FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION STATE ...ahca.myflorida.com/Medicaid/EHR/Downloads/SMHP.pdf · Florida Agency for Health Care Administration State Medicaid Health Information

FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION

STATE MEDICAID HEALTH INFORMATION TECHNOLOGY PLAN

INCLUSIVE OF UPDATES THROUGH 11/30/12

State Medicaid Health Information Technology Plan

Table of Contents ii

Date: 2/10/14 Version: 3.4

Florida Agency for Health Care Administration

State Medicaid Health Information Technology Plan Page i

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State Medicaid Health Information Technology Plan Page ii

Change Record

Date Author Version Change Reference

11/23/10 The Agency 1.01-1.10 Governance changes incorporated

11/23/10 The Agency 1.11 Governance changes incorporated

12/02/10 The Agency 1.12 Governance changes incorporated

2/16/2011 – 3/01/11

North Highland 2.01-2.13 Addressing CMS edits and Agency feedback / revisions

3/7/2011 North Highland 2.14 Final Agency Edits

2/29/2012 Heidi Fox 3.0 Agency SMHP Update

6/1/2012 Heidi Fox 3.2 Revisions per 4/23/12 CMS letter

11/30/12 Heidi Fox 3.3 Amendments to Section C Administration and Oversight of the EHR incentive program and inclusion of post payment audit plan

2/10/14 Heidi Fox 3.4 Changes accepted inclusive of all prior approved updates


State Medicaid Health Information Technology Plan Page iii

TABLE OF CONTENTS

Executive Summary ................................................................................................................................................................. 8

Stakeholder Involvement .............................................................................................................................................. 10

CMS Guidelines Cross-Reference ............................................................................................................................... 15

List of Acronyms ............................................................................................................................................................... 16

Section A. As-Is Assessment .............................................................................................................................................. 26

A.1 State HIT/HIE Self-Assessment .................................................................................................................... 26

A.1.1 Florida Medicaid Overview .................................................................................................................. 26

A.1.2 Objectives and Goals for Statewide HIT .......................................................................................... 26

A.1.3 HIE Advisory and Oversight ................................................................................................................. 28

A.2 As-Is Assessment – Current HIT/HIE Landscape in Florida ............................................................ 32

A.2.1 Introduction ................................................................................................................................................ 32

A.2.2 EHR Adoption ............................................................................................................................................. 32

A.2.3 Statewide HIT/HIE Activities .............................................................................................................. 45

A.2.4 Medicaid HIT/HIE Activities ................................................................................................................ 66

Section B. To-Be Assessment - The Future HIT/HIE Landscape in Florida ................................................... 71

B.1 Introduction ......................................................................................................................................................... 71

B.2 Medicaid HIT/HIE Project Context ............................................................................................................. 71

B.3 Health Information Exchange in Florida .................................................................................................. 72

B.3.1 HIE Vision / Architecture ...................................................................................................................... 72

B.3.2 HIE Overview ............................................................................................................................................. 76

B.3.3 Future Medicaid Capabilities ............................................................................................................... 81

B.4 Medicaid HIT/HIE Goals and Objectives .................................................................................................. 82

B.4.1 High-level Statewide Goals ................................................................................................................... 82

B.4.2 Goals for Eligible Professionals .......................................................................................................... 84

B.4.3 Goals for Eligible Hospitals ................................................................................................................... 84

B.5 HIE Governance .................................................................................................................................................. 84

B.6 EHR Adoption Strategies ................................................................................................................................. 84

B.6.1 Leveraging Existing Grants for EHR Adoption ............................................................................. 85

B.6.2 Approach for Technical Assistance ................................................................................................... 89

B.7 EHR Incentive Program ................................................................................................................................... 89

B.7.1 Strategy to Address Unique Needs .................................................................................................... 89

B.7.2 Required Change to State Law ............................................................................................................ 89


State Medicaid Health Information Technology Plan Page iv

B.7.3 Privacy Policies .......................................................................................................................................... 89

B.8 Definition of Meaningful Use ......................................................................................................................... 90

Section C. Administration and Oversight of the EHR Incentive Program ...................................................... 91

C.1 Purpose .................................................................................................................................................................... 91

C.2 Administration of the EHR Incentive Program .......................................................................................... 91

C.2.1 EHR Incentive Program Current Status ............................................................................................. 91

C.2.2 Incentive program administration organizational chart ......................................................... 93

C.2.3 CMS Registration and Attestation System ......................................................................................... 93

C.2.4 State level registry .................................................................................................................................... 94

C.2.5 IT System Changes For Implementation ............................................................................................ 94

C.2.6 Eligible Providers ....................................................................................................................................... 95

C.2.7 Adopt, Implement Or Upgrade Requirements And Verification ................................................ 95

C.2.8 Meaningful Use ........................................................................................................................................... 96

C.2.9 Eligible Professionals Requirements .................................................................................................... 96

C.2.10 Verification of Eligible Professionals .................................................................................................. 96

C.2.11 Volume Requirements for eligible professionals ............................................................................. 97

C.2.12 Attestations using individual volume ................................................................................................... 98

C.2.13 Attestations using group volume ........................................................................................................... 98

C.2.14 Verification of volume .............................................................................................................................. 98

C.2.15 incentive payments for eligible professionals ................................................................................... 98

C.2.16 Eligibility Requirements And Verification For Eligible Hospitals ............................................ 99

C.2.17 Volume Requirements For Eligible Hospitals................................................................................... 99

C.2.18 Verification Of Volume For Eligible Hospitals ............................................................................. 100

C.2.19 Incentive Payments For Eligible Hospitals ..................................................................................... 100

C.2.20 Hospital Payment Calculation ............................................................................................................. 100

C.3 Issuing Incentive Payments ........................................................................................................................... 101

C.4 Reporting payments.......................................................................................................................................... 102

C.5 Appeals and Administrative Redetermination ......................................................................................... 103

Section D. Audit Strategic Plan ...................................................................................................................................... 103

D.1 Introduction ...................................................................................................................................................... 103

D.2 Implementation Steps for Audit ................................................................................................................ 104

D.3 Approach: Pre-Payment and Post-Payment Audit Activities ....................................................... 105

D.4 Targeted Post Payment Audits .................................................................................................................. 105

D.5 Eligibility Verification Processes .............................................................................................................. 106


State Medicaid Health Information Technology Plan Page v

D.6 Identification and Tracking of Overpayments/Recoupments ...................................................... 109

Section E. Roadmap ........................................................................................................................................................... 109

E.1 Medicaid HIT Roadmap ................................................................................................................................ 109

E.1.1 Introduction ............................................................................................................................................. 109

E.1.2 Gap Analysis ............................................................................................................................................. 109

E.1.3 Medicaid HIT Roadmap ....................................................................................................................... 116

Section F. Outreach ............................................................................................................................................................ 122

F.1 Summary ............................................................................................................................................................. 122

F.2 Understanding the Stakeholders .............................................................................................................. 122

F.2.1 Stakeholder Research .......................................................................................................................... 122

F.2.2 Brand Research ...................................................................................................................................... 127

F.3 Outreach Plan ................................................................................................................................................... 127

F.3.1 Outreach Goal and Timeline .............................................................................................................. 127

F.3.2 Outreach Strategies .............................................................................................................................. 128

Section G. Appendices ....................................................................................................................................................... 147

G.1 CMS Guidelines Cross-Reference .............................................................................................................. 148

G.2 Sample Curriculum for Training Partners ............................................................................................ 155

G.3 Sample Post-Training Evaluation Survey .............................................................................................. 157

G.4 Regional Extension Center Interview Guide ........................................................................................ 158


State Medicaid Health Information Technology Plan Page vi

LIST OF EXHIBITS

Exhibit 1: HIT/HIE Timeline ........................................................................................................................................ 27 Exhibit 2: Florida HIE Advisory Structure ............................................................................................................. 28 Exhibit 3: HIT/HIE Advisory Matrix ......................................................................................................................... 31 Exhibit 4: Survey respondents planning to seek funding from the Medicaid Incentives ................... 38 Exhibit 5: Survey Population and Survey Responses ........................................................................................ 39 Exhibit 6: Percent of Acute Care Non-Federal Hospitals With at Least a “Basic” Electronic Health Record (2008 2010) ......................................................................................................................................................... 40 Exhibit 7: Percent of Acute Care Non-Federal Hospitals Planning to Apply for EHR Incentive Payments............................................................................................................................................................................... 40 Exhibit 8: Percent of Office-Based Physicians Who have Adopted at Least a “Basic” Electronic Health Record ..................................................................................................................................................................... 41 Exhibit 9: Percent of Office-Based Physicians Who are Planning to Apply for EHR Incentive Payments............................................................................................................................................................................... 42 Exhibit 10: Barriers to EHR Adoption ...................................................................................................................... 44 Exhibit 11: Funding Map ............................................................................................................................................... 46 Exhibit 12: Florida Regional Extension Center Awards and Provider Targets....................................... 46 Exhibit 13: Florida Regional Extension Center Coverage Areas ................................................................... 47 Exhibit 14: FQHC Grants from HRSA ........................................................................................................................ 58 Exhibit 15: Florida’s HIE Organizational Relationships ................................................................................... 73 Exhibit 16: The Agency in the HIE Context ............................................................................................................ 74 Exhibit 17: Leveraging Grants for EHR ................................................................................................................... 89 Exhibit 18: Audit Implementation Steps.............................................................................................................. 105 Exhibit 19: EHR Incentive Program Gaps ............................................................................................................ 114 Exhibit 20: HIE Gaps..................................................................................................................................................... 115 Exhibit 21: State Medicaid HIT Roadmap ............................................................................................................ 116 Exhibit 22: EHR Incentive Program Goals ........................................................................................................... 117 Exhibit 23: Goals for Outreach ................................................................................................................................. 119 Exhibit 24: Research Findings .................................................................................................................................. 126 Exhibit 25: Florida EHR Incentive Program Logo ............................................................................................ 127 Exhibit 26: 2011 Outreach Campaign Timeline ................................................................................................ 128 Exhibit 27: Partner Stakeholders ............................................................................................................................ 129 Exhibit 28: Regional Extension Center Key Findings ..................................................................................... 131 Exhibit 29: Florida EHR Incentive Program Website Home Page ............................................................. 134 Exhibit 30: Florida EHR Incentive Program Website Eligibility Page ...................................................... 135 Exhibit 31: Florida EHR Incentive Program Website REC Page .................................................................. 136 Exhibit 32: Internal Communications Training Strategy and Schedule ................................................. 139 Exhibit 33: Partner Stakeholder Training Plan ................................................................................................. 140 Exhibit 34: Electronic Health Record Message Wheel ................................................................................... 141 Exhibit 35: EHR Incentive Program Message Wheel ...................................................................................... 142 Exhibit 36: Sample News Pegs ................................................................................................................................. 144 Exhibit 37: Print Advertising Options ................................................................................................................... 145 Exhibit 38: Digital Advertising Options................................................................................................................ 145 Exhibit 39: Media Cost ................................................................................................................................................. 146 Exhibit 40: Cross Reference from CMS Guidelines to Section A, As-Is Landscape .............................. 149 Exhibit 41: Cross Reference from CMS Guidelines to Section B, To-Be Landscape ............................ 150


State Medicaid Health Information Technology Plan Page vii

Exhibit 42: Cross Reference from CMS Guidelines to Section C, EHR Incentive Program Plan ..... 152 Exhibit 43: Cross Reference from CMS Guidelines – Section D, Audit Deliverable ............................. 153 Exhibit 44: Cross Reference from CMS Guidelines to Section E, Roadmap ............................................ 154

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EXECUTIVE SUMMARY

The Florida Agency for Health Care Administration (Agency) submits this update to State Medicaid Health Information Technology Plan (SMHP), in accordance with implementation activities authorized by the American Recovery and Reinvestment Act of 2009 (ARRA) (Pub. L. 111-5).

CMS provided the Agency with final approval of the previously updated SMHP April 23, 2012.

The purpose of this SMHP document is to make changes needed pursuant to the release of the Stage 2 final rule for meaningful use on October 11, 2012. Section C Administration and Oversight of the EHR Incentive Program and Section D Audit Strategies subsection D.5 has been updated to outline compliance with changes to eligibility requirements that were included in the Stage 2 final rule. Section D Audit Strategies subsection D.4 has been updated to include a reference to Attachment I: Medicaid EHR Incentive Program Post-Payment Audit Procedures which provides a final strategy for post payment audits for eligibility and Meaningful Use Stage 2.

The components of the SMHP include:

The SMHP document is organized as follows:

Section A, As-Is Assessment: An assessment of the current HIT/HIE landscape across the State both inside and outside of Medicaid

Section B, To-Be Assessment: A To-Be plan for Medicaid through the year 2014 including specific goals and objectives

Section C, Activities Necessary to Administer and Oversee the EHR Incentive Program

Section D, Audit Strategy: A description of the business process steps involved in an Audit of the EHR Incentive Program payments

Section E, HIT/HIE Roadmap and Strategic Plan: A plan for the transition from the As-Is to the To-Be landscape

Section F, Outreach Plan: A plan for the outreach activities aimed at encouraging eligible professionals and eligible hospitals to adopt, implement, or upgrade EHRs and qualify for payments in the EHR Incentive Program

Section G, Appendices: Supporting information for this SMHP

Section A, As-Is Assessment:

As-Is HIT Landscape

To-Be Landscape

Administration and Oversight of

the EHR Incentive Program

Audit Process HIT Roadmap Outreach

Plan

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As required, the State has prepared a State Self-Assessment (SS-A) that lists and prioritizes the State’s goals and objectives for Medicaid HIT, defines the State’s current business model, and assesses the State’s current HIT/HIE capabilities. This section is an assessment of the current HIT landscape environment in the State, including inventory description of existing HIT.

Section B, To-Be Assessment:

As correspondingly required in the SS-A, the To-Be assessment is provided in this SMHP to determine the State’s target capabilities. This iteration of the SMHP contains high-level goals and targets which will be subject to further verification and elaboration upon completion of the MITA To-Be visioning sessions. Results of the 2010 Environmental Scan are now included in this iteration of the SMHP.

Section C, the Administration and Oversight of the EHR Incentive Program:

This section contains details on new business processes; identifies functional organization structure; describes the technical solution and steps to implement the solution; and provides program implementation steps and policy for administering the program.

Section D, Audit Strategy:

The Audit Strategy is described in detail in this section is one of the core processes of the EHR Incentive Program. The processes that comprise this functional area are central to the EHR Incentive Program’s task of verifying that incentive payments are made to the appropriate parties, in the approved amounts through pre-payment verification and post payment audit.

Section E, Roadmap:

The Roadmap provides an analysis of the gaps between the As-Is landscape and the To-Be landscape. The State identifies the implementation steps needed to achieve the HIT targets and to implement the EHR Incentive Program. Correspondingly, this section will be augmented and solidified as part of the next SMHP iteration, upon completion of the MITA To-Be, Visioning Sessions.

Section F, Outreach Plan:

The State’s outreach plan includes strategies and tools needed to educate eligible professionals, hospitals, and other partner stakeholders about the EHR Incentive Program. This section describes the State’s approach to providing clear and consistent communication and education strategies. Effectiveness measures are also specified so that strategies can be adjusted as needed over time. The State conducted extensive research with key stakeholder groups to inform the selected outreach strategies.

The Agency recognizes the overall need for modifying the Medicaid program. As the program direction evolves with greater emphasis towards the exchange of clinical information, further

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agency change will be required. The Agency is well underway in establishing a solid foundation, through the Florida HIE network, to achieving a significant mass for EHR adoption across the State.

The Agency is the entity responsible for managing the EHR Incentive Program and HIE for the State and for a seamless coordination of efforts for achieving its common goals for HIE/HIT and the EHR Incentive Program.

The Florida’s EHR Incentive Program and technical solution establishes and validates eligibility; validates, issues, monitors, audits and tracks incentive payments; identifies suspected fraud and abuse; allows for provider appeals; and validates and monitors compliance with meaningful use standards as defined by CMS. The Agency’s approach with the EHR Incentive program is to leverage the existing constructs of people, process, and technology in the Agency.

STAKEHOLDER INVOLVEMENT

Through a focused effort, the incentive program operates in an interconnected fashion with providers, hospitals, local and regional HIE networks, Regional Extension Centers, and other entities that make up the State HIT landscape. These joint efforts have begun and will continue. The results of these efforts will lead to increased adoption of HIT and will certainly contribute to improvements in the overall quality of care for patients.

The following exhibit shows the stakeholders from across the State, participating in a wide range of HIT/HIE activities, including:

Participation or leadership of historical HIT/HIE programs

Participation in the development of the HIT/HIE As-Is landscape assessment

Participation in the development of the HIT/HIE To-Be vision

Current and historical engagement in the development of HIE infrastructure

Current participation in activities tied to the adoption of EHRs across the State

Stakeholder

HIT/HIE Activities

Historical

HIT/HIE

Programs

As-Is

Landscape

Development

(as of

November

2010)

To-Be Vision

Development

(2011 and

beyond)

HIE Infra-

structure

Development

(technology/legal/

sustainability)

(as of November

2010)

EHR

Adoption

Activities

(as of

November

2010)

Agency for Healthcare Research and Quality

Lessons Learned

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Stakeholder

HIT/HIE Activities

Historical

HIT/HIE

Programs

As-Is

Landscape

Development

(as of

November

2010)

To-Be Vision

Development

(2011 and

beyond)

HIE Infra-

structure

Development

(technology/legal/

sustainability)

(as of November

2010)

EHR

Adoption

Activities

(as of

November

2010)

Agency for Health Care Administration (AHCA)

EHR Pilot, Medicaid Health Information Network (Medicaid-HIN)

Conducted SS-A Facilitated vision development

Promulgated patient consent rule

Medicaid Incentive Program

Availity, LLC Medicaid-HIN

Blue Cross Blue Shield of Florida

Governor’s Health Information Infrastructure Advisory Board (GHIIAB), business plan for the Florida Health Information Network, ePrescribe Florida

Ongoing discussions of how to bring health plans into alignment with the State level HIE and Medicaid-HIN

Business plan for the Florida Health Information Network

Align Meaningful Use

Department of Children and Families

Provided input Provided input

Department of Juvenile Justice

Provided input

Economic Development Organizations / Florida Learning Alliance / Dept. of State Libraries and Archives

High speed network development, education and training

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Stakeholder

HIT/HIE Activities

Historical

HIT/HIE

Programs

As-Is

Landscape

Development

(as of

November

2010)

To-Be Vision

Development

(2011 and

beyond)

HIE Infra-

structure

Development

(technology/legal/

sustainability)

(as of November

2010)

EHR

Adoption

Activities

(as of

November

2010)

Florida Department of Health

Developing EHR system for county health departments (CHD), CDC Program for reportable diseases

Provided input

EHR system will meet Meaningful Use

Federally Qualified Health Center

FQHCs are working with the Agency in planning for establishing clinical data sources

Florida Academy of Family Physicians

EMR training and consulting, worked with AHCA with the HISPC Provider Education Toolkit

Engaged with AHCA in promoting adoption of EHRs through invitations to FAFP conferences

Education

Florida Council for Community Mental Health

Health Information Security and Privacy Collaboration (HISPC)

Provided legal input

Florida Department of Management Services

Broadband coordination

Florida Hospital Association / CIO Council

GHIIAB, HISPC


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Stakeholder

HIT/HIE Activities

Historical

HIT/HIE

Programs

As-Is

Landscape

Development

(as of

November

2010)

To-Be Vision

Development

(2011 and

beyond)

HIE Infra-

structure

Development

(technology/legal/

sustainability)

(as of November

2010)

EHR

Adoption

Activities

(as of

November

2010)

Florida Medical Association

GHIIAB, HISPC, worked with AHCA with the HISPC Provider Education Toolkit

Education, collaboration with Tracy Maxwell, Inc., to promote EHRs

Florida Office of Economic Recovery

Broadband coordination

Florida Quality Improvement Organizations (Florida Medical Quality Assurance, Inc.)

EMR training and consulting

Education

Florida State University

GHIAAB, Health Information Exchange Advisory Council (HIECC), HISPC

EHR studies Proposing EHR Summit

Health Choice Network

GHIIAB

HIT Vendors Provided input

Providers / Provider Networks


Regional Extension Centers (REC)

Memorandum of Understanding to promote access to HIE

Education, Technical Support

Regional Health Information Organizations (RHIO)

Local stakeholders

Develop Local / Regional HIE

Southeast Regional HIT-HIE Collaborative


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Stakeholder

HIT/HIE Activities

Historical

HIT/HIE

Programs

As-Is

Landscape

Development

(as of

November

2010)

To-Be Vision

Development

(2011 and

beyond)

HIE Infra-

structure

Development

(technology/legal/

sustainability)

(as of November

2010)

EHR

Adoption

Activities

(as of

November

2010)

Florida Health Care Coalition

Education and promotion


Florida Pharmacy Association

ePrescribe Florida

Florida Osteopathic Medical Association

GHIIAB, worked with AHCA with the HISPC Provider Education Toolkit

Education

Florida Dental Association

GHIIAB

Florida Association of Physician Assistants

Worked with AHCA with the HISPC Provider Education Toolkit

Florida Association of Homes and Services for the Aging

Education

Humana ePrescribe Florida

Medicaid-HIN data source


University of Central Florida

REC, Health professional use of HIT

University of South Florida

REC, Health Information Workforce

Florida Atlantic University

Health professional use of HIT

University of North Florida

ePrescribe Florida

Health professional use of HIT

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Stakeholder

HIT/HIE Activities

Historical

HIT/HIE

Programs

As-Is

Landscape

Development

(as of

November

2010)

To-Be Vision

Development

(2011 and

beyond)

HIE Infra-

structure

Development

(technology/legal/

sustainability)

(as of November

2010)

EHR

Adoption

Activities

(as of

November

2010)

Florida Agricultural and Mechanical University

State ePrescribing Advisory Panel

Health information workforce

University of Florida

Health information workforce

State Health Policy Consortium

Legal policy

Medicaid Medical Care Advisory Committee *

Seminole Health Department (SHD)

No planned activities at this time

*This committee has Medicaid Beneficiary Representation. The Agency provides information to the committee and solicits feedback on the EHR incentive program and health information exchange.

CMS GUIDELINES CROSS-REFERENCE

Tables are provided in Appendix section G.1 that cross-reference sections of the SMHP to the CMS Guidelines of April 27, 2010.

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LIST OF ACRONYMS

The following table provides a list of acronyms and definitions that will be used during the course of this project.

Term Definition

AAA The Department of Elder Affairs (DOEA) administers several programs through contracted Area Agencies on Aging (AAA) to provide home and community-based services to over 600,000 elder Floridians.

ACCESS Automated Community Connection to Economic Self-Sufficiency, a DCF initiative.

AHCA Agency for Health Care Administration: Chief health policy and planning entity for the State of Florida. AHCA has been designated as the state entity for health information exchange and HIT development and is the single state agency for the Medicaid program.

AHRQ Agency for Healthcare Research and Quality – Federal agency charged with improving the quality, safety, efficiency, and effectiveness of healthcare for all Americans.

AIU Adopt, Implement, Upgrade (AIU).

APD The Agency for Persons with Disabilities (APD) is the agency specifically tasked with serving the needs of Floridians with developmental disabilities.

ARRA American Recovery and Reinvestment Act of 2009 – Economic stimulus package enacted by Congress in February 2009 that included a provision (Health Information Technology for Economic and Clinical Health Act or HITECH Act) to advance the use of health information technology.

BPMN Business Process Modeling Notation (BPMN).

BTOP Broadband Technology Opportunities Program (BTOP) awards program.

CARP Computer Aided Reception Process.

CCD Continuity of Care Document (CCD).

CCN Case Control Number (CCN). Note: CMS also uses the same acronym to refer to the CMS certification number of hospital providers. The use of CCN in this context is relevant to determining which hospitals are eligible for the EHR Incentive.

CCR Continuity of Care Record (CCR) of Medicaid claims.

CDC Centers for Disease Control and Prevention – Federal agency dedicated to protecting health and promoting quality of life through the prevention and control of disease, injury, and disability.

CDC+ The CDC+ is a long-term care program alternative to the HCBS. It provides the opportunity for individuals to improve life quality by being empowered to make choices about supports and services that will meet their long-term care needs and help them reach their goals.

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Term Definition

CDS Clinical Decision Support Systems are often used in combination with CPOE functions in hospitals to assist physicians with decision making by providing reminders, suggestions, and support in diagnosing and treating diseases and conditions. The range of features that CDS systems offer includes drug-dosing assistance, checks for drug allergies and drug/drug interactions, access to the latest evidence-based protocols, reminders about preventive-medicine tests, and guidance for complex antibiotic management programs. Both CPOE and CDS systems vary considerably in their complexity and capabilities.

CFR Code of Federal Regulations (CFR).

CHD County Health Departments (CHD).

CHIP Children’s Health Insurance Program (CHIP).

CHIPRA Children's Health Insurance Program Reauthorization Act of 2009 (CHIPRA or Public Law 111-3).

CMS Centers for Medicare & Medicaid Services – Federal agency that administers the Medicare, Medicaid and Children’s Health Insurance Program.

CMS RO Centers for Medicare & Medicaid Services Regional Offices - The Centers for Medicare & Medicaid Services (CMS) has ten Regional Offices (ROs) whose responsibility is to improve Agency performance through uniform issue management, consistent communication and leadership focused on achieving the Agency's strategic action plan.

CMSO Center for Medicaid and State Operations – Provides guidance and direction to the State Medicaid Programs.

COS Category of Service (COS).

COTS Commercial, off-the-shelf (COTS) is a term referring to computer software or hardware systems and may also include free software with commercial support. COTS purchases are alternatives to in-house developments or one-off government-funded developments. COTS typically requires configuration that is tailored for specific uses. The use of COTS has been mandated across many government and business programs; as such products may offer significant savings in procurement, development, and maintenance.

CPOE Computerized Provider Order Entry: A computer application that allows a physician’s orders for diagnostic and treatment services (such as medications, laboratory, and other tests) to be entered electronically instead of being recorded on order sheets or prescription pads. The computer compares the order against standards for dosing, checks for allergies or interactions with other medications, and warns the physician about potential problems.

CQM Clinical Quality Measures.

http://en.wikipedia.org/wiki/Computer_software

http://en.wikipedia.org/wiki/Hardware

http://en.wikipedia.org/wiki/Free_software

http://en.wikipedia.org/wiki/Government_off-the-shelf

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Term Definition

Critical Access Hospitals A Critical Access Hospital (CAH) is a hospital that is certified to receive cost-based reimbursement from Medicare.

CSR Customer Service Request (CSR).

DCF The Florida Department of Children and Families (DCF).

Disease Management A coordinated and proactive approach to managing care and support for patients with chronic illnesses such as diabetes, congestive heart failure, asthma, HIV/AIDS, and cancer.

DJJ The Florida Department of Juvenile Justice (DJJ).

DOAH Florida Division of Administrative Hearings is the state agency that employs full-time Administrative Law Judges to conduct hearings in most cases in which the substantial interests of a person are determined by an agency and which involve a disputed issue of material fact.

DOC The Florida Department of Corrections (DOC).

DOEA The Department of Elder Affairs is designated as the state department unit on aging as defined in the federal Older Americans Act (OAA) of 1965, as amended.

DOH Florida Department of Health (DOH).

DOM The Division of Medicaid (DOM).

DSS Decision-Support System: Computer tools or applications to assist physicians in clinical decisions by providing evidence-based knowledge in the context of patient specific data. Examples include drug interaction alerts at the time medication is prescribed and reminders for specific guideline-based interventions during the care of patients with chronic disease. Information should be presented in a patient-centric view of individual care and also in a population or aggregate view to support population management and quality improvement.

EA Enterprise Architecture: A strategic resource that aligns business and technology, leverages shared assets, builds internal and external partnerships, and optimizes the value of information technology services.

EDI Electronic Data Interchange.

EHR

Electronic Health Record: A real-time patient health record with access to evidence-based decision support tools that can be used to aid clinicians in decision making. The EHR can automate and streamline a clinician's workflow, ensuring that all clinical information is communicated. It can also prevent delays in response that result in gaps in care. The EHR can also support the collection of data for uses other than clinical care, such as billing, quality management, outcome reporting, and public health disease surveillance and reporting.

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Term Definition

Electronic Prescribing (eRx)

A type of computer technology whereby physicians use handheld or personal computer devices to review drug and formulary coverage and to transmit prescriptions to a printer or to a local pharmacy. E-prescribing software can be integrated into existing clinical information systems to allow physician access to patient specific information to screen for drug interactions and allergies.

EMR Electronic Medical Record: An electronic record of health related information on an individual that can be created, gathered, managed, and consulted by authorized clinicians and staff within one health care organization.

eOHS The Office of Health Services operates the Electronic Office of Health Services (eOHS) system and is the early foundation for the DC’s Electronic Practice Management (EPM) system, which interfaces with OBIS.

EP Eligible Professional (EP).

EPM Department of Corrections Electronic Practice Management (EPM) system.

FQHC Federally Qualified Health Centers are working with the Agency in planning for establishing clinical data sources.

FAFP Florida Academy of Family Physicians (FAFP).

FDVA The Florida Department of Veterans’ Affairs (FDVA) is the state agency that provides assistance to Florida veterans in improving their health and economic well being through the provision of long-term health care services, benefit information, advocacy, and education.

FDOH Florida Department of Health is responsible for supporting sixty-seven county health departments (CHDs).

FFP Federal Financial Participation – Percentage of cost contributed by the federal government to a program.

FFY Federal Fiscal Year (FFY).

FHA Florida Hospital Association (FHA).

FHIE Florida Office for Health Information Exchange: Promotes the development of secure health information exchange and is authorized in statute to develop and implement a strategy for the adoption and use of electronic health records, including the development of an electronic health information network to exchange electronic health records among providers and payers. The Office of HIE is responsible for administering and coordinating new federally funded programs created by the HITECH Act of 2009.

FHIN Florida Health Information Network.

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Term Definition

Florida Center Florida Center for Health Policy for Health Information and Policy Analysis: A Division of Florida’s Agency for Health Care Administration created to promote the adoption of electronic health record systems through health information exchange, electronic prescribing, and personal health records software in partnership with health care stakeholders statewide. The Florida Center is the designated lead entity for state planning and implementation for electronic health record adoption and the exchange of health information.

FLSHOTS The Florida Department of Health’s Immunization Registry: Florida SHOTS (State Health Online Tracking System) is a free, statewide, centralized online immunization registry that helps health-care providers and schools keep track of immunization records. This helps ensure that children receive all vaccinations needed to protect them from dangerous vaccine-preventable diseases such as measles, mumps, diphtheria, polio, varicella, and others.

FMMIS Florida Medicaid Management Information System.

FR Functional Requirement (FR).

FRBA The Florida Rural Broadband Alliance (FRBA)

GC Florida Agency for Health Care Administration’s General Counsel’s Office (GC).

HCBS The Medicaid Home and Community Based Services Waiver (HCBS) is a program providing community services to Medicaid-eligible individuals as an alternative to services provided in an institution.

HHS Health and Human Services – The US Government’s principal agency for protecting the health of all Americans and providing essential human services.

HIE Health Information Exchange: The electronic movement of health-related information among organizations according to nationally recognized standards.

HIECC Health Information Exchange Coordinating Committee: Workgroup of the State Consumer Health Information and Policy Advisory Council. Organized in 2007 to advise and support AHCA in the development and implementation of a strategy to establish a privacy-protected, secure, and integrated statewide network for the exchange of electronic health records among authorized physicians. Designated in July 2009 to lead the stimulus-funded health information technology initiatives.

HIN Health Information Network.

HIO Health Information Organization: An organization that oversees and governs the exchange of health-related information among organizations according to nationally recognized standards.

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Term Definition

HIPAA Health Insurance Portability and Accountability Act of 1996: A federal law intended to improve the portability of health insurance and simplify health care administration. HIPAA sets standards for electronic transmission of claims-related information and for ensuring the security and privacy of all individually identifiable health information.

HISPC Health Information Security and Privacy Collaboration. The Agency has also worked with other states through participation in the Health Information Security and Privacy Collaborative (HISPC) which has been of assistance in reconciling differences in federal and state law and in developing outreach and training strategies for providers.

HIT Health Information Technology: The application of information processing involving both computer hardware and software that deals with the storage, retrieval, sharing, and use of health care information, data, and knowledge for communication and decision making.

HITECH The Health Information Technology for Economic and Clinical Health (HITECH) Act: Sets a new direction that greatly expands the role of states in fostering health information exchange and the adoption of EHRs. The act set a goal of 2014 to increase dramatically the number of health care providers who have, and effectively use, EHRs and HIE.

HMS Health Management System.

HP Hewlett Packard (HP).

HRSA Health Resources and Services Administration - Primary Federal agency for improving access to health care services for people who are uninsured, isolated or medically vulnerable.

I-APD Implementation Advance Planning Document – An Implementation - Advanced Planning Document is a federally required document that is used by Florida to inform CMS of their intentions related to federally funded programs, and request approval and funding to accomplish their needs and objectives. The term APD refers to a Planning APD, Implementation APD, or to an Advance Planning Document Update.

ICD-10 International Statistical Classification of Diseases and Related Health Problems (10th Revision) - system for coding diseases and injuries planned to be used by the US healthcare industry in 2013."

IDN An integrated delivery network (IDN).

IHS Indian Health Service – Federal agency responsible for providing federal health services to American Indians and Alaska natives.

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Term Definition

Interoperability Describes the capacity of one health IT application to share information with another in a computable format (that is, for example, not simply by sharing a PDF [portable document format] file.) Sharing information within and across health IT tools depends on the use of a standardized format for communicating information electronically—both among the components that constitute a doctor’s office EHR (clinical notes, lab results, and radiological imaging and results) and among providers and settings that use different health IT applications. An interoperable health IT system would allow a hospital physician to view the contents of an EHR from a patient’s primary care physician and enable the primary care physician in turn to view all notes and diagnostic tests from the patient’s hospital visit.

ITN Invitation to Negotiate.

LBR Legislative Budget Request.

LOS Length of Stay (LOS).

MAPIR Medical Assistance Payment Incentive Program Repository (MAPIR) application developed by HP and a multi-state Medicaid collaborative, and all supporting business processes, staffing, training, and outreach required to implement the program.

MARs Florida Department of Juvenile Justice Medication Administration Records (MARs).

MCM Florida Agency for Health Care Administration: The Bureau of Medicaid Contract Management (MCM).

MCO Managed Care Organization.

MHC The Miccosukee Indian Reservation is the homeland of the Miccosukee tribe of Native Americans in Florida. It is divided into three sections in two counties of southern Florida. The Miccosukee Health Clinic (MHC) is located on the Tamiami Trail Reservation, which is also the center of most tribal operations.

MHIN The Medicaid Health Information Network (MHIN).

MIPPA The Medicare Improvements for Patients and Providers Act (MIPPA), signed into law on July 15, 2008, encompasses significant changes and opportunities for Medicare beneficiaries, particularly those who are low-income.

MIPPS Medicaid Incentive Payment Program System (MIPPS).

MITA Medicaid Information Technology Architecture: A national framework to support improved systems development and health care management for State Medicaid programs.

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Term Definition

MMIS Medicaid Management Information System: An integrated group of procedures and computer processing operations developed to provide automated claims processing and information retrieval systems for Medicaid programs.

MMIS Medicaid Management Information System: The MMIS is an integrated group of procedures and computer processing operations (subsystems) developed at the general design level to meet principal objectives.

MOU Memorandum of Understanding.

MPI Master Patient Index: A database program that collects a patient’s various hospital identification numbers, e.g. from the blood lab, radiology department, and admissions, and keeps them under a single, enterprise-wide identification number.

MTA A Medical Trade Area (MTA) is a largely self-organized geographic market area in which a delineated population receives most of its medical services.

MU Meaningful Use (MU).

Network A general term for terminals, processors, and devices linked either by cable or wireless technology. Peripherals, applications and data can be shared by network users.

NFBA North Florida Broadband Authority (NFBA).

NHIN National Health Information Network (NHIN).

R&A CMS Registration and Attestation System (R&A).

NPI National Provider Identifier (NPI).

NPPES National Plan and Provider Enumeration System (NPPES).

NTIA National Telecommunications and Information Administration (NTIA).

OAA Older Americans Act (OAA) of 1965: A program to provide assistance in the development of new or improved programs to help older persons through grants to the states for community planning and services.

OBIS Florida Department of Corrections Offender-based Information System (OBIS).

OCA Other Cost Accumulators (OCAs).

OIG Florida Agency for Health Care Administration’s Office of Inspector General (OIG).

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Term Definition

ONC Office of the National Coordinator: Is a government agency (part of HHS) that oversees and encourages the development of a national, interoperable (compatible) health information technology system to improve the quality and efficiency of health care. (http:// www.hhs.gov/healthit/)

PA OMAP The Commonwealth of Pennsylvania’s Office of Medical Assistance Programs (PA OMAP).

P-APD Planning - Advance Planning Document – See I-APD.

PECOS Provider Enrollment and Chain Ownership System (PECOS).

PHR Personal Health Record: An electronic application through which individuals can maintain and manage their health information (and that of others for whom they are authorized) in a private, secure, and confidential environment.

PIN Personal Identification Number (PIN).

PRN Medicare or Medicaid Audits and Investigations Peer Review Medical Staff Credentialing Professionals Resource Network (PRN).

PTAN Provider Transaction Account Number (PTAN).

RACECs There are three Rural Areas of Critical Economic Concern (RACECs) in Florida, the Northwest RACEC, the North Central RACEC and the South Central RACEC. These areas cover 28 rural counties which have been designated as eligible to receive broadband awards that will ensure connectivity to the underserved communities. All of these counties are covered by two recipients of the Broadband Technology Opportunities Program (BTOP) awards program.

REC Regional Extension Centers.

RFI Request for Information.

RHIO Regional Health Information Organization: A health information organization that brings together health care stakeholders within a defined geographic area and governs health information exchange among them for the purpose of improving health and care in that community.

RIS Department of Health has a Radiology Information System (RIS).

RLS Statewide Record Locator Service (RLS) network.

ROI Return on Investment (ROI).

SAMH Department of Children and Families Substance Abuse and Mental Health (SAMH) Programs collect, track and analyze data on National Outcome Measures to determine the effectiveness of programs and services.

http://www.hhs.gov/healthit/

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Term Definition

SAMHIS The SAMH Program maintains the Substance Abuse and Mental Health Information System, which is primarily the system designed to collect and report data needed to answer the following management question: Who receives what services from whom to achieve what outcomes at what cost?

SCHIPAC State Consumer Health Information and Policy Advisory Council: Advises AHCA staff regarding health information and statistics. The composition and functions of the State Consumer Health Information and Policy Advisory Council are described in §408.05(8) and §408.61 Florida Statutes.

SDE State Designated Entity (SDE).

SERCH The Agency participates in the Southeast Regional HIT-HIE Collaborative (SERCH) which holds frequent conference calls on topics related to the promotion of electronic health record adoption and health information exchange.

SFY State Fiscal Year (SFY).

SHD The Seminole Health Department (SHD) in Florida provides health care and promotes wellness within the Indian community.

SHOTS Florida (State Health Online Tracking System) is a free, statewide, centralized online immunization registry that helps health-care providers and schools keep track of immunization records.

SMHP State Medicaid Health Information Technology Plan – Document that describes Medicaid’s vision for providing health information technology services.

SNF Skilled Nursing Facility (SNF).

SOP Strategic and Operational Plan (SOP).

SS-A State Self-Assessment (SS-A): An assessment of the current HIT/HIE landscape across the State both inside and outside of Medicaid.

SSO Single Sign-On (SSO).

USDVA United States Department of Veterans Affairs.

WITS Open Source EHR software named WITS – Web Infrastructure for Treatment Services.

Exhibit 2: List of Acronyms

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SECTION A. AS-IS ASSESSMENT

A.1 STATE HIT/HIE SELF-ASSESSMENT

This section of the SMHP is Florida’s As-Is Assessment, is one part of the Health Information Technology (HIT) / Health Information Exchange (HIE) self assessment as required by 42 CFR 495.332 (a) (1) (i). The information provided in this section lists and assesses the State’s current HIT/HIE capabilities. Florida envisions the current efforts to advance HIT and HIE capabilities will be able to eventually provide the means for Medicaid to operate in an interconnected fashion with eligible professionals (EPs), hospitals, local and regional health information exchange networks, and other entities that make up the State HIT landscape, and contribute to the improvements in the overall quality of care for its patients.

A.1.1 FLORIDA MEDICAID OVERVIEW

The Medicaid program is a state-administered program that is jointly financed by state and federal funds to provide health care to aged, blind, and disabled individuals as well as to pregnant women, families, and children in families below specified federal poverty level limits. Each state administers its program under a federally approved state plan. There are federal requirements regarding populations and services that must be provided as well as optional services and eligibility groups that may be covered. Medicaid programs vary from state to state and within states over time due to differences in optional service coverage, limits on mandatory and optional services, optional eligibility groups, income and asset limits for eligibility, and provider reimbursement methodology and levels. For state Fiscal Year 2011-12, Florida Medicaid is appropriated $21.2 billion in funds. The federal share of funding for Medicaid Services is 55.94%, while the State share is 44.06%.

In fiscal year 2012-13, it is projected that there will be 3.29 million eligible recipients and that Florida will spend approximately $ 6,547 per eligible. Forty percent of all Medicaid expenditures are for payments to hospitals, nursing homes, Intermediate Care Facilities for the Developmentally Disabled, Low Income Pool and Disproportionate Share Payments. About nine percent of expenditures are for prescribed medications. Under the Affordable Care Act, the Agency projects that an estimated additional 1.9 million recipients will become eligible for Medicaid.

A.1.2 OBJECTIVES AND GOALS FOR STATEWIDE HIT

The Agency has been advancing HIT within the State since 2004. The following timeline shows significant milestones in the State’s HIT landscape development:

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1/1/2006 12/31/2014

1/1/2007 1/1/2008 1/1/2009 1/1/2010 1/1/2011 1/1/2012 1/1/2013 1/1/2014

7/8/2010

SMHPDevelopment Contract Started

12/31/2010

EnvironmentalScan Completion

2006 - 2009

HISPC Project

Dec 2007

HIECCSteeringCommitteeestablished

Apr 2009

Gov. Crist recognizedHIECC as Representativeadvisory group forHIE development in Florida

8/20/2009

ONC announcedState HIE CooperativeAgreement Program

2/17/2009

ARRA signedinto Law

7/15/2010

Florida HIEITN issued

7/8/2010 - 6/30/2011

SMHPDevelopment

3/1/2011 - 3/1/2012

Staggered

HIE Group

Rollouts

4/1/2012 - 2/1/2013

HIE Group

Rollouts with

Expanded

data exchange

4/1/2013 - 12/1/2013

HIE Group

Rollouts for

Quality Metrics

1/1/2012

HIEProvider Directory

Rollout

2/4/2011

Target – IAPD Funding

6/1/2010

E-scan Contract Start

2/4/2010

P-APDApproved

Exhibit 1: HIT/HIE Timeline

The following sections describe the Agency’s statewide objectives for HIT. Refer to Section A.2.4 for activities specific to the Medicaid program.

The State’s objectives are grouped into eight areas related to health information exchange capacity and oversight:

Governance - addresses how stakeholders will be engaged in oversight of health information exchange activities to encourage provider participation and protect the public interest.

Finance - identifies a business plan for sustaining core health information exchange services as determined by stakeholders and legal requirements.

Technical Infrastructure - describes the network and applications necessary for secure health information exchange and to achieve the performance determined by Florida stakeholders, national standards for interoperability, and legal requirements.

Business and Technical Operations - addresses the management of health information exchange activities including procurement, project management, system maintenance, customer service and adherence to reporting requirements.

Legal Policy - establishes policies and procedures for providers and other stakeholders participating in health information exchange consistent with state and federal laws.

Meaningful Use - identifies key measures of HIE services for Medicaid providers.

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Disaster Preparedness - addresses the need to have a robust HIE infrastructure that can survive local and statewide disasters.

Continuous Improvement - identifies the need to continuously evaluate the meaningful use of electronic health records and health information exchange and modify priorities for capacity development and the promotion of health information technology.

A.1.3 HIE ADVISORY AND OVERSIGHT

Health Information

Exchange Coordinating

Committee (HIECC)

AGENCY FOR HEALTH CARE ADMINISTRATION

State Designated HIE Entity,

State Medicaid Program, and

State HIT Coordinator

State Medicaid Health IT Plan Development

State Consumer Health Information and Policy

Advisory Council

Medicaid HIN

State HIE Cooperative Agreement

Florida Health

Information Exchange

(HIE)

HIE Legal

Workgroup

EHR Incentive Program

Executive Committee

Future

Other Technical and

Clinical Committees

FHIE Management Committee

AHCA, Ex Officio

DOH, Ex Officio

Electronic Prescribing

Advisory Panel

(Disbanded – 2010)

Exhibit 2: Florida HIE Advisory Structure

The Agency is the entity designated to govern the State’s HIT/HIE development activities and, as such, will employ the state agency model for governance and accountability through the end of the collaborative agreement with the Office of the National Coordinator.

Relative to HIT/HIE, the Agency is advised by the State Consumer Health Information and Policy Advisory Council, the Health Information Exchange Coordinating Committee (HIECC) and the HIE Legal Work Group. The Agency is also considering the formation of a new HIE Management Committee in the future. The roles of the advisory groups are as follows:

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A.1.3.1 STATE CONSUMER HEALTH INFORMATION AND POLICY ADVISORY COUNCIL

The mission of the State Consumer Health Information and Policy Advisory Council is to assist the Agency in reviewing the comprehensive health information system including the identification, collection, standardization, sharing, and coordination of health-related data, fraud and abuse data, and professional and facility licensing data among federal, state, local, and private entities and to recommend improvements for purposes of public health, policy analysis, and transparency of consumer health care information.

The Advisory Council advises the Agency regarding the development and implementation of a long-range plan for making health care quality measures and financial data available that will allow consumers to compare health care services. The health care quality measures and financial data will include, but are not limited to, pharmacies, physicians, health care facilities, and health plans and managed care entities.

In addition, the Advisory Council advises the Agency in the development and implementation strategies for the adoption and use of electronic health records (EHRs), including the development of an electronic health information network for the sharing of EHRs among health care facilities, health care providers, and health insurers.

A.1.3.2 HEALTH INFORMATION EXCHANGE COORDINATING COMMITTEE (HIECC)

The Health Information Exchange Coordinating Committee (HIECC) has been organized by the Agency to advise and support the Agency in developing and implementing a strategy to establish a privacy-protected, secure, and integrated statewide network for the exchange of electronic health records among authorized physicians.

The HIECC provides guidance for the Regional Health Information Organizations (RHIOs) operating in Florida to ensure the privacy and security of health information and will recommend technical standards to ensure the interconnectivity of all health care providers and to establish and maintain the security for electronic health information.

The HIECC reviews and evaluates applicant proposals to the Florida Health Information Network Grants Program and makes funding recommendations to the Agency Secretary. It also assists the Agency as it develops and implements specific programs for the creation of a statewide network, adoption of electronic medical record systems and development of health information exchange at the local level.

A.1.3.3 HIE LEGAL WORK GROUP

The Agency is also advised by the HIE Legal Work Group which includes legal experts representing provider associations, clinicians, Regional Health Information Organizations, health plans, government, Regional Extension Centers, and consumer groups. The Legal Work Group addresses legal issues related to HIE, liability and risk mitigation, and provides ethical guidance.

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A.1.3.4 HIT/HIE ADVISORY INVOLVEMENT MATRIX

The following matrix demonstrates broad stakeholder’s participation in statewide HIT/HIE advisory groups:

Stakeholder

HIT/HIE Advisory Organizations

State

Consumer

Health

Information

and Policy

Advisory

Council

HIECC

HIE

Legal

Work

group

State

Electronic

Prescribing

Advisory

Panel

HIE Mgmt.

Committee

Agency for Health Care Administration (AHCA)

To

Be D

etermin

ed

Community Health Centers Alliance

Consumers Representative

County Health Departments

Federally Qualified Health Center

Florida Association of Health Plans

Florida Association of Homes and Services for the Aging

(pending)

Florida Association on Business/Health Coalitions

Florida Council for Community Mental Health

Florida Department of Education

Florida Department of Health

Florida Executive Office of the Governor

Florida Justice Association

Florida Health Information Management Association

Florida Hospital Association


Florida Office of Drug Control

Florida Office of Economic Recovery

Florida Office of Insurance Regulation

Florida Pharmacy Association

Florida State University / Florida A&M

Health Choice Networks

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Stakeholder

HIT/HIE Advisory Organizations

State

Consumer

Health

Information

and Policy

Advisory

Council

HIECC

HIE

Legal

Work

group

State

Electronic

Prescribing

Advisory

Panel

HIE Mgmt.

Committee

Health Plans / Blue Cross Blue Shield of Florida / Humana

Health Planning Council of Northeast Florida, Inc.

Hospitals / Clinics Representative

Industry Trade Organizations

ITFlorida

Law Firms

Pensacola Chamber of Commerce

Pharmacy Representative

Eligible Professionals (EPs) / Provider Networks Representative

Regional Health Information Organizations (RHIO)

University of Central Florida Medical School

Vendor Representatives

Exhibit 3: HIT/HIE Advisory Matrix

A.1.3.5 MEDICAID MEDICAL CARE ADVISORY COMMITTEE

Federal regulations require each state Medicaid Program to establish a committee to serve in an advisory capacity on health and medical care issues. According to 42 CFR431.12, this committee includes the following:

Board-certified physicians and other representatives of the health professions who are familiar with the medical needs of low-income people and with the resources available for their care

Members of consumer groups, including Medicaid recipients or Representative

Management from the Department of Children and Family Services and the Department of Health

The committee provides the Agency with advice on improving Medicaid beneficiaries’ access to specialists, and enhancing communications with Medicaid beneficiaries. Members also review

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and provide input on a variety of Medicaid materials, and make recommendations to the Agency about Medicaid policies, rules and procedures. The Agency has provides regular updates on the EHR incentive program and the implementation of Health Information Exchange to the committee.

A.2 AS-IS ASSESSMENT – CURRENT HIT/HIE LANDSCAPE IN FLORIDA

A.2.1 INTRODUCTION

This section provides a description of the State’s current HIT/HIE landscape including a description of both Agency-led and other intrastate HIT/HIE efforts and current Florida Medicaid Management Information System (FMMIS) HIE capabilities. This section also includes a summary of EHR adoption and use of HIE across the State.

Refer to the Stakeholder Involvement matrix in the Executive Summary Section for a summary of stakeholder participation in the As-Is Landscape Assessment.

A.2.2 EHR ADOPTION

A.2.2.1 CURRENT EHR ADOPTION

The Agency is authorized by the Legislature to promote health information exchange and to foster the adoption of EHR systems. The Agency moved from strategic planning to creating a grants program to leverage the development of local electronic health information exchange and establishing plans to build a statewide health information network. The statutory authority given to the Agency clearly supports its vision to transform health care through the promotion of health information technology. Because of its history of promoting the adoption of EHRs and the creation of a statewide health information network, the Agency has paid close attention to the diffusion of health information technology (HIT) among Florida’s providers.

The use of historical adoption data in the following paragraphs is intended to show the upward trend of EHR adoption by physicians between the years 2005 and 2008. This was used as the basis for the initial planning efforts, pending the results of the 2010 environmental scan survey. The Environmental Scan was completed in December of 2010 and those results have now been used to adjust planning efforts such that current adoption data can be recognized as the new baseline. The Environmental Scan data from 2010 is provided in Section 2.2 of this report and EHR Incentive Program participation targets can be adjusted accordingly based on this data. The rate of provider adoption of EHR systems among Florida’s primary care physicians is fairly well known due to several research studies conducted by faculty at Florida State University and the University of Alabama.

In 2005, Florida State University researchers surveyed the use of HIT among ambulatory care providers in Florida. Over 96% of all respondents had access to computing and the Internet, though non-physician staff used the computers more than the physicians. Among the responding providers, 23.7% reported that they routinely used EHRs in their practice, but only 17.2% of the physicians with computers in their offices used e-mail to communicate with patients. Routine EHR use was significantly related to the age of the physician and his or her medical training, the type of practice and practice size. The use of EHR systems was more likely

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to occur in larger medical practices, among specialists and in multi-specialty practices, and among younger physicians.1

When comparing urban versus rural providers, the research team found that rural providers were less likely to use EHRs, less likely to have prescribing connections to pharmacies through their EHRs, and had less experience with EHRs. Rural physicians were more likely to cite loss of income during the EHR implementation as a barrier to their adoption and were more concerned about privacy and confidentiality concerns about EHRs.2 Also, physicians with a large number of Medicare patients were more likely to have an EHR, whereas those with a large number of Medicaid patients were less likely to have an EHR.3

A similar EHR adoption survey was conducted among Florida’s physicians in 2008 by the same research team. This follow-up survey allowed some adoption trend lines to be drawn between 2005 and 2008.4 In the three year period between surveys, the percentage of physicians using EHRs in Florida increased by more than eleven percentage points, from 23.7% to 35% of respondents. The number of physicians planning on purchasing an EHR in the future increased twelve percentage points, from 45.2% in 2005 to 57.1% in 2008. Of some interest for connectivity, the percentage of respondents using dial-up to access the Internet dropped significantly, but the number of respondents accessing the Internet through high speed wireless increased from 11.2% in 2005 to 90.3% in 2008.

While this data is four years old, clearly there is a move toward the use of electronic records and gaining access to the Internet. In its strategic planning, the Agency recognizes that the robust exchange of health information requires widespread adoption of electronic health record systems among providers and plans to address both issues resolutely.

A.2.2.2 2010 EHR ADOPTION ENVIRONMENTAL SCAN5

Relative to the adoption of EHR technology in the Florida Medicaid landscape, the Agency focused on two perspectives: 1) Florida Medicaid Health Plans HIT Environment; and 2) Florida Medicaid Providers EHR Adoption. The Agency conducted a comprehensive environmental scan of Medicaid providers across the State. The Agency has amended this SMHP to include data from the 2010 Environmental Scan as appropriate. Copies of the surveys are in the Appendix of this document.

CMS requires that the SMHP includes an “As-Is” Assessment, including an environmental scan to dentify a Medicaid Health Information Technology (HIT) baseline for the state. To do so, acute

1 Menachemi N, Brooks RG. (2006). EHR and other IT adoption among physicians: results of a large-scale statewide analysis. J Healthcare Information Management 2006 Summer; 20(3):79-87. 2 Menachemi N, Langley A, Brooks RG. (2007). The use of information technologies among rural and urban physicians in Florida. J Med Syst. 2007 Dec;31(6):483-8. 3 Menachemi N, Matthews MC, Ford EW, Brooks RG. (2007). The influence of payer mix on electronic health record adoption by physicians. Health Care Manage Rev. 2007 Apr-Jun;32(2):111-8. 4 Yeager K, Menachemi N, Brooks, RG ( in press). 5 Florida Health Information Technology Environmental Scan, 2010 prepared by WellFlorida Council, Inc.

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care hospitals, federally qualified community centers (FQHCs), rural health clinics (RHCs), Regional Health Information Organizations (RHIOs)/Health Information Exchanges (HIEs), and select healthcare professionals participating in Medicaid and who may be eligible for the Medicaid EHR incentives (physicians, dentists, certified nurse-midwives, and nurse practitioners, referred to collectively as Eligible Professionals) were surveyed. Findings from the surveys are summarized below and may be reviewed in detail in the Florida Health Information Technology Environmental Scan.

Specifically, the survey sought to answer the following questions.

Identify Eligible Professionals (EPs) and hospitals in Florida who plan to participate in the Medicaid Electronic Health Record Incentive Program.

Identify the Health Information Technology capacity of EPs and hospitals – presence of Electronic Health Record, ability to upgrade to a certifiable Electronic Health Record system and intent to upgrade to the Electronic Health Record.

Assess the integration of Information Technology systems within the EP or hospital for purposes of meaningful use reporting including standardized lab reporting and public health reporting.

Identify hospitals that provide secure delivery of results to physicians (outside their network).

Identify hospitals that maintain Electronic Health Information networks for their attending physicians.

Identify EPs and hospitals that intend to connect to a local or statewide Health Information Exchange.

Identify the access to broadband connectivity of EPs and hospitals.

Identify the EPs and Hospital and their current and projected use of e-Prescribing:

o Already Adopted e-Prescribing

o Have not adopted – projected year of implementing e-Prescribing

o In the process of implementing – project year of implementing e-Prescribing

A summary of the findings for each survey population is provided in the sections that follow.

A.2.2.2.1 ELIGIBLE PROFESSIONALS

Surveys were sent to individual physicians, dentists, certified nurse midwives, and nurse practitioners in group and individual practices who participate in Florida’s Medicaid program and are potentially eligible for the Medicaid EHR Incentive Program. The CMS EHR Incentive Program funds are earmarked specifically for individual eligible professionals—regardless of whether they are in a solo or group practices. We made the assumption that eligible professional respondents to the Environmental Scan survey who are in group practices represented all providers in the group in their responses. Of the 10,108 Eligible Professional surveys distributed, 2,571 were completed, resulting in a survey response rate of 25.4%.

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It is estimated that 450 EPs associated with the CHD may participate in the EHR Incentive Program. This is the estimated number of EPs working through a CHD including CHDs that are FQHCs. Five (5) FQHCs are part of a CHD.

For some group practices, more than one eligible professional responded. In these cases, for the purpose of projecting participation in the program, only one respondent per group was included.

In order to develop a comprehensive list of potentially eligible professionals, several Medicaid databases were used to form the sampling frame for this survey. These databases included any provider who billed Medicaid during the period of January 2010 through May 2010. These files were the Medicaid fee-for-service pay-to-provider file, MediPass primary care provider files, and the Medicaid HMO provider payable file. The provider types included in these files were physicians, ARNPs, RHCs, FQHCs, County Health Departments (CHDs) and provider service networks.

Because these provider-based files were created for Medicaid billing purposes, they had to be extensively cleaned and sorted to accommodate the purpose of the Environmental Scan. The following steps were performed to develop the final dataset to be used for the eligible professional evaluation:

1. Provider types who were not defined as eligible under the Medicaid EHR Incentive Program were removed. Provider types/facilities that were included in the files but were not eligible for the environmental scan sample population include:

a. Independent labs b. Case management workers c. Home health agencies d. Ambulatory surgery centers e. Hospital-based physicians (e.g. anesthesia, pathology, radiology, hospitalists) f. University-employed providers g. Provider Service Networks

2. Providers who were to be surveyed through a separate process (e.g., providers based in

RHCs, FQHCs, or CHDs) were removed.

3. Providers who had out-of-state addresses were removed.

4. Multiple entries of the same provider in one or more of the Medicaid databases were

reduced to one entry. For those eligible professionals who had multiple addresses, the

address with the highest number of claims associated with it was used.

5. Addresses were processed through the U.S. Post Office National Change of Address

program (NCOA) to validate deliverable addresses and identify active change of address

notices.

6. Providers who worked at the same practices were not removed from the sample

population because the CMS EHR Incentive Program funding is earmarked specifically

for individual eligible professionals, not practices.

After these steps were completed, the final sampling frame was 10,108 eligible professionals: 9,489 physicians, 433 dentists, 132 ARNPs, and 54 midwives.

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Of the 2,571 eligible professional respondents, 901 (35.0%) have EHR systems in their practice and 1,663 (64.7%) eligible professionals do not have an EHR system. A multitude of EHR system types are being used by these providers with over 300 vendor/systems being reported in the survey. 701 respondents are considering the purchase of an EHR within the next year.

Collectively, 1,632 (63.5%) of the 2,571 eligible professional respondents plan to participate in the EHR Incentive Programs, of which 563 (30.4%) plan to apply specifically for the Medicaid EHR Incentive Program. Of the eligible professional respondents who plan to apply for Medicaid EHR incentives and who responded to the question regarding the year they would seek funding, 441 (82.1%) of eligible professional respondents plan to apply in 2011, 38 (7.1%) in 2012, and 6 (1.1%) after 2012; 52 (9.7%) reported that they were unsure when they would seek the incentives.

Regarding Internet connectivity, 1,203 (46.8%) eligible professionals access the Internet through a DSL service, and only 73 (2.8%) have no Internet connection. Most respondents (87.8%) are unaware of a RHIO in their area; however, 39.2% are interested in collaborating with a RHIO to exchange information with other providers. If no local RHIO were available, 31.0% of the respondents would be interested in collaborating with a state-level HIE.

A.2.2.2.2 RURAL HEALTH CLINICS

RHCs are located in rural areas and are considered safety net clinics. Most Florida RHCs are located in North Florida or North Central Florida. Surveys were sent to 142 Medicare-certified RHCs, and 77 RHCs completed surveys. The survey response rate of the RHC sample population was 54.2%.

EHRs are implemented in 26 (33.8%) of the RHCs surveyed. Of the 51 RHC respondents without EHRs, 34 (66.7%) are considering purchasing an EHR within the next year.

Of the 77 RHCs surveyed, 67 (87.0%) plan to apply for the EHR incentive payments; 40 (51.9%) of these RHCs plan to apply specifically for the Medicaid EHR Incentive Program. Most RHC respondents (70.1%) anticipate that they will apply for incentives in 2011.

All RHCs surveyed have Internet connectivity; 51 (66.2%) having DSL access. Of the 77 RHCs surveyed, 68 (88.3%) are unaware of a RHIO in their area; however, 39 (50.6%) RHC respondents are interested in collaborating with a RHIO to exchange information with other providers. If no local RHIO were available, 31 (40.3%) of the RHCs surveyed would be interested in collaborating with a state-level HIE.

A.2.2.2.3 FEDERALLY QUALIFIED HEALTH CENTERS

FQHCs provide comprehensive outpatient health care services in underserved areas, both in rural and urban settings. Of the 42 FQHCs identified, 34 (81.0%) FQHCs completed the survey.

EHR systems are currently used by 23 (67.6%) of the 34 FQHCs surveyed. Only seven EHR system types are being used by FQHC providers; the most common FQHC system

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vendors are Sage and GE Healthcare. Six of the 11 FQHCs without EHRs are implementing or plan to implement an EHR within the next 12 months.

Almost 75% of the FQHCs surveyed are planning to receive EHR incentive payments through the healthcare professionals they employ. Of those 25 FQHCs, 19 intend to participate in the Medicaid EHR Incentive Program.

Nineteen (55.9%) FQHCs are aware of a RHIO in their area. If a RHIO were in their area, 30 (88.3%) FQHC respondents are interested in collaborating with a RHIO to exchange information with other providers. Only 10 (29.4%) of the FQHCs surveyed would be interested in collaborating with a state-level HIE.

A.2.2.2.4 ACUTE CARE HOSPITALS

Hospitals use a multitude of EHR and other health information systems, and they are at varying stages of meeting the meaningful use guidelines which are provided in Appendix A. Of the 211 licensed acute care hospitals contacted, 162 (76.8%) responded to the survey.

Of the 162 responding hospitals, 129 (79.6%) hospitals plan to apply for the Medicaid EHR incentives. Based on the hospital respondents’ current knowledge of meaningful use rules and their likelihood of meeting the 10% patient volume requirement for the Medicaid EHR Incentive Program, 91 hospitals report that they will qualify for Medicaid Stage 1 Incentives in 2011, 21 in 2012, and 11 after 2012. Only 26 (16.0%) of the hospitals that responded to the survey are likely to qualify for the EHR incentives by attesting that they can meet the Stage 1 meaningful use measures with an existing EHR, whereas 68 (42.0%) will need to upgrade or expand their EHR systems. Only 25 (15.4%) of the hospitals plan to acquire a new EHR system, and 27 (16.7%) are currently implementing a new EHR system.

Most hospitals (72.8%) are either currently collaborating with their local RHIO or are interested in collaborating with a RHIO. Of the hospitals that responded, 51.2% are interested in collaborating with a state-level HIE.

A.2.2.2.5 RHIOS/HIES

According to the Florida Association of RHIOs, 10 RHIOs/HIEs currently cover 42 counties and are expanding into 21 additional counties to cover 63 of Florida’s 67 counties. Nine out of 10 RHIOs/HIEs responded to the survey.

As indicated by the survey responses, the RHIOs/HIEs across the state are at various stages of operations. Six of the nine RHIOs/HIEs surveyed are currently operational; four of the six operational RHIOs/HIEs are fully active and regularly transmit patient data. Three of the RHIOs/HIEs are capable of exchanging information with other unaffiliated RHIOs/HIEs, within and outside of the state.

The RHIOs/HIEs reported that the majority of their submitted data are through hospitals, community health centers, physicians, and laboratories. With the exception of County Health Departments, no government entities are submitting data through the RHIOs/HIEs. Additionally, the RHIOs/HIEs are not receiving data from insurance

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entities. Two RHIO/HIEs receive submissions from nursing homes and long-term care facilities. No RHIOs have more than 20 providers/entities submitting data.

A.2.2.2.6 SUMMARY OF SURVEY RESPONDENTS

Based on the eligible professional sample population and survey responses, Exhibit 11 below provides an estimate of the percentage of Medicaid providers expected to seek funding from the Medicaid EHR Incentive Program. The eligible professionals’ practices, RHCs, and FQHCs employ multiple providers who may be eligible for the Medicaid EHR Incentive Program.

To arrive at the estimated percentages of eligible professionals who are interested in participating in the Medicaid EHR Incentive Program, the survey data was first sorted using standardized inclusion rules (summarized in the Analytic Approach section of the report). Then, a systematic process to optimize the accuracy of the estimates was followed. This process consisted of three general steps:

1. Surveys in which the respondent reported interest in participating in the Medicaid EHR Incentive Program were extracted for analysis. Respondents who reported that they plan to apply for EHR incentives but are “unsure” about the incentive program to which they will apply (Medicaid or Medicare) were not included in the estimates.

2. From the extracted surveys, surveys that were sent to multiple eligible professionals at the same address were removed (only one survey was allowed per address).

3. If multiple responses were received from eligible professionals at the same practice, only one survey was included in the calculation. For example, if three respondents were from the same practice that had a total of 15 providers, only 15 providers were counted (15 providers were not counted three times). It was assumed that the aggregated number of providers represented eligible professionals. This assumption was approved by UF Biostatistician Babette Brumback, Ph.D. and authorized by the Agency.

Exhibit 4: Survey respondents planning to seek funding from the Medicaid Incentives

Survey Type

Survey

Population

Survey

Responses

# in Practice

of Survey

Respondent

s (B)

#

Respondent

s -Yes to

Medicaid

Incentive

# in

Practice -

Yes to

Medicaid

Incentive

(A)

Estimated % of

Providers

Seeking

Medicaid

Incentives (A/B)

Population

of

Medicaid

Providers

Estimated #

of Program

Participant

s

Eligible Professionals 10,108 2,571 5,523 563 978 17.71% 37,316 6,527

- MDs/DOs 9,489 2,386 5,278 514 911 17.26% 31,526 5,441

- Dentists 433 130 176 41 56 31.82% 1,026 326

- ARNPs 132 38 51 6 9 17.65% 3,521 621

- Midwives 54 17 18 2 2 11.11% 1,243 138

Rural Health Clinics 142 77 111 40 56 50.50%

Federally Qualified

Health Centers

42 34 N/A 25 181*

Hospitals 211 166 N/A 129 N/A

Number of survey respondents planning to seek funding from the Medicaid Incentives and estimated % of providers seeking

Medicaid incentives.

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A.2.2.2.7 SUMMARY OF KEY FINDINGS

The following exhibit provides a summary of the survey population for each type of survey and the number of responses received as of October 13, 2010. Based on the total eligible professionals surveyed, the survey response rate was 25.4%. Based on the total RHC survey population, the response rate was 54.2%. The response rates for FQHCs, hospitals, and RHIOs/HIEs were 81.0%, 76.8%, and 90.0%, respectively.

Survey Type Survey

Population

Undeliverable

Surveys

Surveys

Not

Returned

or

Discarded

Survey

Responses

Eligible Professionals 10,108 817 6,720 2,571

Rural Health Clinics 142 10 55 77 Hospitals 211 N/A 49 162

Federally Qualified Health Centers

42 N/A 8 34

RHIOs/HIEs 10 N/A 1 9

Exhibit 5: Survey Population and Survey Responses

A.2.2.2.8 ONC COMMISSIONED SURVEY DATA

Below are Nationwide and Florida results on both adoption and intention to apply for meaningful use among hospitals and physicians that were released by HHS on January 13, 2011 from the ONC-commissioned survey results6.

Acute Care Hospitals

According to the most recent results of the American Hospital Association’s Survey of IT adoption, 15.1 percent of acute care non-federal hospitals have adopted at least a “basic” EHR. This represents growth of nearly 75 percent since 2008.

In addition, 80.8 percent of acute care non-federal hospitals plan to apply for EHR incentive payments. Of those hospitals, 80.1 percent plan to apply in 2011 or 20127.

6 Released by HHS on January 13, 2011 from the ONC-commissioned survey results 7 Hospital Source: American Hospital Association Information Technology Survey, 2008-2010. Physician Source: National Center for Health Statistics, National Ambulatory Medical Center Survey, 2008-2010

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Exhibit 6: Percent of Acute Care Non-Federal Hospitals With at Least a “Basic” Electronic Health Record (2008 2010)8

Exhibit 7: Percent of Acute Care Non-Federal Hospitals Planning to Apply for EHR Incentive Payments

In Florida, according to the same source, approximately 14 percent (+/-6%) of acute care non-federal hospitals report having at least a “basic” EHR in place.

8 “Basic” electronic health records are defined as electronic capability for managing: Physicians: Patient demographic information, patient problem lists, patient medication lists, clinical notes, orders for prescriptions, and viewing laboratory and imaging results; Hospitals: Patient demographic information, physicians’ notes, nursing assessments, patient problem lists, patient medication lists, discharge summaries, lab and radiologic reports, diagnostic test results, and orders for medications. They are defined in the following sources: Physicians: Hsiao CJ, et al. Electronic Medical Record/Electronic Health Record Systems of Office-based Physicians: United States, 2009 and Preliminary 2010 State Estimates Health E Stats. National Center for Health Statistics, Centers for Disease Control. Hospitals: Jha AK, et al. Use of Electronic Health Records in U.S. Hospitals. N Engl J Med. 2009 360;16

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Office-based Physicians

According to the most recent results from the National Center for Health Statistics Survey of IT adoption in physician practices, 24.9 percent of office-based physicians have adopted at least a “basic” electronic health record. This represents growth of nearly 50 percent since 2008.

Growth in electronic health record adoption was strongest among primary care physicians last year, 29.6 percent of whom have now adopted at least a basic EHR.

In addition, 41.1 percent of office based physicians plan to apply for EHR incentive payments. Of those physicians, 79.1 percent plan to apply in 2011 or 20129.

Exhibit 8: Percent of Office-Based Physicians Who have Adopted at Least a “Basic” Electronic Health Record10

9 Hospital Source: American Hospital Association Information Technology Survey, 2008-2010. Physician Source: National Center for Health Statistics, National Ambulatory Medical Center Survey, 2008-2010 10 “Basic” electronic health records are defined as electronic capability for managing: Physicians: Patient demographic information, patient problem lists, patient medication lists, clinical notes, orders for prescriptions, and viewing laboratory and imaging results; Hospitals: Patient demographic information, physicians’ notes, nursing assessments, patient problem lists, patient medication lists, discharge summaries, lab and radiologic reports, diagnostic test results, and orders for medications. They are defined in the following sources: Physicians: Hsiao CJ, et al. Electronic Medical Record/Electronic Health Record Systems of Office-based Physicians: United States, 2009 and Preliminary 2010 State Estimates Health E Stats. National Center for Health

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Exhibit 9: Percent of Office-Based Physicians Who are Planning to Apply for EHR Incentive Payments

In Florida, according to the same source:

Approximately 22 percent of office-based physicians have at least a “basic” EHR in their practices. The estimated adoption rate among primary care physicians is 24 percent.

An estimated 43 percent of office-based physicians plan to apply for EHR incentive payments.

A.2.2.3 BARRIERS TO EHR ADOPTION

“The federal government’s rewards and Incentive Program related to the meaningful use of HIT in hospitals has created an organizational imperative to implement such systems”11

With statements like this, one might think that the broad adoption of EHRs is a foregone conclusion; however, other studies clearly paint a different picture.

Statistics, Centers for Disease Control. Hospitals: Jha AK, et al. Use of Electronic Health Records in U.S. Hospitals. N Engl J Med. 2009 360;16 11 Ford E, Menachemi N, Huerta T, Yr F, Moore R (2010). Hospital IT Adoption Strategies Association with Implementation Success, Implications for Achieving Meaningful Use. Journal of Healthcare Management; May/June 2010: 175-189

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”A national survey, conducted in 2008, was sent to all acute-care hospitals that are members of the American Hospital Association; responses came from 2,952 hospitals, or approximately 63% of the membership. "Comprehensive" EHR was defined by an expert panel as having 24 functionalities-for example, physician notes, lab reports, medications-present in all major clinical units of a hospital. The criteria for “basic” EHR were having ten functionalities in at least one major clinical unit. The researchers hypothesized that large hospitals and major teaching hospitals would have a higher prevalence of EHR and public hospitals might have lower adoption rates, under the assumption that large institutions have greater access to the capital needed to buy and implement these expensive systems.

The results showed that 1.5% of U.S. hospitals had implemented a comprehensive EHR and an additional 7.6% had a basic EHR in place. Larger hospitals, major teaching hospitals and urban hospitals were more likely to have EHRs. Adoption rates of EHRs were similar between public and private institutions.

The most commonly cited barriers to adoption among hospitals without EHR were:

Inadequate capital for purchase (73%),

Concerns about maintenance costs (44%),

Resistance from physicians (36%),

Unclear return on investment (32%), and

Lack of staff with adequate IT expertise (30%).

Hospitals with EHR cited physician resistance as a major barrier but were less likely to cite the other four as major barriers.”12

In an earlier 2004 study, similar barriers were noted indicating that, while progress has been made, the fundamental barriers remain the same.

The following Exhibit provides another view of adoption barriers:

12 "The Use of Electronic Health Records in U.S. Hospitals," Ashish K. Jha, Catherine M. DesRoches, Eric G. Campbell, Karen Donelan, Sowmya R. Rao, Timothy G. Ferris, Alexandra Shields, Sara Rosenbaum, David Blumenthal, New England Journal of Medicine, online March 25, 2009

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Exhibit 10: Barriers to EHR Adoption

Barriers identified by this study include:

Financial Barriers – cost, lack of ROI, high initial physician time cost, lack of incentives

Technological Barriers – lack of standards, lack of information infrastructure, inadequate data exchange, lack of standard EHR systems, lack of integration between EHR and registries, inadequate technical support

Attitudinal and Behavioral Barriers – office and providers’ attitudes and culture, technical competency, leadership, data entry

Organizational Change Barriers – workflow design and office integration and alignment with workflow, migration from paper, customizing and reorganizing, staff training

Social Barriers – security and privacy, liability, decentralization, stakeholder support

Consumer Barriers – consumer acceptance, privacy13

In addition to the barriers listed above, the Agency has identified issues with the availability of broadband infrastructure to support the exchange of health information especially in rural areas of the State. Refer to Section 2.3.3.4 for more information regarding broadband capabilities.

13 “EHR Adoption: A Barrier Analysis” (2004), Sabogal F

EHR Barriers

Financial

Technical

Organizat-ional

Attitudinal and

Behavioral

Social

Individual

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Refer to Section 3.9, Agency Coordination to Promote Meaningful Use, for an overview of strategies the Agency will employ to overcome adoption barriers.

A.2.3 STATEWIDE HIT/HIE ACTIVITIES

This section provides a description of current HIT/HIE activities across the State. Section A.2.4 summarizes the HIT/HIE activities specific to the Medicaid program.

A.2.3.1 INTRODUCTION

The Florida Center has been designated as the HIT lead agency for the State. The Agency’s Chief Information Officer is the HIT Coordinator. The Agency is also the state-designated entity for administering the ARRA-funded State HIE Cooperative Agreement Program and coordinating the planning for the Medicaid EHR Incentive Program in Florida. Program Administration for the EHR Incentive Program is housed in the Florida Center of AHCA and is accountable via the State Medicaid Director. Having all of these key responsibilities under the Agency leads to a high degree of coordination across HIT/HIE programs and initiatives.

This history of leadership and cooperation to date has pushed the Agency well underway in the transformation journey of the State of Florida’s Health Information Technology landscape. The following sub-sections provide a current snapshot of the State HIT and HIE initiatives, also known as the State As-Is landscape.

The success of the State Medicaid Health Information Technology Plan will be enhanced through collaboration among state agencies and federally-funded programs and leveraging a number of funding sources as detailed in the following exhibit. The Agency has begun such collaboration efforts with other federally-funded, state-based programs administered through the Department of Health, the Department of Elder Affairs, and the Department of Children and Families among others.

The following exhibit provides a view to funding sources for HIT/HIE programs across the State.

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Exhibit 11: Funding Map

A.2.3.2 HIT/HIE ACTIVITIES ACROSS STATE ORGANIZATIONS

A.2.3.2.1 FLORIDA REGIONAL EXTENSION CENTERS

The Agency is supporting the efforts of the Regional Extension Centers (RECs) to provide training and technical support to health care providers for the adoption and implementation of electronic health records. The Agency drafted letters of support for REC applications and, in Florida, four institutions were awarded REC grants. Their targeted region coverage is shown below:

Institution Funded

Amount

# of

Primary

Care

Providers

in region

# of Primary

Care

Providers

targeted by

REC

% of Primary

Care

Providers

targeted

coverage

Health Choice Network $8,536,000 3,351 1,700 51%

University of Central Florida $7,669,328 3,128 1,400 45%

Community Health Centers Alliance (Center for the Advancement of Health IT)

$11,246,879 5,880 2,026 35%

University of South Florida (Paper Free Florida)

$5,884,132 2,546 1,005 39%

Exhibit 12: Florida Regional Extension Center Awards and Provider Targets

Broadband Grants Workforce

Grants

Regional Centers

Cooperative Program

Epidemiology and Laboratory

Capacity for Infectious

Disease Cooperative Agreement

HIE Cooperative Agreement

American Recovery and Reinvestment Act of 2009 ( ARRA )

HITECH Act Grant Programs Electronic Health

Record ( EHR ) Incentive Program

Medicaid EHR Incentive Program

Medicare EHR Incentive Program

Health Resources and Services Administration

Act ( HRSA )

Florida Agency for Health Care Administration ( AHCA )

Partners Stakeholders

Department of Health ( DOH ) and Other Agencies

Department of Management

Services and

Other Agencies

FSU and Various

Educational Institutions

Regional Extension Centers :

- Community Health Centers Alliance , Inc

- Health Choice Network

- University of Central Florida

College of Medicine - University of South

Florida Health

HRSA Funded Programs

Children’s Health

Insurance Program

Reauthorization Act ( CHIPRA )

CHIPRA Quality Demonstration

Program

SAMHSA

State Mental Health Data

Infrastructure Grants for

Quality Improvement

DCF SAMH

Older Americans

ACT

Assistance for Integrating the Long -

Term Care Population into State Grants to Promote Health IT

Implementati on ( CMS /

ASPE )

DOEA

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Exhibit 13: Florida Regional Extension Center Coverage Areas

The Agency has established a Memorandum of Understanding (MOU) with each REC. The intent of the Memorandum of Understanding is to facilitate communication and collaboration between the Agency and the RECs to: coordinate the adoption and implementation of EHR systems by providers, make certain that the Agency’s HIE cooperates with the REC to align the rollout of the state-level HIE with the requirements of the Meaningful Use stages such that providers will have the ability to utilize required HIE functions in Year 1 of the incentives program, encourage providers to connect to the available HIE, and share information and reporting elements to the mutual benefit of the Agency and each of the regional extension centers.

The Agency is executing contracts with the RECs to provide technical assistance services to providers outside the scope of the requirements established by the ONC. The initial contract provides funding for REC technical assistance services to Medicaid dentists.

A.2.3.2.2 REGIONAL HEALTH INFORMATION ORGANIZATIONS (RHIOS)

From 2005 to 2008, the Agency administered the Florida Health Information Network (FHIN) Grants Program with the intent to leverage the development of health information exchange

Walton

Holmes

Wakulla

MadisonLeon

Gadsden

Jackson

Bay

Liberty

Gulf Franklin

Taylor

Lafayette

Hamilton

Baker

Nassau

Duval

Flagler

Putnam

Clay

DixieAlachua

Levy

Marion

Volusia

Citrus Lake

Orange

Seminole

Hernando

Oseola

Polk

Pasco

ManateeHardee

HighlandsSt. Lucie

Sarasota De Soto

Charlotte Glades

Martin

LeeHendry Palm Beach

CollierBroward

Florida Regional Extension CentersThe Center for the Advancement of Health IT

(Community Health Centers Alliance, Inc.)

PaperFree Florida

(University of South Florida)

University of Central

Florida College of Medicine

South Florida Regional

Extension Center

Page 48

locally. The program included planning grants, implementation grants and training grants to support the Regional Health Information Organizations (RHIOs) forming in Florida. The Legislature invested $5.5 million over the three years to spur each of the RHIOs toward full implementation of health information exchange and financial sustainability.

At the end of the FHIN Grants period, each of the mature RHIOs was poised to begin exchanging electronic health records among provider groups in their communities. Half of the RHIOs have continued to develop and increase their capacity to exchange health care records in their local communities. Active RHIOs are located in Jacksonville, Pensacola, Orlando, Tallahassee, and Tampa.

In recent years, several more RHIO efforts have emerged in other regions including; Ocala, Sarasota and Melbourne. According to the Florida Association of RHIOs, there are over ten RHIO-type efforts underway in the State as shown in the following exhibit. Geographic coverage, types of entities involved, types of data exchanged and targeting of specific patient populations are determined by the entities and differ from region to region. Many of these newer RHIO efforts are still in their early stages and are not yet sharing data in production.

The Agency collaborates with RHIOs on promoting health information exchange across the State and in formulating plans for enabling access to local HIE network to statewide authorized users. A representative of a Regional Health Information Organization sits on the HIECC. The strategic planning that went into the FHIN provided a foundation for the creation of the statewide health care network to leverage the meaningful exchange of health care information among Florida’s provider community.

A.2.3.2.3 FLORIDA DEPARTMENT OF HEALTH

The Florida Department of Health (DOH) has long been a national leader in public health. In Florida, DOH is responsible for supporting sixty-seven county health departments (CHDs). Each county health department has an electronic system that was developed by DOH IT staff, and each county’s system is hosted and housed behind DOH’s firewall. This system initially was developed to handle clinic business management, called the Health Management System (HMS). HMS is being expanded into an electronic health record (EHR) for county health departments. This is a strategic priority for DOH with an aggressive timeline of design, development and implementation. The clinical data core foundation is designed around ambulatory-care of Infant, Children, and Adult primary care patients. Building on this core clinical data, the program-specific templates will enhance clinical care documentation of HIV/AIDS, Tuberculosis, Chronic Diseases, Family Planning, Obstetrics, and Healthy Start patients. The fundamental clinical functions of Lab Orders/Results, Medication Orders/Management (ePrescribing), and Radiology/Imaging Orders/Results are either in development or planned for development with the incorporation of third party applications that will interface with HMS.

DOH provides training and supports each county health department, maintaining all health departments on the same software version. DOH is currently piloting the EHR with a few counties, and is planning to begin rollout in January 2011. DOH plans to obtain federal certification for its EHR by the end of calendar year 2012. DOH’s HMS system currently receives State immunization data directly from the DOH statewide immunization registry through a web service call. In addition, LabCorp will initiate the provision of lab test results directly into the

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DOH’s HMS via a third party broker. DOH also places lab test orders from and receives test results directly into DOH HMS from the Florida State labs. DOH is working to have the State labs available for electronic delivery to other providers through its third party broker.

DOH’s HMS clinical data, which includes electronic lab results for patients treated by the DOH county facilities and the DOH immunization registry data, are included as proposed key data sources in the FHIN.

DOH plans to fully leverage the HIE backbone to expose its immunization data on its Florida SHOTS database as a key data source to registered users across the State. Subsequently, DOH will be building the capacity to accept a data query, which means the HIE should be able to do its patient lookup functions with Florida SHOTS and return immunization information.

Statewide, DOH administers the following programs funded through the Health Resources and Services Administration (HRSA) and other Federal sources; namely:

Epidemiology and Laboratory Capacity Cooperative Agreement Program (CDC)

HIV Care Grant Program Part B States/Territories Formula and Supplemental Awards/AIDS Drug Assistance Program Formula and Supplemental Awards (HRSA)

Maternal and Child Health State Systems Development Initiative programs (HRSA)

State Offices of Rural Health Policy (HRSA) - 33 Counties

State Offices of Primary Care (HRSA)

Emergency Medical Services for Children Program (HRSA)

As previously stated, a significant amount of primary care is provided through DOH county health department facilities especially for the uninsured and Medicaid populations. The DOH’s Health Management System is being developed to be a certified EHR and allow all community health department providers to achieve meaningful use .

The Agency collaboration with the Florida Department of Health (DOH) was established in the Planning APD and included consulting services for an assessment of systems readiness for the county health departments and identification of the numbers of providers potentially eligible for the incentive program. The consulting services with the DOH continue in order to facilitate meaningful use by assuring connection through the HIE and to facilitate the submission of electronic data to the immunization registry and the submission of electronic syndromic surveillance data according to applicable law and practice. Medicaid FFP will not be used in any manner to purchase, install, support and operate an EHR for a public health department.

Funding for the DOH Clinics HMS comes from DOH State of Florida base funding. DOH is working to deploy a state-level Electronic Health Record (EHR) system for the sixty-seven county health departments, which are all part of the DOH. The EHR system will provide point-of-care clinical documentation, decision support, and successful health information exchange. The development of this EHR system will ensure evidence-based clinical data documentation and clinical process redesign to support the transition from a paper medical record to an electronic health record environment. Since the majority of county health department patients

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are Medicaid recipients, the DOH will be participants in the EHR Incentive Program. In summary, the Agency collaborates with DOH on promoting health information exchange across the State through its CHDs and in formulating plans for enabling access to its health information to statewide authorized users. A representative of DOH sits on the HIECC.

A.2.3.2.4 FLORIDA DEPARTMENT OF CHILDREN AND FAMILIES

The Florida Department of Children and Families (DCF) provides eligibility determination for Medicaid through ACCESS (Automated Community Connection to Economic Self-Sufficiency). ACCESS interchanges eligibility information with the Florida MMIS (FMMIS).

DCF is committed to the well-being of children and their families. DCF’s responsibilities encompass a wide-range of services, including the Family Safety Program and the DCF Substance Abuse and Mental Health (SAMH) program. Assistance to families working to stay safely together or be reunited, foster care and youth and young adults transitioning from foster care to independence and adoption are all administered under the Family Safety Program. Similar to other programs under DCF, Family Safety program’s providers’ main health information exchange needs are eligibility lookup from payer systems/databases, electronic claims submission, provider-to-provider exchange of patient clinical data, ePrescribing, medication history look-up, and laboratory ordering and results delivery. To the care providers, timely exchange means real-time exchange of information. The whole process of identifying primary care physicians and clinical health information release takes about 2 weeks on average, and is a major workload component that the department intends to deal with by aligning its strategic goals with a statewide HIE.

DCF also includes the program offices of substance abuse and mental health, adult protective services, child care, domestic violence prevention, homelessness coordination, refugee services, and marriage education services. The SAMH Program services are funded primarily through the Federal Block Grant, other federal grants, state general revenue, and Medicaid resources (state and federal funds). The Substance Abuse Prevention and Treatment Block Grant currently funds approximately 50% of substance abuse services. Medicaid funds approximately 80% of children’s and 60% of adult mental health services. These funds are not under the authority of the SAMH program. However, the SAMH program staff continue to work closely with the Agency in policy and program development.

The SAMH Program maintains the Substance Abuse and Mental Health Information System (SAMHIS) which is primarily the system designed to collect and report data needed to answer the following management question: Who receives what services from whom to achieve what outcomes at what cost?

Since a majority of the population served by the program are individuals who are Medicaid eligible, SAMHIS includes the following data in its database:

Medicaid Paid Claims Data

Medicaid Eligibility Data

Medicaid Encounter Data (planned in FY 2010-2011)

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The SAMH Program considers the lack of an EHR system a major challenge to coordinating client care. The Department has signed a license agreement with FEi, Inc. for the use of the Open Source EHR software named WITS – Web Infrastructure for Treatment Services. The first phase of statewide deployment is planned for June 30th, 2011, which will be comprised only of community-based SAMH modules. The subsequent deployment(s), which covers the hospital-based modules, are being planned while a Legislative Budget Request is being submitted for funds to cover the further customization required. The SAMH Program sees this EHR procurement as a major step in meeting the local providers’ needs, which are primarily for an organized, standardized system for managing treatment plans, progress notes, medication plans, and so forth.

The Substance Abuse Program and its patient information is covered by federal law and regulations (codified as 42 U.S.C. Section 290dd-2 and 42 CFR Part 2), enacted about three decades ago after Congress recognized that the stigma associated with substance abuse and fear of prosecution deterred people from entering treatment. This has been a cornerstone practice for substance abuse treatment programs. Part 2 permits patient information to be disclosed to Health Information Organizations and other HIE systems; however, the regulation contains certain requirements for the disclosure of information by substance abuse treatment programs; most notably, patient consent is required for disclosures, with some exceptions. This consent requirement is perceived as one of many challenges in the program’s health information exchange aspirations.

The SAMH Program funds services to serve individuals and families at risk of or challenged by substance abuse and/or mental illnesses and who reside within the State, a majority of whom are Medicaid eligible recipients. The SAMH programs are currently in the procurement process for customization services of an EHR system to achieve meaningful use for the community-based substance abuse and mental health treatment services (first phase). A subsequent phase is also being planned for hospital-based services integration into the EHR system.

A.2.3.2.5 FLORIDA DEPARTMENT OF CORRECTIONS

The Florida Department of Corrections (DOC) is the third largest state prison system in the country, with a budget of $2.4 billion, just over 102,000 inmates incarcerated and another 115,000 offenders on active community supervision. The DOC has 146 facilities statewide, including 62 prisons, 46 work/forestry camps, one treatment center, 33 work release centers and five road prisons. About three quarters of its staff of more than 27,000 employees are either certified correctional officers or probation officers.

Inmate records are electronically stored in the Department’s Offender-based Information System (OBIS), a mainframe system, along with a paper file system maintained in parallel. The OBIS tracks encounter data. The Office of Health Services operates the Electronic Office of Health Services (eOHS) which is the early foundation for the Department’s Electronic Practice Management (EPM) system which interfaces with OBIS. Only 1 (Jefferson Country West) of 4 regions is currently on the eOHS system which acts as the EMR for physical medicine and pulls data from the OBIS system. This system is live and in production. The Department plans to roll out eOHS to the remaining regions in 3-4 years. Mental health and dental records are still maintained in paper form. The Office of Health Services utilizes a COTS system for meeting its pharmacy needs, and it is integrated with OBIS.

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The DOC shares health information with Florida’s Department of Children & Families (DCF) and DOH. They also support an electronic exchange of lab information with DOH. DOH also provides specialty care (e.g., HIV services) to selected inmates. Pharmacy needs are sent electronically to DOH and billed back to the Department. The Department also provides the DOH with continuity of care information for inmates being released and enables set up for pre-release planning.

DCF has several aftercare programs for DOC inmates. For mental health treatment after an inmate is released, the Department exchanges an inmate’s diagnosis electronically to enable the setup of treatment plans post incarceration.

The Department also operates a system to manage the intake of inmates in the corrections system. The main program for inmate reception is CARP, Computer Aided Reception Process. Upon intake, labs are drawn and processed internally or by a vendor (LabCorp or Spectra) and results are shared electronically with the DOH. The Department also has a Radiology Information System (RIS). The Department does envision a future where external radiology images and read data can be loaded into the RIS through eOHS.

Because inmates under the care of the Department are precluded from receiving Medicaid benefits, the Department and its providers are not eligible for the EHR Incentive Program. Also, because of unique security requirements and concerns, the Department currently does not foresee connecting to the statewide HIE in the near future.

A.2.3.2.6 FLORIDA DEPARTMENT OF JUVENILE JUSTICE

The Florida Department of Juvenile Justice (DJJ) operates juvenile residential facilities and detention centers with the following characteristics:

The Department is responsible for over 4,800 operational residential beds for juvenile offenders, with approximately two-thirds of those providing special-needs services;

Juvenile residential facilities range from wilderness and marine camps to halfway houses, youth development centers, sex-offender programs, and maximum-security correctional facilities; and

The Department operates 25 juvenile detention centers in 24 counties with a total of 2,007 beds.

The Department provides primary acute and chronic care medical services, psychiatric, and mental health services to the youth entrusted in its care. The Department provides these services through a combination of state employees and contracted vendors. Most of the current health processes are managed manually, not electronically, through the use of handwritten documentation such as physician orders, screening and evaluation tools, medication administration records (MARs), discharge plans, treatment plans, progress notes, and through stand-alone databases for scheduling and tracking. The Department is also responsible for the documentation of the immunizations previously administered to its student youth and by the Department’s state-employed and vendor staff.

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DJJ is currently in the early planning stages of acquiring an EMR system and is reviewing responses to its RFI, seeking information about the interest and capabilities of a qualified vendor to implement a statewide Electronic Health (Medical) Records (EMR) System for the Office of Health Services. Since the population of the youth cared for by DJJ transition heavily from facility to facility (detention, residential, and probation/after-care), there is a tremendous need for electronically stored health records to facilitate coordinated care among different facility care providers.

DJJ care does not currently use ePrescribing. All the pharmacy services are done through a single pharmacy vendor, Diamond Pharmacy. Prescribing of medication is paper driven.

Per DJJ’s 2008-2012 Strategic Plan document, two-thirds of the youth in its care have substance abuse and mental health issues. There are opportunities for collaboration with other agencies like DCF and the Agency on sharing electronic medical records on individuals. The Chief Medical Director of the Office of Health Services is working with counterparts at the DCF Substance Abuse and Mental Health program.

A.2.3.2.7 FLORIDA DEPARTMENT OF VETERANS’ AFFAIRS

The Florida Department of Veterans’ Affairs (FDVA) is the state agency that provides assistance to Florida veterans in improving their health and economic well being through the provision of long-term health care services, benefit information, advocacy, and education.

Through its state Veterans’ Homes Program, FDVA provides comprehensive long-term health care services to eligible Florida veterans. The State Veterans’ Homes Program has two components:

The State Veterans’ Domiciliary Home, located in Lake City, provides non-medical custodial care (assisted living facility) to assist eligible veterans who are disabled by age or disease, but who are not in need of hospitalization or skilled nursing home care.

The State Veterans’ Nursing Homes provide comprehensive health care services to eligible Florida veterans who are in need of long-term skilled nursing facility (SNF) care. As of September 2010, FDVA operates six 120-bed nursing homes.

The USDVA provides prescription services to the State Veterans’ Homes Program. Each nursing home has USDVA pharmacists on site providing pharmacy services. The USDVA uses an automated system to provide full service prescription services. The system includes physician order sheets, medication administration records, treatment records, and PRN (as needed) medication schedules.

The pharmacy system does not interface with the clinical and financial application.

A limited amount of health information exchange takes place in the form of the submission of electronic claims from FDVA’s clearinghouse to third party payers including Medicare and Medicaid and the submission of clinical information (e.g., Minimum Data Set) to CMS and the USDVA.

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FDVA has been working with the Agency on HIT initiatives and was noted in the Agency’s HIE Strategic and Operational Plan.

In May of 2010, the FDVA began preparing a business case to upgrade its existing HIT systems. The current clinical and financial application vendor has announced that FDVA’s system is nearing the end of its useful life and that they will no longer be making enhancements to the system. In addition, the current application does not support: 1) electronic prescribing, 2) computerized physician order entry or 3) electronic health records. Upgrading the State Veterans’ Homes Program IT system supports Goal Two of FDVA’s Long Range Program Plan 2010 - 2015 – to provide quality long-term health care services to eligible Florida veterans.14

FDVA plans to upgrade the existing HIT system in the August 2012 – February 2013 time frame.

A limited amount of health information exchange takes place in the form of the submission of electronic claims from FDVA’s clearinghouse to third party payers including Medicare and Medicaid. The department is in the planning stages of acquiring an EHR system to achieve meaningful use for medical facilities by 2012.

A.2.3.2.8 DEPARTMENT OF ELDER AFFAIRS

The Department of Elder Affairs (DOEA) is designated as the state department unit on aging as defined in the federal Older Americans Act (OAA) of 1965, as amended. The OAA’s programs provide assistance in the development of new or improved programs to help older persons through grants to the states for community planning and services. Florida’s OAA Title III funds are allocated by formula to area agencies on aging which in turn enter into contracts with service providers to deliver services for eligible individuals age 60 and over and their caregivers. Funds are used to provide an array of periodic disease-prevention and health-promotion services at senior centers or other sites. These services are designed to help elders prevent and/or manage chronic diseases and promote healthier lifestyles. Additionally, the DOEA provides medical needs assessments that are a component of Medicaid eligibility determination for Medicaid waivers and the Institutional Care program. Comprehensive eligibility services are federally mandated and include pre-admission screenings to ensure that applicants for Medicaid reimbursed nursing home care are medically appropriate. In addition, the DOEA administers several programs through contracted Area Agencies on Aging (AAA) to provide home and community-based services to over 600,000 elder Floridians.

The DOEA collects client demographic and assessment data, and tracks service provision in federally and state funded programs serving the elderly. The DOEA also manages program enrollment, program waitlists, managed care encounter data, and tracks the level of care determination process for clients applying for Medicaid funding. The DOEA shares data with the 11 contracted AAAs, 58 case management agencies, over 300 service providers, as well as the Department of Children and Families and the Agency. Implementation of statewide health

14 FDVA, Florida Department of Veterans’ Affairs Long Range Program Plan 2010 -2015, page 4. www.FloridaVets.org

http://www.floridavets.org/

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information exchange would improve service, increase efficiency and facilitate data sharing through other networks. Long term care is a setting in which health information exchange is of crucial importance given the number of health care providers typically seen by seniors, the frequency of hospital admissions, and the frequent migration of individuals among assisted living, skilled nursing and other facilities.

A.2.3.2.9 FLORIDA HEALTHY KIDS CORPORATION

Florida KidCare is the State’s children’s health insurance program for uninsured children from birth to age 19 who meet income and eligibility requirements. Three state agencies and the Florida Healthy Kids Corporation, a nonprofit organization, form the core of the Florida KidCare partnership. The four components are: MediKids for children ages 1 to 5, administered by the Agency; Florida Healthy Kids for children ages 5 to 19, administered by the Florida Healthy Kids Corporation; Children’s Medical Services (CMS) Network for children with special health care needs from birth to age 19 administered by the Department of Health for physical health services and Department of Children and Families for behavioral health services; and the Medicaid for Children program from birth to age 19 administered by the Agency. The Florida Healthy Kids for Children program is fully capitated while the programs administered through the Medicaid program are both capitated and fee for service. The Agency is taking into consideration its administration staff and the Medicaid providers in this program in conducting the strategic planning for Florida Health Information Network (FHIN) and the EHR Incentive Program.

A.2.3.2.10 INDIAN HEALTH SERVICES

The Seminole Health Department (SHD) in Florida provides health care and promotes wellness within the Indian community. The Seminole Health Department has the responsibility and oversight of the administrative, fiscal, and programmatic functions of the Tribe’s health care system on each reservation within the State. The SHD has decided not to participate in the EHR Incentive Program.

The Miccosukee Indian Reservation is the homeland of the Miccosukee tribe of Native Americans in Florida. It is divided into three sections in two counties of southern Florida. The Miccosukee Health Clinic (MHC) is located on the Tamiami Trail Reservation, which is also the center of most tribal operations. Tribal representatives intend to obtain electronic health records capability in the very near future. At this time, however, the MHC is not a Medicaid provider and would therefore not meet the qualification requirements for participation in the EHR Incentive Program.

It should be noted that Eligible Professionals in the tribal locations may still qualify when they practice in FQHC or RHCs. The State will continue to work with Indian Health Services and SHD for stakeholder participation representing the various tribal groups.

Florida is in compliance with Section 1902(a)(73) of the Social Security Act, and Section 5006 of the American Recovery and Reinvestment Act, wherein the State Medicaid agency is required to establish a process to seek advice on a regular, ongoing basis from designees of the Indian Health Service programs concerning Medicaid matters having a direct impact on the tribes. A State Plan Amendment was submitted effective 10/1/2010, and approved by CMS 1/4/2011,

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outlining the consultation process with the federally recognized Miccosukee and Seminole Tribes of Florida. This page is located in Florida’s Medicaid State Plan at Section 1.4, Page 9.

A.2.3.2.11 AGENCY FOR PERSONS WITH DISABILITIES

The Agency for Persons with Disabilities (APD) is the agency specifically tasked with serving the needs of Floridians with developmental disabilities. The APD works in partnership with local communities and private providers to assist developmentally disabled people and their families. APD also provides assistance in identifying the needs of people with developmental disabilities for supports and services.

Support for such persons is accomplished through various Medicaid waiver programs, including the Consumer Directed Care Plus (CDC+) and the Medicaid Home and Community Based Services Waiver (HCBS).

The CDC+ is a long-term care program alternative to the HCBS. It provides the opportunity for individuals to improve life quality by being empowered to make choices about supports and services that will meet their long-term care needs and help them reach their goals.

The HCBS is a program providing community services to Medicaid-eligible individuals as an alternative to services provided in an institution. There are four APD Home and Community Based Services: Waivers, Tier One, Tier Two, Tier Three and Tier Four.

The APD is funded in part by the Medicaid Infrastructure Grant (MIG) which is funded by The Centers for Medicare and Medicaid Services (CMS) of the U.S. Department of Health and Human Services. Florida was initially awarded the grant in 2006. MIG will continue through 2011, at which time Congress shall decide whether to renew the program. The specific objective of the grant is to support efforts by states to enhance employment options for people with disabilities by building Medicaid infrastructure. Funding may be used to remove the barriers to employment of persons with disabilities by creating health systems changes through the Medicaid program, such as develop a Medicaid buy-in, increase availability of Personal Assistance Services, plan a Demonstration to Maintain the Independence and Employment Program, or for State-to-State technical assistance.

The development or enhancement of certain core Medicaid components in each State would enable people with disabilities not only to work, but to sustain adequate health coverage if they find they need to relocate to another State for employment purposes. An adequate personal assistance services benefit and a Medicaid buy-in for employed people with disabilities are, therefore, significant components of the Ticket-to-Work and Work Incentives Improvement Act. The infrastructure grants program provides money to States to develop these core elements.

Core Medicaid enhancements described above will be considered in the upcoming MITA To-Be visioning sessions.

A.2.3.2.12 FEDERALLY QUALIFIED HEALTH CENTERS

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The Social Security Act at section 1905(l)(2) defines an FQHC as an entity which, "(i) is receiving a grant under section 330 of the Public Health Service Act, or (ii)(I) is receiving funding from such a grant under a contract with the recipient of such a grant and (II) meets the requirements to receive a grant under section 330 of the Public Health Service Act, (iii) based on the recommendation of the Health Resources and Services Administration within the Public Health Service, and is determined by the Secretary to meet the requirements for receiving such a grant including requirements of the Secretary that an entity may not be owned, controlled, or operated by another entity; or (iv) was treated by the Secretary, for purposes of Part B of title XVIII, as a comprehensive Federally-funded health center as of January 1, 1990, and includes an outpatient health program or facility operated by a tribe or tribal organization under the Indian Self-Determination Act or by an urban Indian organization receiving funds under Title V of the Indian Health Care Improvement Act for the provision of primary health services." Florida's community health centers play a vital role in providing services to more than 700,000 patients each year and over 220 locations throughout the State15.

The State has two large health center controlled networks of FQHCs, Health Choice Network ®and Community Health Centers Alliance™, that provide services and information technology to their members. In addition, there are some independent FQHCs. Community Health Centers Alliance uses GE Centricity ® EHRs for their member FQHCs. Most of the Health Choice Network FQHC members are currently using SAGE INTERGY® EHRs, and the remainder will be converted to SAGE INTERGY® EHRs by first quarter of 2011. Both of these large FQHC networks received Health Resource Services Administration (HRSA) funding.

The table below lists HRSA Grants to these FQHCs:

HRSA Grantee Program Name and Financial Assistance Program Director

Health Choice Network, Inc 3990 NW 79th Ave Miami, FL 33166-6518

ARRA - Health Information Technology Implementation (H2L) Grant Number: H2LCS18139 - $2,990,887.00

Alejandro Romillo 305-599-1015


ARRA - Health Information Technology Implementation (H2L) Grant Number: H2LIT16607 - $478,125.00






Electronic Health Record Implementation Initiative (H2K) Grant Number: H2KIT08593 - $776,362.00



Electronic Health Record Implementation Initiative (H2K) Grant Number: H2KIT10786 - $347,488.00


15 FACHC.org

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HRSA Grantee Program Name and Financial Assistance Program Director

Community Health Centers Alliance, Inc. 140 Fountain Pkwy N St. Petersburg, FL 33716-1285

ARRA - Health Information Technology Implementation (H2L) Grant Number: H2LCS18173 - $3,000,000.00

Diane I Gaddis 727-573-2422 x225





Electronic Health Record Implementation Initiative (H2K) Grant Number: H2KIT10789 - $1,375,542.00



Health Information Technology Innovation Initiative (H2H) Grant Number: H2HIT08606 - $248,045.00


Exhibit 14: FQHC Grants from HRSA

A.2.3.2.13 INTEGRATED DELIVERY NETWORKS

An integrated delivery network (IDN) is a connected set of health care providers and organizations which provides or arranges to provide a coordinated continuum of services to a defined population and is willing to be held clinically and fiscally accountable for the clinical outcomes and health status of the population served.

The meaningful use incentives are fueling interest in expanding current health information exchange efforts of IDNs and health systems. Several IDNs in Florida are in the process of purchasing more advanced Enterprise Master Patient Index and integration systems for sharing patient data with their affiliated physicians and facilities. These IDNs may or may not be participating with a local RHIO effort, and some may be developing direct connection to NHIN.

The Agency is collaborating with IDNs to facilitate meaningful use of electronic health records in hospitals to enable eligible hospitals to receive Medicaid incentives. The Agency is working closely with hospitals and hospital representatives, including rural hospitals, to establish procedures to encourage participation in the program for all eligible hospitals.

A.2.3.3 HIT/HIE PROGRAMS ACROSS THE STATE

A.2.3.3.1 STATE-LEVEL HEALTH INFORMATION EXCHANGE COOPERATIVE AGREEMENT PROGRAM

The Agency is the designated state entity for the U.S. Health and Human Services (HHS), Office of the National Coordinator for Health Information Technology (ONC) Cooperative Agreement program, which is providing up to $20.7 million to Florida, from the American Recovery and Reinvestment Act of 2009 (ARRA) stimulus funding, to support statewide health information exchange among organizations according to nationally recognized standards, and to support health care providers in meeting the criteria for “meaningful use” of electronic health records

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established by CMS. The Florida State Legislature’s 2010-2011 budget included an appropriation for the creation of a Florida Health Information Exchange Infrastructure. An Invitation to Negotiate (ITN) was issued by the Agency for July 15th to award a contract to a vendor who can demonstrate the expertise to design and create a statewide infrastructure for Health Information Exchange through an integrated solution leveraging the ongoing federal investments to ensure meaningful use of health information. Harris Corporation, an international

communications and information technology company, was awarded a four-year, $19 million contract

in 2010 by Florida's Agency for Health Care Administration (Agency) to implement a statewide health

information exchange infrastructure that will improve the delivery and coordination of health care.

The contract was executed February 4, 2011.

A.2.3.3.2 SERVICES OF THE FLORIDA HIE

Patient Lookup (PLU): Harris is using its open, standards-based solution, Express, to connect 20 state

identified systems and provider networks (RHIOs, IDNs and other HIEs) to the Florida Health

Information Exchange (FHIE) as federated users. Express provides the core infrastructure needed for

the secure exchange of health information and a National Health Information Network (NHIN)

compliant platform. Applicants to the FHIE are evaluated at periodic intervals by the Harris team and

selected applicants are then scheduled for on-boarding which will be completed in 2013.

Direct Secure Messaging (DSM): As a first deliverable, Harris Corporation has implemented a secure email service that allows participants to send and receive encrypted patient health information from other HIE participants. Providers can use the service upon registration if they have an Internet access and need not be a participant in PLU. DSM provides a Participant Directory allowing a search of other participating organizations and individuals authorized to use the service.

A.2.3.3.3 OTHER HIE ACTIVITIES

Outreach and Deployment Subcontracts: Outreach Funding of $1.9 M will be provided to early

adopters to bring in underserved participants through connections to the local HIE and also to increase

DSM adoption. Harris will award this funding and manage the outreach subcontracts. Applicants will

be accepted in early 2012 and awarded mid-year.

Program Evaluation: The ONC directed that 2% of the HIE project funding should be used for

program evaluation. The Agency entered into a contract with Florida International University for the

evaluation. FIU will be conducting interviews, and surveys of health care providers and other

stakeholders. A final deliverable is a metrics dashboard for tracking adoption and use of Florida HIE

services.

Sustainability Plan: Harris has subcontracted with Arduin, Laffer, and Moore Econometrics to conduct an analysis of the costs and benefits of the Florida HIE to all stakeholders and make recommendations about how the Florida HIE might be governed and sustained. A first report examined the literature regarding best practices for HIE sustainability and is posted on FHIN.net. An interim analysis will identify on-going maintenance costs and impact of alternative governance approaches on costs. The final report with recommendations will be available in early 2012.

A.2.3.3.4 ADDRESSING PRIVACY AND SECURITY ISSUES

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The Health Information Exchange Legal Work Group is a subcommittee to the Consumer Health

Information and Policy Advisory Committee established in statute. This work group advises on issues

relating to legal policies for health information exchange including provisions of subscription

agreements for health information exchange by the Health Information Exchange Legal Work Group.

Such agreements include:

DSM Subscription Agreement

PLU Subscription Agreement

HIE Participation Terms and Conditions

DSM Security Best Practices

These agreements are posted at: https://www.florida-hie.net. A network security overview for the

HIE services was presented to the Health Information Exchange Coordinating Committee August 19,

2011 and is posted on www.FHIN.net.

A.2.3.3.5 CURRENT STATUS OF HIE ADOPTION

Harris rolled out DSM in July 2011 and is currently making it available statewide to health care providers eligible for Medicare and Medicaid electronic health record incentive program, clinical laboratories, skilled nursing facilities, and community mental health centers. Harris and the Agency are working with professional associations to make providers aware of the service and to encourage use. The Agency has set an adoption target of 1500 registrants by January 2013.

Harris is on-boarding the PLU early adopters Big Bend Regional Healthcare Information Organization

(Big Bend RHIO) headquartered in Tallahassee, Strategic Health Intelligence LLC based in Pensacola,

and Adventist Health System Sunbelt Healthcare Corporation - Florida Division to complete

connections to the Florida HIE and commence data exchange by January 2012. The next group of

early adopters for the Patient Lookup service was announced November 21, 2011. These are

Atlantic Coast HIE, Florida Department of Health, Health Choice Network, and Orlando

Health.

A.2.3.3.6 FUTURE EXPANSION

The Agency is exploring expansion opportunities for DSM in 2012. These include the ability to

connect DSM with other HISPs (health information service providers). These “HISP to HISP”

connections could be interstate provider HISPs, electronic health record vendors, or payer HISPs. The

Agency also plans to participate in the Nationwide Health Information Network for patient look-up

with partner organizations that accept the privacy and security policies of the Florida HIE.

A.2.3.3.7 ELECTRONIC PRESCRIBING

The passage of the American Recovery and Reinvestment Act of 2009 (ARRA) and its Health Information Technology for Economic and Clinical Health (HITECH) Act provisions established ePrescribing as one of the component requirements for providers to qualify for incentive payments. In addition, the Centers for Medicare and Medicaid Services (CMS) issued a final rule simplifying and providing additional options for reporting documentation to qualify for the ePrescribing incentives established by the Medicare Improvements for Patients and Providers Act of 2008 (MIPPA). The Agency provides free ePrescribing for Medicaid providers. Providers

https://www.florida-hie.net/

http://www.fhin.net/

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can access this service through a desktop application, handhelds and via a single sign-on through the Medicaid Health Information Network (MHIN). In the private sector, ePrescribe Florida sponsored an e-Health Summit as a forum for stakeholders to discuss collaborative approaches for responding to HITECH opportunities, and the Certification Commission for Health Information Technology developed new short and long term approaches for certification of electronic health record technologies consistent with the direction set by ARRA. National and State ePrescribing organizations, payers, and professional associations continued to produce educational materials and tools available to physicians on their Web sites. Together, these developments have resulted in continued growth in the adoption of ePrescribing.

In 2007, the Agency formed the State Electronic Prescribing Advisory Panel and invited representatives of the relevant stakeholder organizations to participate as appointed members of the Panel. The Panel includes representatives of health care practitioners, health care facilities, and pharmacies; organizations that operate ePrescribing networks; organizations that create ePrescribing products; and health information organizations. The Agency is also a member of ePrescribe Florida, a private initiative working to increase ePrescribing. Members of the Panel and ePrescribe Florida have assisted the Agency in promoting ePrescribing adoption in Florida, planning for statewide health information exchange and efforts to coordinate these efforts. The Agency was a member of the Advisory Council for ePrescribe Florida from 2006 to 2010.

In 2009, the Agency continued its collaboration with the private sector to develop and expand its strategies to accelerate the adoption of ePrescribing in Florida. With the assistance of data provided by national ePrescribing organizations, the Agency produced a quarterly dashboard of ePrescribing metrics showing trends, statistics for metropolitan areas, and a comparison of Florida rates to national ePrescribing rates. The Agency has worked with the Department of Health to distribute Florida Medicaid ePrescribing tools in Duval County and provided information to encourage their use in other counties. In addition, the Agency developed educational materials to encourage Florida physicians to take advantage of the MIPPA incentives and distributed information to Medicaid providers. During 2009, the Agency also worked with the private sector to distribute a consumer brochure that explains ePrescribing basics and the benefits for patients. The Agency held three public meetings of the State Electronic Prescribing Advisory Panel during 2009 with two of the meetings held in conjunction with the Agency’s Health Information Exchange Coordinating Committee.

The amount of ePrescribing relative to all prescriptions that could have been ePrescribed is the ePrescribing rate. The ePrescribing rate for the third quarter of 2009 was 12% up from 9% for the first quarter of 2009, 4.3% in 2008 and 1.6% in 2007. The annual rate at which physicians used ePrescribing tools to request medication information such as eligibility, benefits or medication history is the medication record request rate. The medication record request rate for the third quarter of 2009 was 17%, up from 11% for the first quarter of 2009, and 5.5% in 2008. These results indicate that use of ePrescribing clinical applications exceeds use to transmit prescriptions or refills electronically.

In August 2010, following its annual review and audit of electronic prescribing activity in the United States, Surescripts® determined that Florida ranked as the tenth-rated ePrescribing state in the nation. With this accomplishment, Florida will receive the Fifth Annual Safe-Rx™ Award,

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being part of the top ten states in the nation that have shown outstanding progress and leadership in advancing ePrescribing technology.

A.2.3.3.8 TELEMEDICINE

Under Florida’s 1915 (b) Managed Care Waiver, telemedicine is provided but limited to certain state plan covered services, and is only provided to Medicaid eligible children enrolled in the Children’s Medical Services Network (CMS) who reside in underserved areas of the State. Eligible providers include those CMS Network approved providers currently allowed to provide consultative and office visits within their licensed scope of practice. The services delivered to recipients via telemedicine are reimbursed to eligible providers on a fee-for-service basis, at the same rate as the Medicaid allowed fee for the service provided in a traditional face-to-face manner. Medicaid will not pay for the purchase or installation of the equipment, or for any technical support required for telemedicine. A State Plan Amendment has been finalized allowing telemedicine as a modality for other services.

A.2.3.3.9 BROADBAND, BROADBAND INFRASTRUCTURE, AND ADOPTION

The limited access to broadband Internet in some rural areas of the State poses a challenge to HIT and HIE. There are three Rural Areas of Critical Economic Concern (RACECs) in Florida, the Northwest RACEC, the North Central RACEC and the South Central RACEC. These areas cover 28 rural counties which have been designated as eligible to receive broadband awards that will ensure connectivity to the underserved communities. All of these counties are covered by two recipients of the Broadband Technology Opportunities Program (BTOP) awards program.

The American Recovery and Reinvestment Act of 2009 appropriated $4.7 billion to the National Telecommunications and Information Administration (NTIA). This was to provide grants for broadband initiatives throughout the United States, particularly in unserved and underserved areas, under the BTOP program. The BTOP program made grants available to facilitate the expansion of broadband communications services and infrastructure, spur job creation and stimulate long-term economic growth and opportunity. All funds were disbursed as of September 30, 2010. The BTOP funds were available through three categories of eligible projects: Broadband Infrastructure, Public Computer Centers, and Sustainable Broadband Adoption.

The Broadband Infrastructure category funded projects to deliver broadband access to unserved and underserved areas. Four organizations in Florida received these grants, the North Florida Broadband Authority (NFBA), the Florida Rural Broadband Alliance (FRBA), Level 3 EON, LLC and the University Corporation for Advanced Internet Development, for a total of $118.4 million.

The Public Computer Center category funded projects to expand public access to broadband service and enhanced broadband capacity in community colleges and public libraries. Florida A&M University received the only grant in Florida for $1.5 million.

The Sustainable Broadband Adoption category funded innovative projects to promote broadband demand, including broadband education, awareness, training, access, equipment or support. Six applicants received awards in this category, the City of Tallahassee, Communication Service for the Deaf, Inc., One Community, One Economy

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Corporation, the School Board of Miami-Dade County and the Tampa Housing Authority for a total of $67.8 million.

The two awardees that will make the most difference to the RACEC counties are the FRBA and the NFBA.

The Florida Rural Broadband Alliance (FRBA) is a coalition of 14 counties and tribal lands within the Northwest and South Central RACECs. These were designated as RACECs due to a disparity in income and access to education and healthcare services. Community anchor institutions in these RACECs often lack the necessary broadband infrastructure to thrive in the modern economy. The proposed FRBA networks will receive $23.7 million to build broadband infrastructure to anchor institutions, including health care facilities in the 14 counties covered. The FRBA’s Florida Rural Middle Mile Networks project proposes to deploy an 1,800-mile microwave-based middle-mile network across the 14 rural counties to support and improve healthcare, educational opportunities, library services, economic development, and public safety services. The Florida Rural Broadband Alliance brings together multiple local and tribal governments, economic development agencies, and commercial partners in a collaborative effort to address the unmet broadband needs of this area of the state.

The North Florida Broadband Authority (NFBA) covers the 14 rural counties within the North Central RACEC and Wakulla County. NFBA received $30.1 million in infrastructure funding to build the Ubiquitous Middle Mile project that plans to bring high-speed broadband services to these rural counties through the deployment of a 1,200-mile fixed wireless broadband network that will enhance economic development, health care, education, and public services throughout the region. The network plans to directly connect more than 300 community anchor institutions at speeds of 10 Mbps to 1 Gbps. These anchor institutions include healthcare facilities, public schools and universities, libraries, public safety organizations, and government agencies.. The project, which was jointly created by the area’s local governments, will utilize 128 existing wireless towers and sites, and is designed to withstand the weather hazards endemic to the region.

The Agency has identified the need to drive the efficient exchange of health information over secure broadband channels that will support the exchange of text, image and video data as the health information network reaches its potential. The Agency has included Environmental Scan data outlining the extent of broadband usage and disparity of accessibility and affordability to the State’s health care providers in this SMHP. The Agency is also working with the FRBA and the NFBA to EHR and HIE adoption in their marketing and education plans.

A.2.3.3.10 CHILDREN’S HEALTH INSURANCE PROGRAM REAUTHORIZATION ACT QUALITY DEMONSTRATION

GRANT

In February 2010, the Agency in partnership with the State of Illinois, received a grant award of $11.3 million to improve health care quality and delivery systems for children enrolled in Medicaid and the Children’s Health Insurance Program (CHIP). The Medicaid and CHIP agencies in Florida and Illinois will collaborate to use the CHIPRA grant to improve health outcomes for children by enhancing access to information for use by providers, consumers, and State agencies and undertaking new quality improvement activities in their Medicaid and CHIP programs.

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The Agency intends to work in collaboration with other agencies such as the Department of Health, providers, consumers, advocates, the HIECC, and other stakeholders, as it seeks to leverage current statewide HIT infrastructure-building efforts to improve quality of care for children. A detailed project work plan is being developed for completion in 2010.

The collaboration among the Agency, other state agencies, and private and public organizations in Florida integrates the critical components of broadband infrastructure and educational outreach implementation support, leading toward a comprehensive approach to health care through a state-level HIN.

A.2.3.4 HIT WORKGROUPS AND COLLABORATIVE EFFORTS IN FLORIDA

Over the past five years, the Agency has worked with stakeholders to create a secure and efficient infrastructure for the statewide exchange of electronic health records. The Health Information Exchange Coordinating Committee (HIECC) was created in December 2007 as a work group of the State Consumer Health Information and Policy Advisory Council (Advisory Council) which advises the Agency as provided in Section 408.05, Florida Statutes. The HIECC includes representatives of Florida’s Regional Health Information Organizations (RHIOs), hospitals and clinics utilizing advanced electronic health records systems, rural health centers, practitioners using advanced electronic health records systems, medical and hospital associations, health plans, university medical schools, consumers, the legal community, information technology associations, and State government.

The HIECC functions to assist the Agency as it develops and implements programs for the creation of a state-level health information exchange, the adoption of electronic health record systems, and the development of health information exchange at the local level. The HIECC advises on standards to ensure the interconnectivity of all health care providers and the privacy and security of electronic health information. The HIECC coordinates its activities with the State HISPC Legal Working Group to reduce barriers to electronic health information exchange. The first HIECC meetings were held in early 2008. With the passage of ARRA, the HIECC was designated by Governor Crist to be the stakeholder group to advise the Agency on the planning and implementation of health information exchange activities.

A.2.3.5 OTHER COLLABORATION ACTIVITIES

As the Agency moves forward with its plans to implement the Medicaid EHR Incentive Program and the state-level Health Information Exchange, it will be able to draw on the support of its many key stakeholders to collaborate in this effort. Examples of the State’s collaborative efforts include the following:

Health care providers including those serving the low income and underserved

The Agency, as the single State Medicaid Agency, works closely with health care providers, including those serving the low income and underserved through its administration of the Medicaid program and through its collaboration with DOH and the FQHCs. As the entity that will administer both the Medicaid Electronic Health Record (EHR) Incentive Program and the state-level Health Information Exchange Cooperative Agreement Program, there is close coordination of these activities. The Agency works

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closely with Florida associations representing health care providers, such as the Florida Medical Association, South Florida Hospital Association, Florida Osteopathic Medical Association (FOMA), Florida Academy of Family Physicians (FAFP), and the Florida Hospital Association (FHA).

Managed care organizations

The Agency meets regularly with the Florida Association of Health Plans and attended its recent annual meeting to describe and discuss planning and implementation activities. Several health plans participate in the common portal program as discussed above.

Patient or consumer organizations

Consumer groups represented on Agency advisory bodies include the American Association for Retired Persons, the Florida Council for Community Mental Health, and the Florida Justice Association. The Florida Public Interest Research Group is an active participant in the Agency’s Advisory Council meetings.

Health information technology vendors

The Agency meets regularly with vendors interested in Florida’s health information exchange efforts to learn about their technical offerings and their experience in other health information exchange activities which may have relevance to Florida’s efforts.

Health care purchasers and employers

The Agency is closely involved with health care purchasers with the goal of streamlining administrative burden and improving health outcomes by employing common approaches. The use of a common portal for eligibility, benefits, claims submission, and claims history is an example. In addition, a representative of the Florida Retail Federation is a member of the Agency’s Advisory Council.

Public health agencies

The Agency is engaged in several joint planning activities with the Florida Department of Health (DOH) as previously described. Representatives of the DOH sit on the Agency’s Advisory Council and on the HIECC. Efforts are underway to ensure that the HIT efforts of the DOH and the Agency are fully integrated.

Health professions schools, universities, and colleges

Faculty from health professions schools, universities, and colleges provide valuable advice and assistance to the Agency through participation in various advisory workgroups. The Agency explores opportunities to partner with state universities to further the mission of the Agency and health care research, train health professionals, and provide community service. Representatives sit on the HIECC and the Agency’s Advisory Council.

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Clinical researchers

The Agency supports clinical research by making administrative hospital discharge data available as authorized for research purposes. The Agency works with the DOH to share data and build research capacity as suggested by the research community.

A representative of the Florida Health Information Management Association participates on the Agency’s Legal Working Group.

A.2.3.6 HIT/HIE ACTIVITIES THAT CROSS STATE BORDERS

The Agency participates in multiple coordination activities with other states. The Agency participates in the Southeast Regional HIT-HIE Collaborative (SERCH) which holds frequent conference calls on topics related to the promotion of electronic health record adoption and health information exchange. The Agency has also worked with other states through participation in the Health Information Security and Privacy Collaborative (HISPC) which has been of assistance in reconciling differences in federal and state law and in developing outreach and training strategies for providers.

In addition, the Agency participates via webinar with the Agency for Health Care Research and Quality (AHRQ) and presents information to other states on lessons learned particularly in the area of ePrescribing.

More recently, the Agency has initiated an HIE Cooperative Agreement Inter-State Planning Collaborative with Georgia, Alabama, Arkansas, Florida, Kentucky, Louisiana, Mississippi, North Carolina, South Carolina and Tennessee to more specifically determine how health information exchange will take place among these states not only for disaster response but also for day-to-day cross border care delivery. The Inter-State Planning Collaborative is currently working through SERCH and may expand later to include Puerto Rico.

A facility utilization study was conducted by the Agency in April 2010 on the subject of crossing state lines to access health care. The study tracked the cross-state movement of patients into Florida facilities. The facility counties with the highest number of out-of-state patients were Duval, Broward, Escambia, Palm Beach and Orange County.

A.2.4 MEDICAID HIT/HIE ACTIVITIES

In addition to the collaboration efforts on the implementation of the Medicaid claims-based Health Information Network described in Section A.2.4.1 below and expansion of ePrescribing within Medicaid, the Agency has developed the State Medicaid Health Information Technology Plan (SMHP) that includes the implementation of the Medicaid provider EHR Incentive Program.

The activities underway that may influence the direction of the EHR Incentive Program over the next five years are:

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An outreach and training plan will be developed, as part of the SMHP, to encourage and assist all providers in the use of electronic health records and health information exchange

Medical Home Pilot Program - The Medical Home Task Force was established by Senate Bill 1986, under the authority of Section 409.91207(5), Florida Statutes. The responsibility of the Task Force was to assist the Agency in reviewing medical home models and make recommendations for a Medicaid medical home pilot project. Based on these presentations and discussion among Task Force members, the Task Force made recommendations in the following areas:

o Defining the medical home

o Determining medical home pilot sites

o Determining medical home pilot participants

o Determining medical home pilot services

o Administration of the medical home pilot project

o Financing and reimbursement for the medical home pilot project

Expansion of Managed Care Organizations (MCO), the Agency anticipates further expansion of MCO’s throughout the State. The Agency conducted a health plan survey which indicates that MCO’s are interested in encouraging provider adoption of EHR.

Expansion of Medicaid in 2014, assuming that implementation of the Patient Protection and Affordable Care Act proceeds, the expansion of Medicaid will potentially increase the number of Medicaid eligible professionals and hospitals. Additional outreach will be required to reach these new providers.

CHIP Grant – Data available on children’s care will be enhanced creating an opportunity to provide this information through the HIE to providers and policy makers.

A.2.4.1 MEDICAID HEALTH INFORMATION NETWORK (MEDICAID-HIN)

In 2009, and prior to the passage of the American Recovery and Reinvestment Act (ARRA), the Agency entered into a no-cost contract with Availity, LLC to develop the Medicaid-Health Information Network (HIN) in order to make Medicaid claims records available to any treating provider in Florida. Using a federated model, a treating provider submits an HL-7 request via the Medicaid-Health Information Network to the Agency and a Continuity of Care Record is generated from Medicaid claims data and returned to the provider via the Availity portal.

The Medicaid-HIN is part of a collaboration involving other major payers in Florida, Blue Cross Blue Shield of Florida and Humana, to provide a solution that would reach as many providers with information about the majority of insured covered lives in Florida. The multi-payer portal housing the Medicaid-HIN is subscribed to by 100% of hospitals and approximately 95% of physician offices in Florida. Any Medicaid treating provider can subscribe, free of charge, and access the Medicaid-HIN.

The Medicaid-HIN allows treating providers to query a patient’s eligibility and benefits; to submit claims to the Florida MMIS; and to obtain a patient’s claims history, rendering providers,

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medication history, and demographics. The Medicaid-HIN includes links to Medicaid prior authorization vendors.

As part of the Medicaid-HIN, the Agency launched in November 2009 an online Personal Health Record (PHR) through which Medicaid recipients are able to use the PHR to manage their own care as well as their children’s. In the first year, the PHR allows the recipients to enter health related information into the record. The PHR is now populated with claims history records for Medicaid recipients. The PHR is offered to all Medicaid recipients at no charge. Other care management content such as information about preventative care and care for recipients with chronic disease will be included. Additionally the PHR provides links to web-based resources.

A.2.4.2 IMPACT ON THE MEDICAID PROGRAM

Section A.2.3 of this As-Is landscape provides a detailed description of HIT/HIE activities across the State in both the public and private sectors.

The impacts of these HIT activities on Medicaid recipients are:

Empower recipients through the Medicaid-HIN PHR, with the skills and information necessary to care for their own health as well as their child’s

Improve health care quality and patient safety

Prevent medical errors

Correspondingly, the impacts of these HIT activities on the Medicaid Program are:

Reduce health care costs

Increase administrative efficiencies

Decrease paperwork

Expand access to care via telemedicine

Reduce fraud and abuse of Medicaid programs

A.2.4.3 FMMIS HIE CAPABILITIES

The following sections summarize the specific FMMIS HIE capabilities as they exist today.

A.2.4.3.1 MEDICAID MANAGEMENT INFORMATION SYSTEM (MMIS) CURRENT HIE CAPABILITIES

The Florida MMIS supports real-time processing of Medicaid claims, prior authorizations and eligibility verification. The MMIS portal is a web-based interface used by providers, managed care organizations and other partners to submit claims and verify eligibility. Connected to MMIS is a Decision Support System (DSS), a large data warehouse and decision support application, that is used for analytical queries. DSS also feeds other systems such as the Medicaid-HIN.

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The Florida MMIS currently interfaces with over 90 external systems for the exchange of data including the Department of Health, Department of Children and Families, Department of Justice, Department of Juvenile Justice, Department of Elder Affairs, Social Security Administration and the Agency for Persons with Disabilities. This data falls into five main categories:

Provider data

Recipient data

Eligibility data

Claims data

ePrescribing data

Even though there is significant data interchange currently, the State does not have a statewide Health Information Exchange that can be integrated with MMIS; therefore, most data is exchanged through interfaces developed between MMIS and the other systems. As of 2010, ninety-six percent of Medicaid claims are received through electronic data interchange (EDI) or the Medicaid portal. In addition, MMIS is a source of claims data to the existing Medicaid-HIN as described in Section A.2.4.1 above.

A.2.4.3.2 FLORIDA MEDICAID MITA STATE SELF-ASSESSMENT

In 2010 AHCA conducted the first part of the Florida Medicaid Information Technology Architecture State Self-Assessment (FL MITA SS-A) Project, by completing the “As-Is” Assessment portion of the MITA SS-A. In January 2011, AHCA continued work on the MITA SS-A, in a project in which the Agency planned to identify the Florida Medicaid enterprise goals and objectives, complete the “To-Be” Assessment phase of the MITA SS-A, and create the roadmap for achieving the identified goals and objectives. The purpose of developing the goals and objectives is to define the accomplishments to be achieved so that a clear path and strategy can be set to guide both the business development and subsequent technical infrastructure implementation needed to meet the ever-changing Medicaid Enterprise. The development of the goals and objectives set the goals or ending points to be accomplished over the next few years. With the “As-Is” and “To-Be” points identified, the Florida Medicaid Enterprise can develop the roadmap that lays out the specific action steps required to accomplish its goals and objectives. As the Agency neared completion of the “To Be” portion of the SS-A, the Centers for Medicare and Medicaid Services (CMS) announced the planned release of an updated version of the MITA framework, referred to as MITA 3.0. Because of the critical nature of the announced planned changes in the MITA framework and the timing of the completion the Florida SS-A, the Agency, with CMS’ support, decided to upgrade this iteration of the Florida SS-A to the MITA 3.0 framework. As such, Florida is functioning as a pilot state for the MITA 3.0 framework implementation. The upgrade to MITA 3.0 required work to develop a gap analysis between the MITA versions and the work already completed in Florida; additional training of a sub-set of the Subject Matter Experts affected by the upgraded MITA version; a new schedule of Joint Application Development sessions to address the new and revised requirements in MITA 3.0; and development of artifacts required in MITA 3.0, such as scorecards.

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The resulting MITA SS-A, based on the MITA 3.0 framework, will be completed by the end of June 2012, with the first iteration of the MITA SS-A for Florida Medicaid. The SS-A, along with the required supporting artifacts and documentation, will be presented to CMS for review. In addition, the Agency will develop a plan for maintaining the SS-A with annual and “as needed” updates, as required by MITA 3.0. The Agency will progressively leverage this MITA “to be” visioning activity to incorporate into future iterations of the SMHP document as needed to support the Agency’s goals and objectives for the next five years.

A.2.4.4 STATE LAWS AND REGULATIONS

There have not been any recent changes to state laws or regulations that might affect the implementation of the EHR Incentive Program. The Agency believes there is no additional authority needed to administer the EHR Incentive Program. State law requires the Agency to obtain budget authority to use and distribute EHR incentive program funding.

A.2.4.5 REQUIREMENTS FOR MEANINGFUL USE: GAP ANALYSIS

Medicaid providers’ meaningful use of EHRs is intended to be attained in part through the provision of the statewide HIE technology. In August 2010, the Agency conducted a gap analysis between the current state of HIT/HIE in the State versus the final requirements for meaningful use. This analysis can be reviewed in the Agency’s submitted Draft 2.1 of the Strategic and Operational Plans, dated 10/15/2010.

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SECTION B. TO-BE ASSESSMENT - THE FUTURE HIT/HIE LANDSCAPE IN FLORIDA

B.1 INTRODUCTION

The Agency and Florida stakeholders recognize that health information technology infrastructure development is a means to better health care for all Floridians. The development of a statewide Health Information Exchange Plan will result in the implementation of a statewide health information exchange for Florida, addressing goals related to health information exchange capacity and oversight that are essential for supporting and measuring the meaningful use of electronic health records. Through this effort, the Agency and its partner stakeholders will enable Florida health care providers to improve care coordination, public health, and health care outcomes, and ultimately reduce health care costs. All of these statewide goals are aligned with high-level Medicaid program goals.

Clearly, the opportunity afforded as a result of passage of the health information technology provisions of ARRA and its focus on promoting the adoption of electronic health records among providers, the use of standards-based technology and the exchange of health information will result in improved care for patients and a better use of limited health care resources. Florida embarked on this journey several years ago and has a strong group of committed and knowledgeable stakeholders who are now engaged in moving communities, regions, the State and the nation to a full and broad adoption of the meaningful use of health information among providers. The participation of Medicaid providers and state agencies serving Medicaid recipients is critical to the success of the HIE.

The following sections provide an overview of the Agency’s vision for HIE within the State and Medicaid’s participation in this infrastructure as well as HIT/HIE initiatives specific to the Medicaid program. As discussed in Section B.2 below, the Medicaid vision for HIE, while in full alignment with the State’s HIE Plan, is in its early stages of development and, therefore, will continue to evolve over the next few years. What is known, however, is that the services to be provided by the HIE will be leveraged by the State’s Medicaid program to supplement those services provided through MMIS and other Medicaid-related systems.

B.2 MEDICAID HIT/HIE PROJECT CONTEXT

The State’s Medicaid Health Information Technology Plan is highly dependent on and integrated with the State’s HIE initiative as described in this document.

The SMHP time horizon is five years. Due to the dependency on processes yet to be completed, the SMHP itself will be delivered in an iterative fashion. Aside from the fact that long-range plans often change, the State sees interrelationships among all of the initiatives currently underway.

Certain required To-Be Assessment topics will be deferred for a later update of the SMHP. The following paragraphs describe these dependencies in further detail:

MITA To-Be Visioning

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The second portion of the Medicaid Information Technology Architecture (MITA) State Self-Assessment (SS-A) is the MITA To-Be Assessment. It began immediately upon the award to the selected vendor in the late December 2010 timeframe. The MITA To-Be High-Level visioning activities will be completed in June 2012. The Agency will progressively leverage this MITA To-Be visioning activity to incorporate into future iterations of the SMHP document the descriptions of the system architecture, including FMMIS, needed to support the Agency’s goals and objectives for the next five years.

EHR Incentive Program Implementation

The Agency has implemented the Medicaid Incentive Payment Program System (MIPPS), using the Medical Assistance Payment Incentive Program Repository (MAPIR) application developed by HP and a multi-state Medicaid collaborative, and all supporting business processes, staffing, training, and outreach required for the program.

Florida HIE Project

Florida has launched the Statewide HIE project. Further updates to the SMHP will include a governance and sustainability plan.

B.3 HEALTH INFORMATION EXCHANGE IN FLORIDA

Through guidance provided by the Governor’s office, the Legislature and involvement from Florida health care stakeholders, the State of Florida has developed a vision for Health Information Exchange (HIE). This vision encompasses the implementation of a sustainable HIE with the intent of strengthening Florida’s health care system through timely, secure and authorized exchange of patient health information among health care stakeholders. The Agency, as both the State Designated Entity (SDE) and the State Medicaid Agency which is responsible for the implementation of the EHR Incentive Program, played a central role in defining Florida’s HIE vision.

A primary component of carrying out the vision is the design, implementation and operation of a statewide HIE. The process of defining the technical architecture is dynamic and partially dependent upon visioning related to the future of Florida’s MMIS which will be accomplished through the MITA To-Be project. As both the MITA and statewide HIE development efforts are currently underway, any dependencies that impact the vision and architecture presented here will be modified in future iterations of the SMHP.

The following section outlines the current Florida HIE vision and how the Agency’s technical architecture will evolve over the next five years and integrate with the HIE to support the achievement of related goals and objectives.

B.3.1 HIE VISION / ARCHITECTURE

The vision for the Florida Health Information Exchange is to strengthen Florida’s health care system through the timely, secure and authorized exchange of patient health information among health care stakeholders. Health information exchange is expected to support patient-centered

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health care and continuous improvements in the quality, safety and efficiency of care, as well as supporting public health.

B.3.1.1 FLORIDA’S HIE ORGANIZATIONAL RELATIONSHIPS

The following exhibit depicts the high-level relationships between the Federal, State, not-for-profit and Private Sector entities that have organizational associations related to the statewide HIE or the EHR Incentive Program.

Exhibit 15: Florida’s HIE Organizational Relationships

The Private Sector consists of providers including both eligible professionals and hospitals. These providers will interact with the Agency with regard to the EHR Incentive Program. Eligible primary care providers will also work closely with the Regional Extension Centers for support in achieving the meaningful use of EHRs. The Agency has awarded a contract to an HIE vendor, Harris Corporation for the planning, design and implementation of the statewide HIE.

Private

State / Not for Profit

Federal

HIE Vendor

Federal Health and Human Services ( HHS ) Office of the National

Coordinator Centers for Medicare and Medicaid Services ( CMS )

AHCA

Providers Hospitals Eligible Professionals

Regional Extension

Centers ( REC )

State Designated

Entity ( SDE ) State Medicaid

Agency

Governance

Stakeholders

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B.3.1.2 THE AGENCY IN THE HIE CONTEXT

The Agency’s IT architecture will continue to evolve as the HIE vendor begins its work and the MITA To-Be vision is completed in the June 2012. This section details the current HIE context and provides a high-level view of the data relationships from the statewide HIE, Agency environment and the EHR Incentive Program perspectives. The context and high-level view of data relationships is presented in the exhibit and further described below.

Exhibit 16: The Agency in the HIE Context

The Statewide HIE

Florida’s HIE is envisioned as a data conduit or hub between large, existing data sources. The statewide HIE will connect to the NHIN and will follow the required NHIN accountability measures and requirements. The HIE will provide record locator services through a federated model rather than requiring and maintaining a single, statewide master patient index for all patient records in Florida.

In addition to the above stated large network entities, state government entities will provide the following data to the statewide HIE:

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o Clinical data from the Florida Department of Health (DOH) Health Management System including lab results from state labs and LabCorp test results ordered by county health departments

o DOH immunization registry data

o FQHC clinical data

o Prescription histories from Surescripts (which includes Florida Medicaid)

o Continuity of Care Record (CCR) of Medicaid claims data for Medicaid patients

o Others, as determined and feasible.

The direct point of interface between the HIE and the Agency will evolve as the MITA To-Be vision is finalized.

The Agency’s Environment

The Agency has both developed and procured applications that provide electronic health information to both Medicaid recipients as well as Medicaid providers. The Medicaid-HIN and Medicaid recipient portal make Medicaid claims records available to providers and recipients. Using a federated model, a treating provider submits an HL-7 request via the Medicaid-HIN to the Agency and a Continuity of Care Record is generated from Medicaid claims data and returned to the provider via the Medicaid-HIN to a requesting treating provider.

The EHR Incentive Program

Eligible Professionals (EPs) and hospitals will initiate their registration for participation in the EHR Incentive Payment Program at the CMS Registration and Attestation System (R&A). Once registered with the R&A, the Agency will receive a batch file transfer from the R&A that will pre-populate an applicant record in the Agency’s Medicaid Incentive Payment Processing System (MIPPS). The vision is that the MIPPS and supporting business processes will be implemented using the Medical Assistance Payment Incentive Program Repository (MAPIR) application developed by HP for a multi-state Medicaid collaborative.

Providers will have one point of access to the MIPPS via the secure Medicaid Provider Portal. The portal is a communication, data exchange, and self-service tool for the Medicaid provider community. MIPPS will be a web based application that will support R&A interfaces and data exchanges. Further, it will gather state requirements for determining and issuing EP and hospital incentive payments. The application will have both a provider facing and a user support component for use by Agency program support staff.

Applicants will continue their registration process with the State using the MIPPS. Data transfers and interfaces between the MIPPS and the R&A and the MIPPS and the FMMIS will determine eligibility and establish a completed registration for the EHR Incentive

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Program. FMMIS will be used to issue the incentive payment to Eligible Professionals (EPs) and hospitals.

B.3.2 HIE OVERVIEW

The Agency has the responsibility for creating and administering a statewide health information network that will provide a state-level infrastructure and shared service capabilities directed by the Legislature and as prioritized by Florida health care stakeholders.

The Agency recognizes that Florida has a very large number of health care organizations at varying degrees of adoption of health information technology. The Agency also understands that provider adoption and the sustainability of the use of health information exchange through EHRs is soley dependent upon the availability of clinically relevant patient data for a large percentage of a provider's patients. The Agency recognizes that the majority of patient care occurs in local communities, and that the goal of local health information exchange (HIE) efforts will be connecting providers with local sources of patient data. The Agency, with the input of multiple stakeholders, has identified what value could be brought to the local HIE efforts to help them achieve critical mass and significant provider adoption. The Agency plans to facilitate the availability of clinical data sources not otherwise accessible by, or feasible for, local networks to provide.

The Agency is also working to obtain electronic lab test results on Medicaid recipients from two national laboratories to be able to make that available for patient look-up through the statewide network.

The capabilities envisioned at the provider level include, at a minimum:

The ability for providers to send CCR/CCD records to other providers

The ability to send immunization data to the DOH registry and check immunization status

The ability for hospitals to send discharge information to referring providers

The ability for providers to refer patients to other providers (e.g., a specialist) and hospitals

The ability for the laboratories to send aggregate data and test results to DOH

The ability for providers to report quality measures to the State and CMS

The ability for providers to send reportable disease diagnosis data to DOH

The ability for providers to order lab tests and receive lab results

The ability for providers to electronically submit prescriptions

Another key component to the statewide network is connectivity to the Nationwide Health Information Network (NHIN) and the standards that need to exist between the two networks to enable data sharing. Establishing this infrastructure will enable streamlined access to federal data sources that are valuable to patient care in Florida such as the Veterans’ Administration, Department of Defense and Medicare records as such sources become available. Connectivity to

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the NHIN will also enable data exchange between Florida and other NHIN participants such as other states and regions. Florida is in a good position to benefit from such connectivity due to significant tourism, temporary residents of the State during the winter, and the historical influx of neighboring states’ residents during natural disasters.

Thus, the state-level network will be the infrastructure for system-to-system connectivity to enable patient look-up. This service enables authorized health care providers to retrieve or “pull” records available on a patient from the data sources participating in the state-level network. This pulling of a patient’s records could be automatic (e.g., upon hospital admission as validated by the hospital’s registration system) or could be initiated by the end user provider’s specific request through his local HIE network. The display of the data received through the statewide network would then be handled by the local network system (e.g., some may have a RHIO portal; others may integrate the data directly into the provider’s electronic health record showing the source of the data; some may even utilize a patient-designated Personal Health Record). Decisions about how to integrate clinical data from other sources will be made at the local level as would provider authentication. The state-level network will authenticate the local systems to connect, but the local systems will be responsible for end user authentication and access controls consistent with the HIE participation agreement requirements.

In addition to the services to be provided by the state-level network, the Agency proposes to utilize its leverage to negotiate discounts for interface costs charged by EHR vendors as well as to explore volume discounts for access to certain national data sources that can be provided through the statewide network.

Other areas to be explored by the Agency and Florida stakeholders include utilizing the state-level network to facilitate eligibility and benefit look-ups, and related ancillary services. The Agency will also utilize the Florida health information exchange infrastructure to enable connectivity with DOH for public health reporting, where feasible, and where it would enhance the level of provider participation. Discussions are continuing on other possible future uses and functions of the statewide network. The Agency will work with Florida stakeholders on a quarterly planning process to determine and prioritize any additional interfaces and/or services to be implemented for the following quarter and the roll-out schedule.

As an estimated 60% of health care occurs in the physician office setting, the Agency recognizes the need for physician practices to adopt EHRs and be participants both as a source of data and as a consumer of data in their local HIE networks which will facilitate their participation in the statewide network. The Agency proposes to collaborate with Regional Extension Centers, funded by the federal government to encourage EHR adoption, and EHR vendors to help move these efforts forward and remove or reduce barriers to adoption.

In summary, the statewide HIE network’s primary function is as a data hub, or conduit, for linking data requesting networks with large, existing data source systems and other networks. Florida MMIS will be an early and key contributor to this network. The HIE vendor, under contract to the Agency, will not only support the data hub interconnectivity, but will also assist some data sources with becoming accessible through the statewide HIE network.

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B.3.2.1 FUTURE HIE CAPABILITIES

The Agency considered several health information exchange services and plans to begin with a patient look-up service for the state-level health information exchange. This direction is based on a review of existing and developing services available to health care providers in the private market. The Agency seeks to fill the gaps in the health information exchange consistent with proposed federal meaningful use requirements. Robust HIE capabilities will allow Medicaid providers to meet the meaningful use requirements of the EHR Incentive Program.

The following bullets summarize the functional capabilities of the proposed statewide HIE:

Patient Look-up

The patient look-up service enables the search and retrieval of a patient’s longitudinal health information. It requires a record locator service as well as the availability of patient data (e.g., labs, medication history, and discharge summaries) from different sources. In addition, the Agency will:

o Provide options for subsidizing rural/safety net provider participation by identifying cost effective options such as facilitating access to the HIE using the HIE Vendor’s 10% set aside and

o Enable stakeholders to leverage and access the functionality of NHIN. The Agency will facilitate interested Florida stakeholder participation in a pilot, if feasible.

Provider Directory

The Agency will establish a provider directory that is authoritative, enables network authentication processes and includes addresses or other information for routing of HIE documents. The Agency’s strategy is to review various approaches to establishing such a provider directory with the input of Florida’s stakeholders. This will include identifying providers and/or entities that will be included, and considering the extent of the build, whether it will be developed from registered users or based on other sources such as using Department of Health licensure data or National Provider Identifier (NPI) records. The Agency will explore options for working with its contracted Florida HIE Vendor for provider directory development; or identify existing provider directories currently in use and pursue leveraging those.

Connectivity to Data Sources

The Agency has made it a high priority to enable certain sources of clinical data to be available through the statewide HIE network. These sources of data will include:

o Medical information available from Medicaid claims data

o Surescripts medication history data which includes Florida Medicaid claims prescription history as of July 1, 2010, if feasible

o Clinical lab results on Medicaid recipients from national laboratories, if feasible

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o Florida County Health Departments through the DOH Health Management System

o DOH’s immunization registry data (called SHOTS)

o Two FQHC networks (Community Health Centers Alliance and Health Choice Network)

o Others as may be negotiated

The HIE vendor, under contract with the Agency, will work with the entities necessary in making these data sources available for patient look-up through the statewide HIE network. For the DOH and the two FQHC networks, this will entail implementing a master patient index or similar functionality for matching patient records to enable those sources of data to be available for query by other participating systems on the statewide HIE network. This may also include development of interfaces, adapters or connection gateways, standardization of data, and possible generation of clinical summaries to enable responses to such queries.

The vendor will also assist with connectivity to Surescripts for medication history on a patient in response to a patient look-up query through the statewide HIE network. The vendor will work with local HIE network participants to meet any certifications required by Surescripts to make such data available through the statewide HIE network for use by the local HIE network systems.

The Agency proposes to make the above sources of data available to Regional Health Information Organizations (RHIOs), integrated delivery networks (IDN) of hospitals and other providers, and other networks through a standardized, statewide Record Locator Service (RLS) network. This direction includes making the state-level network a federated model of local networks with RLS’s or similar connectivity functionality. Each network will be responsible for maintaining its own master patient index and RLS to retrieve the relevant patient records within its own local network when a request from another statewide network participant is received. This will eliminate the need for developing and maintaining a statewide master patient index for all persons in Florida and will eliminate the need for data sources to send all their patient demographic data to populate a state-level patient index and continuously update it. This approach also provides more flexibility to allow local decisions to be made about how to integrate within a medical trading area. A Medical Trade Area (MTA) is a largely self-organized geographic market area in which a delineated population receives most of its medical services16.

Interoperability

16 A Medical Trade Area (MTA) is a largely self-organized geographic market area in which a delineated population receives most of its medical services.

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The Agency’s strategic plan for health information exchange is based on the guidelines for the NHIN developed by the Office of the National Coordinator for Health IT to provide a foundation for standards-based, secure and confidential exchange of patient records. The Agency plans to build the capacity for the secure exchange of electronic health records in Florida and improve the coordination of care among multiple providers by ensuring that the appropriate patient records are available at the point of care.

The Agency will require the state-level network to actively pursue the core capabilities of locating and integrating records for health information exchange. The exchange of health information in Florida will be based on common trust agreements that establish the obligations and assurances between the state-level HIE and other health care organizations in the network.

Health Information Exchange for Public Health

The state-level HIE will provide the patient look-up service to clinicians serving patients at Florida’s county health departments. The network will support the coordination of care for Floridians who seek primary care treatment at a county health department and who receive referrals for specialty care or lab tests.

The Agency is also seeking to increase the level of provider participation in electronic public health reporting. Electronic public health reporting is one of the meaningful use criteria for providers to receive federal incentive payments. The Agency would like to utilize the Florida health information exchange infrastructure to facilitate connectivity with DOH for public health reporting, where feasible, and where it would enhance the level of provider participation.

Trust Agreements

The Agency and Florida stakeholders, upon the advice of the HIE Legal Work Group, will develop recommended standardized documents and processes to facilitate health information exchange for use by the state-level health information exchange and those entities that agree to connect directly to the state-level infrastructure. For their own use, RHIOs and other HIE networks in Florida may elect to use the same or similar agreements among their participants. The Agency will develop additional types of participation (trust) agreements or agreement addendum as required through a priority-setting process.

The Agency and Florida stakeholders wish to establish accountability and transparency regarding health information exchange participation and the terms of the agreement. As part of this accountability, the Agency will develop policies to ensure that its health information exchange agreements are available and easily accessible to the public.

Oversight of Information Exchange and Enforcement

The Agency and Florida stakeholders will develop recommended policies to address issues of noncompliance with federal and state laws and policies that affect health

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information exchange services for electronic health records. Policies and procedures will address actions to be taken by the Agency and organizations that are participants in the state-level HIE for noncompliance with established policies and procedures, notice, and dispute resolution. Such policies and procedures will be incorporated in the trust agreements of the state-level network and available to the general public. The Agency will enforce the policies of the FHIN through the contractual provisions of its HIE Participation Agreement. In addition, the recommended policies and procedures will address steps to be taken by the Agency and participating organizations to refer possible violation of federal or state laws to the appropriate jurisdiction. Similarly, the Agency will enforce policies and procedures through contractual provisions with its state-level HIE vendor and as specified in the Participation Agreement.

The following bullets summarize the additional HIE services being implemented by the Agency:

Direct Secure Messaging

Direct Secure Messaging enables providers to “push” clinical documents to providers locally and potentially to providers in other states. The meaningful use requirement to share clinical summaries addresses scenarios such as a physician sending a referral or a summary of care document to a specialist, sending an order or summary of care to a hospital or for a specialist sending a care summary back to the referring physician.

B.3.3 FUTURE MEDICAID CAPABILITIES

In the future, it is envisioned that the MMIS will be modified to support the statewide HIE as required:

The Agency is tasked with promoting, measuring and providing incentives for meaningful use of EHR for the State. In the future, MMIS will support the measuring, tracking and reporting of meaningful use and the distribution of incentive payments to Medicaid meaningful users. The role of MMIS in these processes and any related development requirements is still to be determined. At a minimum, it is envisioned that the MMIS will need to:

o Interface to the HIE using required standards for data exchange

o Implement reporting to verify meaningful use

o Create a Continuity of Care Record (CCR) and Continuity of Care Document (CCD), including clinical data, for exchange over the HIE

o Integrate with the MIPPS to support the EHR Incentive Program

Use of a statewide HIE will promote sharing of health care information and improvement of health outcomes throughout the State. Future planning activities will define how the HIE will be used to manage the health of the State’s Medicaid population.

The services to be provided by the HIE will be leveraged by the State’s Medicaid program to supplement those services provided through MMIS.

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The Medicaid program will conduct additional planning activities as parts of the statewide HIE and MITA To-Be projects to further define how Medicaid providers will participate in the statewide HIE. This includes finalizing the HIE services that will be available to Medicaid, defining the submission methods for electronic reporting of clinical quality measures via EHR technology, and determining how the HIE will support Medicaid providers in meeting the requirements of meaningful use for Stage 1 and future stages when defined. Refer to Section C, for a full definition of how the EHR Incentive Program will be implemented including the technical solution and program registration, payment requests, payment processing and auditing processes.

B.4 MEDICAID HIT/HIE GOALS AND OBJECTIVES

Due to these dependencies discussed in Section B.2, the Agency is setting the HIT/HIE related goals and objectives using an iterative approach. This section presents the Agency’s goals for the next five years. Specific objectives related to these goals are derived based upon the results of the 2010 environmental scan and the HIE procurement process. As well, results of the MITA To-Be project will be incorporated into future iterations of this document when available. As such, the objectives will be presented in a future iteration of this plan.

B.4.1 HIGH-LEVEL STATEWIDE GOALS

The State Medicaid Agency has developed high-level goals for the next five years related to the implementation of the statewide HIE and the use of health information technology within the Agency.

The following goals were developed through visioning sessions with Medicaid subject matter experts and further refined through sessions conducted with Agency leadership. The high-level goals are as follows:

Increase Provider Adoption of EHRs

The Agency’s primary goal over the next two years is to increase provider adoption and meaningful use of EHRs. It is essential to achieve this goal in order to achieve the other goals of the Agency. Florida Medicaid’s priority is to implement the EHR Incentive Program, with the goal of issuing incentive payments to eligible providers by August of 2011. Further, the Agency recognizes the critical need to conduct effective provider outreach and communications. This is an integral part of the implementation of the EHR Incentive Program.

The Agency is in the process of identifying specific objectives that will be used to assess the progress against a baseline of provider EHR use over time. These objectives will be based upon the baseline data obtained in the 2010 EHR Environmental Scan.

Improve Quality of Care and Patient Safety

The Agency recognizes that opportunities exist to improve quality of care and patient safety by providing timely access to patient data at the point-of-care. This will further be

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accomplished through the use of personal health records, electronic record adoption, and opportunities to utilize the HIE to facilitate holistic case management across state operated health and human service programs. Further, the Agency anticipates increased opportunities for provider collaboration which will contribute to achieving this goal.

Improve Health Care Outcomes

The Agency recognizes the potential to use clinical data for outcome-based decision-making. The ability to access a rich set of health care information for analytical purposes through the HIE will expand opportunities for improved health care outcomes. The HIE will enable, among other things, the ability to better assess the impact of interventions, public health efforts and changes in service delivery approach.

Improve Program Administrative Efficiencies

The Agency recognizes opportunities related to increased administrative efficiency within the Medicaid program and in the other payer programs. This includes opportunities to streamline public health reporting as well as health plan quality reporting.

Enhance Cost Containment

The use of HIE in the Florida Medicaid program presents several opportunities to enhance cost containment efforts. Included is the ability to implement value-based contracting and reduced cost of audit and fraud recovery through the use of automated tools. Further, the Agency anticipates opportunities to reduce duplication of tests and related costs. It is expected that this will be achieved through improved access to existing lab reports through the HIE.

Increase Practice Efficiency

In order for EHRs to be accepted by providers, there must be clear practice efficiencies that result. Provider practice efficiencies are expected to result through improved eligibility determination processes, reduced duplication of tests and improvements in provider office processes. Further, access to a more complete set of health care data may result in better care decisions for patients and, thus, a reduction of malpractice costs for participating providers.

Improve Efficiencies of Provider-to-Provider Communication

Improved communication among providers is expected to result through the secure, efficient, national standards-based exchanges of clinical information.

Enhance Public Health Services

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Through the use of the HIE infrastructure, health care providers will have a direct connectivity to public health databases and the means for timely reporting, which would then translate to an improved public health management at the state and national levels.

As noted, Florida Medicaid continues to develop its HIE objectives related to these goals. The objectives will provide specific targets and timeframes related to these goals. Specific objectives will be provided in future iterations of this plan.

B.4.2 GOALS FOR ELIGIBLE PROFESSIONALS

The goals for eligible professionals are in this version of the SMHP and established based upon the results of the 2010 Environmental Scan.

B.4.3 GOALS FOR ELIGIBLE HOSPITALS

Hospitals manage a significant amount of health care information and are expected to be critical contributors to the universe of data accessible through the HIE. Further, as a class of provider, hospitals are generally further ahead in the process of implementing and using EHRs. As such, the Agency expects 100% of Eligible Hospitals to be meaningful users of EHRs and to participate in the EHR Incentive Program by 2014.

B.5 HIE GOVERNANCE

The Medicaid program is represented in the existing advisory structure / organizations and is involved in statewide issues relative to HIE. Medicaid is also represented on the HIE Cooperative Agreement project team for the design and implementation of the statewide HIE infrastructure.

In addition, the State is considering the addition of a new HIE Management Committee composed of actual HIE users that will oversee the business operations of the HIE and report the status of these operations to the Agency. The proposed HIE Management Committee will oversee the business operations of the HIE and report the status of these operations to the Agency. It is proposed that the Committee will be charged with making decisions regarding new entrants in the participation agreement, changes in technical requirements affecting participants, enforcing the agreement, handling disputes and terminating participants and other matters as deemed necessary.

The Agency does not anticipate any other modifications to the existing governance structure at this time or for the development of Medicaid-specific governance structure; however, the State’s and Medicaid’s governance needs will be evaluated over time and adjustments made as necessary.

B.6 EHR ADOPTION STRATEGIES

This section provides a summary of the Agency’s outreach efforts to encourage provider adoption of certified EHR technology.

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Build and maintain collaborative relationships with partner stakeholder groups to disseminate educational information about the Incentive Program

Collaborate with Regional Extension Centers (RECs) to share and exchange information

Create, launch and maintain the EHR Incentive Program web page

Establish a process to respond to provider inquiries and direct them to the appropriate resources

Create and update outreach materials for internal and external stakeholders

Conduct internal and external trainings for consistent messaging and effective use of outreach materials

Use internal and external communications channels to promote the EHR Incentive Program

Use story placement and a paid media campaign in targeted publications to enhance outreach efforts

For a full description of the Agency’s outreach plan, refer to Section F.

B.6.1 LEVERAGING EXISTING GRANTS FOR EHR ADOPTION

B.6.1.1 LEVERAGING OF FQHCS

As described in Sections A.2.3.3.12, the Agency has incorporated input from the FQHCs in the HIE vision and is facilitating the creation of a data exchange connection between the existing Medicaid-HIN and the Health Choice Network to provide encounter histories for uninsured patients in South Florida as a first step. The Agency will also be actively involved in assisting the two FQHC networks in the state establish the required patient matching and record locator service to make their clinical data available for patient look-up by systems connected to the state-level HIE network.

B.6.1.2 LEVERAGING OF GRANTS FOR THE EHR INCENTIVE PROGRAM

External Entity Grants / Nature of the Relationship Opportunity to Leverage

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Regional Extension Centers (RECs)

Grants: RECs are operating based on federal grants to encourage the adoption of EHR technologies. Agency relationship: Collaboration on assisting providers adopt EHRs through training and technical support; possible contracting work being laid out through Memorandum of Understanding with RECs during EHR Incentive Program implementation; partnering with RECs on implementing an outreach to served providers on qualifying for payments from the EHR Incentive Program.

The Agency has executed MOUs with RECs to encourage the RECs to address Medicaid providers.

The Agency is considering the potential to contract with the RECs to support Medicaid providers in achieving meaningful use.

The Agency will gain lessons learned from the RECs as providers adopt EHR systems and work to achieve meaningful use.

The Agency plans on building relationships between the RECs and the Medicaid Area offices to support providers in meaningful use.

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Department of Health (DOH)

Grants: Statewide, DOH administers the following programs funded through the Health Resources and Services Administration (HRSA) and other Federal sources:

Epidemiology and Laboratory Capacity Cooperative Agreement Program (CDC)

HIV Care Grant Program Part B States/Territories Formula and Supplemental Awards/AIDS Drug Assistance Program Formula and Supplemental Awards (HRSA)

Maternal and Child health State Systems Development Initiative programs (HRSA)

State Offices of Rural Health Policy (HRSA) - 33 Counties

State Offices of Primary Care (HRSA) Emergency Medical Services for Children

Program (HRSA) Immunization Registry grant

Agency relationship: Collaboration on managing and oversight of federally-funded state programs, Health Information Exchange Coordinating Committee (HIECC) collaboration on the policy decisions to create a robust statewide Health Information Exchange.

The HIE is key in the DOH’s plan for connecting Community Health EHR systems.

The Agency will support their efforts to achieve certification of DOH’s EHR system and the achievement of meaningful use.

DOH has a new two year grant to pull detailed cancer-related information from hospital EHR systems into their cancer registry. The HIE will be used as the backbone for data submission.

Department of Children and Families (DCF), Substance Abuse and Mental Health Program

Grants: Substance Abuse and Mental Health (SAMH) services are funded primarily through the Federal Block Grant, other federal grants, state general revenue, and Medicaid resources (state and federal funds). The Substance Abuse Prevention and Treatment Block Grant currently funds approximately 50% of substance abuse services. State Mental Health Data Infrastructure Grant for Quality Improvement. Agency relationship: Collaboration on management and oversight of State Mental Health data Infrastructure Grants for Quality Improvement under a SAMHSA grant relative to HIE and ways in which the DCF and its sub grantees will participate in HIE in Florida.

The Agency will collaborate with DCF to support their adoption of EHR and connection to the HIE.

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Department of Elder Affairs (DOEA)

Grants: The Older American’s Act’s programs provide assistance in the development of new or improved programs to help older persons through grants to the states for community planning and services. Agency relationship: Collaboration on management and oversight of Medicaid home and community based waiver programs related to the elderly and issues related to HIE and ways in which the DOEA and its sub grantees will participate in HIE in Florida.

Some DOEA contracted providers may be eligible for the EHR Incentive Program.

Federally Qualified Health Centers (FQHC)

Grants: There are nine HRSA Grants to the two FQHC networks. Agency relationship: In the future, the Agency will assist the two (2) FQHC networks in establishing required patient matching and record locator service to make their clinical data available for patient look-up by systems connected to the state-level HIE network.

The FQHCs are in scope of the HIE Cooperative Agreement.

The HIE Cooperative Agreement project will define the opportunity to work with the FQHCs in the exchange of health information.

Collaboration on encouraging as many providers as possible in participating in the EHR Incentive Program.

Children’s Health Insurance Program Reauthorization Act Quality Demonstration Grant / Florida Healthy Kids Corporation

Grants: In February 2010, the Agency, in partnership with the State of Illinois, received a grant award of $11.3 million to improve health care quality and delivery systems for children enrolled in Medicaid and the Children’s Health Insurance Program (CHIP). The Medicaid and CHIP agencies in Florida and Illinois will collaborate to use the CHIPRA grant to improve health outcomes for children by enhancing access to information for use by providers, consumers, and state agencies and undertaking new quality improvement activities in their Medicaid and CHIP programs. Agency relationship: Collaborating with the Administrative Simplification, Service and Quality Committee of the corporation in planning and implementing the CHIPRA-funded grant projects: child health quality measures, health information technology, a Children’s Medical Services Initiative on the medical home model and a March of Dimes initiative focused on perinatal outcomes.

The Children’s Health Insurance Program will be part of a pilot project to test meaningful use requirements.

The Agency will also continue to support the development of local networks to allow providers to connect to the HIE and achieve meaningful use.

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Workforce Training Grants

Grants: Three community colleges in the State received workforce training grants to ensure that a trained workforce is available to support the adoption of EHR technology.

Having a capable workforce to support providers is key to the adoption of EHR systems and the achievement of meaningful use.

Exhibit 17: Leveraging Grants for EHR

B.6.2 APPROACH FOR TECHNICAL ASSISTANCE

A full description of the process the Agency will use to provide technical assistance to Medicaid providers for the adoption and meaningful use of certified EHR technology is included in Section C, Administration and Oversight of the EHR Incentive Program.

B.7 EHR INCENTIVE PROGRAM

When fully deployed, the EHR Incentive Program (fully described in Section C of the SMHP) will establish and validate eligibility; validate, issue, monitor, audit and track incentive payments; identify suspected fraud and abuse; allow for provider appeals; and validate and monitor compliance with meaningful use standards as defined by CMS.

B.7.1 STRATEGY TO ADDRESS UNIQUE NEEDS

The Agency’s plans on how the needs of unique populations will be addressed by the EHR Incentive Program are still being formulated; however, refer to Section A.2.3.2 for a description of current HIT activities across the State. Some of these activities address unique populations (e.g., Florida Department of Children and Families, the Agency for Persons with Disabilities, and Department of Elder Affairs). This section of the SMHP will be completed once this broader plan is available.

B.7.2 REQUIRED CHANGE TO STATE LAW

A full description of the required changes to State law to implement the EHR Incentive Program is included in Section C, Administration and Oversight of the EHR Incentive Program. Refer to Section A.2.4.4 for an analysis of State law relative to the implementation of the HIE.

B.7.3 PRIVACY POLICIES

The Agency is developing terms and conditions for EHR Incentive Program enrollees that will reflect the appropriate emphasis on privacy controls and safeguards required at the provider level.

In the Meaningful Use Rule for Year 1, data encryption in EHR systems is an “addressable” requirement (i.e., optional). The Agency intends for the attestation process to emphasize to EHR

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Incentive Program participants the importance of health data encryption at the provider level. Providers are required, by HIPAA and the Meaningful Use Rule, to perform a risk analysis compliant with the National Institute of Standards and Technology guidelines.

Recognizing that a substantial amount of providers are fairly new adopters of EHR technology and that connecting to a network entity that goes beyond the physical confines of their practice is a new dynamic, the Agency intends to provide risk education materials (e.g., Home Page for Privacy and Security, FAQs, etc.) and emphasize to providers the need for regular security risk assessments. While likely proficient with the physical and administrative aspects of security, the new adopters of EHR technology may not be as proficient in the technical aspects of security. As part of the Agency’s plan for the expanded collaboration with RECs during the EHR Incentive Program implementation period, assistance may be provided by RECs to providers in education and/or in acquiring the expertise and ability to assess risks and other security services.

B.8 DEFINITION OF MEANINGFUL USE

The Agency does not plan on proposing any changes to the meaningful use definition as allowed by CMS.

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SECTION C. ADMINISTRATION AND OVERSIGHT OF THE EHR INCENTIVE PROGRAM

C.1 PURPOSE

The section of the update to the SMHP provides a description of the policies and processes Florida

uses to distribute payments to eligible providers according to state and federal regulations.

At the time of its original submission the SMHP described Florida’s plan or the “to be” state for the

administration and operation of the EHR Incentive Payment Program. Florida has since implemented

the first year of its EHR plan and this document describes the program now that it is operational.

C.2 ADMINISTRATION OF THE EHR INCENTIVE PROGRAM

Florida’s plan for its EHR Incentive Program has been implemented and is designed to get incentive funds to providers quickly while providing for the appropriate level of program oversight. Several strategic decisions have been made that help ensure Florida will be successful as it operates its EHR program.

1. The Agency established an administrative team that supports the business processes and

provides the necessary oversight, monitoring and program integrity.

2. The Agency selected and implemented the Hewlett Packard (HP) MAPIR product as the EHR

Incentive Program’s technical solution

3. The Agency has a sophisticated and collaborative provider outreach plan that leverages

resources both within and beyond the Agency to put EHR Incentive Program information into

the communities and offices of the targeted providers. The Agency has contracted with an

outreach vendor to coordinate and implement these activities.

4. The Agency has contracted with HP to expand its existing call center staff, provider

enrollment staff and system staff for additional support of the program.

5. The Agency will contract with a vendor to provide EHR Incentive Program audit plan.

Taken together, these resources make it possible for Florida to implement and manage an effective

EHR Incentive Program that achieves the vision for EHR adoption set forth by the federal

initiative. Florida expects that with time and continued provider outreach, the State will realize the

program’s goals of increasing the adoption and meaningful use of EHR, ultimately contributing to

improved health outcomes for those served.

C.2.1 EHR INCENTIVE PROGRAM CURRENT STATUS

Florida launched the Incentive Payment Program September 5, 2011. Program statistics are provided below though February 2, 2012, week 22 of the program.

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As of February 2, 2012, 1406 eligible professionals have been paid a total of $24,047,921.

As of February 2, 2012, 99 hospitals have been paid a total of $87,166,574.

0

500

1000

1500

2000

2500

3000

3500

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22

Nu

mb

er

of

Ap

plic

atio

ns

Program Week

Eligible Providers

Paid

Review Complete

Under Review

Not Ready

Mismatch

0

20

40

60

80

100

120

140

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1 3 5 7 9 11 13 15 17 19 21

Nu

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Eligible Hospitals

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C.2.2 INCENTIVE PROGRAM ADMINISTRATION ORGANIZATIONAL CHART

C.2.3 CMS REGISTRATION AND ATTESTATION SYSTEM

To apply for payment, providers or their designees register with the CMS Registration and

Attestation System (R&A) and Florida’s State Level Registry (SLR). Providers submit their

profile information to the R&A via the CMS Registration and Attestation (R&A) site. The R&A,

the SLR and Florida Medicaid Management Information System exchange information that is

used to determine eligibility and issue payments.

AHCA STAFF ACTIVITIES

State Medicaid Director


Administrator

Contact Center

CONTRACTED FISCAL AGENT SUPPORTED ACTIVITIES

Portal Modifications

Program Audit

Outreach


VENDOR SUPPORTED ACTIVITIES


Medicaid Contract Management Chief

Program Operations and

Support

Appeals

EHR Incentive Program Implementation Team

Project Manager --other contractual

services

Program Manager

EHR IP Technical Solution – Core and

Customization

DOH Collaboration

Technical Support Vendor

Existing MCM Technical Staff


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C.2.4 STATE LEVEL REGISTRY

Florida contracted with HP to provide MAPIR, the state level registration tool. The tool was designed

and developed by a multistate collaborative workgroup to accept applications and distribute payments

to eligible providers. It has been integrated with each state’s Medicaid Management Information

System (MMIS) and interfaces with the National Level Registry.

In Florida, eligible providers or their designees access MAPIR using Florida’s MMIS provider web

portal. During registration they are asked to attest that they meet all the requirements for payment and

to upload documentation that supports their attestation. The EHR incentive payment administrative

team reviews the submitted documentation as well as other information that validates the provider’s

eligibility. The administrative team then authorizes or denies payment based on their review.

MAPIR sends a file to R&A of the final decisions. If the provider has been approved to receive a

payment, the R&A validates the provider has not received payment in another state and from Medicare

and notifies the state to proceed with paying the provider. MAPIR then pays the provider using the

MMIS financial system.

C.2.5 IT SYSTEM CHANGES FOR IMPLEMENTATION

The technical solution for the state level registration and attestation system is comprised of

the MAPIR application, which has a core HP interChange component and a customized

component specific to Florida, the FMMIS, and the secure Florida Medicaid Provider Web

Portal. The MAPIR system is a web-based application that interfaces with the FMMIS, the

central system for administering the Florida Medicaid program. The MAPIR system will

provide the majority of the necessary technical functions to implement the EHR Incentive

Program. MAPIR integrates with the State’s MMIS and links to the CMS Registration and

Attestation System (R&A). The R&A has the functionality to guard against duplicate

provider payments.

MAPIR is configurable, recognizing that there are state-specific customization requirements

in User Interface, navigation/workflow and so forth. Data transfers and interfaces between

MAPIR, the R&A, and FMMIS will determine eligibility and establish a completed

registration for an EHR Incentive payment. FMMIS will issue the incentive payment to

eligible professionals and hospitals once all criteria for payment have been met and will track

and monitor payment information. MAPIR will communicate with registrants on the status of

their application.

MAPIR has both a provider-facing and a user support component for use by Florida EHR

Incentive Program support staff. Providers have one point of access via the secure Medicaid

Provider Portal. The portal is a communication, data exchange and self-service tool for the

Florida Medicaid provider community. Florida EHR Incentive Program staff is able to use

MAPIR to track application and decision status, attach notes and documents to provider

records, and generate provider correspondence. When a payment approval has been made,

the information will be sent to the R&A, which will then confirm and register the payment

and authorize the state to make the payment. FMMIS will then generate an incentive payment

for the provider using existing payment processes.

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C.2.6 ELIGIBLE PROVIDERS

Eligible providers are categorized into two broad groups-Eligible Professionals and Eligible Hospitals.

To receive the initial payment, EPs and EHs must adopt, implement or upgrade (AIU) to an EHR

technology, meet a specified Medicaid patient volume, and be one of the eligible professionals or

facilities. To receive subsequent payments, EPs and EHs must demonstrate meaningful use of the

EHR technology. The eligibility requirements and the state’s methods for verifying that they are met

follows.

C.2.7 ADOPT, IMPLEMENT OR UPGRADE REQUIREMENTS AND VERIFICATION

MAPIR accepts provider attestations for the AIU component of the incentive payment. During

registration, MAPIR requires providers/applicants to attest that they have adopted, implemented or

upgraded to a certified EHR technology and to provide a valid EHR certification number. MAPIR

verifies the certification number through an interface with HHS’s Certified Health IT Product List. If

the certification number is invalid, MAPIR rejects the application.

Providers are also required to upload copy of a business record that demonstrates the provider has

purchased or contracted with a third party for the EHR system. The administrative team reviews the

business record during prepayment review before authorizing payment.

A business record for the documentation for purchased systems must include the following elements:

• The provider’s name • The system name and version • The financial obligation • A timeframe for adopt, implement or upgrade

Examples of documentation for purchased systems are:

• Paid invoice;

• Executed upgrade agreements for which a cost and timeframe are stated; • A vendor letter only if it contains the provider name, the system name and version, the

financial obligation, a timeframe for adopt, implementation or upgrade, and is signed by the vendor. The vendor letter in essence becomes a legally binding document such as a contract or agreement.

A business record for the documentation for “free” EHR systems may include:

• A copy of Page One of the license agreement if in a format that can be uploaded. • A copy of the EHR system’s screen that displays at a minimum the provider’s name and

the name of the free software (usually a header at the top of each screen). • A vendor letter is acceptable if it contains the provider’s name; the name of the

software and the version of the software. • The “welcome email/letter” that is sent by the vendor upon signing up.

A business record for documentation of arrangements in which the EHR system from another practice is used

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• A copy of the agreement between the owner of the system and the applicant indicating the name and version of the software

• A screenshot from the EHR system indicating the software’s name and version

C.2.8 MEANINGFUL USE

To receive payments for meaningful use eligible providers must demonstrate meaningful use of their

EHR technology. For eligible professionals, there are a total of 25 meaningful use objectives. To

qualify for an incentive payment, 20 of these 25 objectives must be met. For eligible hospitals and

CAHs, there are a total of 24 meaningful use objectives. To qualify for an incentive payment, 19 of

these 24 objectives must be met.

In January 2012, MAPIR will begin accepting attestations from Eligible Hospitals for the meaningful

use of the incentive payment. Hospitals meeting Medicare meaningful use requirements are deemed

eligible for Medicaid meaningful use incentive payments and can receive payments for both Medicare

and Medicaid.

The MAPIR collaborative workgroup is currently developing modifications that will capture

meaningful use attestations from eligible professionals. The modifications will be available for EP

attestations by April 2012.

C.2.9 ELIGIBLE PROFESSIONALS REQUIREMENTS

In Florida, Eligible Professionals are individuals who: are fully enrolled in Florida Medicaid, are free from sanctions; do not render more than 90% of their covered services in a hospital (non-hospital based); and are licensed or eligible to practice their profession in the state as one of the following:

(1) A physician, (2) A pediatrician, (3) A dentist, (4) A certified nurse-midwife, (5) A nurse practitioner, or (6) A physician assistant who practices in a Federally Qualified Health Center (FQHC) or a

rural health clinic (RHC) that is led by a physician assistant. Note: The non-hospital based requirement does not apply to EPs who practice predominantly at a FQHC or RHC.

An exception will be made to allow an EP to enroll in the incentive program who would be excluded under the definition of hospital based but who demonstrates that they funded and continue to fund the acquisition, implementation and maintenance of certified EHR technology, including supporting hardware and any interfaces necessary to meaningful use without reimbursement from an eligible hospital; and who uses such certified EHR technology in the inpatient or emergency department of a hospital (instead of the hospital’s certified EHR technology). Florida will include messaging about this exclusion in our outreach materials to

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eligible professionals and upload to our registration and attestation system documentation that the EP has met the requirements of this exception.

C.2.10 VERIFICATION OF ELIGIBLE PROFESSIONALS

To receive an incentive payment, eligible professionals must first register at the CMS Registration and

Attestation System (R&A). The R&AR&A then sends a file of the Florida registrants to Florida

Medicaid that is matched to the Medicaid provider file. It is a systematic process that uses the

provider’s NPI to locate an active provider record on the Medicaid provider file and then determines,

whether the provider is an eligible professional (EP) based on the Medicaid provider type and

specialty.

If a match is found, MAPIR creates a record which eligible professionals access via the MMIS web

portal and use to apply for the incentive payment. Providers who are not eligible or do not match the

Medicaid provider file are listed on a report. The administrative team contacts the providers on the

report to resolve their matching issues if possible.

C.2.11 VOLUME REQUIREMENTS FOR ELIGIBLE PROFESSIONALS

To qualify for an incentive payment EPs must meet the required Medicaid patient volume or medically needy volume if practicing predominately at a Rural Health Clinic or a Federally Qualified Health Center. Patient volume is calculated by dividing the number of Medicaid encounters by the total number of patient encounters over a continuous, representative 90-day period in the prior calendar year, or, effective, 1/1/2013 for the 2013 program year, 90 days in the preceding 12 month period. For the purposes of this program an encounter is any one day where Medicaid paid for all or part of the service or Medicaid paid the co-pays, cost-sharing, or premiums for the service. Effective 1/1/2013 for the 2013 program year, that definition is expanded to include all encounters with a Medicaid enrolled patient, paid or unpaid. EPs can attest to the required patient volume using encounters attributable to Medicaid that are services rendered on any one day to a Medicaid enrolled individual regardless of payment liability. This will include zero pay claims and encounters with patients in Title XXI funded Medicaid expansions but not separate CHIP programs. EPs that practice at an RHC or FQHC can use encounters attributable to needy volume. EPs have the option to choose whether they will use their individual patient volume or their group’s patient volume to meet the required volume. However, each encounter may be used toward patient volume only once.

Non-Hospital-Based Eligible Professionals:

Patient Volume Over 90-Day Period

Physician (MD, DO) 30% Medicaid Dentist 30% Medicaid Certified Nurse Midwife 30% Medicaid Nurse Practitioner 30% Medicaid Physician Assistant (PA) in a Rural Health Clinic or FQHC led by PA

30% Medicaid

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Pediatrician 20% Medicaid Note: Eligible professionals practicing at least 50% of the time in an RHC or FQHC can count “needy individuals” when determining patient volume.

C.2.12 ATTESTATIONS USING INDIVIDUAL VOLUME

An EP, who is attesting using individual volume, may use any encounter (as described above) for which s/he rendered the service.

C.2.13 ATTESTATIONS USING GROUP VOLUME

1. An EP, who is attesting using group volume, must be affiliated with the group at the time of attestation.

2. An EP, who is attesting using group volume that is affiliated with multiple groups, may only use the group volume from one of their groups.

3. An EP, who is attesting using group volume, must use the same reporting period as all other members of the group.

4. An EP, who is attesting using group volume must use the group’s entire patient volume and may not limit it in any way.

5. An EP, who is attesting using group volume, must have rendered an auditable Medicaid service sometime between the 90 day reporting period and the attestation date.

Note: Due to the complex structure of some provider groups Florida permits providers to request an exception to the group volume policy. Each request is considered on a case-by-case basis and only if the provider can produce auditable documentation in support of the exception.

C.2.14 VERIFICATION OF VOLUME

EPs are asked during registration to upload documentation from their practice management system that validates their Medicaid patient volume and their total patient volume. The administrative staff use Medicaid claims history to compare to the provider’s practice management documentation. Payment is approved if the numbers are the same and meet the required volume. Florida accepts a variance of 7% between the provider’s practice management report and the Medicaid claims history report as long as either of the numbers meets the volume requirement. The variance allows for discrepancies between when a service is rendered and the claim is paid as well as allowing for encounters that were not billed to Medicaid. If there are no claims in MMIS for an individual member of a the group, which may be the case for ARNPs or PAs who bill under a supervising physician, providers may document that they have rendered a service using a medical record.

C.2.15 INCENTIVE PAYMENTS FOR ELIGIBLE PROFESSIONALS

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Eligible professionals can receive an annual payment over six years for the adoption, implementation and meaningful use of an EHR technology. Payments are made once in a calendar year, however EPs do not have to apply for payments in consecutive years; they are allowed to skip payment years. Eligible professionals can register to receive the payment directly or reassign payment to a Medicaid enrolled group provider with which they have contractual arrangement that allows the group to bill and receive payment for the EP’s covered professional services. The following chart displays the payment amount for AIU and meaningful use that is available during the program.

Note: Program Year 2014 only requires a demonstration of 90 days of Meaningful Use. For payment years two through six, EPs will attest to Meaningful Use according to the applicable rule. EPs will attest to two years of Stage 1 measures, followed by two years of Stage 2 measures. EPs that skip a year will also have two years at each stage. Requirements for subsequent stages have yet to be determined. The online application will be updated to comply with all changes in rule.

C.2.16 ELIGIBILITY REQUIREMENTS AND VERIFICATION FOR ELIGIBLE HOSPITALS

Eligible hospitals are acute care hospitals, critical access hospitals and children’s hospitals. Like EPs,

eligible hospitals first register at the National Level Registry. The R&A determines if the

hospital/applicant is an eligible hospital based on the following:

Acute Care and Critical Access Hospitals- have a CMS Certification Number (CCN) with the

last 4 digits of 0001 – 0879 or 1300 – 1399.

Children’s Hospital-have a CCN with the last 4 digits of 3300 – 3399.

Once the hospital has been determined eligible, the R&A sends the registration to Florida. It is

matched by MAPIR to the MMIS like the EPs and a record is created in MAPIR if a match is found.

C.2.17 VOLUME REQUIREMENTS FOR ELIGIBLE HOSPITALS

Acute care hospitals and critical access hospitals must have an average length of patient stay of 25

days or fewer and have at least a 10% Medicaid patient volume. Children's hospitals do not have a

patient volume requirement.

Payment Year Maximum Payment EHR Attestation Requirement Year 1 $21,250 Adopt, Implement, Upgrade Year 2 $8,500 90 consecutive days of Meaningful Use Year 3 $8,500 365 consecutive days of Meaningful Use Year 4 $8,500 365 consecutive days of Meaningful Use Year 5 $8,500 365 consecutive days of Meaningful Use Year 6 $8,500 365 consecutive days of Meaningful Use

Maximum $63,750

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The calculation for patient volume is the Total Medicaid patient encounters in any representative

continuous 90-day period in the previous hospital fiscal year / divided by Total patient encounters in

that same 90-day period] * 100. For purposes of calculating hospital patient volume, the following are

considered Medicaid encounters:

Services rendered to an individual per inpatient discharges where Medicaid or a

Medicaid demonstration project under section 1115 paid for part or all of the service or part of

their premiums, co-payments, and/or cost-sharing;

Services rendered to an individual in an emergency department on any one day where

Medicaid or a Medicaid demonstration project under section 1115 of the Act either paid for

part or all of the service; or part of their premiums, co-payments, and/or cost sharing.

Medicaid inpatient discharges and Medicaid emergency department encounters as defined above

would be added together as the numerator, and all inpatient discharges and emergency department

encounters would be added together as the denominator.

C.2.18 VERIFICATION OF VOLUME FOR ELIGIBLE HOSPITALS

The administrative staff verify that the hospital meets the volume and length of stay requirement using

the cost reports submitted to Medicaid for rate setting purposes.

C.2.19 INCENTIVE PAYMENTS FOR ELIGIBLE HOSPITALS

Incentive payments to eligible hospitals are based on a complex formula in which a base incentive

amount of $2,000,000 for each hospital is modified by the number of Medicaid discharges, bed days

and other factors. Eligible hospitals can receive incentive payments over 3 years. The allocation of the

aggregate hospital incentive payment will be 50% in the first participation year, 40% in the second,

and 10% in the third.

Hospitals participating in multiple states must choose only one state to receive payments from.

Additionally, hospitals meeting Medicare meaningful use requirements are deemed eligible for

Medicaid incentive payments and can receive payments for both Medicare and Medicaid.

C.2.20 HOSPITAL PAYMENT CALCULATION

C.2.20 HOSPITAL PAYMENT CALCULATION

MAPIR calculates the incentive payment for hospital based on the data entered by the hospitals. For verification, the administrative staff compares the submitted data to the data taken directly from the hospital cost reports. Discrepancies will be resolved before incentive payments are issued. Florida is accepting a 3%variance between the calculations based submitted data and the Medicaid cost report data. A template for the calculation of the hospital incentive payment is available for hospitals on the website at www.ahca.myflorida.com/medicaid/ehr/incentive_payments_hospitals.shtml. This template has been revised to reflect the change in rule that allows eligible hospitals to use the

http://www.ahca.myflorida.com/medicaid/ehr/incentive_payments_hospitals.shtml

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most recent continuous 12 month period for which data are available prior to the payment year as a base year for the incentive payment calculation.

The following chart displays a summary of the prepayment verification that occurs before a payment is

issued. The results of the review are recorded on Eligible Hospital Eligibility Verification form:

Policy Requirement Verification Requirement and Data Source

Verify that the hospital is not excluded from

receiving Medicaid payments.

MAPIR verifies using the FMMIS provider file

Verify that the hospital is licensed to

practice in the State of Florida.

Staff verifies via AHCA’s licensure data.

Verify that the hospital is an acute care

hospital.

Staff verifies via AHCA’s licensure data.

Verify the average length of stay is 25 days

or less

Staff verifies through submitted cost report and

Florida Hospital Financial Data Book

Verify Medicaid patient volume. Staff verifies via Florida Center Hospital

Administrative data.

Verify the eight data points for the incentive

payment calculation; total discharges for the

base FY and previous three FYs, total

inpatient Medicaid bed days, total inpatient

bed days, total charges for all discharges,

total charges less charity care.

Staff verifies via submitted cost reports. Staff will

accept a variance of 3% when the information

attested to does not match the submitted cost

report.

Verify attested to status of adopted,

implemented, upgrade for the EHR system.

Staff verifies AIU status by obtaining an

acceptable business record that indicates that the

certified EHR technology has been acquired,

purchased, or is under contract with a third party

vendor.

C.3 ISSUING INCENTIVE PAYMENTS

The activities that comprise the Issue Incentive Payments process are: 1) Verify Payment Meets

Requirements; 2) Verify Assignment is Voluntary; 3) Confirm Payment with R&A Prior to Issuance;

and 4) Issue Payment.

The incentive payments are made in the same manner as other payments using the MMIS’ financial

system. The incentive payment appears on the provider’s remittance voucher once it is paid. The

payment is included along with other claims that are paid during the payment cycle.

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Payment issued by the EHR incentive payment program will not be used to offset existing liens or

overpayments that a provider may currently owe however; if an EHR overpayment is erroneously

made, it will be offset against future claims payments or incentive payments.

Payments are issued according to existing MMIS processes. EPs and EHs meeting program

requirements will be paid an incentive payment unless they have been sanctioned or excluded from

receiving payments or previously received payment from Medicare or another state.

The following table shows the activities and actors associated with issuing a payment.

Issue Payments

Activity

Label System Activity Description

Actor Activity

Description

Actors

Verify

Payment

Meets

Requirements

Attestations to requirements

are verified prior to payment

EP and EH attest to

meeting program

requirements and

attestations are verified.

Eligible

Professional,

Eligible

hospital,

Program

Staff

Verify

Assignment

is Voluntary

MAPIR captures information

for eligible professionals who

have assigned their incentive

payment to verify that the

assignment was voluntary.

The EP attests at the

SLR if the payment is

voluntary. If not

voluntary, payment is

withheld and EPs can

change payee selection

at the R&A.

Eligible

professional

Confirm

Payment with

R&A Prior to

Issuance

MAPIR interfaces with the

R&A to provide payment

notification to the R&A and

to confirm payment has not

been made in another state or

under Medicare.

None required. None

required

Issue

Payment

MAPIR issues the incentive

payment through the MMIS

Receive incentive

payment.

Eligible

professional,

hospital

Table 3: Activities for the Issue Incentive Payments

C.4 REPORTING PAYMENTS

EHR Incentive payments are reported at the state and federal level. For reporting at the state level the Agency established state accounting codes that capture expenditures for the EHR Incentive Payment program. They are included here for

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documentation purposes and displayed in the following table based on federal financial participation. FFP Florida Code Category Code FFP 100% ORG Code 68105020000 Expansion Option 4F OCA EHRIR Object Code 109911 FFP 90% ORG Code 68105020000 Expansion Option 6X OCA EHRIP Object Code 139942 .

For reporting at the federal level, Florida’s modified its CMS 64 report to include expenditures for the

EHR incentive payment program. New forms and lines have been added to account for this program.

The process for reporting EHR payments follows Florida’s existing federal reporting processes.

C.5 APPEALS AND ADMINISTRATIVE REDETERMINATION

Providers may request appeals regarding eligibility determinations, incentive payments, and

determinations regarding the demonstration of adopting, implementing, or upgrading and

meaningfully using certified EHR technology using MAPIR.

Appeals will initially be handled via the re-determination function in MAPIR. Once a provider has

followed the appropriate steps, the administrative staff will assess the information and render an

Administrative Re-determination. Decisions that stand as originally rendered, yet are still disputed by

the provider, will be referred to the Agency’s Office of the General Counsel and required to follow the

state’s administrative procedure for formal appeals.

SECTION D. AUDIT STRATEGIC PLAN

D.1 INTRODUCTION

An effective audit capability is critical to the success of the EHR Incentive Program. This is evidenced by the numerous CMS requirements that either address the audit function by name, or by the many instances of “ensure,” “assure,” and “verify” used to describe the required level of substantiation. Florida proposes a comprehensive set of audit activities, conducted pre- and post-payment to provide the level of assurance necessary for a program as complex as the EHR Incentive Program. The following graphic presents the flow of audit activities surrounding the issuance of eligible professional and hospital incentive payments.

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The overall set of business processes proposed for Florida’s EHR Incentive Program (as presented in Section C of the SMHP) reflect a balance between efficiently issuing incentive payments while not issuing inappropriate incentive payments and protecting against fraud and abuse. The set of proposed audit activities are the primary means of successfully striking this balance.

All Florida EHR Incentive Program audit activities are designed to limit the burden of program participation on eligible professionals and hospitals. Reliance on pre-payment system verifications minimizes disruptions to the daily operations of program participants. Post-payment audit verifications will also be carried out in the least intrusive manner possible, while not sacrificing the due diligence necessary to gain an understanding of participant compliance with program requirements, for example, where appropriate desk (versus onsite) audits will be employed.

D.2 IMPLEMENTATION STEPS FOR AUDIT

MAPIR provides numerous pre-payment verification and auditing controls and supports the level of program integrity as outlined per the CMS Guidelines. Specific program integrity features are embedded throughout the program’s business processes (see section on Business Processes) and the audit sub-process also addresses requirements identified in the guidelines. Pre-payment system verifications in combination with random and targeted post-payment audits ensure overall program integrity. The Agency plans to contract with an external auditing vendor with Medicaid subject matter expertise to provide the post payment audits. The contract deliverables include a detailed audit plan that will define a desk audit, the flags for targeted audits, detail the process for onsite visits including information that will be requested of providers who are selected for audits. The steps necessary to implement the audit function and coordination activities required to begin auditing in November of 2011 are listed below.

Activities include :

Verifying eligibility

Verifying adopt, implement or upgrade

Activities include :

Random and targeted samples selected for

onsite and desk audits

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Implementation Steps Start Date End Date

Define required audit documentation for prepayment verification

June 2011 September 2011

Finalize audit strategy pre and post payment November 2011 December 2011

Define audit services to be procured January 2011

Develop procurement documentation for audit services January 2011 February 2011

Procure audit services March 2011 June 2011

Audit Process Initiated Prepayment Verification September 2011

Audit Plan for post payment approved July 2012

Random and targeted desk and review and on sire audits begin August 2012 Ongoing

Exhibit 18: Audit Implementation Steps

D.3 APPROACH: PRE-PAYMENT AND POST-PAYMENT AUDIT ACTIVITIES

The following describes the pre- and post-payment audit activities.

Pre-Payment Audit Activities – the pre-payment audit activities rely on 1) automation within MIPPS; 2) participants’ certified EHR systems providing reliable Meaningful Use and Clinical Quality Measures data; and 3) internal and external sources of data.

Post-Payment Audit Activities –Post-payment audit activities will subsequently be conducted on a random and targeted basis to assess provider compliance. The post-payment audit activities will largely be manual processes performed by contracted auditors.

A key to the effectiveness of the EHR Incentive Program will be the extent to which the pre- and post-payment audit activities work together to ensure participant compliance with program requirements.

The eligibility verification process detailed in the next section covers the full set of pre- payment audit activities envisioned for Florida’s EHR Incentive Program verification of eligibility and AIU. Post payment audit activities and pre-payment verification for Meaningful Use will be developed by a contractor subsequent to a competitive procurement process to be initiated in early 2012.

Internal and external data sources for prepayment and post payment audit activities include; Florida’s MMIS system, claims, encounters and provider information, Florida Center hospital administrative data which includes all payer hospital discharges, and Emergency Department visits, Hospital Financial Data reported to the Agency’s Division of Health Quality Assurance, Medicaid hospital cost report data, and hospital and provider billing system information. Additional sources of external data may be identified by the audit vendor during the development of the audit plan.

D.4 TARGETED POST PAYMENT AUDITS

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A number of risks have been identified that result in a provider being targeted for post payment audit. These include ARNPs using the supervising physician’s volume, being unable to verify ‘non-hospital based’ for providers who are new to the group and don’t have documented encounters in the MMIS, RHCs due to the inability to verify needy encounter volume, providers who render services through HMOs for whom we are unable to verify encounter volume, and, Physician Assistants (PA) who attest to practicing in an RHC or FQHC that is led by a PA.

In September 2012, the Audit Team (KPMG LLP and HealthTech Solutions LLC) worked with the

Agency to further develop the post-payment audit procedures as presented in Attachment I to

this SMHP update, Medicaid EHR Incentive Program Post-Payment Audit Procedures.

D.5 ELIGIBILITY VERIFICATION PROCESSES

Eligibility Requirements EP EH Statute Final Rule Pre-payment Verification

Process and Data Elements

Post-payment

Verification 1. EP or EH must be one of the permissible professional or hospital types

42 USC § 1396b(t)(2) (A-B)

§ 495.368 (a)(1)(i) Combating fraud and abuse

Verify that the applicant’s provider type meets eligibility requirements.

Staff will verify the applicant’s provider type in FMMIS provider file.

Staff will verify that Physician Assistants who apply meet the requirement of leading a FQHC or RHC. Staff will contact the FQHC/RHC to confirm.

Staff will verify pediatrician specialty code in MMIS provider file.

Random and targeted desk audits Random and targeted onsite audit activities

2. EP or EH must be licensed to practice in the State(5)


Verify that the provider is licensed to practice in the state of Florida. Verification via Department of Health and Agency for Health Care Administration licensure Website.


3. EP or EH must be a Medicaid provider in that State.

§ 495.304 (a) Medicaid provider scope and eligibility

MAPIR verifies against the MMIS provider file.


4. EP or EH cannot be excluded, sanctioned, or otherwise deemed ineligible to receive payments from the State


MAPIR verifies via FMMIS provider file. Additional verification is conducted at the R&A prior to release of payment.

Random and targeted desk audits Random and

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Post-payment

Verification

(e.g. already received incentive payment)

targeted onsite audit activities

5. EP must have at least a 30% Medicaid patient volume (or 20% for pediatricians), unless s/he is practicing predominantly in an FQHC or RHC

42 USC § 1396b(t)(2)(A)

§ 495.304(c)(1) Medicaid provider scope and eligibility

The Florida Medicaid numerator for all EPs will be verified via Medicaid Decision Support System (DSS) query and the EPs practice management information. Staff will coordinate with other states to confirm out of state Medicaid volume


6. EP must have at least a 30% needy individual patient volume, if s/he is practicing predominantly in an FQHC or RHC

42 USC § 1396b(t)(2)(A)

§ 495.304(c)(3) Medicaid provider scope and eligibility

Needy volume for EPs practicing at an FQHC or RHC will only be verified through an FQHC encounter report.


7. EPs must have more than 50% of his/her patient encounters occur at a FQHC or RHC in a six month period during the prior calendar year to practice predominantly in an FQHC or RHC

§495.366 (b)(4) Financial oversight and monitoring of expenditures


8. EH must have at least 10% Medicaid patient volume (acute care hospital only)

42 USC § 1396b(t)(2)(B)

§ 495.304(e)(1) Medicaid provider scope and eligibility

Verification via Florida Center Hospital Administrative data.


9. EP must not be hospital-based (more than 10% of his/her Medicaid claims must be outside POS 21 or

42 USC § 1395w-4. (a)(o)(1)(C)(i-ii)

§ 495.304 (c) Medicaid provider scope and eligibility

Verification via DSS query from FMMIS. Sub level providers with no documented encounters in FMMIS will be targeted for post payment audit.


10. EP must practice in a PA-led FQHC or RHC if s/he is a Physician Assistant (PA)

42 USC § 1396b(t)(3)(B)

§ 495.304(b) Medicaid provider scope and eligibility

Staff will verify that Physician Assistants who apply meet the requirement of leading a FQHC or RHC via MMIS owner file, Florida Association of FQHCs and/or contact the FQHC/RHC to confirm


11. EH must have an average length of stay of 25 days or less (acute care hospital only)

§ 495.332(b)(5) State Medicaid HIT plan requirements

Verification through submitted cost report and Florida Hospital Financial Data Book.

Random and targeted desk audits Random and

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Post-payment

Verification

targeted onsite audit activities

12. EP or EH must adopt, implement, or upgrade (AIU) certified EHR technology capable of meeting meaningful use

42 USC § 1396b(t)(6)(ii)

§ 495.366 (c) Financial oversight and monitoring of expenditures

Verify attested to status of Adopted,

Implemented, Upgrade for the EHR system. The state will accept uploaded documentation that ;

identifies the specific EHR technology and modules being adopted or already in use,

indicates that certified EHR technology has been acquired, purchased, or a third party EHR vendor is under contract, and

is a business record rather than a written promise, pledge, or plan to adopt EHR.


13. EP or EH must meaningfully use (MU) certified EHR technology

42 USC § 1396b(t)(6)(ii)

§ 495.366 (c) Financial oversight and monitoring of expenditures


14. Managed care providers must not receive EHR incentive payment that exceeds 105 percent of their capitated rate if Medicaid is the payer, unless incentives are documented and actuarially sound.

42 CFR 438.6(c)(5)(iii) Special contract provisions. 42 CFR 438.6(c)(4)(B) (iv) Documentation.

§ 495.366 (e)(7) Financial oversight and monitoring of expenditures (See also § 438.6 (c)(v)(5)(iii))

MCOs are not making incentive

payments to providers under Florida’s program.


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D.6 IDENTIFICATION AND TRACKING OF OVERPAYMENTS/RECOUPMENTS

Tracking overpayments to providers is addressed in this section. Incentive payments made inappropriately or fraudulently obtained will be recouped using the existing agency recoupment process. The Agency will comply with CMS guidelines that require the Medicaid Agency to track the total dollar amount of overpayments identified by the State as a result of oversight activities conducted during the fiscal year.

A primary goal of the EHR Incentive Program processing procedure is to limit overpayments to a minimal number, and therefore to a limited amount. The activities that occur during the Eligibility Verification process are designed to prevent overpayments. The Agency acknowledges that regardless of the system, some overpayments or inappropriate may be made. Therefore, audit post-payment activities conducted are intended to identify overpayments. The Agency has a systematic ability to track overpayments on an individual provider basis, and to report on overpayments in the aggregate for a specified time period.

When potential fraud is detected – this can occur at several points in the application/payment-process, such cases are referred to the Agency’s existing fraud and abuse process and therefore do not formally end until a determination is made regarding the potential fraud and/or abuse

SECTION E. ROADMAP

E.1 MEDICAID HIT ROADMAP

E.1.1 INTRODUCTION

The Medicaid Health Information Technology Roadmap is a high-level plan to address the implementation of the EHR Incentive Program and future Medicaid HIT/HIE goals. The roadmap contains high-level steps that the Agency will take to implement the Medicaid EHR Incentive Program and fulfill Medicaid’s HIT/HIE goals and objectives. The Roadmap is not meant to be a static plan but is a living document that will continue to evolve as the HIT/HIE strategic business direction and technology environment and MITA To-Be planned activities are further defined.

The Agency’s Medicaid HIT Roadmap is consistent with the Florida HIT Strategic and Operational Plan and the initial plan for the design and implementation of the statewide HIE. Florida Medicaid will continue to work with stakeholders across the State to further define the Medicaid HIT/HIE roadmap as part of the State’s progress toward the planning and implementation of the statewide HIE.

E.1.2 GAP ANALYSIS

The Agency conducted an initial analysis to identify gaps between the As-Is and required To-Be, for the implementation of the EHR Incentive Program and statewide HIE related to Medicaid’s development of HIT. Addressing these gaps will enable the Agency to achieve the goals for each of these initiatives.

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E.1.2.1 EHR INCENTIVE PROGRAM GAPS

The following gaps must be addressed to implement the EHR Incentive Program. Refer to Section C for a detailed implementation plan.

Gap Category Current State(original

SMHP)

Future State

(Activity and

Milestones)

Current State

(updated SMHP)

IAPD An IAPD to request funding for the EHR Incentive Program implementation activities needs to be developed, submitted to CMS, and approved.

The Division of Medicaid will submit an IAPD for the EHR Incentive Program in November 2010.

Initial HIT-IAPD approved April 9, 2011. Update IAPD submitted November 2011.

Organization Design Staffing Training

The organizational elements of the EHR Incentive Program have been identified and need to be implemented. Additional program staff are needed to coordinate and develop a number of program start up activities. Staff supporting the EHR Incentive Program will need training in the use of the MAPIR system and processes and in the EHR Incentive Program policies and processes.

Organizational placement of the EHR Incentive Program along with a plan for filling the necessary functional roles, will be finalized in November 2010 as part of the IAPD. Pending IAPD approval, staff to support the program will be put in place in February 2011. Staff training will begin May 2011.

Plan finalized December 2010. Additional staff hired Juky 2011 Staff Training began August 2011

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SMHP)

Future State

(Activity and

Milestones)

Current State

(updated SMHP)

Payment Technical Solution MAPIR Design and Customization Provider Portal Staffing and Training

A technical solution to register providers, determine eligibility, and calculate and issue payments will need to be implemented. The system must support the monitoring and controlling of these processes to ensure program integrity. A web portal is needed to allow providers to register for the EHR Incentive Program and conduct other program-related transactions with the Florida Medicaid. Staff supporting the MAPIR solution maintenance will need training in the architecture of the MAPIR system, and the maintenance standards and processes.

Florida has selected the HP software, MAPIR, as the Technical Solution to support the EHR Incentive Program. MAPIR software was developed as a multi-state collaborative effort led by Pennsylvania. Testing with the R&A will be conducted by the Core development team prior to March 2011. MAPIR core application will be implemented by HP, the current Fiscal Agent. Customization of MAPIR will be led by Contract Management in the Division of Medicaid in collaboration with an EHR Incentive Program Implementation Team. The customized application will be called the Medicaid Incentive Program Payment System (MIPPS). Testing and user acceptance of the MIPPS is scheduled for Summer 2011. The Agency will begin to make modifications to the secure Medicaid Provider Portal following the first release of the core MAPIR application in February 2011 to allow providers access to the registration module in MAPIR.

MAPIR implementation, customization and smoke test with the R&A complete August 2011.

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SMHP)

Future State

(Activity and

Milestones)

Current State

(updated SMHP)

Outreach An outreach plan has been developed. The plan is designed to inform eligible providers about the EHR Incentive Program and requirements for participation. It includes strategies to coordinate with other key partners, including RECs and industry associations.

Outreach activities have begun and will continue by leveraging existing Agency resources such as the Medicaid provider email alert system and the current Agency website. Strategic media activities, web communications and other outreach activities are targeted to begin in January 2011, pending approval of the IAPD.

Outreach contractor procured and on-site August 2011. A detailed plan has been developed and approved and included in this update to the SMHP.

Contracting Procurement documents and contract requirements must be developed, and vendors selected for any outsourced business processes (outreach, auditing, and call center).

The Agency will use existing staff to start the processes of defining contractual requirements for vendor support. Upon approval of the IAPD, Program Administration staff will refine these requirements and begin any needed procurement activities for contracted services. Official procurement activities are scheduled to begin with the approved I-APD.

Procurement activities completed

Outreach Vendor Call Center Services Expansion of

Provider Enrollment

MAPIR/MMIS customization, maintenance and enhancements.

Call Center/Program Support Training

Call center services are needed to support providers as they begin to enroll in the program, and as they have on-going program questions or technical issues. Call center services staff will need training in time to support the program.

A comprehensive call center and support strategy will be developed by the Program Administration staff. This activity will begin in January 2011. Training will begin in February 2011.

Call center services began August 2011.

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SMHP)

Future State

(Activity and

Milestones)

Current State

(updated SMHP)

Appeals Process Implementation Training

An Appeal Process and policy are needed.

The Division of Medicaid anticipates hiring additional staff to refine the initial plan for Florida’s Appeal Process. Once program staff are hired and trained, the Appeal Process will be revised as needed and implemented by August 2011. Appeal staff will be trained in July 2011.

Incentive program processing staff will also handle the redetermination process for provider appeals

Audit Implementation Standards Procurement Training Processes Benchmarks for Audit and Oversight

Standards for the audit function, which dictate frequency, thresholds and audit scope, are needed. See Contracting. Audit processes for the EHR Incentive Program must be implemented. Specifically, the Program benchmarks for audit and oversight activities must be developed.

The Division of Medicaid anticipates hiring additional staff to define the EHR Incentive Audit and procurement requirements, if needed. See Contracting. Auditors for the EHR Incentive Program will be trained during the Summer 2011. Audit processes will be in place no later than November 2011. Annual benchmarks for audit will be developed in the Spring of 2011.

Incentive program processing staff is performing prepayment verification audits. Post payment audit activities and pre-payment verification for Meaningful Use will be developed by a contractor subsequent to a competitive procurement process to be initiated in early 2012.

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SMHP)

Future State

(Activity and

Milestones)

Current State

(updated SMHP)

Performance Measures Service Levels

Performance measures must be established for the implementation of the Program and for on-going operations. Operational service levels must be established to measure and report on the quality of service.

Upon implementation of the EHR Program Administration, program staff will establish Performance Metrics and Service Level Agreements, prior to August 2011. Internal and external measures: e.g., Call Center – Internal, HP Service Level Agreements (SLAs) – External, Auditing Contractors – Internal, etc.

Service levels are tracked and monitored in order to develop a benchmark for performance metrics and service levels.

Benchmarks (General)

The Agency has benchmark data from 2008 that has been documented in A.2.2.1. More current benchmark data is needed to support the Goals and Objectives of the State HIT Plan and the EHR Incentive Program. Specifically, the Program benchmarks for oversight activities must be developed.

Benchmarks will be developed from two primary sources: 2010 Environmental Scan Data. MITA To-Be visioning information will be delivered in June 2012 Annual benchmarks for program oversight will be developed by Program Administration in the Spring of 2011.

Exhibit 19: EHR Incentive Program Gaps

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E.1.2.2 STATEWIDE MEDICAID HIE GAPS

The gaps shown in the Following exhibit have been identified and need to be addressed to implement the statewide HIE. Addressing these gaps is essential to the successful implementation of the EHR Incentive Program.

Gap

Category

Current State

(original SMHP)

Future State

(Activity and Milestones)

Current State

(updated SMHP)

Prioritization of HIE Connectivity

Systems that may connect to the HIE must be analyzed and prioritized in order to develop an implementation plan that maximizes the value of the HIE to statewide stakeholders.

With Florida Medicaid participation, development of a priority list will begin soon after the contract award and will be defined prior to March 2011.

Minimum requirements for Patient Look Up HIE services were developed and a readiness questionnaire and assessment process initiated.

Rollout of Statewide HIE Network and Services

The HIE must be rolled out in successive waves, according to established priorities, until services are available statewide.

Strategies to ensure provider connectivity will be developed. Outreach to Medicaid providers will be planned and implemented.

HIE Operations and Support

An infrastructure must be established to support users who try to connect to the HIE, or those experiencing technical issues with HIE services.

The Statewide HIE Operations and Support plan will be developed prior to March 2011, and will be coordinated with Medicaid’s SMHP. Outreach to Medicaid providers will be planned and implemented.

MITA To-Be Assessment (Executive Visioning Phase)

The MITA To-Be Assessment proposal evaluations are in progress. Vendor selection expected in November 2010.

MITA Executive visioning will be completed in June 2012.

Exhibit 20: HIE Gaps

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E.1.3 MEDICAID HIT ROADMAP

The following graphic depicts the high-level roadmap to address the gaps identified to date in this section. Refer to Section C for an overview of the EHR Incentive Program Strategic Plan. Refer to Section F, the EHR Incentive Program Outreach Plan, for detailed project plans and roadmaps specific to outreach activities. The Agency anticipates that this will be an iterative process and the roadmap will be updated on a periodic basis.

Exhibit 21: State Medicaid HIT Roadmap

E.1.3.1 GOALS FOR EHR INCENTIVE PLAN

Florida completed an analysis of the 2010 Environmental Scan results. These results assisted in the development of goals and benchmarks for the EHR Incentive Program. With very limited data available to the Agency at this time, Florida’s goals for the EHR Incentive Program are:

Q2 Q3 Q1 Q2 Q3 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4

Outreach

Organization Design

Staffing

Training (all areas)

IAPD

Performance

Measures/SLA

Audit Process

Appeals Process

Call Center / Support

Procurement

Benchmarks for Audit and

Overall Program

MAPIR Design &

Customization

Provider Portal

HIE Procurement

Prioritization

Design of HIE

Statewide Rollout

HIE Operations Plan

HIT RoadmapCY 2010 CY 2011 CY 2012 CY 2013 CY 2014

EH

R I

nce

nti

ve

Pro

gra

m

Act

ivit

ies

to I

mp

lem

en

t P

rogr

am People

Process

Q4 Q4

Technology

HIT

/HIE

Sta

tew

ide

Me

dic

aid

HIE

Process

Technology

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EHR Incentive Program Goals Effectiveness Measure

Forty percent (40%) of all eligible hospitals will enroll in the EHR Incentive Program in the first year. Analysis of the Agency’s hospital financial data indicates roughly 100 hospitals will meet the Medicaid eligibility requirements.

Percentage of eligible hospitals enrolled in the incentive program per year

The preliminary estimate of the number of Medicaid eligible professionals is 4,600 participants in the EHR incentive program over the course of the program. The potential expansion of the Medicaid program in 2014 resulting from the Affordable Care Act, along with the addition of County Health Department providers in 2012, will potentially result in increased numbers of eligible professionals participating in the program.

Percentage of enrolled eligible professionals Percentage increase in potentially eligible professionals in 2014.

Based on the preliminary results of the environmental scan over half of surveyed providers who said they were eligible to participate plan to participate in the first year of the program. The Agency expects that a majority of these providers will participate in the first year.

Percentage of enrolled eligible professionals by June 30, 2012.

County Health Department (CHD) providers will enroll in the incentive program upon the certification of DOH’s statewide EHR (Health Management System).

Percentage of enrolled eligible professionals in CHDs by June 30, 2012

Use specific Environmental Scan data to refine annual adoption benchmarks by provider type

Development of specific annual benchmarks by provider type

Exhibit 22: EHR Incentive Program Goals

E.1.3.2 GOALS FOR OUTREACH

Outreach is vital to the success of Florida’s EHR Incentive Program. The Agency has developed an ambitious and comprehensive plan for outreach that will encourage the adoption and use of EHRs, and aid in achieving both EHR Incentive Program and HIE goals. The Agency anticipates working with both internal and external stakeholders to develop an effective outreach plan. The goals and strategies for Outreach include:

Outreach Goal & Strategies Effectiveness Measure

Goal: Increase awareness among eligible professionals and hospitals to generate participation in the EHR Incentive Program and encourage EHR adoption.

Strategy 1: Build and maintain collaborative relationships with partner stakeholders to promote the Incentive Program

Rating of satisfactory or higher on an annual partner performance evaluation Formalized agreements with a minimum of one partner from each partner stakeholder group

Strategy 2: Collaborate with Regional Extension Centers to share and exchange information

Cumulative rating on annual survey equal to satisfactory or higher

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Strategy 3: Create, launch and maintain the EHR Incentive Program web page

The number of monthly page views, key words, and most viewed pages at least equal to industry standards for similar websites (analytic reports will be used and necessary adjustments made to website copy, navigation, and keywords) Percentage of partners who link the EHR Incentive Program site to their websites The number of eligible professionals accessing the eligibility calculator as compared to the number registering to participate in the Incentive Program

Strategy 4: Establish a process to respond to provider inquiries and direct them to the appropriate resources

Number of calls, by topic, decreasing over time

Strategy 5: Create and provide outreach materials for internal and external stakeholders

The percentage of survey respondents rating messaging and materials as satisfactory or higher

Strategy 6: Conduct internal and external training for consistent messaging and effective use of outreach materials

The percentage of partner stakeholders rate communications materials as satisfactory or higher in monthly contact calls or visits The percentage of partner stakeholders rate educational events as satisfactory or higher in monthly calls or visits

Strategy 7: Use internal and external communications channels to promote the Incentive Program

The percentage of partner stakeholders rate communications materials as timely and satisfactory or higher in monthly contact calls or visits The percentage of partner stakeholders rate educational events as timely and satisfactory or higher in monthly contact calls or visits

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Strategy 8: Use story placement and a paid media campaign in targeted publications to enhance outreach efforts

Though difficult to determine effectiveness of these strategies, the following data points will be documented and tracked as indicators: Flow of information generated by call to action in print and digital media The number of Medicaid EHR Incentive Program articles picked up by Florida news sources Percentage of Medicaid EHR Incentive program website visitors who join the Agency’s interested parties list Graph the trend of Medicaid EHR Incentive program website hits

Exhibit 23: Goals for Outreach

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E.1.3.3 GOALS FOR STATEWIDE MEDICAID HIE

The Agency has developed high-level goals related to the implementation of the statewide HIE actions and the use of health information technology within the Florida Medicaid Program. These goals cover a five-year timeframe. The high-level goals for HIE are as follows:

Pursue statewide Health information Exchange (HIE) opportunities for the State, consistent with national initiatives funded through the HITECH Act of 2009 through a public-private partnership.

The Health Information Exchange Coordinating Committee (HIECC) will assist the Agency in the implementation of the State Health Information Exchange Cooperative Agreement Program.

The Health Information Exchange Legal Work Group will advise on the implementation of Florida Health Information Exchange participation agreements that are used to describe the rights and responsibilities of participants in the electronic exchange of health information.

The HIECC will also participate in the implementation of the State Medicaid Health Information Technology Plan. The plan describes the details of the implementation of the Medicaid Electronic Health Record Incentive Payment Program as well as the future of Medicaid Health Information Technology and how the Medicaid program will operate in conjunction with the larger health system and Statewide HIT efforts.

Measurable Objectives:

1. Increase adoption of Direct Secure Messaging, the implemented secure messaging using national Direct standards including a Participant directory of registered physicians and other participants, to support Florida eligible providers in meeting the requirements for electronic health record meaningful use incentive during 2012. Measure – Register 1,500 – 2,000 health care providers in the Participant directory by January 1, 2013

Measure – Achieve 50% active participants (who have sent a transaction at least one time in the last month) by December 2012 (track monthly).

Measure – Establish one HISP to HISP connection with one or more transactions by July 1, 2011 and an additional interstate, payer, and provider HISP connection by January 1, 2013.

2. Identify and engage early adopters (e.g. hospital systems, provider networks, RHIOs, county health departments) to participate in the Florida HIE patient look-up network in 2012. Measure – Ten to twelve early adopters will be implemented for data sharing by January 1, 2013.

3. Increase the volume of electronic prescriptions and number of electronic prescribing physicians within the state and increase the participation of independent pharmacies in electronic prescribing.

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Measure - Increase the electronic prescriptions by 25% and electronic prescribing physicians by 10% within the state from 2011 to 2012 and increase the participation of independent pharmacies in electronic prescribing.

4. Achieve increased meaningful use of certified electronic health records among Florida eligible professionals.

Measure - Achieve an increase in eligible professionals that are engaged in meaningful use of a certified electronic health record and/or adoption, implementation, upgrade of certified electronic health records that exceeds the baseline average for Florida reported by Centers for Medicare and Medicaid in 2011 by 10% in 2012.

5. Administer the Florida Medicaid Electronic Health Record Incentives Program and make program payments accordingly during 2012. Measure – Make initial Medicaid Incentive payments to 50% of eligible hospitals in 2012.

Measure – Make initial Medicaid Incentive payments to 25% of estimated eligible professionals in 2012.

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SECTION F. OUTREACH

F.1 SUMMARY

The Agency’s outreach plan includes strategies and tools needed to educate eligible professionals, hospitals, and other partner stakeholders about the EHR Incentive Program. The State’s approach will be research supported and will focus on clear and consistent communication and education strategies. Effectiveness measures will be included so that strategies can be adjusted as needed.

The Agency will leverage current resource, while ensuring non-duplication, by working with current Division of Medicaid staff, including area office staff.

By working collaboratively with Regional Extension Centers, RHIOs, professional associations, and other State agencies, synergies can be achieved and more successful outreach expected. Outreach strategies will be implemented throughout the life of the program and adjusted as needed to achieve programmatic goals.

The Agency entered into a contract with First Data government Solutions August 24, 2011 to implement to provide outreach services as outlined in this plan.

F.2 UNDERSTANDING THE STAKEHOLDERS

F.2.1 STAKEHOLDER RESEARCH

To build an effective outreach plan research with key stakeholder groups was completed. In-depth interviews were conducted with eligible professionals, representatives of the RECs, FQHCs, RHIOs, and professional associations. Questions were posed about:

EHR Awareness

EHR Incentive Program awareness

Provider decision-making processes

Benefits of EHR adoption

Barriers to EHR adoption

Trusted and preferred communications sources

Research findings indicate that there is a high level of awareness about EHR in Florida, but there are varied levels of awareness and understanding about the Incentive Program. In addition, the Agency learned that eligible professionals are receiving messaging from many sources, including some conflicting information. This creates a confusion factor that must be overcome in the outreach program.

During the research interviews and experience with other state’s efforts to implement the EHR incentive program, it is common for the administrative personnel in physician’s offices to act as key advisors and influencers on technical matters. Specifically, the office staff review information and advise physicians on technology upgrades and other such issues. While decisions for such changes

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rest ultimately with the physician, outreach should include specific activities to include physician administration personnel.

Interviewees reported the benefits of EHR as increased quality of care and ease of information exchange. The expense offset of the Incentive Program was reported as the primary benefit of the program.

In terms of barriers, our research revealed a distrust of government incentive programs in general, and a lack of understanding about eligibility for this particular incentive program. Provider age played a role in the concerns expressed about the cost of EHR and the return on investment; older providers tended to question whether it would be beneficial to make the financial investment needed, with the alternative being retirement.

Providers tend to trust the local chapters of their professional associations for accurate information and appropriate educational opportunities. Medical journals and online publications were often cited as preferred communications channels.

Detailed research findings, by interview group are shown in the following exhibit.

Issues Eligible professionals FQHCs Professional

Associations and RHIOs

Awareness of EHR High awareness of EHR

Overwhelming amount of information about EHR

Currently using EHR technology

Generally happy with the technology and appreciate patient care benefits

EHR is a top issue Organizations are

at various stages in communicating EHR information to their members

Awareness of EHR Incentive Program

Mixed levels of awareness about the Incentive Program

Low awareness of the criteria to determine Incentive eligibility

Most are very aware of the program, but not state specific requirements

Most seem interested in the program and want to pursue the application process

Most have questions about the details of the Incentive Program

Very few have communicated information about the Incentive Program, because they have not received the full details

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Decision-Making Process

Administrative staff may help research/organize information, but the doctor is the ultimate decision-maker

Efficiency and monetary benefits are critical

Investment of staff time involved in upgrading and learning a new system

Operate through a chain of command that oversees day-to-day operations

N/A

Barriers Age of providers and how adept they are at using technology

Small percentage of providers meet 30% requirement

Costs versus the benefits of implementing EHR

Distrust of government incentive programs

Confusion over EHR certified systems

Concerns with payment timeline

Hospitals are early adopters of EHR, but concern that few providers can send/accept info electronically

Behavioral health providers and dentists have unique challenges with adopting EHR (different codes used, confidentiality)

Concerns about costs versus the benefits of implementing EHR

Concern about meeting qualifications for the program

Need more specific information about the program

Mistrust in why the government would create an incentive program

Concern about patient security

Concern that most providers won’t meet the volume threshold

AHCA viewed as not easy to work with

Worried their members will receive inconsistent messaging

Contacted by many groups about EHR (often with conflicting info)

Need more information about the program in one easy-to-find location

Providers have expressed difficulty in determining eligibility for the program

Deep trust issues with government incentive programs

Different stages in communicating

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the EHR message (some have not addressed EHR, while others are coordinating their own education programs)

Benefits Monetary incentive for providers

Could improve workflow and efficiency of operations

EHR helps keep good records on patients. This could result in cost and time savings

The main benefit of the program would be the offset of costs incurred from obtaining the EHR technology

Quality of care would increase due to the faster and easier transfer of information between physicians

N/A

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Trusted Sources and Preferred Communications Channels

Regional/local groups considered a trusted source

Medical journals, trade associations and online publications targeted for physicians

Mix of traditional and online materials about the program

Peer-to-peer referrals

Staff attend seminars and trainings to stay up-to-date on information

Trade associations and government agencies are considered reliable

Interest in a mix of online, print and in-person information

Associations are willing to distribute information to members

Associations and medical groups are viewed as trusted sources of information

Use existing communications channels to reach providers

Coordinate informational sessions in rural areas to reach providers most likely to qualify for the program

CME courses are effective ways to get medical professionals information

Help centers are not a preferred method to address provider questions

Exhibit 24: Research Findings

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F.2.2 BRAND RESEARCH

Branding for EHR and the Incentive Program is key to awareness building. To determine the most desirable EHR Incentive Program brand platform, three Florida specific logos, along with the CMS EHR logo, were tested with a sample of internal and external stakeholders. The logo depicted below was preferred by stakeholders.

Exhibit 25: Florida EHR Incentive Program Logo

A review of the detailed stakeholder comments will be used to refine this logo for final use. Once the logo has been created, logo guidelines will be developed and the logo will be incorporated in all collateral materials used for the outreach program.

F.3 OUTREACH PLAN

F.3.1 OUTREACH GOAL AND TIMELINE

The goal of Florida’s outreach effort is to increase awareness among eligible professionals and hospitals about the EHR Incentive Program, encouraging participation, and ultimately the adoption and meaningful use of EHR. To reach this goal, the Agency will strive to continually understand and meet the communication and education needs of each unique stakeholder group.

The timeline shown in the following exhibit will serve as a guide for the outreach campaign implementation for calendar year 2011.

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Exhibit 26: 2011 Outreach Campaign Timeline

F.3.2 OUTREACH STRATEGIES

The Agency will use the following eight strategies to build and maintain an effective outreach program:

Build and maintain collaborative relationships with partner stakeholder groups to disseminate educational information about the Incentive Program

Collaborate with Regional Extension Centers (RECs) to share and exchange information

Create, launch and maintain the EHR Incentive Program web page

Establish a process to respond to provider inquiries and direct them to the appropriate resources

Create and update outreach materials for internal and external stakeholders

Conduct internal and external trainings for consistent messaging and effective use of outreach materials

Use internal and external communications channels to promote the Incentive Program

Use story placement and a paid media campaign in targeted publications to enhance outreach efforts

STRATEGY ACTIVITY JAN FEB MAR APR MAY JUN JUL AUG SEPT OCT NOV DEC

1 Recruit and secure partners to disseminate information.

2 Collaborate with RECs to share and exchange information

3 Create, launch and maintain updates to Medicaid EHR Incentive Program webpage

4 Establish help line to address program inquiries

5 Create and update outreach materials for internal and external stakeholders

6 Conduct trainings with internal and external stakeholders.

7 Use internal and external communications channels and events to promote the program

8 Implement a paid and earned media campaign in targeted print and online outlets

All Monitor and evaluate outreach plan effectiveness

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F.3.2.1 BUILD AND MAINTAIN COLLABORATIVE RELATIONSHIPS WITH PARTNER

STAKEHOLDER GROUPS TO DISSEMINATE EDUCATIONAL INFORMATION ABOUT THE

INCENTIVE PROGRAM

The Agency will pursue relationships with RECs, professional associations, RHIOs, and other key stakeholder groups that have existing connections with eligible professionals and hospitals. The following exhibit provides a list of partner stakeholders with which the Agency will work for these purposes.

Partner Stakeholders

Provider Professional Associations, including County Medical Societies Hospital Professional Associations Regional Extension Centers Regional Health Information Organizations Federally Qualified Health Centers Payer Groups Managed Care Organizations Other State Agencies

Exhibit 27: Partner Stakeholders

Where possible, the Agency will seek formalized agreements, memorandums of understanding, to document the various outreach efforts, commitments, and resources available, and prevent duplication of effort. The Agency will create and maintain a database with stakeholder contact information and use it to track ongoing contacts made by the various parties involved in outreach efforts.

Effectiveness Measures:

Rating of satisfactory or higher on an annual partner performance evaluation

Formalized agreements with a minimum of one partner from each partner stakeholder group

F.3.2.2 COLLABORATE WITH REGIONAL EXTENSION CENTERS (RECS) TO SHARE AND

EXCHANGE INFORMATION.

Florida has four RECs. The four RECs and their respective service areas are depicted in Exhibit 6.

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To learn more about the RECs in Florida, and develop a plan for collaboration with them, staff at all four RECs were interviewed. Interviews included the following topic areas:

Current outreach and communications efforts

Benefits and barriers to EHR

Benefits and barriers to the Incentive Program

Future partnership opportunities

The following exhibit provides a summary of key findings from the REC interviews conducted.

Issues Key Findings Comments

Current Environment

Only 1 of 4 RECs has received any funding

All RECs have different operational plans and strategies for outreach and awareness, and provide different services

3 of 4 RECs have connections to medical schools and support/infrastructure help from them

All are interviewing software vendors and assisting in some way with selection, training or best use of EHR systems

“The RECS have a little different mission than AHCA, because we receive financial incentives for signing up providers. We need legitimacy. “

“We need to build trust, rapport and credibility with many different organizations.”

“We are hiring a full-time marketing person to assist in outreach and awareness communications. We hope to have a marketing plan in place soon.”

“We are frustrated because no funding has been received to date. We are still waiting for the release of funds and are behind schedule because of this.”

“We have contacts with the medical students and doctors affiliated with our college to talk up EHR.”

“We are in the vendor selection process…and we have to select 5-7 ‘preferred’ vendors.”

Awareness of EHR Incentive Program

Currently focused on EHR software and implementation first , RECs are working with providers who are at various stages in the process

“Some providers have heard of the incentive but don’t care much about it because they know they are not eligible.”

“Before we focus on the incentives, we’re just trying to determine level of certified EHR in use in their areas, which doesn’t appear to be very high.”

Main barriers/obstacles to address

RECs are in start-up phase now with very limited staffing

Providers do not understand how the Incentive Program works; they want an easy way to know if they qualify and consistency

“We need to hire more staff to assist with admin and outreach. We plan to hire a marketing director when funds are available.”

“Providers are confused about how the incentive program works. They want a better explanation from either the Feds or AHCA in simple language.”

“There is a constant push and pull with

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Issues Key Findings Comments

from AHCA RECs slow to receive

funding Providers near

retirement age do not see EHR as a worthwhile investment; no ROI

AHCA as far as how to get this all accomplished.”

“Providers who think they might be eligible are skeptical that they will see money from the Feds. They want an easy way to determine if they meet the criteria and what kind of money they will receive. They are looking at the Medicare incentive as well.”

“We are trying to show older doctors the benefits of EHR. There is still a cost involved with paper records, so we need to convince them that moving to EHR would be better for their practice when they are ready to retire and sell than staying with paper.”

Preferred Communications Channels

Providers prefer peer-to-peer communications

RECs have respected experts in the field on staff

RECs would like to have consistent messaging and trainings from AHCA

RECs would like a chart or tool to help providers determine if they meet the qualifications

RECs would like to coordinate outreach with other organizations

“The best way to reach doctors is peer-to-peer; doctors trust other doctors.”

“We’d love to see the creation of a learning management system that offers providers a series of educational programs”

“We don’t want to duplicate messages, so some coordinated messages and materials with AHCA would be helpful.”

“Doctors have asked for a chart or an easy way to help them determine if they meet the patient threshold and how much incentive they could expect.”

“We need marketing educational materials; specifically information for those who think they may qualify for the incentive and then what the next steps are how to get there.”

“We want to work with Florida Medical Association to provide CME training courses.”

Exhibit 28: Regional Extension Center Key Findings

F.3.2.2.1 COLLABORATION STRATEGY

The Regional Extension Centers are valuable partners to help the State successfully promote the EHR Incentive Program. While some RECs have been slow to implement their operational models, they will all soon have the resources and expertise required to assist eligible professionals and hospitals. Sharing and exchanging information and resources with the RECs will help to:

Ensure outreach success

Increase provider participation

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Eliminate confusing or mixed messages, and

Create goodwill between the Agency and REC staff and members

To kick-off the Agency’s collaboration and outreach efforts with the RECs, a Workshop was held on February 10, 2011. This event provided an opportunity for REC and Agency representatives to meet and discuss the Incentive Program, share ideas, best practices and identify a unified communication strategy.

In addition to the workshop, the Agency will continue to communicate with the REC’s on monthly conference calls. Through this collaboration we will maintain relationships and support networks that will enhance the Incentive Program and further enhance the probability of EHR adoption.

The monthly calls will include discussions and a review of outreach efforts, training programs, marketing collaterals, and progress made with registrations.

The Agency will conduct an annual satisfaction survey to determine strategy changes needed. The survey will be sent to key staff in all four RECs and will include questions about materials, training, and organizational communications between the Agency and the RECs.

Effectiveness Measure:

Cumulative rating on annual survey equal to satisfied or higher

Note: Subject to legislative appropriations and available funding, The Agency plans to contract with RECs to provide technical assistance as needed to eligible providers who do not qualify for REC assistance under ARRA legislation.

F.3.2.3 CREATE, LAUNCH AND MAINTAIN THE EHR INCENTIVE PROGRAM WEB PAGE

The Agency created a centralized web page for the Incentive Program. The web page was designed to be easy-to-navigate and is updated regularly to assure that the information provided remains current.

F.3.2.3.1 ONLINE ELIGIBILITY CALCULATOR

As an additional component to the web page, the Agency created an online eligibility calculator that is unique to Florida Medicaid. During the in-depth interviews, providers repeatedly indicated that they were unsure if their practice would meet the eligibility requirements. The RECs also expressed their interest in such a tool. They stated that such a tool would help providers determine the likelihood of qualifying for the Incentive Program, thereby making it easier to promote provider participation.

The calculator will ask providers a series of short questions about their practice and provide a formula to help them calculate their patient volume over the required 90-day period. Based on their responses, the calculator will then let the provider know if they are likely to be eligible to participate in the Incentive Program. It will also provide information on next steps.

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While many questions will mirror the CMS Eligibility Wizard, a Florida-specific tool will lead users to state-specific resource links. For example, users indicating that their practice is not currently using a certified EHR will be directed to information about one of the four Florida Regional Extension Centers. Or, users indicating they are using EHR but do not know if their system is certified, will be directed to the certified product list. Directing users to state-specific resources in addition to the CMS website will help users become familiar with the state website and local resources available to them.

F.3.2.3.2 WEBSITE

The EHR Incentive Program website is organized in a hierarchical fashion with easy to navigate drop down menus. The pages are populated with information and tools to help hospitals and eligible professionals learn about the program and access helpful links. The below screenshots provide a sample of the format and content included in the various pages.

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Exhibit 29: Florida EHR Incentive Program Website Home Page

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Exhibit 30: Florida EHR Incentive Program Website Eligibility Page

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Exhibit 31: Florida EHR Incentive Program Website REC Page


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The number of monthly page views, key words, and most viewed pages as compared to industry standards for similar websites (Analytic reports will be used and necessary adjustments will be made to website copy, navigation and keywords)

Number of partners who link the EHR Incentive Program site to their websites

The number of eligible professionals accessing the eligibility calculator as compared to the number registering to participate in the Incentive Program

F.3.2.4 ESTABLISH A PROCESS TO RESPOND TO PROVIDER INQUIRIES AND DIRECT

THEM TO THE APPROPRIATE RESOURCES

During the preliminary education and informational stage of outreach, the existing e-mail address [[email protected]] will continue to be used for inquiries about the Incentive Program. This is an easy way for providers to send in their initial questions and allow for prompt responses.

Some providers will have specific inquiries or prefer more high-touch interactions regarding the Incentive Program and will likely look to Medicaid area offices for assistance, as this is a known and trusted source. The Agency will therefore gear up for this likely occurrence by designating resources at each area office to respond to phone calls and inquiries from providers.

In addition, a centralized Help Line will be established and promoted on the Incentive Program website. This will serve as another avenue for providers with very specific questions about the program. EHR certification and implementation questions will be referred to the RECs. Scripts will be developed and training provided to help line staff and designated resources in area offices. This effort will help staff to be responsive to provider calls and provide accurate information.

Designated staff will record and log questions and queries, which will periodically be reviewed by supervisors to ensure that callers receive accurate information and are referred to the appropriate resources. Multiple questions on the same topic will be addressed by posting information on the website as needed.

The help line will be implemented in April 2011 and will be available Monday- Friday during regular business hours. Once the registration portal is live, and payments have begun, the Agency will establish a call center to respond to special-case inquiries.


Number of calls, by topic, decreasing over time

F.3.2.5 CREATE AND UPDATE OUTREACH MATERIALS FOR INTERNAL AND EXTERNAL

STAKEHOLDERS

Because partner stakeholders are a critical component to reaching the target audiences, the Agency will create an Outreach Education Toolkit for their use. Toolkit materials will be made available online and in print format. The materials will be updated as new program information becomes available. See Section G - Appendices for sample Outreach Education Toolkit.

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The Outreach Education Toolkit will include:

Introduction to the EHR Incentive Program

Fact Sheets

Messaging

Incentive Program: Q&A

Newsletter Article Templates

Suggested Outreach Events and Activities

Presentation Materials

o Event Planning Guide

o Sample Curriculums

o PowerPoint Presentation Template

o Post-Training Evaluation Surveys

o Social Media Plan

Creative Materials (postcards, web banners, print ads, etc.)

Resources and Contacts

While MCO network providers will be exposed to the publicly available outreach activities, other outreach efforts are being directed specifically to MCO network providers. To create awareness and to facilitate registration in the EHR Incentive Program, the Agency discusses the program monthly on the Technical and Operations calls with staff from the MCOs and provides direct communication to the MCOs through the Medicaid MCO Contract Managers. Feedback will be solicited from stakeholder partners on messaging and materials. This will be done through surveys, workshops, and conference calls. The feedback received will be used to refine the creative approach and add, edit, or delete components of the toolkit for increased effectiveness.


75% of survey respondents rating messaging and materials satisfactory or higher

F.3.2.6 CONDUCT INTERNAL AND EXTERNAL TRAINING OF STAKEHOLDERS

F.3.2.6.1 INTERNAL TRAINING

The first step in an effective outreach program is educating appropriate internal stakeholders. The Agency staff training will take place in the first month of implementation of the program, with follow-up trainings as new information is received. Staff to be trained will include: the Medicaid Team, Project Team, Steering Committee, and designated Medicaid area office staff. This group of internal stakeholders will receive detailed training on the Incentive Program so they can educate other Agency staff and external stakeholders as needed. A sample curriculum is provided in Section G - Appendices.

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All other staff should have a basic understanding of the program. The Agency will provide them information through identified communication channels. Staff will be instructed to refer detailed and specific questions about the Incentive Program to designated staff along with the Communications Teams who have received more detailed training.

The following exhibit provides the internal communications training strategy and schedule.

Organization Schedule

Updates in Agency committee and council meetings Regular (as they meet)

Employee workshops As needed

Splash screens As needed

AHCA web portal As needed

Bulletin boards As needed

Team meetings Monthly

E-blasts As needed

Conference calls As needed

Exhibit 32: Internal Communications Training Strategy and Schedule

F.3.2.6.2 EXTERNAL TRAINING

Once internal stakeholders have been trained, Agency-designated staff will conduct partner stakeholder training sessions. The research interviews revealed partner stakeholders are interested in participating in training so they can learn more about the Incentive Program. Rather than duplicate efforts or confuse providers with a variety of messaging sources, these partner organizations will be trained directly. Training partner stakeholders will begin in February 2011. See Section G – Appendices for a sample training curriculum.

In addition, the Agency will work with partner stakeholders and the RECs to offer educational programs and training to eligible professionals and hospitals on an ongoing basis. We will endeavor to promote the training sessions on both the REC and Incentive Program web pages.

The next exhibit outlines our plan for partner stakeholder training sessions.

Target Audience Training Method Training Topic Length

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Target Audience Training Method Training Topic Length

Trade Associations

Conference Call/Association Meetings; by Agency-designated staff

Provide training on Incentive Program; who qualifies; where to go for info; overview of the tools available to promote program to membership

1 Hour

County Medical Societies

Regular meetings Overview of EHR; specifics on Incentive Program and how to qualify; provided by “early adapter” champion of EHR with Q&A

50 Minutes

FQHCs RHIOs

Seminar in-house with Agency-designated staff

Provide on-location training with specifics on Incentive Program for organizations with Q&A

2 Hours; offered multiple times per year

Hospitals Agency-designated staff

Specifics on how hospitals can become eligible for the Incentive Program; how to register for the program, how to calculate incentive payments

1 Hour with hospital senior level administrators

RECs In-Person by Agency-designated staff via conference call

Provide on- location or conference call training with RECs on the specifics of the Incentive Program and tools to promote the program with Q&A

1-2 Hours, Additional conference calls as needed with updates

Universities and Medical Schools

RECs and Agency-designated staff

Overview of EHR; specifics on Incentive Program and meaningful use

1 Hour

Exhibit 33: Partner Stakeholder Training Plan

The Agency will evaluate training session information and effectiveness on an ongoing basis. Feedback from internal and external audiences will be used to improve the curriculum and materials. See Section G, Appendices for a sample post-training evaluation survey.


75% of partner stakeholders rate communications materials as satisfactory or higher in monthly contact calls or visits

75% of partner stakeholders rate educational events as satisfactory or higher in monthly calls or visits

F.3.2.7 USE INTERNAL AND EXTERNAL COMMUNICATIONS CHANNELS TO PROMOTE THE

INCENTIVE PROGRAM

F.3.2.7.1 MESSAGE WHEELS

A message wheel can serve as a valuable reference tool and simple guide for internal and external trainings. The center circle of the wheel is the primary message about the issue or program. The outer ring provides four key points that support the main message. Each of the four points includes

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detailed information to explain the messages. There is no start or finish to message wheels, and no right order in which to use the messages.

Message wheels will be used to communicate key messages clearly and consistently. Message wheels will be updated periodically, as more information and details become available. The message wheel shown below outlines the key points needed for communicating information about EHR.

Exhibit 34: Electronic Health Record Message Wheel

The message wheel shown in the following exhibit outlines the key points needed when communicating information about the Incentive Program.

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Exhibit 35: EHR Incentive Program Message Wheel

F.3.2.7.2 INTERNAL COMMUNICATIONS

The following Agency resources and communications channels will be used to promote the Incentive Program:

Mail an introductory postcard to all Medicaid providers and hospitals

Include information in the AHCA Provider Alerts, eNotes

Post information on Medicaid area office web pages

Send information to the HMOs and other entities regulated by the Agency

F.3.2.7.3 EXTERNAL COMMUNICATIONS

The Agency will inventory and leverage partner communications channels and existing activities such as:

Print and/or online publications (newsletters, magazines, journals, bill stuffers)

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Conferences, meetings, trainings and/or trade shows

E-blasts

Website posting

Leads for provider champions

Social media – Facebook, Twitter, blogs, etc. See Section G - Appendices for the partner social media plan.

Agency-designated staff will contact partner stakeholders on a monthly basis to learn of outreach progress. A variety of metrics will be tracked each month to help determine if communication and education materials and events are effective. Those metrics will include:

Number of events and trainings held

Number of attendees at trainings and events


75% of partner stakeholders rate communications materials as satisfactory or higher in monthly contact calls or visits

75% of partner stakeholders rate educational events as satisfactory or higher in monthly contact calls or visits

F.3.2.8 MEDIA PLAN - STORY PLACEMENT AND PAID MEDIA CAMPAIGN

F.3.2.8.1 EARNED MEDIA

The Agency will regularly write and distribute custom releases, articles, e-blasts and social media messages for placement in partner stakeholder communications, using the sample news pegs shown in the following exhibit.

Media Suggested Outlets Sample News Peg

Health Reporters Major Florida newspapers with dedicated health reporters; eHealth News

EHR benefits for patients as well as physicians with introduction to EHR Incentive Program

Interview provider champions to share their stories

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Media Suggested Outlets Sample News Peg

Business/Technology Reporters

Florida cities with Business Journals (Orlando, Jacksonville, Tampa, Miami, Northwest Florida -850); Florida Trend

How the Incentive Program will save money for government and insurance businesses and employers

EHR software uses and implementation in practices

How it works to streamline business and mention specifics of EHR Incentive Program

Niche Publications

Association magazines such as: FMA Today, The FOMA Journal, Florida Medical Business, Health Management Technology, HealthNews.

Insurance industry publications

Medical society bulletins

Incentive Program story placements in publications specific to insurance, health care, technology, nursing, etc.

Exhibit 36: Sample News Pegs

F.3.2.8.2 PAID MEDIA

Based on the research conducted, eligible professionals and hospitals prefer receiving information from their peers and professional associations. To reach these audiences, the Agency will use a combination of print and digital advertising in targeted publications and websites. Ads that clearly focus on one message, and include a call to action, will be created. Print and digital ads will provide a greater return on investment and can be easily adjusted throughout the lifetime of the campaign.

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The following exhibit provides information on the current cost estimates of paid media in Florida markets.

Publication Organization Distribution Reach

(Subscribers)

Cost*

(½ page,

color, 1x )

Cost* (¼ page,

color, 1x)

Florida Family Physician

Florida Academy of Family Physicians

Quarterly 9,000 $1,005 $700

The FOMA Journal

Florida Osteopathic Medical Association

Quarterly 2500 $1,000 $900

Today’s FDA Florida Dental Association

Bi-monthly 6500 $1,008 $7,20

Florida Medical Magazine


Quarterly 15,500 $1,590 $1,400 (1/3 pg)

*Cost estimates are net rates and subject to change upon implementation. Fees for graphic design and production not included.

Exhibit 37: Print Advertising Options

Digital ads provide more creative flexibility, are cost-effective, and can be geo-targeted to specific audiences. The Agency will test 2-3 ads for a short duration, and adjust the creative and messaging based on the ad performance. One or more of the websites listed below will be used for digital advertising.

Outlet Organization Distribution Dimensions Audience Cost

FMA Member Connection E-blasts


Twice Monthly 300 x 250 Current Members (approx. 10,000)

$0.10 per delivered email

FMAOnline.org Florida Medical Association

Daily Impressions/ Month

Homepage Top Banner 550 x 70

Physicians $1,800/month

FMAOnline.org Florida Medical Association

Daily Impressions/ Month

Homepage Lower Right 294 x 96

Physicians $500/month

Monthly E-News Alerts

Florida Pediatric Society

Monthly Unknown Pediatricians $400/month

*Cost estimates are net rates and subject to change upon implementation. Fees for graphic design and production not included.

Exhibit 38: Digital Advertising Options

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While tracking effectiveness of media buys can be challenging, it is our plan to track various metrics as indicators of effectiveness. A call to action will be included with print and digital media, generating a flow of information that will provide data points.

For example, the number of EHR articles picked up by Florida news sources will be tracked as an earned media metric. Paid media (print and digital) will include our website address. When visiting the website, stakeholders will have the opportunity to join our interested parties list. Through this list register, they will be asked where they heard about the program. In addition, digital ads will include a link back to the EHR website, where hits will be logged and counted. Tracking this data will help us to understand which media sources are creating interest in the Incentive Program.

Outlet Organization Cost

FMA Member Connection E-blasts


$0.10 per delivered email

Monthly E-News Alerts

Florida Pediatric Society

$400/month

Exhibit 39: Media Cost

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SECTION G. APPENDICES

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G.1 CMS GUIDELINES CROSS-REFERENCE

The following tables identify the sections of this document where specific SMHP document requirements, primarily the CMS Guidelines, are addressed. An asterisk, “*”, indicates the requirement is considered optional by CMS.

Cross Reference from CMS Guidelines to Section A, As-Is Landscape:

CMS Guidelines (Section A: The State’s As-Is Landscape) Location in

Document

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.)?

Section A.2.2

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?

Section A.2.3.3.4

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.

Section A.2.3.2.12

4. Does the State have Veterans Administration or Indian Health Service clinical facilities that are operating EHRs? Please describe.

Section A.2.3.2.7, A.2.3.2.10

5. What stakeholders are engaged in any existing HIT/E activities and how would the extent of their involvement be characterized?

Section A.2.3.2, A.2.3.3.2, A.2.3.4, A.2.3.5

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?

Section A.2.3.2

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?

Section A.2.3.2.2

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.

Section A.2.4.5, A.2.4.3.1 and A.2.4.3.2

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?

Section A.2.3.2.1, A.2.4.1, A.2.4.2, B.9, Section F

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.

Section A.2.3.1

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?

Section A.2.4

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.

Section A.2.4.4

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CMS Guidelines (Section A: The State’s As-Is Landscape) Location in

Document

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.

Section A.2.3.6

14. What is the current interoperability status of the State Immunization registry and Public Health Surveillance reporting database(s)?

Section A.2.3.2.3

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.

Section A.2.3.3.5

*May be deferred **The first part of this question may be deferred but States do need to include a description of their HIE(s); geographic reach and current level of participation.

Exhibit 40: Cross Reference from CMS Guidelines to Section A, As-Is Landscape

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Cross Reference from CMS Guidelines to Section B, To-Be Landscape:

CMS Guidelines (Section B: The State’s To-Be Landscape) Location in

Document

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.

Section B.4

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?

Section B.3.1, B.4

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.)?

Section B.4, B.7, C.2.1-2.7

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.

Section B.5

5. What specific steps is the SMA planning to take in the next 12 months to encourage provider adoption of certified EHR technology?

Section B.6 Section F

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?

Section B.6.1.1

7. * How will the SMA assess and/or provide technical assistance to Medicaid providers around adoption and meaningful use of certified EHR technology?

Section B.6.2 Section F

8. * How will the SMA assure that populations with unique needs, such as children, are appropriately addressed by the EHR Incentive Program?

Section B.6.1.2

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.?

Section B.6

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.

Section B.7.2

Please include other issues that the SMA believes need to be addressed, institutions that will need to be present and interoperability arrangements that will need to exist in the next five years to achieve its goals.

Section E.1.2.1 and E.1.2.2

*This question may be deferred if the timing of the submission of the SMHP does not accord with when the long-term vision for the Medicaid IT system is decided. It would be helpful though to note if plans are known to include any of the listed functionalities / business processes. ** May be deferred.

Exhibit 41: Cross Reference from CMS Guidelines to Section B, To-Be Landscape

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Cross Reference from CMS Guidelines to Section C, EHR Incentive Program Plan:

CMS Guidelines (Section C: EHR Incentive Program) Location in

Document

1. How will the SMA verify that providers are not sanctioned, are properly licensed/qualified providers?

C.2.14

2. How will the SMA verify whether EPs are hospital-based or not? C.2.14

3. How will the SMA verify the overall content of provider attestations? C.2.14

4. How will the SMA communicate to its providers regarding their eligibility, payments, etc?

C.2.5 Section F

5. What methodology will the SMA use to calculate patient volume? C.2.14

6. (a) What data sources will the SMA use to verify patient volume for EPs and acute care hospitals? 6. (b) How will the SMA verify adopt, implement or upgrade of certified electronic health record technology by providers?

D.4

7. (a) How will the SMA verify that EPs at FQHC/RHCs meet the practices predominately requirement? 7. (b) How will the SMA verify meaningful use of certified electronic health record technology for providers’ second participation years?

D.4

8. 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.

No

9. How will the SMA verify providers’ use of certified electronic health record technology?

D.4

10. 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?

C.2.8

11. * How will this data collection and analysis process align with the collection of other clinical quality measures data, such as CHIPRA?

B3.2

12. What IT, fiscal and communication systems will be used to implement the EHR Incentive Program?

C.2.5 Section F

13. What IT systems changes are needed by the SMA to implement the EHR Incentive Program?

C.2.5

14. What is the SMA’s IT timeframe for systems modifications? Complete

15. When does the SMA anticipate being ready to test an interface with the CMS National Level Repository (R&A)?

Complete

16. What is the SMA’s plan for accepting the registration data for its Medicaid providers from the CMS R&A (e.g., mainframe to mainframe interface or another means)?

C.2.5

17. What kind of website will the SMA host for Medicaid providers for enrollment, program information, etc?

Section F

18. Does the SMA anticipate modifications to the MMIS and if so, when does the SMA anticipate submitting an MMIS I-APD?

Florida’s update IAPD inclusive of MMIS modifications has been submitted and approved (February 2012)

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CMS Guidelines (Section C: EHR Incentive Program) Location in

Document

19. What kinds of call centers/help desks and other means will be established to address EP and hospital questions regarding the incentive program?

Section F

20. 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?

C.5

21. 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?

C.4

22. (a) What is the SMA’s anticipated frequency for making the EHR Incentive payments (e.g., monthly, semi-monthly, etc.)? 22. (b) 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?

Weekly payments – C.3

23. 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?

Not Applicable

24. What will be the process to assure that there are fiscal arrangements with providers to disburse incentive payments through Medicaid managed care plans does not exceed 105 percent of the capitation rate per 42 CFR Part 438.6, as well as a methodology for verifying such information?

Not Applicable

25. What will be the process to assure that all hospital calculations and EP payment incentives (including tracking EPs’ 15% of the net average allowable costs of certified EHR technology) are made consistent with the Statute and regulation?

This requirement is no longer relevant

26. 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.?

C.2.5

27. * 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 The role, approved plans and status of the HIE cooperative agreements State-specific readiness factors

C.5.2.8.1, F.3.2.2.1

*May be deferred

Exhibit 42: Cross Reference from CMS Guidelines to Section C, EHR Incentive Program Plan

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Cross Reference from CMS Guidelines to Section D, Audit Strategy:

CMS Guidelines (Section D: Audit Deliverable) Location in

Document

1. (a) 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 post-payment, use of proxy data, sampling, how the SMA will decide to focus audit efforts etc): 1. (b) 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.

D.3 D.3

2. 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?

D.5

3. Describe the actions the SMA will take when fraud and abuse is detected. D.5

4. 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.

D.5

5. 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)

D.3

6. **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)?

Section D

7. Where are program integrity operations located within the State Medicaid Agency, and how will responsibility for EHR incentive payment oversight be allocated?

D.5

*The sampling methodology part of this question may be deferred until the State has formulated a methodology based upon the size of their EHR incentive payment recipient universe. **May be deferred

Exhibit 43: Cross Reference from CMS Guidelines – Section D, Audit Deliverable

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Cross Reference from CMS Guidelines to Section E, Roadmap:

CMS Guidelines (Section E: The State’s HIT Roadmap) Location in

Document

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.

Section C.5 Section D.3 Section E (All) Section F.3.1

2. What are the SMA’s expectations re provider EHR technology adoption over time? Annual benchmarks by provider type?

Section E: 1.3.1, 1.3.2, 1.3.3

3. Describe the annual benchmarks for each of the SMA’s goals that will serve as clearly measurable indicators of progress along this scenario.

Section E: 1.3.1, 1.3.2, 1.3.3

4. Discuss annual benchmarks for audit and oversight activities. Section A.1.3 Section D.3 Section E: 1.3.1, 1.3.2, 1.3.3

CMS is looking for a strategic plan and the tactical steps that SMAs will be taking or will take successfully implement the EHR Incentive Program and its related HIT/E goals and objectives. We are specifically interested in those activities SMAs will be taking to make the incentive payments to its providers, and the steps they will use to monitor provider eligibility including meaningful use. We also are interested in the steps SMAs plan to take to support provider adoption of certified EHR technologies. We would like to see the SMA’s plan for how to leverage existing infrastructure and/or build new infrastructure to foster HIE between Medicaid’s trading partners within the State, with other States in the area where Medicaid clients also receive care, and with any Federal providers and/or partners. *Where the State is deferring some of its longer-term planning and benchmark development for HIT/ E in order to focus on the immediate implementation needs around the EHR Incentive Program, please clearly note which areas are still under development in the SMA’s HIT Roadmap and will be deferred.

Section A.1.3 Section C.5 Section D.3 Section E (All)

Exhibit 44: Cross Reference from CMS Guidelines to Section E, Roadmap

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G.2 SAMPLE CURRICULUM FOR TRAINING PARTNERS

Course: EHR Incentive Program: Facts, Figures and Resources

Purpose: Educate partner organizations conducting outreach for the Incentive Program

Audience: Associations, RECs, RHIOs, etc.

Trainer: Agency-designated staff

Length: 1 hour – half day

Type: In-Person Training/Webinar/Conference Call

Introduction

Welcome, introduction of speaker and overview of course

What are Electronic Health Records?

Definition

What is “meaningful use”?

Status of EHR Nationwide


The Basics

Who is eligible

Qualifying Criteria

How payments work and timeline

Role of the Regional Extension Center

Outreach Education Toolkit and Dissemination Strategy

Overview of the outreach toolkit and recommended strategies to promote the Incentive Program

How to address eligible provider questions

Frequently Asked Questions by Providers

o How to calculate Medicaid patient volume

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o How to calculate potential incentive payments

o Benefits to eligible professionals

o Helpful Resources

Wrap-up/Questions

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G.3 SAMPLE POST-TRAINING EVALUATION SURVEY

The Agency for Health Care Administration is always looking for ways to serve you better. Please take a moment to complete this short survey about our EHR Incentive Program training workshop. It will help us know how we’re doing, and how we can better serve your needs in the future.

Satisfaction

Please circle the appropriate number for your level of response.

How satisfied are you with: Not Satisfied

Somewhat

Satisfied Satisfied

Very

Satisfied

The relevance of information to your needs?

1 2 3 4

Presentation quality of presenter? 1 2 3 4

Subject matter knowledge of presenter? 1 2 3 4

How satisfied are you with the outreach materials?

1 2 3 4

The overall quality of the training workshop?

1 2 3 4

Was the information easy to understand? ___Yes ____No

Did the training workshop meet your expectation? ___Yes ____No

Any additional topics do you wish the training covered? What did you like the most about this training workshop? What did you like the least about this training workshop? Do you have any additional comments or suggestions?

Thank you for completing this evaluation.

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G.4 REGIONAL EXTENSION CENTER INTERVIEW GUIDE17

Introduction

Hello, thank you so much for talking with me today, [name of respondent]. I am calling from Salter>Mitchell. We are working with AHCA to create a communications outreach plan to eligible professionals about the Medicaid EHR Incentive Program. I know that the Regional Extension Centers are already well on their way to helping practices and practitioners move to EHR. I really would like to have a short conversation to learn what you have already done regarding this program, and what your future plans are. Ultimately, we’d like to be able to work together and see how we can enhance what you have already begun, I’ll be taking notes during our conversation to write a report later, but the report will only contain the ideas and opinions of all the participants we talk to and will not identify any individual.

Current Environment

Can you give me a brief overview of where you are today in your outreach regarding EHR? What are your goals? Are you as far along in your plan as you would like to be? Are you talking about or promoting the Medicaid EHR Incentive Program as well—or only about EHR in general?

Outreach Efforts

Do you have a communications outreach plan? What challenges or obstacles have you faced—if any—in trying to get doctors and practices to implement EHR? What have been the more successful outreach efforts in helping promote this program with stakeholders? Can you please describe these? What outreach efforts have been less successful in helping promote the Medicaid incentive program? Can you please describe these? Thinking about the stakeholders you work within your community, what makes those interested in the EHR incentive program receptive to that program? What makes those who are NOT interested in the EHR incentive program less receptive to it? In your own experience, what are the kinds of things that have made stakeholders more receptive to seeking information about this program? What kind of educational information is your organization currently offering stakeholders about electronic health records, health information exchange or the Incentive Program? What kind of outreach materials are you missing that you wish you had?

17 This is a sample interview guide. Interview guides similar to this were used in conducting in-depth interviews with eligible professionals, hospitals, and partner stakeholder groups.

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Wrap-up

Thank you so much for your time. Was there anything else you would like to add?

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Documents

FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION STATE ...ahca.myflorida.com/Medicaid/EHR/Downloads/SMHP.pdf · Florida Agency for Health Care Administration State Medicaid Health Information