Innovating Medicaid IT: Modularity & Reuse Gina Molla

Innovating Medicaid IT: Modularity & Reuse Gina Molla

About MITRE 2 The MITRE Corporation operates seven FFRDCs, including the CMS Alliance to Modernize Healthcare FFRDC MITRE works in the public interest by applying systems engineering expertise to address the most challenging problems facing government. --------------- CAMH seeks to advance the nation's progress toward an integrated health system with improved access and quality at a sustainable cost

3 Topics The Medicaid IT Enterprise CMS goals for transforming the Medicaid IT Enterprise CMS transformation of Medicaid IT Modularity Reuse of modules Modularity and Reuse in the Medicaid IT context Opportunities for State Medicaid Agencies & Vendors

4 The Medicaid IT Enterprise The Medicaid Enterprise is a system of systems, composed of Medicaid Management Information System (MMIS) Enrolling providers, processing claims, detecting fraud and waste, generating reports Eligibility and Enrollment systems (E&E) Determining eligibility and enrolling beneficiaries Immunization (and other) registries Recording and analyzing population immunization and other health information State Level Repositories (SLRs) Collecting Meaningful Use measure data from providers Electronic quality measures systems Collecting, cleaning, analyzing and storing electronic clinical quality information and others (provider directories, clinical data warehouse, identity management, etc.)

The Medicaid IT Enterprise 5 Collectively, these systems are known as the Medicaid Enterprise System. Some states may include several of the systems mentioned, others just a few. Each state designs, develops and maintains its own MES, so there is a great deal of variation from state to state. CMS funds the MES through Federal Funds Participation (FFP) matching. States can receive funds to plan, develop and operate their Medicaid systems.

The Medicaid Enterprise 6 The MMIS is the largest and oldest of these Medicaid systems In the past, states would hire a vendor to build a monolithic system and deploy it a big bang fashion. Development would last several years, was expensive, and inhibited innovation. Using various policies and frameworks, CMS is transforming Medicaid IT by promoting open, modular, and reusable system architectures. CMS provides states with 90% of necessary funding to develop approved MES systems and 75% of their operation costs.

7 The Medicaid Enterprise Frameworks In order to qualify for the federal funding matches, state systems must build systems that adhere to certain guidelines: Standards and conditions for Medicaid IT These are found in the recent final rule, page 95 Medicaid Information Technology Architecture https://www.medicaid.gov/medicaid-chip-program-information/bytopics/data-and-systems/medicaid-information-technologyarchitecture-mita.html https://www.federalregister.gov/articles/2015/12/04/2015-30591/medicaidprogram-mechanized-claims-processing-and-information-retrievalsystems-9010

8 CMS Goals for Medicaid IT Transformation Two of the critical requirements are modularity and re-use. By requiring states to build modular systems, CMS seeks to Support healthcare transformation goals and the Triple Aim Promote the re-use of technical solutions among states Minimize customization and configuration needs Increase competition in the Medicaid Enterprise marketplace Reduce costs Improve system interoperability, and Increase adherence to Medicaid Information Technology Architecture (MITA) and current standards and conditions.

What is Modularity in the Medicaid IT Context? 9 CMS has defined modularity as A packaged, functional business process or set of processes implemented through software, data, and interoperable interfaces that are enabled through design principles in which functions of a complex system are partitioned into discrete, scalable, reusable components. - 42 CFR, Part 433.111(h) CMS envisions Medicaid enterprise systems (MES) composed of modules, where a module from one vendor can be easily swapped for another vendor s module.

10 What is Reuse in the Medicaid IT Context? Reuse refers to one state appropriating with very little change, a module, code, or documentation used by another state. Reuse can take several forms Documents (templates, SDLCs, concept of operations, standard wording for contracts, etc.) System or module components and code Commercial off the shelf (COTS) modules Open source code

Opportunities for States & Vendors in Medicaid IT Space 11 CMS is particularly interested in encouraging the development and use of modules that would have wide application across multiple MES systems, such as Clinical data warehouse (CDW) modules Identity management modules

Opportunities for States & Vendors in Medicaid IT Space 12 CMS wants to understand and minimize barriers vendors and states face in moving to modular MES architectures: What are the key challenges for creating and marketing a modular CDW solution and how could those be addressed? What clinical and quality analytics and metrics are important to state Medicaid stakeholders, and are products available in the marketplace that can provide these analytics and metrics? What are the key challenges for creating and marketing an identity management module for state Medicaid agencies, and how can those challenges be addressed by CMS?

Opportunities for States & Vendors in Medicaid IT Space 13 States can incorporate systems that that streamline healthcare transformation: electronic quality reporting data analytics data warehouses provider directories master person indices Modular architectures open the Medicaid IT market to smaller vendors because a vendor is no longer obligated to conceptualize and develop an entire MES application Vendors could, using APIs and ONC guidance (ONC Interoperability Standards Advisory), market a small sub-set of modules that interoperate with any other vendor s MES offerings

14 Additional Information Over the next several months, CMS will be issuing a set of subregulatory guidance letters that clarifies MES modularity and reuse concepts. These guidance letters will be posted to https://www.medicaid.gov/federal-policy-guidance/federal-policyguidance.html

15 Additional Information ONC Interoperability Standards Advisory: https://www.healthit.gov/standards-advisory December 4, 2015 rule: https://www.gpo.gov/fdsys/pkg/fr-2015-12-04/pdf/2015-30591.pdf MITA framework: http://www.medicaid.gov/medicaid-chip-program-information/bytopics/data-and-systems/mita/medicaid-information-technologyarchitecture-mita-30.html State Medicaid Director Letter (2/29/16): https://www.medicaid.gov/federal-policyguidance/downloads/smd16003.pdf

Questions? 16