts are targeted on improved clinical outcomes. AHCCCS continues to monitor member coverage via the providers participating in the EHR-incentive program to determine how comprehensive the Meaningful Use data is for measuring quality of care and where more information is needed. At this time, AHCCCS does not believe that the data would accurately reflect the population served; however, ongoing efforts continue to ensure the Meaningful Use of EHRs in order to increase the accuracy and availability of electronic clinical quality data. The agency added staff to manage clinical quality reporting in its Division of Health Care management and this person helps staff a clinical reporting workgroup made up of representatives from AHCCCS health plans. Through the ASET office, and their work with ADHS, AHCCCS is supporting public health menu objectives which have a strong relationship to children, either through the immunization registry, laboratory or the syndromic surveillance program. 3.4.1 Leveraging FQHC Resources and Experiences The Arizona Association of Community Health Centers (AACHC) is the Primary Care Association (PCA) for the State of Arizona and represents the Federally Qualified Health Centers (FQHC's). They advocate Page 67 of 129
for the health care interests of the medically underserved and uninsured, and have a long history of working collaboratively with the Agency. Based on the survey responses, highlighted in Section 3, the Current HIT Landscape, the AACHC has made the decision to hire a full-time staff person to help implement the EHR program for all of their members. This staff person will assist those facilities that are already using a certified EHR attest to Meaningful Use, and assist those that have not already selected a product to adopt, implement or upgrade. AHCCCS and the REC met with the association to identify ways that the REC could showcase the implementation experiences that the current EHR users had and share those with other FQHCs and other types of providers, like group practices. AACHC has facilitated the registration of their EPs at the REC and is using REC and AHCCCS guest speakers at their board meetings to encourage EHR adoption among their facilities. In addition, AHCCCS hopes to act as a catalyst and encourage Medicaid providers to move beyond EHR adoption and into exchanging information. As a result, AHCCCS received permission from CMS to launch a program to help lower the cost of building interfaces with the FQHCs and RHCs. 3.5 Future of AHCCCS IT Architecture (SMHP Template Question #2) Figure 3.6 shows AHCCCS vision of the IT system environment in the next five years. Primary changes are in the new service opportunities of the HIE, such as the following: Alerts for Urgent Care, Emergency Departments, and Admission and Discharge Alerts, including: Emergency Departure Registrations, Inpatient Admissions, 23-Hour Observation Bed Assignments, Pending Discharges, Pending Admissions, Ambulatory Facility Registrations, and Practice and Urgent Care Registrations Direct Secure Messaging, which can be used to: Deliver ADT Alerts, Deliver Referrals, Request Patient Information from other Providers, Share Patient Information Across Care Settings Public Health Reporting Tools, including: Immunization Registry Reporting, Syndromic Surveillance, Reportable Lab Results and Diseases, and Local, Regional, National Registries Reporting Participant Direct Data Access Tools, including Comprehensive Organizational Data Warehouse and Data Cubes, such as clinical financial, operational, and consumer, and Advanced Business Intelligence and Data Analytics Tools Referrals Request Patient Information from Other Providers Share Information Across Care Settings Longer term, AHCCCS foresees an operational HIE that facilitates the exchange of patient medical information directly with patients and other allied healthcare providers. Page 68 of 129
Figure 3.6: Integrated Medicaid IT Environment Future Plans (2019 Vision) Page 69 of 129
3.6 Future of Medicaid Provider Interface with IT System and IT System Architecture (SMHP Template Question #3) Future plans for epip include enhancing the messaging available to providers (so they know where attestation is in review/payment cycle) and modifications for the new stages of Meaningful Use. AHCCCS continues to review the system to ensure a user-friendly, logically progressive interface for providers in order to maximize efficiency of use. AHCCCS continues to review e-cqm reporting requirements and while an electronic reporting mechanism is not currently developed, such is being considered in the future 3.7 Leveraging HIT-Related Grant Awards (SMHP Template Question #9) 3.7.1 Medicaid Transformation Grant As discussed in Section 2 AHCCCS received a Medicaid Transformation Grant that is no longer in operation. This grant allowed AHCCCS to develop the first operational electronic web based HIE called the Arizona Medical Information Exchange (AMIE). The following is a summary of Medicaid Transformation Grant Products and information that has been leveraged for current HIT/HIE efforts: Table 3.2: Medicaid Transformation Grants Products for HIT/HIE Efforts Domain/Content Area Lessons Learned Information Transitioned Governance Convening health care stakeholders to create trust and consensus, oversight and accountability of HIE to protect public interest Finance Identification and management of financial resources, including public and private funding for HIE. Business and Technical Operations Procurement, identifying Requirements, process design, functionality development, project management, help desk, etc. Technical Infrastructure Architecture, hardware, software applications network configurations that enable technical services for HIE Multi-stakeholder process to ensure HIE among providers are in Compliance with applicable policies and laws Medicaid Value Model (Fox Report) PACeHR Business plan and Letter of Interest AMIE Monthly Reporting Summary AMIE/Gartner Final Assessment & Lessons Learned U of A AMIE Project Proof of Concept Evaluation AHCCCS/AzHHA Hospital Study CHIR/ASU HIE Participation Agreement AMIE Patient Consent and Design Specifics AMIE Provider Viewer User Manual, On-boarding manual Provider Focus Group Feedback PACeHR Notice of Standardized Inquiry PACeHR Vendor Response Evaluation PACeHR Communications Plan AHCCCS Search Engine Conceptual Design AHCCCS Clinical Decision Support AMIE/Initiate Integration AMIE/ Emulator Technical Design AMIE Consent Design HINAz GOHIE AzHeC CMS HINAz GOHIE CMS HINAz AzHeC CMS HINAz CMS Page 70 of 129
Table 3.2: Medicaid Transformation Grants Products for HIT/HIE Efforts Domain/Content Area Lessons Learned Information Transitioned Legal/Policy Legal and policy barriers and enablers related to electronic use and exchange of health information Security Policies Privacy and Security requirements for system development and use AMIE Proof of Concept Privacy and Security Policy Manual AMIE Data sharing agreements White paper Consumer Consent Multi-state policy harmonization activities thru HISPC Health Information Security & Privacy Collaboration Report on Overview of Basic Authentication HINAz AzHeC CMS 3.7.2 ONC Cooperative Agreement Funds Under the ONC HIE Cooperative Agreement Program, many activities were supported with AzHeC to promote EHRs Adoption and to Facilitate HIE. Since 2010, AzHeC has worked extensively with ASET, the state Agency charged with implementing and overseeing the ONC HIE Cooperative Agreement Program. ASET contracted AzHeC to gather stakeholders and support the development of a state level strategic and operational plan for HIT/HIE that was approved by ONC in April, 2010. In 2012, ASET reviewed its own state level procurement processes and identified that it was in the States best interest to award HIE Cooperative agreement funds to AzHeC to carry out numerous projects described below as well as provide assistance for developing the HIT Roadmap 2.0. HIE Marketplace ASET was charged with enabling HIE activities throughout the state. Specifically, as part of the ONC HIE program, ASET was charged with ensuring that all Arizona health care providers had viable options to participate in HIE. ASET awarded AzHeC the contract to support HIE in Arizona through the formation of a Health Information Exchange Marketplace (The Marketplace). The Marketplace serves as a trusted and unbiased source where health care providers can review viable HIE options. AzHeC developed specific technical and operational policies and evaluated vendors to ensure vendors could provide secure HIT transport options for providers to meet the escalating HIE requirements of Meaningful Use Stage 2. Additionally, engaging AzHeC provided a number of unique benefits that are not easily replicated or available within other organization to the best of our knowledge. These unique benefits include: A greatly reduced time for implementation of transport options, especially Direct. Having this reduced time was critical to the HIE grant s ability to meet its Stage 1 MU account goals and move into its Stage 2 ROBUST HIE implementation plans. AzHeC created and defined state standards for approving Health Information Service Providers (HISPS) based on technical specifications, privacy and security standards, and operational requirements and an evaluation process for entities participating in The Marketplace. AzHeC continues to oversee and lead updates and changes to The Marketplace through their participation in the ONC sponsored workgroups. This is particularly important because HISP certification will be coordinated through Federal standards and the DIRECT Trust. E-Prescribing Scope of Work ASET set state goals for e-prescribing through the ONC HIE Cooperative agreement grant to enhance patient safety and health care for citizens of Arizona. AzHeC was tasked with coordinating an education and technical assistance campaign to assist health care providers and pharmacies to achieve e-prescribing goals. Through its leadership and use of subject matter experts, AzHeC was able to deploy a number of Page 71 of 129
successful strategies culminating in an increase of e-prescribed prescriptions from 33 percent to 50 percent by the end of the program. (Source: Surescripts 2012 most recent statistic released). AzHeC formed and coordinated an e-prescribing steering committee, provided information and statistics to providers and pharmacies, recognized top e-prescribers, researched and published Arizona case studies, and oversaw a pharmacy incentive program to encourage unconnected pharmacies to adopt e-prescribing technology. As a result of their efforts, the e-prescribing rate of Arizona providers rose from 48 percent to 63 percent by the end of the program. (Source: Surescripts 2012 most recent statistic released). Consumer Outreach and Education Campaign AzHeC worked closely with the Health Information Network of Arizona to deploy a consumer and provider outreach and education campaign. AzHeC created a Consumer Connections Task Force made up of more than 50 health plans, health care organizations, government agencies and non-profit organizations. In a very short amount of time, the campaign was able to achieve over 1.5 million gross impressions on Phoenix Public Radio, over 2.2 million impressions in the Arizona Republic Section A Sunday print ads, through all mediums was able to generate over 10 million total impressions from all of their outlets. An additional portion of this campaign included the development of a provider toolkit for helping to explain patient consent for participation in health IT, which was also developed under the campaign. Projects to Facilitate EHR Adoption and Exchange ASET launched two different grant programs The first grant program was called Unconnected Providers with the focus of helping EPs that were ineligible for the EHR incentive program to receive funds and strategic planning assistance. A total of 14 grants were awarded to a variety of health care organizations including behavioral health providers, long term care organizations, department of corrections, rural health group and some community providers. The amounts were small if a single organization submitted an application (no more than $50,000) but if they brought a trading partner with them, the amount could go up to $100,000. The second grant program was the HIE Enterprise Grant Program that provided grant funding opportunity to accelerate HIE for large health care organizations that are creating, developing, or maturing enterprisewide HIE capabilities in Arizona. The HIE Enterprise grants targeted organizational HIEs to support acceleration of connecting providers within their own networks. The total amount of funding available for distribution was up to $1 million dollars. Five grants were awarded in August 2013. For more complete information about these grant program, please go to the ASET website at: www.aset.azdoa.gov. 3.7.3 State Innovation Model Grant Proposed AHCCCS submitted a State Innovation Model (SIM) testing grant application to CMS in July 2014 as part of Round 2 of these grants. AHCCCS proposed a multi-pronged strategy with numerous initiatives to address healthcare challenges across the State. The SIM application is designed around three overarching strategies: 1) Facilitating Integration and Decreasing System Fragmentation; 2) Improving Care Coordination; 3) Driving 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 1) Improve population health; (2) Transform the health care delivery system; and/or (3) Decrease per capita health care spending. A key component of the application is the requirement to use HIT and leverage existing state HIT programs and investments. Arizona is proposing to use the SIM grant to develop a competitive process to allocate funds to the strongest proposals for HIT/HIE funds. Arizona will specifically look for providers who will leverage HIT and HIE to drive improved quality. Funding for HIT and HIE initiatives will be available for the following strategies : HIT/HIE for Behavioral Health, Partnerships for Integrated Care, Super-Utilizers, Page 72 of 129
American Indian Care Coordination, Qualified Health Plan Coordination, and Justice System Transitions. More information on these strategies is provided below: 3.8 o o o o o Behavioral health: There are two components to this strategy: 1.) provide $10 million for adoption and implementation of EHRs for behavioral health providers to adopt and implement EHRs and participate in the electronic exchange of patient data. 2.) provide $20 million to support some combination of ACOs, large provider systems, FQHCs and behavioral health providers to partner and form Integrated Delivery Systems that are focused on patient centered whole health care coordination strategies. Super-utilizers: Arizona will provide $6 million for projects to develop necessary IT and other infrastructure to accelerate care coordination for super-utilizers. These efforts will complement existing efforts regarding data sharing and care coordination by filling in gaps where robust data exchange is not occurring but is critical to managing this high-need/high-cost population. Qualified Health Plan Care Coordination: Arizona is proposing to use $2 million to build necessary interfaces for data exchange between Qualified Health Plans and AHCCCS plans and RBHAs to ensure coordinated care for members transitioning between the two systems. Between 3-5% of AHCCCS members churn on and off the program each month. Prior to the availability of affordable coverage through the FFM, those members often did not have access to alternative coverage; however, it is expected that now many members who lose Medicaid eligibility will have access to coverage through Qualified Health Plans. American Indian Care Coordination: To accelerate care coordination for the American Indian Population, Arizona is proposing to leverage HIT in two ways: 1.) allocate $3 million to develop a care coordination platform that will leverage Medicaid claims data to better coordinate care for American Indian members using a care management system that will provide nurses and care coordinators with extensive data analytics to evaluate and provide better care to high cost members 2.) allocate $10 million for regional care coordination initiatives, which will need to leverage HIT to create actionable data as part of developing care coordination protocols and strategies. Justice System Transitions: $5 million in award grants to Criminal Justice entities to partner with Medicaid and greatly expand the capability to provide appropriate care coordination by leveraging actionable health care information for care coordination for individuals transitioning between systems. Current care coordination efforts are largely manual processes and focused on a very limited number of individuals, but Arizona can expand these efforts through HIT. Need for New Legislation or State Laws (SMHP Template Question #10) In 2014 stakeholders have not requested any changes in state laws and regulations that may affect the implementation of the EHR incentive program. Earlier, in 2011 and 2012, AzHeC supported legislation that was intended to update medical records laws and remove barriers to HIE. The legislation included the following changes: Permitted healthcare providers and clinical laboratories to disclose information to HIOs, if they have HIPAA business associate agreements in place that requires HIOs to protect the confidentiality of health information. Being a HIPAA business associate also subjects an HIO to HIPAA enforcement by HHS and the Arizona Attorney General s Office. Permitted HIOs to re-disclose health information in a manner consistent with the underlying medical records confidentiality statutes. This ability to re-disclose health information to authorized individuals is essential to the HIE process. Removed the requirements for written records or documentation. Allowed e-prescription for controlled substances. Page 73 of 129
At this time there are no other legislative initiatives that AzHeC has undertaken. 4 Program Implementation and Administration Section 4 provides a detailed overview of the administration and operation of the EHR Incentive Program. Additionally, this section discusses how AHCCCS plans to ensure the quality and efficacy of their EHR Incentive Program by monitoring as well as providing appropriate training and education to EPs and EHs. AHCCCS will rely on CMS guidance for the proper oversight of EHR and HIT adoption by applicable providers and hospitals. Each sub-section outlines how AHCCCS plans to operationalize its Medicaid EHR Incentive Program, based on CMS guidelines as well as Agency assumptions, to support key programmatic goals and objectives. Additionally, sub-sections will include references to the CMS template to demonstrate compliance with requirements. 4.1 Assumptions (SMHP Template Question #29) In the past, AHCCCS identified the following assumptions regarding the initial implementation of the EHR Incentive Program: The development and support of the CMS Registration and Attestation (R&A) System stayed on schedule and adhered to the timelines for testing and implementation, which supported the Agency s July 2011 go-live date The Regional Extension Center (REC) was successful in developing a business plan that met its operational milestones and could generate the milestone payments. AHCCCS also assumed the REC would be able to better define its outreach and education offerings by October 2011 CMS approved the Agency s SMHP and IAPD by May June 2011 CMS finalized Stage 2 Meaningful Use rules ONC finalized the EHR certification rules Currently, the Agency is operating on several assumptions to ensure adequate support of the HIT adoption for eligible providers: CMS provides timely technical assistance in understanding the final rule and its implications on Meaningful Use criteria to ensure the Agency has created a smooth administrative process for providers to register, attest to Meaningful Use, administer payments and provide program oversight. AHCCCS receives the resources needed from CMS to develop the infrastructure and tools to set up interfaces with the CMS R&A System and all information services processes. REC is going to acquire the needed resources to become the vendor expert for Arizona s Medicaid providers, especially as it relates to the selection and technical implementation of an electronic application(s). REC will be successful in developing a business plan that meets its operational milestones and can generate the milestone payments. AHCCCS will be capable of generating payments to EPs and EHs by identifying and working closely with a couple of different provider types to go through the CMS R&A System and testing. HIE s role, approved rules and cooperative agreement are available in 2015. Page 74 of 129
CMS approves the NPRM (rule regarding 2014 CEHRT) in 2014. 4.2 4.2.1 Implementing the EHR Incentive Program Identifying Eligible Professionals and Hospitals and Making Payments (SMHP Template Questions #1, 2, 3, 27) AHCCCS will employ a process to ensure that EPs and EHs meet Federal and State statutory and regulatory requirements for the EHR incentive program. In order to ensure that providers qualify as EPs, AHCCCS will check sanctions and licensing twice during the EHR Incentive Program payment process. First, when providers apply for EHR Incentive Program payment, their status and the payee will be checked in the AHCCCS PMMIS provider database to determine if the provider is registered as an AHCCCS Provider, active and in good standing. PMMIS receives provider additions, changes, and deletions from the Arizona Medical Board and updates its provider database on a regular basis. Unlicensed providers are not qualified or approved to be AHCCCS providers and will be reflected in PMMIS as inactive and/or not in good standing. Therefore, such providers can be easily identified as ineligible. Second, after the payment calculations and before the incentive payment is released to the provider, AHCCCS will make a second status check in PMMIS for licensure and sanctions. Additionally, AHCCCS will ensure that EPs selecting Medicaid Patient Volume Type are not hospitalbased since hospital-based EPs do not qualify for the EHR Incentive Program. Medicaid Hospital-based EPs must have 90 percent or more of their covered professional services in a hospital setting. EPs must submit the total number of Medicaid Title XIX Inpatient Hospital, Emergency Department and Total Patient Encounters paid during the prior calendar year. AHCCCS will query this information in the Data Warehouse to validate the percentage of hospital-based encounters based on the provider s input. If the results of either of these calculations show that the provider has 90 percent or more hospital-based encounters, then the provider is not eligible for the EHR Incentive Program payment. The following hospitals are eligible to participate in the Medicaid EHR Incentive Program: Acute care hospitals (including CAHs and cancer hospitals) with at least 10 percent Medicaid patient volume; and Children s hospitals (not Medicaid patient volume requirements). Under the Medicaid EHR Incentive Program, EHs can qualify for incentive payments if they adopt, implement, upgrade or demonstrate meaningful use of certified EHR technology during the first participation year or successfully demonstrate meaningful use of certified EHR technology in subsequent participation years. Appendix F provides a sample of an incentive payment calculation for EHs. In addition to verifying the eligibility of qualifying EPs and EHs, AHCCCS will also review and verify the content of provider attestations. AHCCCS plans on using the Electronic Provider Incentive Payment system (epip) and other internal processes. Providers will submit data on the AHCCCS epip website that will hold all data elements. In following years, EHs will need to enter their information in the eligibility and payment system. Children s hospitals may be subject to have additional reporting requirements based on internal policies. The epip administration system and AHCCCS staff will perform various data validation tests to ensure improper payments are not made to ineligible providers. EPs will be able to modify their responses. However, once an EP has attested in the system, AHCCCS will have to unlock their submission to allow for the correction. If the provider does not meet the criteria tests identified below, then they will be determined as not eligible for an EHR Incentive Program payment. 4.2.2 Calculating Patient Volume (SMHP Template Questions #5, 6, 7, and 12) In order to participate in the EHR Incentive Program, eligible providers must meet patient volume targets established by CMS. The qualifying patient volume thresholds for Medicaid s EHR Incentive Program are the following: Page 75 of 129
Table 4.1: EHR Patient Volume Threshold Criteria Provider Type Minimum 90-day Medicaid Patient Volume Threshold (%) Eligible Professionals Physicians 30 Pediatricians 30 or optional 20 Dentists 30 Certified nurse Midwives 30 Physician Assistants when practicing at an FQHC/ RHC led by a physician assistant 30 Nurse Practitioner 30 Note: For Medicaid EP practices predominantly in an FQHC or RHC 30 percent of needy individual patient volume threshold Eligible Hospitals Acute care hospital 10 Children s hospital No Patient Volume Requirements AHCCCS EHR Staff will use existing systems, such as the PMMIS/Data Warehouse to access or run data reports to validate the provider s data regarding patient volume. To verify the EP s number of Medicaid patient encounters, AHCCCS will validate the provider s entry using data from PMMIS (via the Data Warehouse) to establish the reported number of unique visits captured in the encounter process for the EP. If EPs use aggregate patient volume for their volume qualifications, AHCCCS will perform the above validation using the Data Warehouse to amass the total Medicaid volume for the group for the designated time period. AHCCCS will also use PMMIS/Data Warehouse to validate the EH s reported patient volume. In order to calculate patient volume to determine whether EPs and EHs qualify for the EHR Incentive Program, AHCCCS adopted CMS Patient Encounter Methodology. EPs and EHs (excluding Children s Hospitals) are required to meet a specific patient volume threshold each program year in which they are applying to be eligible for the EHR Incentive Program. EP measurements are based on the Medicaid Patient Volume Type or Needy Patient Volume Type. EPs in FQHCs/RHCs have a special option of qualifying using either the Medicaid Patient Volume Type or Needy Patient Volume Type. Needy Individuals are FQHC/RHC patients receiving medical assistance from Medicaid (Title XIX), the Children s Health Insurance Program (Title XXI), individual furnished uncompensated care by the provider, or individuals furnished service either no cost or reduced cost based on a sliding scale determined by the individual s ability to pay. Note that anyone paying per the sliding scale with payments over the calculated cost of service does not qualify as a needy individual. All other EPs measurements are based on the Medicaid Patient Volume Type. Pediatricians have a special exception in meeting the patient volume. EPs selecting Needy Patient Volume must practice predominantly at FQHC/RHC facilities. For purposes of determining Medicaid s EHR Incentive Program eligibility, Practice Predominantly is defined as an EP for whom the clinical location for over 50 percent of his/her patient encounters over a period of six (6) months in the prior calendar year occur at FQHC/RHC facilities. Page 76 of 129
EPs must input the FQHC/RHC facility Patient Encounters and Total Patient Encounters during any six (6) month period in the prior calendar year. AHCCCS validates the provider s entry using data from PMMIS (via the Data Warehouse). In subsequent years, EPs, including FQHCs/RHCs will be required to submit and upload their documents in the epip system in order to successfully attest for the Medicaid EHR Incentive Program. If the results of either of these calculations show that the provider has less than 50 percent patient encounters, then the provider is not eligible for the EHR Incentive Program payment. Similarly, EH measurements are also based on the Medicaid Patient Volume Type. The Patient Volume percentage is defined as the total Medicaid/Needy Individual patient encounters in any representative continuous 90-day period in the preceding year, divided by the total of all patient encounters in the same 90-day period multiplied by 100. AHCCCS will use Medicaid Patient Volume calculations to verify that the hospital s patient volume aligns with EHR Incentive Program requirements. 4.2.3 Payments Methodologies (SMHP Template Questions #24, 25, 26, 27, 28) Once a provider has applied for the EHR incentive payment and it is verified that they have met federal and State statutory and regulatory requirements for the EHR Incentive Program payments, the provider will receive feedback regarding a timeline in which s/he can expect payment. Additionally, providers will be able to check their payment status in the epip system. At any time during the process, if AHCCCS has a question or needs verification of some of the provider data, AHCCCS will send a direct e-mail to that provider or provider designee. AHCCCS has established a dedicated e-mail box for queries and questions from providers. Similarly, if a provider can submit a question, AHCCCS will answer within two to three business days. Batched payments to EPs and EHs will be made monthly. These payments will be made via the epip system, which AHCCCS designed according to the statute and regulations of the Final Rule. The Medicare and Medicaid Extenders Act of 2010 (Public Law No: 111-309), enacted on December 15, 2010, amended the Health Information Technology for Economic and Clinical Health (HITECH) established by the American Recovery and Reinvestment Act of 2009. The amended section changed the definition and calculation of the net average allowable cost for which a provider is responsible. The new changes allowed CMS to estimate the average payment that Medicaid providers will receive from other (non-governmental) sources. Rather than requiring each EP to calculate payments received from outside sources, each will use the average amount established by CMS. Subsequently, it is not necessary to calculate the net average allowable cost. Anytime there is a system upgrade, AHCCCS s epip system is tested by the Acceptance Test Unit of AHCCCS Information Services Division (ISD) followed by a set of pilot provider volunteers representing a cross section of AHCCCS providers. During testing and pilot, there is a designated tester who verified all of the operations and results of the systems, including the accuracy of EP and EH payment calculations. The epip System also includes a notification statement for the provider to verify that there will be no deduction or rebate resulting from this payment. The provider will sign an attestation to this fact. When suspicious information is presented, EHR Incentive staff verifies payee information with the provider prior to payment. 4.2.4 Verifying the Adoption, Implementation, and Upgrade of Certified EHRs (SMHP Template Questions #11) As part of the EHR Incentive Payment Program, AHCCCS will be responsible for tracking and monitoring the adoption, implementation, or upgrade of certified EHRs by eligible providers. Eligible providers must select their adoption, implementation and upgrade requirements in the epip system, provide the EHR Certification Number and agree to an attestation statement. Providers will also upload documentation showing that they have adopted, implemented or upgraded to certified EHR technology. The EHR Staff will manually review the submitted documentation for each Page 77 of 129
provider. AHCCCS will require documentation such as copies of vendor contracts, paid invoice. Screen shots to verify software versions, and system production reports as verification for particular requirements. Provider must electronically sign the above attestation disclaimer statement. Providers will input the EHR Certification Number during the application process. The epip system will verify the number by checking it against the list maintained on Certified HIT Product List (CHPL) by the ONC website. During the post payment audit process, AHCCCS will request sample reports from the provider s EHR system to verity use of certified EHR technology. 4.2.5 Reporting of Meaningful Use (SMHP Template Question #10, 11, and 12) In addition to verifying adoption, implementation and upgrade of EHRs, AHCCCS is responsible for tracking the Meaningful Use of this technology. AHCCCS has system attestation pre-payment audit checks that assist with the verification process. AHCCCS will also request additional data during pre and post-payment audits such as screen shots, EHR reports and/or public health testing documentation as needed to verify Meaningful Use of CEHRT. The State Medicaid Agency is no longer requesting any changes to the Meaningful Use definition. In previous years, the SMA requested and received permission to exclude the EP Syndromic Surveillance Menu measure from the attestation. There is no mechanism for EPs to report relevant information in Arizona and ADHS has no future plans to incorporate an EP reporting element at this time. Additionally, the tool used by ADHS (Biosense 2.0) only has hospital reporting capability. It is the SMA s understanding that IHS EPs can report Syndromic Surveillance data directly to the federal government; therefore, the measure will be incorporated back into the MU attestation so that those EPs that are able to attest to the measure can do so. With regards to the Clinical Quality Measures (CQMs) associated with Meaningful Use, AHCCCS is continually looking for opportunities to utilize specific fields in provider EHRs to collect data for CQMs and Meaningful Use objectives, as well as the CHIPRA and Adult Core Measures, many of which align with Meaningful Use measures. It is anticipated that most, if not all, data necessary to conduct these and other outcomes measures will be available electronically from providers that have implemented EHRs. In addition, AHCCCS continues to explore possible use of the state s HIE to collect more detailed information from EHRs in order to provide only Medicaid data necessary for the Agency to calculate, report and/or develop QI initiatives related to Meaningful Use. AHCCCS anticipates storing necessary field data in the AHCCCS data warehouse for use in analyzing and reporting CQMs and developing interventions to improve care. The EHR data will also be used to supplement current HEDIS outcomes measures and mandatory Performance Improvement Projects as required by federal Medicaid Managed Care regulations (42 CFR 438.240). AHCCCS will have different approaches to clinical outcomes measures for the shortterm and the long-term. Short Term Approach for Meeting Meaningful Use In order to meet federal requirements and expectations for health care quality improvement, AHCCCS will capture timely, accurate and meaningful data that can be used to monitor quality among various types of providers and in a way that is consistent with national standards or core measures developed/adopted by CMS, so that health information is available and actionable from both the individual provider level and also from a system perspective. To move further down this path, AHCCCS has implemented sections of the American Recovery and Reinvestment Act (ARRA) to promote and provide Medicaid EHR Incentive Program payments for the adoption and Meaningful Use of EHRs to EPs and EHs, as well as those related to the electronic use and exchange of health information for quality improvement and oversight purposes. Agency staff have implemented Meaningful Use functionality and reporting of the related CQMs by EHs/CAHs and EPs through the epip system. AHCCCS staff is also responsible for collecting, analyzing and reporting existing clinical quality measures and other quality and outcomes data utilized by the Agency has plans to develop processes for collection, storage, analysis and reporting of MU/CQM data Page 78 of 129
from EPs and potentially EHs. AHCCCS EHR staff are evaluating existing processes for collection, analysis and reporting of clinical quality data, including Healthcare Effectiveness and Data Information Set (HEDIS) measures currently collected, to determine how the Agency may use existing processes/resources and what additional resources or tools are necessary to fulfill federal requirements. The Agency has identified staff that will be responsible for monitoring and evaluating quality measurement and improvement. Processes under development include methods of data validation that are the most cost-/resourceefficient, and mechanisms for reporting aggregate data by provider to CMS. Existing HEDIS and other reports may be used to benchmark provider-reported data and identify any opportunities for quality improvement in the future. Data imported from public health registries such as ASIIS also may be used to benchmark and/or validate provider-reported data in the future. Long Term Approach for Meeting Meaningful Use Long-term, AHCCCS will expand capabilities to the next level of inter-operability as we head into a new generation of quality reporting. Through the wide-spread implementation of EHRs, AHCCCS anticipates improvements in monitoring of quality of care and outcomes at a variety of levels in the Medicaid system: provider, managed care organization, county/geographic service area, population (e.g., by race/ethnicity, diagnosis or special health care need), program/state and including national comparisons. To further expand the focus on clinical outcomes rather than processes or episodes of care, AHCCCS will focus on developing the mechanisms needed to incorporate electronic health information into quality performance measures, such as the HEDIS Measures and Meaningful Use measures. EHRs offer a much richer data source than administrative data, providing information such as laboratory values indicating improvement in a members 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 and Periodic Screening, Diagnostic and Treatment Services (EPSDT) Program. Implementing a philosophical shift toward incorporating EHR connectivity/data sources will add another layer of complexity to the clinical outcomes measure process. AHCCCS also anticipates the following objectives related to capturing and sharing data: Support reporting of CMS Core Measures and Meaningful Use and CQMs as they are approved and implemented by CMS, including reporting of HEDIS measures. Determine ways to improve quality oversight of contracted managed care organizations and their network providers, including ensuring complete, accurate, and timely reporting of data. Secure electronic health information from Medicaid providers including hospitals, physicians, FQHCs, RHCs, behavioral health providers, long- term care facilities, dental providers, etc., in order to test processes and applications for quality monitoring and oversight. Develop mechanisms to reduce process waste and maximize automation to increase administrative simplicity and efficiency in quality measurement/oversight. Share information for care coordination and quality measurement with other entities serving AHCCCS members (e.g., Arizona Department of Health Services, Tribal Entities, IHS) in a timely and seamless manner while ensuring the privacy of AHCCCS members and data security. Enhance existing processes to report quality measurement data through the AHCCCS website, as well as through stakeholder forums (State Medicaid Advisory Committee, Arizona Medical Association Maternal and Child Health Committee, The Arizona Partnership for Immunization, legislative caucuses, etc.). Increase transparency in the Medicaid program by making available performance and quality data to a variety of stakeholders, including members/patients, other health care professionals, Page 79 of 129
policy makers and the public at large. AHCCCS also anticipates that activities implemented as a result of clinical outcomes and Meaningful Use measures may result in improved outcomes. The use of EHRs and the implementation of clinical outcomes measures may result in an increase in productive patient/provider interactions, improved clinical decision support, improved delivery system design including patient navigator, work up nurses, care manager/clinical outreach coordinator, health educator and support staff, and the establishment of EP and EH goals such as, better chronic disease control, reduced medication errors, improved discharge planning, improved patient cycle time, improved patient self- management, reduced tobacco use, improved immunization rates and reduced inappropriate ER utilization. AHCCCS also expects the reporting of CQMs to result in changes to the organizational and payment structures surrounding the care experience to focus on outcomes and quality of life. Current changes underway include payment reform methodologies based on performance of established measures as well as contractor promotion of patient-centered medical home and accountable care organization models of care. Ultimately, focusing efforts on clinical outcomes measures may result in cost savings/benefits for AHCCCS including: Increased chart data from EHRs will increase accuracy and completeness of data used to report clinical quality measures (including HEDIS) without the cost of data abstraction by nurses or other qualified individuals AHCCCS data will be more comparable to other states when submitted to CMS and NCQA Complements current data sources by including chart data, public health data, registry data into all applicable clinical quality measures without additional human resource requirements Reduced administrative burden on providers, health plans and AHCCCS as data can be collected, received and analyzed electronically Identification of opportunities for population health management and quality improvement initiatives Potential to reduce clinical and medication errors Potential to drive down emergency room and inpatient utilization Potential to improve discharge planning and thus reduce hospital re-admissions 4.2.6 Integration of Meaningful Use Activities with Other Quality Initiatives (SMHP Template Question #13) AHCCCS will eventually use Meaningful Use-reported data as a comparison to other performance measures tracked by the Agency. In addition, AHCCCS continues to monitor the development of new Meaningful Use measures, especially those proposed for Stage 3, to determine alignment of Meaningful Use measures to agency-selected performance measures. As noted, many of the CHIPRA and Adult Core Measures, as well as existing clinical quality/performance measures utilized by AHCCCS to evaluate contractor performance and the program overall, align with Meaningful Use CQMs. Since AHCCCS already has the capability to analyze existing quality measures by Contractor, county/geographic service area (GSA), etc., data collected from providers will be compared to other measure data collected and reported by AHCCCS to check for reasonableness and to identify opportunities for improvement; e.g., by provider type or GSA. The EHR data will also be used to supplement current HEDIS outcomes measures and Performance Improvement Projects as required by federal Medicaid Managed Care regulations (42 CFR 438.240), since EHRs have the capability to produce additional information for quality improvement that cannot be obtained from administrative (encounter) data alone. Page 80 of 129
4.3 4.3.1 Administration of the EHR Incentive Program Communicating Key Information to Providers (SMHP Template Question #4 and 18) To communicate important information to providers and stakeholders regarding the EHR Incentive Program, AHCCCS has instituted a web site with information and links to Arizona s Medicaid EHR Incentive Program. This gives the provider community key information regarding the EHR Incentive Program eligibility and payments. The AHCCCS programs plan for accepting the registration data for its Medicaid providers from the CMS NLR is through a communication protocol called Connect:Direct. Connect:Direct is a computer software tool used to securely transfer files between entities. It accepts the registration data from Medicaid providers from the CMS NLR. Providers may also sign on to the epip System at any time to get information about their attestation and payment status. The system will be used as a communication vehicle to provide updates and keep the provider informed. Once the provider completes the registration process, epip will reflect messages indicating if an action is In Progress or Completed. Both attestations and payments will be tracked in the epip. The screenshot on the next page is the first screen an EP would see after successfully registering with CMS and AHCCCS. The screenshot is a summary of the first page of the epip system. epip maintains the provider information and helps track each provider s progress in receiving incentive payments. To the left of the screen providers can pick options to help them oversee their participation in the program. On the Main Menu, providers can select: Manage My Account where they can review & edit their contact information Attest Where the provider can create & maintain attestations for separate program years Payments Where providers can track payments for separate program years Manage Documents Where providers can submit documents to support their attestation Log Off EPS log out of epip EHR Certification Tool Providers can validate their system CMS EHR Certification ID before applying Page 81 of 129
4.3.2 Establishing Adequate Technical Systems and Administrative Processes (SMHP Template Questions #14, 15, 16, 17, 18, 19, 20, 21, 23, 24, 25, 26and 28) The EHR Incentive Program has long-established systems (such as the Electronic Provider Incentive Payment system, also known as epip, and all other systems such as PMMIS, Outlook, Oracle, and AFIS - described below) in place to support all aspects of attestation, review, payment, audit, and ongoing provider support. There are no planned changes to the systems beyond those that are needed to maintain operations of the Program or support federal Rule changes. Regarding the recent Flexibility Rule, changes have been submitted to CMS for review via a separate amendment. Once the changes are approved, additional detail will be added to this document. Page 82 of 129
In order to achieve the goals and objectives of the EHR Incentive Payment Program, AHCCCS adopted and established the appropriate technical infrastructure to support key initiatives and activities. The following systems were utilized: Agency website for general information regarding the HITECH Act and the EHR Incentive Program, including instructions on who was eligible, how and where to register, what was needed to request a Medicaid EHR incentive payment, and contact information for questions or more information PMMIS subsystems, including: o o o Provider: To validate provider Medicaid status, type of service, NPI, TIN, and EFT status Finance and Payments: To process the actual incentive payments Data Warehouse: To capture the Medicaid EHR Incentive Program data, report provider patient volume, and generate program reports Microsoft Outlook email for communication with providers as they register and progress through the process to payment The epip was built for provider registration, attestation, and payment. The epip system interfaces with the R&A system at CMS and PMMIS. AHCCCS will use PMMIS as a source for current provider information. The website accesses PMMIS using a script to call provider information. No modifications to PMMIS have been needed given AHCCCS has modified the system to comply with the new HIPAA standards, 5010, and will implement ICD-10 in October 2015. APDs are already approved for these projects. However, the epip continues to be updated according to the new rules for Stage 1 Meaningful Use, Stage 2 Meaningful Use, and will continue to change as new rules are published in the future. AHCCCS began file exchange testing work with CMS for this program on October 1, 2010. Arizona was in the second group of states to test with the NLR which started in January 2011. AHCCCS has been capable of interfacing with the CMS National Level Repository (NLR) since July 2011. Additionally, AHCCCS has met the IT system modification milestones as described below with additional detail provided in Appendix G in the program implementation timeline milestones. The process AHCCCS will use to assure that all Federal funding, both for the 100% incentive payments as well as the 90% Administrative match are accounted for separately and not commingled with the MMIS FFP is that at this time the agency has not requested any MMIS funds for the HITECH program. All EHR program activity is tracked separately from other agency activities and are reported on the CMS 64 on its own line items. The process AHCCCS will use to assure that payments go to an entity promoting the adoption of certified EHR technology and are designated by the state if participation in the arrangement is voluntary and is no more than 5% of payments are retained for cost unrelated to EHR technology adoption. This is not applicable to AHCCCS. AHCCCS did not delegate the promotion to any entity for the adoption of the certified EHR technology or handling of any incentive payments to an external entity. Additionally, AHCCCS ensures that no EHR incentive payments go through the MCO capitation process because the incentive payments are being paid by the agency to the individual eligible professional and eligible hospital or as assigned. No funds are paid by the agency to MCOs for the EHR program. Table 4.2: AHCCCS IT Major Milestones Activity Completion Dates Implement MU Stage 1 Phase 2 2/15/2013 Page 83 of 129
Table 4.2: AHCCCS IT Major Milestones Activity Completion Dates Implement MU Stage 1 Phase 3 7/31/2014 Implement Stage 2 9/1/2014 AHCCCS received approval for the 2013 epip screens which capture Meaningful Use Stage 2 attestations. These screens are referenced in Appendix H. Currently, the Division of Health Care Management Clinical Quality Unit is responding to provider questions via phone (602-417-4333) and e-mail (EHRIncentivePayments@azahcccs.gov). AHCCCS has established a dedicated e-mail box for queries from providers. At any time during the process, a provider may submit a question and will be answered within two to three business days. AHCCCS also maintains a full-service website that includes access to epip, methods of contact for the EHR Incentive Program staff, provider resources such as guides and tools for all elements of attestation, and News. The site can be viewed at: http://www.azahcccs.gov/ehr/default.aspx. In addition, AHCCCS will continually work with and engage stakeholders to support and facilitate adoption and use of certified EHRs by EPs and EHs. Additionally, AHCCCS has implemented a process to account for all Federal funding. AHCCCS is required to follow the State Accounting Manual guidelines for recording accounting transactions. By policy, Federal Grants are recorded in the Federal Grants Fund. Separate tracking is maintained by unique grant and phase numbers in the State s accounting system (AFIS). The unique grant and phase numbers provide a separate account for each federal grant. By state statute, normal and APD/PAPD enhanced MMIS funds are accounted for in the AHCCCS Fund that is separate from the Federal Grants Fund and that will prevent any commingling of the HIT grant funds. In addition, to ensure that funding is being properly allocated by providers, the epip system that includes a statement that requires the provider to verify that they are voluntarily applying for this payment and that no more than five percent of such payment is retained for costs unrelated to EHR technology adoption. The provider signs an attestation to this fact. Additionally, AHCCCS ensures that no EHR reimbursement funds go through MCO capitation process given that the funds are being paid by the Agency and not through the MCO. AHCCCS EHR Incentive payments are only made to EPs and EHs directly. 4.3.3 Appeals and Grievances (SMHP Template Questions #22) Should eligible providers have grievances regarding the EHR Incentive Program, AHCCCS will use the existing provider grievance and appeal process, which was established in accordance with federal CMS requirements. The appeals process is managed by the AHCCCS Office of Administrative Legal Services (OALS) that coordinates with EHR Program staff on all cases related to the EHR Program. Once a decision is made on an attestation, the provider is given detailed information regarding their options, which include resubmission (if applicable) and the appeal process. Providers are able to work with EHR staff throughout the entire process to help resolve any questions or concerns. Providers that choose to appeal must submit a written request to AHCCCS OALS as outlined in their Decision Notification. An appeal is a request from an EP and EH to reconsider or change a decision, also known as an action. Eligible providers may appeal all AHCCCS adverse decisions. The provider may appeal any of the following decisions: Provider eligibility determinations Demonstration of adoption, implementation or upgrade of certified EHR technology Page 84 of 129
Meaningful Use eligibility Denial of EHR Incentive Program payment Level or amount of payment Recoupment of payment Request for an appeal must be sent within 30 days of the date of AHCCCS notice. 4.3.4 Role of Contractors (SMHP Template Question #28) AHCCCS MCOs will be involved in communicating pre-established information to the provider networks with which they contract and to direct providers to the AHCCCS website for more detailed information. AHCCCS MCOs will be asked to indicate support for the implementation of EHRs in provider practices to improve the efficiency of health care and to improve clinical outcomes measures. AHCCCS has a state-operated MMIS which was developed, and is currently maintained and operated by a combination of FTEs and staff-augmented consultants. A similar combination of staff and consultants are developing the EHR Electronic Provider Incentive Payment System. Page 85 of 129
5 Audit and Oversight Section 5 provides a general overview outlining how Arizona plans to accept and validate data from Medicaid Eligible Professionals and Eligible Hospitals seeking to demonstrate the Meaningful Use of Health Information Technology (HIT). The Health Information Technology for Economic and Clinical Health (HITECH) Act required that States develop financial oversight and monitoring of expenditures for the Medicaid EHR Incentive Program. In addition, this section also provides a description of how AHCCCS will respond when identifying providers and hospitals that are at risk for improper payments. Each sub-section includes references to the CMS template to demonstrate compliance with template requirements. However, please note that the processes and strategies identified in this section are subject to change as AHCCCS is in the process of identifying a subject matter expert to assist in the review of the audit process, including training needs related to audits, and efficiency and effectiveness of the audit strategy. 5.1 General Auditing Requirements and Processes (SMHP Template Question #1, 6) AHCCCS EHR Staff provides financial oversight and monitoring of the Medicaid EHR Incentive Program and have procedures in place for monitoring provider eligibility as a basis for making payments. This audit program establishes specific procedures to perform for each eligible provider participating in the Medicaid EHR Incentive Program prior to disbursing incentive payments. The procedures in this audit program are based on the following compliance requirements in 42 CFR 495.366. Table 5.1: Description of Federal Compliance Requirements Eligible Professionals Eligible Hospitals Collect and verify basic information on Medicaid providers to assure provider enrollment eligibility upon enrollment or reenrollment to the Medicaid EHR Incentive Program. Collect and verify basic information on Medicaid providers to assure patient volume. Collect and verify basic information on Medicaid providers to assure that EPs are not hospitalbased including the determination that substantially all health care services are not furnished in a hospital setting, either inpatient or outpatient. Collect and verify basic information on Medicaid providers to assure that EPs are practicing predominantly in a Federally Qualified Health Center (FQHC) or Rural Health Clinic (RHC). Have a process in place to assure that Medicaid providers who wish to participate in the Medicaid EHR Incentive Program has or will have a National Provider Identifier (NPI) and will choose only one program from which to receive the incentive payment using the NPI, a Tax Identification Number (TIN), and CMS national provider election database. Collect and verify basic information on Medicaid providers to assure provider enrollment eligibility upon enrollment or reenrollment to the Medicaid EHR Incentive Program. Collect and verify basic information on Medicaid providers to assure patient volume. Page 86 of 129
AHCCCS s audit strategy will help create a structured process to determine if participants in the EHR Incentive Program meet the program requirements outlined by CMS and HITECH. One of the main goals of the state s audit strategy is to minimize risk of improper payments. Subsequently, the State s riskbased audit strategy provides pre- and post-payment procedures used while auditing providers to verify that EPs and EHs have adopted, implemented, or upgraded and meaningfully used certified EHR technology. The risks of making improper payments are reduced by leveraging the following quality controls within the Agency. The below areas will support the EHR Incentive Program Division of Health Care Management (DHCM) Clinical Quality Unit is responsible for auditing the provider s information, ensure calculations are accurate, and disburse payments for EPs and EHs who meet the program s requirements as well as for validating the Meaningful Use Measures and Clinical Quality Measures for EPs and EHs who meet the program s requirements CMS is responsible for validating the Meaningful Use Measures and Clinical Quality Measures for Eligible Hospitals who meet the program s requirements Information System Division is responsible for the accuracy of the validating tools in the Electronic Provider Incentive Payment (epip) System Office of Business Intelligence (OBI) is responsible for the accuracy of the business intelligence reports used to determine the provider s eligibility for the program. Division of Business & Finance (DBF) is responsible for the cash management, validity of the provider s Electronic Funds Transfer (EFT) accounts, financial reporting and disbursement or recovery of funds through a combination of monitoring and validation in the financial system before payments are made Office of Inspector General (OIG) is responsible for program integrity by preventing, detecting and investigating fraud and abuse through the Provider Compliance Division Investigative Analysis Unit, Investigations Unit and Provider Registration Units. DHCM Clinical Quality Unit will facilitate by identifying suspected fraud and abuse through the pre-payment and post-payment audits. OIG will also be responsible for conducting OIG, state, and medical board sanctions Office of Administrative Legal Services (OALS) is responsible for providing legal counsel to the EHR Staff and will support grievances and disputes Division of Fee-for-Service Management is responsible for assisting with pre-payment and post-payment audit checks AHCCCS has set parameters to identify potential questionable data that could be entered during the provider registration and attestation process. These elements include provider sanction checks and the review of attestation documentation as well as the validation of data submitted pertaining to patient volume, length of stay, and system certification. Application information that fall outside of those variances may require pre-payment review and will be flagged as potential post-payment audit cases. The pool of potential audit cases will be examined and assessed for risk and materiality. AHCCCS set a standard of conducting audits for all prepayments. Additionally, AHCCCS will adhere to the risk stratifications laid out in Section 5.3 for post payment audits. All post-payment audits may include review of detailed reports from the provider. Some audits may require a representative of AHCCCS to be onsite at the provider s office when the reports are queried and generated. Pre-payment controls are audits that are performed prior to the disbursement of the EHR Incentive Program payment. Automated and manual processes have been established to prevent improper payments. Pre- Page 87 of 129
payment audits will reduce the AHCCCS risk of disbursing incorrect payments. AHCCCS will perform the following pre-payment audit controls: System to System: Coordination between AHCCCS epip System and the CMS Registration & Attestation System will reduce incidences of erroneous/duplicate payments Medicaid System: The epip System will perform internal checks to reduce incidences of erroneous/duplicate payments Manual: The EHR Staff will perform reasonability and investigative checks to reduce incidences of erroneous/duplicate payments Post-payment audit controls are audits that are performed after the disbursement of the EHR incentive payment. AHCCCS has criteria in the work management tool that will flag providers as potential audit cases. These providers will collectively make up the audit pool. Auditable Reports are reports that can be assessed to validate the provider s data. These include: PMMIS/Data Warehouse Reports Medicare Cost Reports (CMS 2552-96, CMS 2552-10) Provider Registration Reports (State and Medicare) Business Intelligence Reports Providers who do not comply with the auditing requirements will be referred to the OIG for investigation. AHCCCS will rely on existing data to reduce provider burden and maintain integrity and efficacy of oversight processes. For instance, AHCCCS plans to use provider data in PMMIS to verify provider eligibility and to calculate projected patient volume percentages as well as verify reasonableness of Meaningful Use measure data. 5.2 Conducting Pre-Payment Audits (SMHP Template Question #1, 5) AHCCCS will conduct pre-payment verification when a provider or hospital applies for a Medicaid EHR Incentive Payment. The primary objective of the pre-payment audit is to reduce the risk of improper payment and to identify those providers which have submitted an improper attestation prior to payment. Pre-payment controls will include the verification of provider information, eligibility requirements, patient volume, adoption, implementation, or upgrade of certified EHR technology, Meaningful Use of EHR technology, and appropriate payment amounts. The following areas are evaluated: Provider Type Qualifications (Licensure, Sanctions, State Medicaid Provider) Practice Location (Hospital-Based, FQHC/RHC, PA Led) Volume (Patient Volume, Hospital- Based, Practice Predominantly, Average Length of Patient Stay) Certified EHR Technology Documentation (demonstration of legal contractual obligation) MU Measures (Core, Menu, and Clinical Quality Measures) including public health and exclusion requirements Payment Calculation Verification (Acute Care Hospitals & Children s Hospitals) Page 88 of 129
As part of the pre-payment audit strategy, AHCCCS identified data and documentation required to verify provider registration, including reports or proof of provider billing systems, evidence of EHR systems that have been adopted, installed, or upgraded, and additional parameters that trigger a prepayment review and audit flag. However, the EHR staff does not have the means to validate all eligibility data during pre-payment audit process. Some providers will need to submit additional documentation during the post-payment audit process. All documentation submitted with the provider s attestation is subject to audit. During the pre-payment audit, the EHR Staff will perform validation of the submitted numerator and performs reasonableness checks on the submitted denominator since the State cannot validate the provider s denominator. AHCCCS established tolerance variance which allows the EHR staff to define the risk of misstatement that can be accepted while still approving an incentive payment during the prepayment process. When a provider submits a numerator within the tolerance variance, despite the overall outcome, it offers some level of confidence that the provider submitted denominator may be materially correct. Should the EHR Staff identify significant variances when reviewing the attestation, the risk increases that the denominator may be materially incorrect. Therefore, the EHR Staff is closely examining any variance that exceeds the recommended tolerance variance to determine if a legitimate cause for this variance exists. AHCCCS is using the following guidelines: A base tolerance variance of 20 percent Additional review when any variance identified (even less than 20 percent) would make the provider ineligible Review of all variances above 20 percent Engage the DHCM Data Research and Analysis Team for cases that raise a significant level of concern Documents the reason for approval (or denial) for all provider submitted attestations Pre-payment audits will most likely identify differences between self-reported data submitted by EPs and EHs and actual historical claims data, cost reports, projected estimates of total utilization, and other potential sources utilized to validate providers attestations. The basis for each analysis and the overall variance calculated will utilize actual claims data and/or cost report information. Certain self-reported amounts will be compared to available data in order to perform the following: Test the provider s assertions for reasonableness Determine the difference between the Patient Volume and historical claims data or other source Determine the percentage difference between the Patient Volume and historical claims data or other source Determine variance between MU measure data and Medicaid encounter data, Public Health testing/submission data and/or measure thresholds vs. actual rates reported Recommend approval or denial of an incentive payment or other potential action. If fraud, waste or abuse is detected during the pre-payment audit, a referral is submitted with documented evidence of the fraud, waste, or abuse to the OIG. The EHR Staff summarizes tracks and monitors the pre-payment audit results for all of the EPs who have applied for the Medicaid EHR Incentive Program. Page 89 of 129
5.3 Conducting Post Payment Reviews (SMHP Template Question #5) Post-payment review procedures are designed to assist AHCCCS in identifying recoupment indicators and other potential improper payments. Using defined risk categories and thresholds, EPs and EHs receiving a Medicaid incentive payment will be subject to a post-payment review. Please note that AHCCCS will audit all EHs pre-and-post payment. A risk-based approach is used for the post-payment audits to target providers that may pose an elevated risk of improper payments and noncompliance with the requirements of the Medicaid EHR Incentive Program. AHCCCS EHR staff will gather, and analyze data and conduct desk reviews and/or on-site visits. All providers are subject to a post-payment audit review and those with variances greater than the tolerance variance will be placed into a higher risk audit flag. Table 5.2: Risk Stratification Description Risk Strata High-Risk Providers Medium- to High- Risk Providers Medium-Risk Providers Low-Medium-Risk Providers Low-Risk Providers Sampling Methodology Providers whose overall risk score is assessed as high are selected for a desk level review and/or an option of an on-site review to perform the postpayment audit. Providers whose overall risk score is assessed as medium-high is selected for a desk review to perform the post-payment audit. A random sample of providers whose overall risk scores is assessed as medium are selected for a desk review to perform the post-payment audit.. The number of providers selected for a post-payment audit is 40 percent of the medium risk audit pool. A random sample of providers whose overall risk score is assessed as lowmedium is selected for a desk review to perform the post-payment audit. The number of providers selected for a post-payment audit is 20 percent of the low - medium risk audit pool. A random sample of providers whose overall risk score is assessed as low is selected for a desk review to perform the post-payment audit. The number of providers selected for a post-payment audit is five percent of the low risk audit pool. To verify the accuracy of post-payment audits, AHCCCS may require providers to submit additional documentation. AHCCCS will review cases where erroneous information was provided or duplicative payments are identified. Based on the nature and extent of the infraction, AHCCCS can determine next steps, including but not limited to the following: Disqualifying the provider from receiving future payments Recouping incentive funds already paid to a provider and returning the funds to CMS Conducting an on-site audit once the payment has been issued Audits will generally start as desk audits. However, if compliance cannot be determined and the desk audit is deemed insufficient, an on-site audit will be scheduled with the EP or EH. The goal of the on-site review is to support EPs and EHs to be in a position to adequately participate in the EHR Incentive Program. Page 90 of 129
5.4 Tracking Meaningful Use (SMHP Template Question #4) Meaningful Use measures are evaluated based on requirement outlined in 42 CFR 495.6 (d-k), depending on the Stage the EP is attesting to. Measures are evaluated for reasonableness in comparison to AHCCCS encounter data, public health status summaries, measure threshold requirements, and responses from like provider types. Additional information can be found in the comprehensive audit strategy, provided separately. The audit procedures for verifying Meaningful Use of certified EHRs will be designed to test the accuracy of eligible providers reporting and calculations for core and menu set requirements, in addition to CQMs. AHCCCS may verify reported clinical data against existing databases as they become operational. AHCCCS audit strategy for Meaningful Use will closely adhere to the guidelines set forth by CMS. However, specifically AHCCCS is evaluating existing monitoring and validation processes such as the immunization audit, data validation projects, medical record reviews of Primary Care Physicians and high volume (50 or more patients) specialists, to identify opportunities for the Agency to leverage existing data sources with the audit process 5.5 Monitoring Fraud and Abuse (SMHP Template Questions #1, 2, 3, 7, and 8) Suspected fraud, waste or abuse may be detected at any point during the audit process. The epip System and AHCCCS policies and procedures include validation checks and audit controls throughout the entire process of the payment cycle, to identify potential fraud and abuse issues. At any time in the process, if fraud or abuse is suspected, AHCCCS EHR staff will submit all relevant details to the OIG pursuant to that office s guidelines. The Clinical Quality Unit of AHCCCS Department of Health Care Management will calculate provider payments/recoupments. Debits and Credits for provider payments and recoupments will be made through the Department of Business and Finance and coordinated with the Information Services Division (ISD). OIG is the office charged with the responsibility for conducting criminal investigations and investigative audits for all AHCCCS programs involving State and/or federal tax dollars. This office is also responsible for overseeing provider registration functions in the Arizona Medicaid program. The OIG is designated as a criminal justice Agency and is authorized by the FBI and the Arizona Department of Public Safety to access criminal justice information relevant to official investigations. The office has statutory authority to issue subpoenas and place persons under oath to obtain evidence for investigations. Additionally, the unit works closely with federal, State and local law enforcement agencies in the detection, investigation and prosecution of any provider, subcontractor, member or employee involved in fraudulent activity involving the program. In addition to criminal investigations, OIG also issues and collects civil monetary penalties in accordance with federal and State statutes, rules and regulations. AHCCCS currently tracks all supplemental payments to providers. The EHR incentive payments will be tracked with standard payment tracking procedures that are used for all other supplemental payments. In the event that AHCCCS recoups EHR funds: DHCM will write a certifying memo to the Division of Business and Finance (DBF), indicating the provider name, AHCCCS Provider Number, and any payments and/or amount to be recouped. ISD will process recoupments in epip and disburse payments to CMS and DBF DBF will load recoupment amounts into payment system (Oracle) via the Invoice Files DHCM or OIG will issue a demand letter to providers ISD will process recoupment amounts in the Invoice Files Page 91 of 129
If funds are not received within 60 days, DHCM will send a memo to OIG that will include the following: o o o o o Provider attestation Details Date of original payment Reason for recoupment Amount of recoupment Correspondence regarding recoupment, communication with provider Page 92 of 129
6 Program Evaluation, Metrics, and Targets Section 6 provides a description on how AHCCCS will monitor and evaluate the success of the Medicaid EHR Incentive Program as well as EHR/HIT adoption by providers and hospitals. This section will also outline special projects or programs that AHCCCS plans to implement to ensure that the State is achieving their overall HIT goals. Each subsection includes references to the CMs template to demonstrate compliance with the template requirements. 6.1 AHCCCS High-Level Strategy for HIT (SMHP Template Questions #1, 2, and 3) AHCCCS developed several goals to support the State s HIT vision to encourage the adoption of certified EHR technology and promote health care quality among EPs and EHs, as described in Section 3. These goals align with the high-level strategy for AHCCC s HIT plan. The following figure provides an overview of the Agency s HIT goals over the next few years. Figure 6.1: AHCCCS High-Level HIT Strategy Page 93 of 129
6.1.1 Increase the Adoption of EHR by EPs and EHs In addition to Agency long-term goals for their EHR Incentive Program, AHCCCS is committed to encouraging EHR and HIT adoption for eligible providers in the next five years. The following table provides an overview of the number of EPs in Arizona expected to apply and qualify for the EHR Incentive Program: Table 6.1: AHCCCS Goals for Eligible Professionals EHR Adoption, Meaningful Use Program Metrics SFY 2014-2019 *SFY 2014 SFY 2015 Estimates SFY 2016 Estimates SFY 2017 Estimates SFY 2018 Estimates SFY 2019 Estimates EP Registered in epip 3,909 4,200 5,000 5,000 5,000 5,000 EP Receive AIU payment 2,555 2800 4,400 4,400 4,400 4,400 Registered EP Received AIU Payment 65.4% 66.7% 85.0% 85.0% 85.0% 85.0% EP Receive MU Stage 1 Payment 482 1,100 2,000 2,600 3,100 3,520 Successful AIU EP Received MU Stage 1 18.9% 30.4% 45.5% 59.1% 70.5% 80.0% Payment EP Receive MU Stage 2** Payment 0 75 350 800 1,300 1,850 Successful MU1 EP Received MU Stage 2 0.0% 6.8% 17.5% 30.8% 41.9% 52.6% Payment EP Receive MU Stage 3 Payment 0 0 0 0 50 400 Successful MU2 EP Received MU Stage 3 0.0% 0.0% 0.0% 0.0% 3.8% 21.6% Payment *Note: Please note that the State Fiscal Year (SFY) goes from July 1 to June 30 **Note: The earliest MU Stage 2 attestation date will be 9/2014. As described by the table, AHCCCS anticipates that approximately 85 percent of their EPs will receive a payment for the AIU of certified EHR technology. However, given the delayed implementation of Stage 2 and Stage 3, the Agency anticipates that the number of EPs qualifying for Stage 2 and 3 will be less than the EPs qualifying for Stage 1. In addition, these projections are based on the timely release of Stage 3 guidance from CMS. AHCCCS is also committed to support the adoption, implementation, and upgrades for certified EHRs to meet Meaningful Use for EHs. AHCCCS anticipates that hospitals representing ninety percent of inpatient days will qualify and meet Meaningful Use and achieve four years of EHR Incentive Program payments by 2020. Table 6.2 provides an overview of the number of EHs in Arizona expected to apply and qualify for the EHR Incentive Program: Page 94 of 129
Table 6.2: AHCCCS Goals for Eligible Hospitals EHR Adoption, Meaningful Use Program Metrics SFY 2014-2019 SFY 2015 SFY 2016 SFY 2017 SFY 2018 SFY 2014 Estimates Estimates Estimates Estimates SFY 2019 Estimates EH Registered in epip 73 73 74 74 74 74 EH Receive AIU payment 67 70 73 73 73 73 Registered EH Received AIU Payment 91.8% 95.9% 98.6% 98.6% 98.6% 98.6% EH Receive MU Stage 1 payment 55 2 69 71 73 73 Successful AIU EH Received MU1 82.1% 87.2% 94.5% 97.3% 100.0% 100.0% Payment EH Receive MU Stage 2* payment 1 4 12 18 24 26 Successful MU Stage 1 EH Received MU 1.8% 6.5% 19.4% 25.4% 32.9% 35.6% Stage 2 Payment EH Receive MU Stage 3 payment 0 0 0 0 0 0 Successful MU Stage 2 EH Received MU 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% Stage 3 Payment *Note: Please note that the State Fiscal Year (SFY) goes from July 1 to July 30 **Note: The earliest Meaningful Use 2 attestation date will be 9/2014. The table above illustrates the number of EHs projected to receive AIU and Meaningful Use Stage 1, 2, and 3 payments. AHCCCS anticipates that of the 74 registered EHs, 73 will receive an AIU payment, 73 will receive a Stage 1 payment, 26 will receive a Stage 2 payment, and 0 will receive a Stage 3 payment. This decrease in the number of payments disbursed after Stage 1 is due to the fact that EHs are only required to report AIU and Meaningful Use data for four years. AHCCCS assumes that EHs will not take the burden of reporting Stage 3 Meaningful Use metric if not required by the State or federal governments. 6.1.2 Accelerate Statewide HIE Participation for all Medicaid Providers and Plans One of the main objectives for AHCCCS in their HIT program is the ability to exchange health information among providers as a way of diminishing adverse events and increasing the quality of care being delivered to patients. As a result, AHCCCS is committed to implementing and expanding the HIE Onboarding Program for current and future populations. AHCCCS established that by 2019: There will be 100 percent of CAH connected to the HIE There will be 100 percent of IHS and 638 hospitals that connect and share data There will be 100 percent of FQHCS/RHCS connected to the HIE by 2018 There will be 90 percent of all Medicaid EPs receiving Meaningful Use Stage 2 incentive payments that will move forward in the HIE The majority of other eligible EP types will begin to connect and share data in the HIE Page 95 of 129
6.1.3 Ensure Program Integrity (SMHP Template Question #4) AHCCCS is also committed to ensuring program integrity and conducting comprehensive audit and oversight activities. In order to verify the eligible providers participating in the program, AHCCCS will conduct several audits. The pool of potential audit cases will be examined every six (6) months for risk assessment and materiality. AHCCCS will perform post payment audits based on the risk stratification criteria identified in Section 5. Please note, however, that all payments go through a pre-payment audit conducted by AHCCCS. In addition, AHCCCS is seeking a subject matter expert to assist and conduct an evaluation regarding the effectiveness and efficiency of the audit process. Subsequently, the audit and program integrity benchmarks will be subject to change based on these findings. The following table provides an illustration of the audit and oversight benchmarks estimated by AHCCCS for the EHR Incentive Program for 2014-2019: Table 6.3: Predicted Audit & Oversight Cumulative Annual Benchmarks Year Audits of Previous Year 2014 15 2015 225 2016 600 2017 900 2018 1,200 2019 1,500 Page 96 of 129
7 APPENDICES Appendix A 7.1: Acronyms B 7.2: Description of Changes Version 5.0 August 2014 C 7.3: Crosswalk Between AHCCCS SMHP and CMS Requirements D 7.4: Description of AHCCCS Executive Offices E 7.5: Hospital Medicaid EHR Incentive Payment Detail F 7.6: Sample of Eligible Hospital EHR Incentive Program Payment Calculation G 7.7: Arizona Medicaid EHR Incentive Program Implementation Calendar 7.8: Appendices H J Please note that the following appendices are not included in this document due to size and can be viewed separately. H epip Screen Shots I Version 5.0 Change Control Document J HIE Financial Statements Item Page 97 of 129
7.1 Appendix A: Acronyms Acronym Definition ACE AHCCCS Customer Eligibility ADHS Arizona Department of Health Services AHCCCS Arizona Health Care Cost Containment System AI / AN American Indian / Alaska Native AIU / AIU1 Adoption, Implementation or Upgrade; AIU for first year ARRA American Recovery and Reinvestment Act ASIIS Arizona Statewide Immunization Information System ASET Arizona Strategic Enterprise Technology ASU-BMI Arizona State University s Department of Biomedical Informatics AzHeC Arizona Health-e Connection CAH Critical Access Hospital CCN CMS Certification Number CHIP Children s Health Insurance Program (also known as KidsCare in Arizona) CIO Chief Information Office CMS Centers for Medicare and Medicaid Services CY Calendar Year (used by Eligible Professionals) DBF Division of Business & Finance DEA Drug Enforcement Agency DHCM Division of Health Care Management DSH Disproportionate Share Hospital Report EFT Electronic Funds Transfer EIN Employer Identification Number EH Eligible Hospital EHR Electronic Health Record EHR IP Electronic Health Record Incentive Program EP Eligible Professional epip Electronic Provider Incentive Payment System FFY Federal Fiscal Year (used by Eligible Hospitals in the EHR Incentive Program) FQHC Federally Qualified Health Center FTP File Transfer Protocol FY Fiscal Year (used by Hospitals) GOER Governor s Office of Economic Recovery HIE Health Information Exchange HIPAA Health Insurance Portability and Accountability Act of 1996 HIT Health Information Technology HITECH Health Information Technology for Economic and Clinical Health Act HINAz Health Information Network of Arizona HIX Health Insurance Exchange HSAG Health Services Advisory Group HRSA Health Resources Services Administration I&A CMS Identity & Access Management IAPD Implementation Advanced Planning Document ICD-9/10 International Classification of Diseases IHS Indian Health Services ITU IHS, Tribal & Urban Indian Health Facilities (also referred to as IHS and 638 Tribally Operated Facilities) LEIE List of Excluded Individuals/Entities Page 98 of 129
Acronym Definition MCR MED MU/MU1 MMIS NIHB NLR NPI NPPES OAH OIG ONC ONC-ATCB PA PMMIS R&A REC RHC RPMS SMHP SSI TIN Medicare Cost Report Medicare Exclusion Database Meaningful Use; Meaningful Use for first year Medicaid Management Information Systems National Indian Health Board National Level Repository; also known as CMS Registration & Attestation System National Provider Identifier National Plan & Provider Enumeration System Office of Administrative Hearings Office of Inspector General Office of the National Coordinator for Health Information Technology Office of the National Coordinator - Authorized Testing & Certification Board Physician Assistant Prepaid Medicaid Management Information System CMS Registration and Attestation System Regional Extension Center Rural Health Clinic Regional Extension Center State Medicaid Health Information Technology Plan Supplemental Security Income Taxpayer Identification Number; (Also see Payee TIN) Page 99 of 129
7.2 Appendix B: Description of Changes Version 5.0 August 2014 The revised SMHP updates all sections to reflect the activities that AHCCCS has undertaken to administer the EHR incentive program and covers activities that AHCCCS will be involved in over the next five years to implement Medicaid provisions of section 4201 of the American Recovery and Reinvestment Act (ARRA) AHCCCS has developed multiple objectives central to the goals of its HIT planning initiative that builds on the Electronic Health Record and Health Information Exchange investments made by CMS and ONC. These goals are designed to move the Arizona Provider community from data capture and sharing into advanced clinical processes and improved outcomes. Arizona s Health IT Roadmap 2.0 describes 19 key initiatives to advance HIT/ HIE recommending action in areas ranging from stakeholder engagement and policy development to technology infrastructure implementation, and exploration of innovative technology models that support care delivery transformation. An overview of major changes is described section-by-section below with a more detailed table of changes immediately following. Section 1: State and AHCCCS Background Updated number of recipients enrolled in Arizona s Medicaid program Updated the number of providers receiving the incentive payments, Updated Arizona s Healthcare cost Containment Organizational Chart Updated discussion of Medicaid population and program Section 2: Current HIT Landscape, As Is Environment (Corresponds to Section A of the CMS SMHP Template) Section A has been updated throughout to reflect EHR adoption by practitioners and hospitals, the status of state wide planning for enabling health information exchange and activities that AHCCCS is engaging in to facilitate HIE and EHR adoption including the status of broadband coverage. Updated EHR adoption rates by professionals and hospitals Updated BAP Broadband Coverage Spring 2014 Updated discussion of integrated Medicaid IT Environment Updated information on FQHCs participating in the incentive program Added Arizona s Health IT Roadmap 2.0 which provides strategies on EHR adoption and advancement of HIT/HIE in Arizona. Updates regarding REC and AHCCCS partnership in 2014 Added The Network Board of Directors updated HINAz governing members Added description of 90/10 activities from approved IAPD HIE onboarding and public health initiatives Updated AHCCCS HIT Steering Committee Updated strategic opportunities for HIT/HIE Section 3: Future HIT Landscape, To Be Environment (Corresponds to Section B of the CMS SMHP Template) Describes HIT/HIE goals and objectives that AHCCCS expects to achieve in the next five years and strategies used to ensure EHR adoption. Added AHCCCS 5 year HIT/HIE Strategic Plan 2014-2019 Updates related to the three stages of Meaningful Use reporting by providers and projected years for each stage Figure 3.3: Roadmap 2.0 Timeline describes the 19 key initiatives to advance HIT/HIE Plans to collect ecqm, allow providers to attest to Meaningful Use Stage 2 Section 4: Program Implementation and Administration (Corresponds to Section C of the CMS SMHP Template) This section provides details on how AHCCCS intends to ensure the quality and efficacy of their EHR incentive program through monitoring and providing appropriate training to EPs and EHs Page 100 of 129
Updates IT timeframes for system modifications Updated to describe application and enrollment process in program year 2 and beyond. Minor updates to EHR incentive program payment methodologies Updates to AHCCCS IT major milestones Section 5: Audit and Oversight (Corresponds to Section D, Auditing Strategy, of the CMS SMHP Template) The audit section outlines AZ s plan to validate data from Medicaid eligible providers and eligible hospitals demonstrating the Meaningful Use of health information technology including steps for dealing with improper payments Updates on post payment reviews and audit conclusions. Updates for monitoring fraud and abuse Section 6: Program Evaluation, Metrics, and Targets (Corresponds to Section E, HIT Roadmap, of the CMS SMHP Template) Describes how AHCCCS will evaluate the success of EHR/HIT adoption by providers and Hospitals including plans to implement the state s HIT goals Includes HINAz benchmarks to meet reporting requirements for CMS Included HIE onboarding long term goals for expanding the onboarding program for current and future populations Appendices No significant changes made on the glossary of common HIT terms. Added summary of changes made to version the August 2014 revised SMHP. Added crosswalk between AHCCCS SMHP and CMS Requirements Updated AHCCCS Executive and Divisional Offices No changes to Sample of Eligible Hospital EHR Incentive program payment calculation Updated epip screenshot Includes changes to version 5.0 control document. Page 101 of 129
Requirement Description SMHP Page Number CMS Requirements - include in August 2014 SMHP Update Revise and cite the HIE and Data sources Submit IAPDU outlining the Public Health HIE funding for (3) key Public Health measures upon fair share approval Show intent to have the public health agency support the 10% state match For the proposed fair share formula - specifically for the creation of the electronic submission of required electronic lab results for State 2 MU. (3) Key Public Health measures: syndromic surveillance, immunization, and electronic lab reporting Include website with TA Discussion begins on page 43 Discussion begins on page 39 ISA was signed Budget in OPS 39 2013 Medicaid changes Stage 1 Information on EHR climate/ Environmental Scan HIE governance activities These are MU screen changes. All changes must be approved in the SMHP before AZ can accept program 2013 attestations Provide more information on details regarding EHR climate and plans for updating the environmental scan, including adoption rates (not just percentages) Description of activities which describes geographic reach. Need more timeline information and expansion of technology components description Page 82, Appendix H Discussion begins on page 12 Pages 26-30, 66-67 Telemedicine Effects MITA Waiver Program HIE and Public Health Surveillance IT System Architecture HIE governance structure Registry performance metrics Describe how telemedicine will effect the EHR program landscape (p. 46) 23 Include discussion on MITA and reference section in HIT - IAPD 53 Provide updates on waiver program and whether the updates have any effects on EHR incentive payments There is no impact on the EHR Incentive Program Discussion begins on page 39 Align information from IAPD into SMHP regarding HIE and Public Health Surveillance (p. 79) Include more information in the Figure on p. 105 above the agency's IT system architecture as it affects the operational technology components over the next 5 years. 69 HIE governance structure plan for the next 5 years speaks about plans to incorporate HIE connectivity but doesn't include information about structure or timeframe (p. 106) Role of Board Pages 26-30, 66-67 Provide a description of performance metrics for each developed or enhanced registry (p. 118-123) 26 Page 102 of 129
Requirement Description SMHP Page Number CMS Requirements - include in August 2014 SMHP Update State HIT Roadmap completion Describe how roadmap will be completed in November 2013 and update SMHP to reflect findings Roadmap 2.0 is complete and described on pages 54, 64 Provider EHR adoption HIE Annual Benchmarks - Contributions HIE Annual Benchmarks - Successful Connections HIE Annual Benchmarks - Covered Lives HIE Annual Benchmarks - Goal Progress HIE Annual Benchmarks - Financial Status HIE Annual Benchmarks - Electronic Quality Measures HIE Annual Benchmarks - MU HIE Annual Benchmarks - Leadership Describe the SMAs expectations for provider EHR adoption - elaborate on technology adoption (p. 269) Pages 26-30, 66-67 Identify all other payers and how much they have contributed to the HIE. Specify whether it was direct funding and/or in-kind each year. Please provide details. High-level pie chart 25 Provide the cumulative number and % of total providers successfully connected to the HIE each year overall. Provide the same for total Medicaid providers, and of those, separate by Medicare, Medicaid Eligible Hospitals, or EPS 26 Provide cumulative number and % of total Medicaid covered lives. Provide context needed to understand the growth or lack of growth (may include Medicaid providers: accessing the HIE viewer to get information, receiving hospital alerts from provider notification services, sending data to the HIE from their EHR or having a direct account regardless of how it is used. 26 In Appendix D, provide a status update on meeting the Year 1 goals for onboarding hospitals and FQHCs/RHCs 38 Provide prior year's financial statement for the HIE plus any other details to help explain financial status Appendix J Provide information on progress for using the HIE to capture clinical quality measures electronically from EHRs for Medicaid providers participating in the Medicaid EHR incentive program 67 Provide information on progress in enabling MU (e.g., connections to public health facilities and successful transmissions of summary of care records) 67 Identify any changes in HIE leadership in the prior year. No leadership changes made. Page 103 of 129
Requirement CMS Recommended Changes Description SMHP Page Number EHR Program Administration & Oversight - Messaging EHR Program Administration & Oversight - Coordination Elaborate on next steps for messaging for providers to check for attestation and payment progress 81 Elaborate on coordination efforts with Public Health to verify MU attestation information IAPD Discussion begins on page 39 EHR Program Administration & Oversight - Changes Elaborate on changes in MU definition 78 EHR Program Administration & Oversight - Methodologies Elaborate on payment reform methodologies. 72, 80 EHR Program Administration & Oversight - References Provide references information for APDS approving the MMIS 53 Page 104 of 129
7.3 Appendix C: Crosswalk between AHCCCS SMHP and CMS Requirements No. Section A: The State s As Is HIT Landscape (Arizona SMHP Section 2) 1. What is the current extent of EHR adoption by practitioners and by hospitals? How recent is this data? Does it provide specificity about the types of EHRs in use by the State s providers? Is it specific to just Medicaid or an assessment of overall statewide use of EHRs? Does the SMA have data or estimates on eligible providers broken out by types of provider? Does the SMA have data on EHR adoption by types of provider (e.g. children s hospitals, acute care hospitals, pediatricians, nurse practitioners, etc.)? 2. To what extent does broadband internet access pose a challenge to HIT/E in the State s rural areas? Did the State receive any broadband grants? 3. Does the State have Federally-Qualified Health Center networks that have received or are receiving HIT/EHR funding from the Health Resources Services Administration (HRSA)? Please describe. 4. Does the State have Veterans Administration or Indian Health Service clinical facilities that are operating EHRs? Please describe. 5. What stakeholders are engaged in any existing HIT/E activities and how would the extent of their involvement be characterized? 6. * Does the SMA have HIT/E relationships with other entities? If so, what is the nature (governance, fiscal, geographic scope, etc.) of these activities? 7. Specifically, if there are health information exchange organizations in the State, what is their governance structure and is the SMA involved? ** How extensive is their geographic reach and scope of participation? 8. Please describe the role of the MMIS in the SMA s current HIT/E environment. Has the State coordinated their HIT Plan with their MITA transition plans and if so, briefly describe how. 9. What State activities are currently underway or in the planning phase to facilitate HIE and EHR adoption? What role does the SMA play? Who else is currently involved? For example, how are the regional extension centers (RECs) assisting Medicaid eligible providers to implement EHR systems and achieve Meaningful Use? 10. Explain the SMA s relationship to the State HIT Coordinator and how the activities planned under the ONC-funded HIE cooperative agreement and the Regional Extension Centers (and Local Extension Centers, if applicable) would help support the administration of the EHR Incentive Program. 11. What other activities does the SMA currently have underway that will likely influence the direction of the EHR Incentive Program over the next five years? 12. Have there been any recent changes (of a significant degree) to State laws or regulations that might affect the implementation of the EHR Incentive Program? Please describe. 13. Are there any HIT/E activities that cross State borders? Is there significant crossing of State lines for accessing health care services by Medicaid beneficiaries? Please describe. 14. What is the current interoperability status of the State Immunization registry and Public Health Surveillance reporting database(s)? 15. If the State was awarded an HIT-related grant, such as a Transformation Grant or a CHIPRA HIT grant, please include a brief description Page Number of Arizona SMHP Section 12 20 15 15 48 23 23 49 31 5 (Introduction) 23, 31 73 23 48 53 Page 105 of 129
No. Section B: To Be Landscape (Arizona SMHP Section 3) 1. Looking forward to the next five years, what specific HIT/E goals and objectives does the SMA expect to achieve? Be as specific as possible; e.g., the percentage of eligible providers adopting and meaningfully using certified EHR technology, the extent of access to HIE, etc. 2. *What will the SMA s IT system architecture (potentially including the MMIS) look like in five years to support achieving the SMA s long term goals and objectives? Internet portals? Enterprise Service Bus? Master Patient Index? Record Locater Service? 3. How will Medicaid providers interface with the SMA IT system as it relates to the EHR Incentive Program (registration, reporting of MU data, etc.)? 4. Given what is known about HIE governance structures currently in place, what should be in place by 5 years from now in order to achieve the SMA s HIT/E goals and objectives? While we do not expect the SMA to know the specific organizations will be involved, etc., we would appreciate a discussion of this in the context of what is missing today that would need to be in place five years from now to ensure EHR adoption and Meaningful Use of EHR technologies. 5. What specific steps is the SMA planning to take in the next 12 months to encourage provider adoption of certified EHR technology? 6. ** If the State has FQHCs with HRSA HIT/EHR funding, how will those resources and experiences be leveraged by the SMA to encourage EHR adoption? 7. ** How will the SMA assess and/or provide technical assistance to Medicaid providers around adoption and Meaningful Use of certified EHR technology? 8. ** How will the SMA assure that populations with unique needs, such as children, are appropriately addressed by the EHR Incentive Program? 9. If the State included in a description of a HIT-related grant award (or awards) in Section A, to the extent known, how will that grant, or grants, be leveraged for implementing the EHR Incentive Program, e.g. actual grant products, knowledge/lessons learned, stakeholder relationships, governance structures, legal/consent policies and agreements, etc.? 10. Does the SMA anticipate the need for new or State legislation or changes to existing State laws in order to implement the EHR Incentive Program and/or facilitate a successful EHR Incentive Program (e.g. State laws that may restrict the exchange of certain kinds of health information)? Please describe. Page Number of Arizona SMHP Section 60 60, 68 70 57 57 67 57 67 70 73 No. Section C: Activities Necessary to Administer and Oversee the EHR Incentive Payment Program (Arizona SMHP Section 4) Page Number of Arizona SMHP Section 1. How will the SMA verify that providers are not sanctioned, are properly licensed/qualified providers? 75 2. How will the SMA verify whether EPs are hospital-based or not? 75 3. How will the SMA verify the overall content of provider attestations? 75 4. How will the SMA communicate to its providers regarding their eligibility, payments, etc.? 81 5. What methodology will the SMA use to calculate patient volume? 75 6. What data sources will the SMA use to verify patient volume for EPs and acute care hospitals? 75 7. How will the SMA verify that EPs at FQHC/RHCs meet the practices predominately requirement? 75 8. How will the SMA verify adopt, implement or upgrade of certified electronic health record technology by providers? 75 9. How will the SMA verify Meaningful Use of certified EHR technology for 75 Page 106 of 129
No. Section C: Activities Necessary to Administer and Oversee the EHR Incentive Payment Program (Arizona SMHP Section 4) providers second participation years? 10. Will the SMA be proposing any changes to the MU definition as permissible per rule-making? If so, please provide details on the expected benefit to the Medicaid population as well as how the SMA assessed the issue of additional provider reporting and financial burden. 11. How will the SMA verify providers use of certified electronic health record technology? 12. How will the SMA collect providers Meaningful Use data, including the reporting of clinical quality measures? Does the State envision different approaches for the short-term and a different approach for the longer-term? 13. How will this data collection and analysis process align with the collection of other clinical quality measures data, such as CHIPRA? 14. What IT, fiscal and communication systems will be used to implement the EHR Incentive Program? 15. What IT systems changes are needed by the SMA to implement the EHR Incentive Program? Page Number of Arizona SMHP Section 78 77, 78 16. What is the SMA s IT timeframe for systems modifications? 81 17. When does the SMA anticipate being ready to test an interface with the CMS 83 National Level Repository (NLR)/Registration and Attestation System (R&A)? 18. What is the SMA s plan for accepting the registration data for its Medicaid providers from the CMS NLR/R&A (e.g. mainframe to mainframe interface or 81 another means)? 19. What kind of website will the SMA host for Medicaid providers for enrollment, program information, etc.? 20. Does the SMA anticipate modifications to the MMIS and if so, when does the SMA anticipate submitting an MMIS I-APD? 21. What kinds of call centers/help desks and other means will be established to address EP and hospital questions regarding the incentive program? 22. What will the SMA establish as a provider appeal process relative to: a) the incentive payments, b) provider eligibility determinations, and c) demonstration of efforts to adopt, implement or upgrade and Meaningful Use certified EHR technology? 23. What will be the process to assure that all Federal funding, both for the 100 percent incentive payments, as well as the 90 percent HIT Administrative match, are accounted for separately for the HITECH provisions and not reported in a commingled manner with the enhanced MMIS FFP? 24. What is the SMA s anticipated frequency for making the EHR Incentive payments (e.g. monthly, semi-monthly, etc.)? 25. What will be the process to assure that Medicaid provider payments are paid directly to the provider (or an employer or facility to which the provider has assigned payments) without any deduction or rebate? 26. What will be the process to assure that Medicaid payments go to an entity promoting the adoption of certified EHR technology, as designated by the state and approved by the US DHHS Secretary, are made only if participation in such a payment arrangement is voluntary by the EP and that no more than 5 percent of such payments is retained for costs unrelated to EHR technology adoption? 27. What will be the process to assure that there are fiscal arrangements with providers to disburse incentive payments through Medicaid Managed Care plans do not exceed 105% of the capitation rate per 42 CFR Part 438.6, as well as a methodology for verifying such information. 28. What will be the process to assure that all hospital calculations and EP payment 77 75,78 80 81 82 81 81 81 84 83 77 77, 81 83 83 Page 107 of 129
No. Section C: Activities Necessary to Administer and Oversee the EHR Incentive Payment Program (Arizona SMHP Section 4) incentives are made consistent with the Statute and regulation? 29. What will be the role of existing SMA contractors in implementing the EHR Incentive Program such as MMIS, PBM, fiscal agent, managed care contractors, etc.? 30. States should explicitly describe what their assumptions are, and where the path and timing of their plans have dependencies based upon: The role of CMS (e.g. the development and support of the National Level Repository; provider outreach/help desk support) The status/availability of certified EHR technology The role, approved plans and status of the Regional Extension Centers Page Number of Arizona SMHP Section 83 74 The role, approved plans and status of the HIE cooperative agreements State-specific readiness factors No. Section D: Audit Strategy (Arizona SMHP Section 5) 1. What will be the SMA s methods to be used to avoid making improper payments? (Timing, selection of which audit elements to examine pre or postpayment, use of proxy data, sampling, how the SMA will decide to focus audit efforts etc.): 2. Describe the methods the SMA will employ to identify suspected fraud and abuse, including noting if contractors will be used. Please identify what audit elements will be addressed through pre-payment controls or other methods and which audit elements will be addressed post-payment. 3. How will the SMA track the total dollar amount of overpayments identified by the State as a result of oversight activities conducted during the FFY? Page Number of Arizona SMHP Section 84, 86, 89 4. Describe the actions the SMA will take when fraud and abuse is detected. 89 5. Is the SMA planning to leverage existing data sources to verify Meaningful Use (e.g. HIEs, pharmacy hubs, immunization registries, public health surveillance databases, etc.)? Please describe. 6. Will the state be using sampling as part of audit strategy? If yes, what sampling methodology will be performed?* (i.e. probe sampling; random sampling) 7. **What methods will the SMA use to reduce provider burden and maintain integrity and efficacy of oversight process (e.g. above examples about leveraging existing data sources, piggy-backing on existing audit mechanisms/activities, etc.)? 8. Where are program integrity operations located within the State Medicaid Agency, and how will responsibility for EHR incentive payment oversight be allocated? No. Section E: HIT Roadmap (Arizona SMHP Section 6) 1. *Provide CMS with a graphical as well as narrative pathway that clearly shows where the SMA is starting from (As Is) today, where it expects to be five years from now (To Be), and how it plans to get there. 89 89 86, 88 84 89 89 Page Number of Arizona SMHP Section 2. What are the SMA s expectations re provider EHR technology adoption over 91 91 Page 108 of 129
No. Section E: HIT Roadmap (Arizona SMHP Section 6) time? Annual benchmarks by provider type? 3. Describe the annual benchmarks for each of the SMA s goals that will serve as clearly measurable indicators of progress along this scenario. Page Number of Arizona SMHP Section 4. Discuss annual benchmarks for audit and oversight activities 94 91 Page 109 of 129
7.4 Appendix D: Description of AHCCCS Executive Offices Director Deputy Director Chief Medical Officer Executives - Office of the Director The Director has overall responsibility for ensuring that the Agency meets the goals established in the Agency strategic plan and insures that the organization has the administrative infrastructure to meet the needs of the Agency. The Director provides strategic direction and manages high level, critical issues for the Agency at the local, state and federal levels. Through the Executive Staff, the Director manages all aspects of the Agency s business processes and is responsible for implementing and developing administrative policies and procedures to support the delivery of health care services for over one million AHCCCS members. Under the general direction of the Agency Director, the Deputy Director assumes responsibilities of the Director in his/her absence or discretion and represents the Agency among a wide range of Agency stakeholders. The Deputy Director oversees the majority of the Agency operations and is responsible for providing counsel and recommendations to the Director on Agency issues and programs. The Chief Medical Officer (CMO) oversees the quality and delivery of healthcare services provided by AHCCCS health plans and contractors. The Chief Medical Officer approves AHCCCS medical policies and assures the appropriate evaluation of the health plan s and contractor s compliance. The CMO can serve as an expert witness on behalf of AHCCCS and the state on legal and regulatory matters involving the provision of medical care services and assists in evaluating and resolving member and provider grievances if they were not resolved at lower levels. Divisions Reporting to the Director of AHCCCS Office of Inspector General Deputy Director Chief Medical Officer Administrative Legal Services Fee for Service Management Health Care Innovations Infrastructure Management Human Resources and Development HIT Coordinator Project Management/Payment Modernization Divisions Reporting to the Deputy Director of AHCCCS Business and Finance Business Intelligence and Analytics Information Services Intergovernmental Relations Member Services Health Care Management and Rate Development Divisions Reporting to the Chief Medical Officer of AHCCCS Clinical Services Health Care Management/Operations and Medical Management Medical Policy & Coding Page 110 of 129
7.5 Appendix E: Hospital Medicaid EHR Incentive Payment Detail CMS AHCCCS CCN Organization Name Register Register Attest Pre-Payment Audit Payment Post Payment Audit Program Years 30126 Apache Junction Hospital, LLC 2012 30107 Arizona Spine and Joint Hospital 30088 Banner Baywood Medical Center 2011 2012 Rev 30061 Banner Boswell Medical Center 2011 2012 Rev 30093 Banner Del E Webb Medical Center 2011 2012 2013 30065 Banner Desert Medical Center Review 2011 2012 Rev 30115 Banner Estrella Medical Center 2011 2012 2013 30122 Banner Gateway Medical Center Review 2012 2013 30134 Banner Goldfield Medical Center 30002 Banner Good Samaritan Medical Center 2011 2012 2013 30105 Banner Heart Hospital 30130 Banner Ironwood Medical Center 30089 Banner Thunderbird Medical Center 2011 2012 2013 31301 Benson Hospital Corporation Review 2011 2012 Rev 31312 Bisbee Hospital Association Copper Queen Community Hospital Review 2011 2012 2013 30101 Bullhead City Hospital Corporation Review 2012 Rev 30010 Carondelet Health Network Review 2011 2012 2013 30011 Carondelet Health Network Review 2011 2012 Rev 30100 Carondelet Heart & Vascular Institute 2011 Rev 30016 Casa Grande Community Hospital 2012 Rev 30036 Catholic Healthcare West 2012 Rev 30119 Catholic Healthcare West 2011 2013 30024 Catholic Healthcare West 2011 2013 31314 Cobre Valley Regional Medical Center Review 2011 2012 Page 111 of 129
CMS AHCCCS CCN Organization Name Register Register Attest Pre-Payment Audit Payment Post Payment Audit Program Years 31303 Community Healthcare of Douglas Inc 2011 2013 31300 COMMUNITY HOSPITAL ASSOCIATION 2012 Rev 30078 DHEW IND HLTH SV HLTH SVS & MNTL 2011 30077 DHHS PHS IHS PHOENIX AREA 30113 DHHS PHS IHS PHOENIX AREA 2012 31305 DHHS PHS IHS PHOENIX AREA 2012 31307 DHHS PHS IHS PHOENIX AREA 30074 30084 DHHS PHS IHS TUCSON AREA IHS TUCSON SELLS INDIAN HOSPITAL DHHS PHS NAIHS CHINLE COMPREHENSIVE HEALTH CARE FACILITY Review 2011 2012 Rev Review 2011 2012 2013 30023 Flagstaff Medical Center 2012 30132 Florence Hospital at Anthem, LLC 30129 Florence Hospital, LLC 31308 Gila River Health Care Corporation 2011 Rev 30120 Gilbert Hospital LLC 2013 30069 Havasu Regional Medical Center LLC 2011 2012 2013 31313 Holy Cross Hospital Inc 2011 2012 Rev 30110 Hospital Development of West Phoenix Inc 2011 2013 30014 John C. Lincoln Health Network 2012 2013 30092 John C. Lincoln Health Network 2012 2013 30055 Kingman Hospital Inc. 30067 La Paz Regional Hospital, Inc Review 2011 2012 2013 33301 Los Ninos Hospital Inc. 2012 2013 30022 Maricopa County Special Health Care District Review 2011 2012 Rev 30103 Mayo Clinic Arizona 30121 Mountain Vista Medical Center LP Review 2011 2012 2013 Page 112 of 129
CMS AHCCCS CCN Organization Name Register Register Attest Pre-Payment Audit Payment Post Payment Audit Program Years 30068 MT Graham Regional Medical Center Inc. 2013 31302 Northern Cochise Community Hospital Inc 2011 2012 30085 Northwest Hospital LLC 2012 Rev 30114 Oro Valley Hospital LLC 2012 Rev 30112 Orthopedic and Surgical Specialty Company, LLC 31304 Page Hospital 2011 2012 Rev 30033 Payson Hospital Corporation 2012 Rev 30117 PHC-Fort Mohave Inc Review 2011 2012 2013 33302 Phoenix Children's Hospital 2013 30043 RCHP-Sierra Vista Inc. 2011 2012 Rev 30038 Scottsdale Healthcare Hospitals 2011 2013 30087 Scottsdale Healthcare Hospitals 2011 2013 30123 Scottsdale Healthcare Hospitals 2011 Rev 30037 St Lukes Medical Center LP Review 2011 2012 2013 30062 Summit Healthcare Association 2013 30108 Surgical Specialty Hospital of Arizona LLC 30071 The Fort Defiance Indian Hospital Board, Incorporation 2012 Rev 30073 TUBA CITY REGIONAL HEALTH CARE CORPORATION 2012 Rev 30006 Tucson Medical Center Review 2011 2012 2013 30064 University Medical Center Corporation Review 2011 2013 30111 University Physicians Healthcare 2012 30007 Verde Valley Medical Center 2012 Page 113 of 129
CMS AHCCCS CCN Organization Name Register Register Attest Pre-Payment Audit Payment Post Payment Audit Program Years 30001 VHS Acquisition Corporation Review 2011 2013 30083 VHS Acquisition Subsidiary Number 1 Inc Review 2011 2013 30094 VHS of Arrowhead Inc Review 2011 2013 30030 VHS of Phoenix Inc 2011 2013 31315 White Mountain Communities Hospital 2012 Rev 31311 Winslow Memorial Hospital Inc 2012 30012 Yavapai Community Hospital 2012 2013 30118 Yavapai Community Hospital 2012 2013 30013 Yuma Regional Medical Center 2011 Rev 0 68 56 23 0 Subtotal Payment Year 1 80 74 68 68 68 10 Subtotal Payment Year 2 N/A N/A 56 42 42 0 Subtotal Payment Year 3 N/A N/A 23 13 13 0 Totals 80 74 147 123 123 10 Page 114 of 129
7.6 Appendix F: Sample of Eligible Hospital EHR Incentive Program Payment Calculation Provider Payment Criteria Payment Eligible Hospital reports Discharges, Medicaid Inpatient Bed Days, Total Inpatient Bed Days, Total Hospital Charges/Cost and Total Charity Care Charges in Hospital Medicare Cost Reporting Period Hospital Medicare Cost Reporting Period: Hospital Medicare Cost Report Preparation Date: A 12-month period representative of the Hospital s Accounting Fiscal Year Preparation Date from the Current filed Hospital Medicare Cost Report Average Annual Growth Rate A1 A2 A3 A4 Total Discharges in Current Year Total Discharges in Prior Year 1 {PY1} Total Discharges in Prior Year 2 {PY2} Total Discharges in Prior Year 3 {PY3} Number of All Unique Total Discharges in the Current Hospital Medicare Cost Reporting Period Number of All Unique Total Discharges in the Prior Year 1 Hospital Medicare Cost Reporting Period Number of All Unique Total Discharges in the Prior Year 2 Hospital Medicare Cost Reporting Period Number of All Unique Total Discharges in the Prior Year 3 Hospital Medicare Cost Reporting Period B1 Discharges Growth from Current PY1 epip calculates: A1 A2 B2 Discharges Growth from PY1 PY2 epip calculates: A2 A3 B3 Discharges Growth from PY2 PY3 epip calculates: A3 A4 C1 Discharges % Growth from Current PY1 epip calculates: (B1 / A2) * 100 C2 Discharges % Growth from PY1 PY2 epip calculates: (B2 / A3) * 100 C3 Discharges % Growth from PY2 PY3 epip calculates: (B3 / A4) * 100 C D Cumulative Discharge Percent Growth Rate Over 3 Years Average Annual Growth Rate Over 3 Years epip calculates: C1 + C2 + C3 epip calculates: C / 3 Discharge Related Amount E1 Projected Discharges in Payment Year 1 epip user input: A1 E2 Projected Discharges in Payment Year 2 epip calculates: E1 + (E1 * D) E3 Projected Discharges in Payment Year 3 epip calculates: E2 + (E2 * D) E4 Projected Discharges in Payment Year 4 epip calculates: E3 + (E3 * D) Page 115 of 129
Projected Discharges E5 1 1,149 E6 1,150 23,000 Allowable Discharges Value of Projected Discharges Value of Projected Discharges Discharge Related Amount Allowable Discharges are the number of projected discharges allowed in determining the Discharge Related Amount not to exceed 23,000 allowable discharges. E7 > 23,000 23,000 F1 Allowable Discharges in Payment Year 1 epip calculates based on E5 or E6 or E7 F2 Allowable Discharges in Payment Year 2 epip calculates based on E5 or E6 or E7 F3 Allowable Discharges in Payment Year 3 epip calculates based on E5 or E6 or E7 F4 Allowable Discharges in Payment Year 4 epip calculates based on E5 or E6 or E7 Allowable Discharges Discharge Related Amount F5 1 1,149 $0 F6 1,150 23,000 $200 * Allowable Discharges Discharge Related Amount is $0 for allowable discharges 1 to 1,149 and $200 per allowable discharge for allowable discharges from 1,150 to 23,000. G1 Discharge Related Amount Payment Year 1 epip calculates based on F5 or F6 G2 Discharge Related Amount Payment Year 2 epip calculates based on F5 or F6 G3 Discharge Related Amount Payment Year 3 epip calculates based on F5 or F6 G4 Discharge Related Amount Payment Year 4 epip calculates based on F5 or F6 G Total Discharge Related Amount Over 4 Years epip calculates: G1 + G2 + G3 + G4 Initial Amount H Base Amount epip defaults to $2,000,000 (defined by Statue) I1 Initial Amount Payment Year 1 epip calculates Base Amount + G1 I2 Initial Amount Payment Year 2 epip calculates Base Amount + G2 I3 Initial Amount Payment Year 3 epip calculates Base Amount + G3 I4 Initial Amount Payment Year 4 epip calculates Base Amount + G4 Transition Factor Transition Factor Transition Factor phases down the EHR Incentive Program payments over a 4-year period. It is defined by the Statue based on Payment Year. J1 Transition Factor Year 1 100% 1.00 epip defaults based on Payment Year 1 J2 Transition Factor Year 2 75% 0.75 epip defaults based on Payment Year 2 J3 Transition Factor Year 3 50% 0.50 epip defaults based on Payment Year 3 Page 116 of 129
J4 Transition Factor Year 4 25% 0.25 epip defaults based on Payment Year 4 Overall EHR Amount K1 EHR Amount Payment Year 1 epip calculates I1 * J1 K2 EHR Amount Payment Year 2 epip calculates I2 * J2 K3 EHR Amount Payment Year 3 epip calculates I3 * J3 K4 EHR Amount Payment Year 4 epip calculates I4 * J4 K Overall EHR Amount Over 4 Years epip calculates: K1 + K2 + K3 + K4 Medicaid Share L1 Medicaid Inpatient Bed Days Number of Unique Medicaid Title XIX Inpatient Bed Days in denominator L2 Total Inpatient Bed Days Number of All Unique Total Inpatient Bed Days in Hospital Medicare Cost Reporting Period L3 Total Hospital Charges or Hospital Cost* Number of All Unique Total Hospital Charges / Hospital Cost* in Hospital Medicare Cost Reporting Period *Applies to EHR Facilities & 638 Tribally Operated Facilities L4 Total Charity Care Charges ** Hospital Medicare Cost Reporting Period Number of All Unique Total Charity Care Charges in ** Charity Care Charges Report required L5 Adjusted Total Inpatient Bed Days epip calculates: L2 * [ (L3 L4) / L3 ] Numerator Medicaid Inpatient Bed Days epip user input: L1 Denominator Adjusted Total Inpatient Bed Days epip calculates: L5 L Medicaid Share epip calculates: [ L1 / L5 ] * 100 Medicaid EHR Incentive Program Payment N1 EHR Incentive Program Payment Year 1 epip calculates M * 40% Disbursement Payment Year 1 Percentage N2 EHR Incentive Program Payment Year 2 epip calculates M * 30% Disbursement Payment Year 2 Percentage N3 EHR Incentive Program Payment Year 3 epip calculates M * 20% Disbursement Payment Year 3 Percentage N4 EHR Incentive Program Payment Year 4 epip calculates M * 10% Disbursement Payment Year 4 Percentage N Medicaid EHR Incentive Program Payment Over 4 Years epip calculates: N1 + N2 + N3 + N4 Page 117 of 129
7.7 Appendix G: Arizona Medicaid EHR Incentive Program Implementation Calendar No. Activity Milestones CMS Guideline Owner Projected Start Date Projected End Date Actual End Date 1 SMHP 2011 Draft SMHP 2011 Edition (optional, recommended) 6 weeks to review SMA 1/1/2011 3/31/2011 NA 2 SMHP 2011 Part A: Official Final SMHP 2011 Edition submission 3 SMHP 2011 4 SMHP 2011 Part A: Subsequent Final SMHP 2011 Edition submissions (responses to CMS comments or updated SMHPs) Part B: Official Final SMHP Audit Strategy 2011 Edition submission 6 weeks prior to launch SMA 1/1/2011 5/31/2011 3/22/2011 6 weeks to review SMA 6/1/2011 7/31/2011 7/18/2011 6 weeks prior to launch SMA 4/1/2011 5/31/2011 10/1/2012 5 SMHP 2011 Part A: CMS SMHP 2011 Edition Approval (includes conditional approval) 6 weeks after submission CMS 6/1/2011 6/30/2011 6/16/2011, 9/14/2011 6 SMHP 2011 Part B: CMS SMHP Audit Strategy 2011 Edition Approval (includes conditional approval) 7 SMHP 2012 Part A: Official Final SMHP 2012 Edition submission 8 SMHP 2012 9 SMHP 2012 10 SMHP 2012 11 SMHP 2012 Part A: Subsequent Final SMHP 2012 Edition submissions (responses to CMS comments or updated SMHPs) Part B: Official Final SMHP Audit Strategy 2012 Edition submission Part A: CMS SMHP 2012 Edition Approval (includes conditional approval) Part B: CMS SMHP Audit Strategy 2012 Edition Approval (includes conditional approval) 12 SMHP 2013 Part A: Official Final SMHP 2013 Edition submission 13 SMHP 2013 14 SMHP 2013 15 SMHP 2013 Part A: Subsequent Final SMHP 2013 Edition submissions (responses to CMS comments or updated SMHPs) Part B: Official Final SMHP Audit Strategy 2013 Edition submission Part A: CMS SMHP 2013 Edition Approval (includes conditional approval) 6 weeks after submission 6 weeks prior to expiration CMS 6/1/2011 6/30/2011 3/22/2011 SMA 4/1/2012 4/15/2012 4/8/2013 6 weeks to review SMA 6/1/2012 6/15/2012 5/9/2013 6 weeks prior to annual renewal 6 weeks after submission 6 weeks after submission 6 weeks prior to expiration SMA 4/1/2012 4/15/2012 10/3/2012 CMS 4/16/2012 6/1/2012 NA CMS 4/16/2012 6/1/2012 10/23/2012 SMA 4/1/2013 4/15/2013 7/22/2013 6 weeks to review SMA 6/1/2013 6/15/2013 NA 6 weeks prior to annual renewal 6 weeks after submission SMA 4/1/2013 4/15/2013 7/30/2013 CMS 4/16/2013 6/1/2013 11/19/2013 Page 118 of 129
No. Activity Milestones CMS Guideline Owner Projected Start Date Projected End Date Actual End Date 16 SMHP 2013 Part B: CMS SMHP Audit Strategy 2013 Edition Approval (includes conditional approval) 17 SMHP 2014 Part A: Official Final SMHP 2014 Edition submission 18 SMHP 2014 19 SMHP 2014 20 SMHP 2014 21 SMHP 2014 Part A: Subsequent Final SMHP 2014 Edition submissions (responses to CMS comments or updated SMHPs) Part B: Official Final SMHP Audit Strategy 2014 Edition submission Part A: CMS SMHP 2014 Edition Approval (includes conditional approval) Part B: CMS SMHP Audit Strategy 2014 Edition Approval (includes conditional approval) 6 weeks after submission 6 weeks prior to expiration CMS 4/16/2013 6/1/2013 9/18/2013 SMA 4/1/2014 4/15/2014 6 weeks to review SMA 6/1/2014 6/15/2014 6 weeks prior to annual renewal 6 weeks after submission 6 weeks after submission SMA 4/1/2014 4/15/2014 CMS 4/16/2014 6/1/2014 CMS 4/16/2014 6/1/2014 9/18/2013 22 IAPD 2011 Draft IAPD 2011 Edition (optional, recommended) 6 weeks to review SMA 1/1/2011 3/31/2011 NA 23 IAPD 2011 Official Final IAPD 2011 Edition submission (includes Administration, Contracts & HIE Activities) 6 weeks prior to launch SMA 5/1/2011 5/31/2011 5/20/2011 24 IAPD 2011 25 IAPD 2011 26 IAPD 2012 27 IAPD 2012 28 IAPD 2012 29 IAPD 2013 30 IAPD 2013 31 IAPD 2013 Any subsequent Final IAPDs 2011 Edition (responses to CMS comments or IAPD updates) CMS IAPD 2011 Edition Approval (includes conditional approval) Official Final IAPD 2012 Edition submission (includes Administration, Contracts & HIE Activities) Any subsequent Final IAPDs 2012 Edition (responses to CMS comments or IAPD updates) CMS IAPD 2012 Edition Approval (includes conditional approval) Official Final IAPD 2013 Edition submission (includes Administration, Contracts & HIE Activities) Any subsequent Final IAPDs 2013 Edition (responses to CMS comments or IAPD updates) CMS IAPD 2013 Edition Approval (includes conditional approval) 6 weeks to review SMA 8/15/2011 8/31/2011 NA 6 weeks after submission 6 weeks prior to annual renewal CMS 6/1/2011 6/30/2011 6/16/2011 SMA 5/1/2012 5/31/2012 1/27/2012 6 weeks to review SMA 8/15/2012 8/31/2012 3/6/2012 6 weeks after submission 6 weeks prior to annual renewal CMS 6/1/2012 8/31/2012 3/15/2012 SMA 5/1/2013 5/31/2013 6/17/2013 6 weeks to review SMA 8/15/2013 8/31/2013 8/13/2013 6 weeks after submission CMS 6/1/2013 8/31/2013 8/14/2013 Page 119 of 129
No. Activity Milestones CMS Guideline Owner 32 IAPD 2014 33 IAPD 2014 34 IAPD 2014 35 36 37 38 39 40 IAPD 2015 IAPD 2015 IAPD 2015 IAPD 2015 Implementation Implementation Implementation Implementation Implementation Implementation Official Final IAPD 2014 Edition submission (includes Administration, Contracts & HIE Activities) Any subsequent Final IAPDs 2014 Edition (responses to CMS comments or IAPD updates) CMS IAPD 2014 Edition Approval (includes conditional approval) Official Final IAPD 2015 Edition submission (includes Administration, Contracts & HIE Activities) Any subsequent Final IAPDs 2015 Edition (responses to CMS comments or IAPD updates) CMS IAPD 2015 Edition Approval (includes conditional approval) Official Additional IAPD 2015 Edition submission (includes Administration, Contracts & HIE Activities) 6 weeks prior to annual renewal Projected Start Date Projected End Date Actual End Date SMA 5/1/2014 5/31/2014 9/23/2013 6 weeks to review SMA 8/15/2014 8/31/2014 10/18/2013 6 weeks after submission CMS 6/1/2014 8/31/2014 10/20/2013 SMA 5/1/2014 5/31/2014 3/25/2014 SMA 6/1/2014 6/30/2014 4/6/2014 CMS 6/1/2014 8/1/2014 5/5/2014 SMA 8/1/2014 12/31/2014 State contact information for CMS records Daily (as needed) SMA 5/1/2011 6/30/2011 5/20/2011 State information for the public (for publication on CMS website) (i.e. estimated launch date, informational website, general e- mail for provider inquiries) Contact CMS to initiate file exchange testing between State systems and CMS systems Data Use Agreements (originals - mailed & emailed) Connectivity arrangements, including Secure Point of Entry (SPOE) form (originals - mailed & emailed) Forms for secure access to CMS reporting systems (originals - mailed & emailed) Monthly (by last Monday of each month) At least 2 months prior to program launch 4 weeks prior to beginning systems file exchange testing 4 weeks prior to beginning systems file exchange testing SMA 5/1/2011 6/30/2011 5/20/2011 SMA 10/1/2010 5/1/2011 11/19/2010 SMA 10/1/2010 12/31/2010 11/24/2010 SMA 10/1/2010 12/31/2010 11/24/2010 2 weeks to process SMA 6/6/2011 6/20/2011 4/28/2011 Page 120 of 129
No. Activity Milestones CMS Guideline Owner 41 42 43 44 45 46 Implementation Implementation Implementation Implementation Implementation Implementation Website URL for the State s EHR Incentive Program eligibility verification and payment portal Email address for production support issues Email address for audit and appeal alerts (for EH audit) State Meaningful Use Stage 1 Phase 1 (effective CY/FFY 2011) State Meaningful Use Stage 1 Phase 2 (effective CY/FFY 2013) State Meaningful Use Stage 1 Phase 3 (effective CY/FFY 2014) Notice of Proposed Rule Making (NPRM) CEHRT Edition Year Flexibility 15 calendar days prior to program launch 15 calendar days prior to program launch 15 calendar days prior to program launch SMHP Update required prior to implementation SMHP Update required prior to implementation SMHP Update required prior to implementation Projected Start Date Projected End Date Actual End Date SMA 6/13/2011 7/4/2011 6/15/2011 SMA 6/13/2011 7/4/2011 5/20/2011 SMA 6/13/2011 7/4/2011 8/8/2014 SMA 10/1/2011 9/1/2012 9/1/2012 SMA 11/1/2012 2/15/2013 2/15/2013 SMA 8/15/2013 7/31/2014 7/31/2014 47 Implementation If finalized, the proposal would allow providers to meet Stage 1 or Stage 2 of meaningful use with EHRs certified to the 2011 or 2014 Edition criteria or a combination of both Editions. SMHP Update required prior to implementation SMA 9/1/2014 Pending CMS Notification 48 49 Implementation Implementation Beginning in 2015, all eligible providers would be required to report using 2014 Edition CEHRT. State Meaningful Use Stage 2 Phase 1 (effective CY/FFY 2014) State Meaningful Use Stage 2 Phase 2 (effective CY/FFY TBD) SMHP Update required prior to implementation SMHP Update required prior to implementation SMA 9/1/2014 SMA Pending CMS Notification Pending CMS Notification Pending CMS Notification Ongoing Page 121 of 129
No. Activity Milestones CMS Guideline Owner 50 Implementation 51 Launch State Meaningful Use Stage 3 Phase 1 (effective CY/FFY TBD) State s final assurance of ready to launch (CMS puts into production) 52 Production State Provider Registration in production 53 Production Notify CMS that the State is accepting and processing eligibility information and provider attestations (AIU) 54 Production Notify CMS that the State is disbursing incentive payments 55 Production Begin conducting audit and oversight activities 56 Production State Meaningful Use Stage 1 Phase 1 (effective CY/FFY 2011) 57 Production State Meaningful Use Stage 1 Phase 2 (effective CY/FFY 2013) 58 Production State Meaningful Use Stage 1 Phase 3 (effective CY/FFY 2014) SMHP Update required prior to implementation 10 calendar days prior to launch No later than 3 months after the program is launched No later than 3 months after the program is launched No later than 5 months after the program is launched Within 4 months of making the first payment CMS SMHP Approval required prior to implementation CMS SMHP Approval required prior to implementation CMS SMHP Approval required prior to implementation SMA Projected Start Date Pending CMS Notification Projected End Date Pending CMS Notification Actual End Date Ongoing SMA 7/4/2014 7/4/2011 6/30/2011 SMA 7/4/2011 10/4/2011 7/25/2011 SMA 7/4/2011 10/4/2011 SMA 7/4/2011 12/4/2011 SMA 10/1/2011 2/1/2012 EHs 10/24/2011 EPs 01/12/2012 EHs 10/24/2011 EPs 01/30/2012 EHs 03/04/2013 EPs 04/20/2014 SMA 11/1/2012 3/31/2013 3/31/2013 SMA 4/1/2013 4/30/2014 4/30/2014 SMA 9/1/2014 Pending CMS Notification Page 122 of 129
No. Activity Milestones CMS Guideline Owner Notice of Proposed Rule Making (NPRM) CEHRT Edition Year Flexibility Projected Start Date Projected End Date Actual End Date 59 Production If finalized, the proposal would allow providers to meet Stage 1 or Stage 2 of meaningful use with EHRs certified to the 2011 or 2014 Edition criteria or a combination of both Editions. SMA Pending CMS Notification Pending CMS Notification Beginning in 2015, all eligible providers would be required to report using 2014 Edition CEHRT. 60 Production State Meaningful Use Stage 2 Phase 1 (effective CY/FFY 2014) 61 Production State Meaningful Use Stage 2 Phase 2 (effective CY/FFY TBD) 62 Production State Meaningful Use Stage 3 Phase 1 (effective CY/FFY TBD) 63 Financials Form CMS-37 2011 Report (includes the related program expenditures, including estimates of incentive payments) Submit supplemental CMS-37 for spending in the quarter in which IAPD was approved, and one for each subsequent quarter by the CMS-37 submission CMS SMHP Approval required prior to implementation CMS SMHP Approval required prior to implementation CMS SMHP Approval required prior to implementation Following IAPD approval and 1 months, 15 days prior to the beginning of each Federal Fiscal Quarter Quarterly (Q1, Q2, Q3, Q4) SMA 8/15/2013 7/31/2014 SMA SMA SMA Pending CMS Notification Pending CMS Notification 08/01/2010 11/01/2011 02/01/2011 05/01/2011 Pending CMS Notification Pending CMS Notification 08/15/2010 11/15/2011 02/15/2011 05/15/2011 Ongoing Ongoing TBD (Q1) TBD (Q2) TBD (Q3) TBD (Q4) Page 123 of 129
No. Activity Milestones CMS Guideline Owner 64 Financials 65 Financials 66 Financials Form CMS-37 2012 Report (includes the related program expenditures, including estimates of incentive payments) Submit supplemental CMS-37 for spending in the quarter in which IAPD was approved, and one for each subsequent quarter by the CMS-37 submission Form CMS-37 2013 Report (includes the related program expenditures, including estimates of incentive payments) Submit supplemental CMS-37 for spending in the quarter in which IAPD was approved, and one for each subsequent quarter by the CMS-37 submission Form CMS-37 2014 Report (includes the related program expenditures, including estimates of incentive payments) Submit supplemental CMS-37 for spending in the quarter in which IAPD was approved, and one for each subsequent quarter by the CMS-37 submission Following IAPD approval and 1 months, 15 days prior to the beginning of each Federal Fiscal Quarter Quarterly (Q1, Q2, Q3, Q4) Following IAPD approval and 1 months, 15 days prior to the beginning of each Federal Fiscal Quarter Quarterly (Q1, Q2, Q3, Q4) Following IAPD approval and 1 months, 15 days prior to the beginning of each Federal Fiscal Quarter Quarterly (Q1, Q2, Q3, Q4) SMA SMA SMA Projected Start Date 08/01/2011 11/01/2012 02/01/2012 05/01/2012 08/01/2012 11/01/2013 02/01/2013 05/01/2013 08/01/2013 11/01/2014 02/01/2014 05/01/2014 Projected End Date 08/15/2011 11/15/2012 02/15/2012 05/15/2012 08/15/2012 11/15/2013 02/15/2013 05/15/2013 08/15/2013 11/15/2014 02/15/2014 05/15/2014 Actual End Date 08/15/2011 01/30/2012 TBD (Q3) TBD (Q4) TBD (Q1) TBD (Q2) TBD (Q3) TBD (Q4) TBD (Q1) TBD (Q2) TBD (Q3) TBD (Q4) Page 124 of 129
No. Activity Milestones CMS Guideline Owner Projected Start Date Projected End Date Actual End Date 67 Financials Form CMS-64 2011 Report (reconciling program spending with funds drawn) This form includes a breakdown of incentive payments made to physicians, pediatricians, nurse practitioners, dentists, certified nurse midwives, and physician assistants. End of each Federal Fiscal Quarter Quarterly (Q1, Q2, Q3, Q4) SMA 1/1/2011 4/1/2011 7/1/2011 10/1/2011 3/31/2011 6/30/2011 9/30/2011 12/31/2011 TBD (Q1) TBD (Q2) TBD (Q3) TBD (Q4) 68 Financials Form CMS-64 2012 Report (reconciling program spending with funds drawn) This form includes a breakdown of incentive payments made to physicians, pediatricians, nurse practitioners, dentists, certified nurse midwives, and physician assistants. End of each Federal Fiscal Quarter Quarterly (Q1, Q2, Q3, Q4) SMA 12/15/2011 03/15/2012 06/15/2012 09/15/2012 12/31/2011 03/31/2012 06/30/2012 09/30/2012 10/28/2011 01/30/2012 TBD (Q3) TBD (Q4) 69 Financials Form CMS-64 2013 Report (reconciling program spending with funds drawn) This form includes a breakdown of incentive payments made to physicians, pediatricians, nurse practitioners, dentists, certified nurse midwives, and physician assistants. End of each Federal Fiscal Quarter Quarterly (Q1, Q2, Q3, Q4) SMA 12/15/2012 03/15/2013 06/15/2013 09/15/2013 12/31/2012 03/31/2013 06/30/2013 09/30/2013 TBD (Q1) TBD (Q2) TBD (Q3) TBD (Q4) 70 Financials Form CMS-64 2014 Report (reconciling program spending with funds drawn) This form includes a breakdown of incentive payments made to physicians, pediatricians, nurse practitioners, dentists, certified nurse midwives, and physician assistants. End of each Federal Fiscal Quarter Quarterly (Q1, Q2, Q3, Q4) SMA 12/15/2013 03/15/2014 06/15/2014 09/15/2014 12/31/2013 03/31/2014 06/30/2014 09/30/2014 TBD (Q1) TBD (Q2) TBD (Q3) TBD (Q4) Regional Office Data Reporting Tool - 2011 71 Reporting Progress report documenting specific implementation and oversight activities performed during the quarter, including progress in implementing the State's approved Medicaid HIT plan Quarterly (Q1, Q2, Q3, Q4) SMA - - - Page 125 of 129
No. Activity Milestones CMS Guideline Owner Projected Start Date Projected End Date Actual End Date 73 Reporting Regional Office Data Reporting Tool - 2013 Progress report documenting specific implementation and oversight activities performed during the quarter, including progress in implementing the State's approved Medicaid HIT plan Quarterly (Q1, Q2, Q3, Q4) SMA 04/01/2013 07/01/2013 10/01/2013 01/01/2014 04/11/2013 07/11/2013 10/10/2013 01/10/2014 04/30/2014 07/30/2014E 10/30/2014E 01/31/2015E 74 Reporting Regional Office Data Reporting Tool - 2014 Progress report documenting specific implementation and oversight activities performed during the quarter, including progress in implementing the State's approved Medicaid HIT plan Quarterly (Q1, Q2, Q3, Q4) SMA 04/01/2014 07/01/2014 10/01/2014 01/01/2015 04/11/2014 07/11/2014 10/10/2014 01/10/2015 04/11/2014 07/24/2014 TBD (Q3) TBD (Q4) Annual Data Reporting Tool - 2011 75 Reporting 76 Reporting Per 42 CFR 495.316, states are required to provide CMS with an annual report which must include: Provider adoption, implementation, or upgrade of CEHRT activities and payments AND Aggregated, de-identified meaningful use data. Annual Data Reporting Tool - 2012 Per 42 CFR 495.316, states are required to provide CMS with an annual report which must include: Provider adoption, implementation, or upgrade of CEHRT activities and payments AND Aggregated, de-identified meaningful use data. Annual Data Reporting Tool - 2013 Annual (04/01) SMA - - - Annual (04/01) SMA 1/1/2013 4/30/2013 4/30/2013 77 Reporting Per 42 CFR 495.316, states are required to provide CMS with an annual report which must include: Provider adoption, implementation, or upgrade of CEHRT activities and payments AND Aggregated, de-identified meaningful use data. Annual (04/01) SMA 1/1/2014 4/25/2014 6/25/2014 Page 126 of 129
No. Activity Milestones CMS Guideline Owner Projected Start Date Projected End Date Actual End Date Payment Adjustment Report - 2015 (for Medicaid Provider Exception List) 79 Reporting States will initially include the Meaningful Use attestation information for all of the Medicaid EHs and EPs that initially attested to Meaningful Use. As these providers are deemed Meaningful Users or found not to be a Meaningful User (through pre- or post-payment audits), the States are required to update the attestation information on a federal fiscal quarterly basis. 1st of each Federal Fiscal Quarter Quarterly (Q1, Q2, Q3, Q4) SMA 09/20/2014 12/20/2015 03/20/2015 06/20/2015 10/01/2014 01/01/2015 04/01/2015 07/01/2015 Stakeholder Report (HIT Steering Committee) 80 Reporting The EHR Staff provides monthly and year-to-date updates to the HIT Steering Committee (Assessment Team) and other internal stakeholders of the EHR Incentive Program activities performed using the Summary Dashboard. Monthly SMA Ongoing Ongoing Ongoing 81 Administration Program Registration States administration of the EHR Incentive Program. Determined by State - Daily SMA Ongoing Ongoing Ongoing 82 Administration Program Attestation States administration of the EHR Incentive Program. Determined by State - Daily SMA Ongoing Ongoing Ongoing 83 Administration Program Pre-Payment Audit States administration of the EHR Incentive Program. Determined by State - Daily SMA Ongoing Ongoing Ongoing 84 Administration Program Notice of Decision States administration of the EHR Incentive Program. Determined by State - Daily SMA Ongoing Ongoing Ongoing Page 127 of 129
No. Activity Milestones CMS Guideline Owner 85 Administration 86 Administration 87 Administration 88 Administration Program Payment States administration of the EHR Incentive Program. Program Appeals & Grievance States administration of the EHR Incentive Program. Program Post Payment Audit States administration of the EHR Incentive Program. Program Recoupment States administration of the EHR Incentive Program. Determined by State - Monthly Determined by State - Daily Determined by State - 4 months after payment Determined by State - Daily Projected Start Date Projected End Date Actual End Date SMA Ongoing Ongoing Ongoing SMA Ongoing Ongoing Ongoing SMA Ongoing Ongoing Ongoing SMA Ongoing Ongoing Ongoing Page 128 of 129
7.8 Appendix H-J Please note that the following appendices are not included in this document due to size and can be viewed separately. H I J epip Screen Shots Version 5.0 Change Control Document HIE Financial Statements Page 129 of 129